Home health providers, staff in ‘rude awakening’ after public health emergency expires

Although it may not feel like it at times, the expiry of the Public Health Emergency (PHE) will come one day.

And when it does, it will have implications for home health providers specifically and home care more generally. With the declaration came several exemptions and flexibilities designed to ease the harsh impacts of the pandemic on home health care providers.

While an extension is more than likely on the horizon, providers will need to prepare for the day PHE ends.

PHE was originally declared in March 2020, backdated to January 27, 2020. Last April, the US Department of Health and Human Services (HHS) extended the emergency status for an additional 90 days until July 15.

HHS has yet to make an official announcement about the current status of the public health emergency, but there is one clear sign that points to an extension.

“We expect it to be extended because we’ve been informed by CMS that they’re going to give 60 days’ notice before they end it so they have time to prepare,” Cindy Krafft, co-owner and co-founder of consulting firm Kornetti & Krafft Health Care Solutions, said for Home Health Care News. “Since we weren’t given 60 days notice before July, it would seem logical … for them to extend it at least one more time.”

Denials and flexibility concerns

Along with the PHE declaration came a number of regulatory exemptions and flexibilities designed to streamline healthcare processes and ease the overall burden of the pandemic on providers.

One of those exemptions made it possible for any discipline—nursing, physical therapy (PT), occupational therapy (OT) or speech—to conduct home health appointments based on a patient’s needs.

If the public health emergency ends, that exemption is not expected to become permanent, according to Kraft.

“There are deeper regulatory issues and things that need to be resolved, but it’s still permissible in the exemption situation,” she said. “The reason I think it’s going to be a challenge is the current home health staffing situation. We know that several agencies are at crisis levels and being able to shift therapy intake and take some of that away from nursing when appropriate has become routine.”

Kraft noted that a provider she recently spoke with “relied heavily” on this waiver option to get patients to start services.

Another concern for providers is staff members who have practiced their entire careers in this exemption.

“They came in [home health] at the same time as the release,” Kraft said. “What they think of as routine — being a therapist and doing admissions or being a nurse and not always having to do it — can be a bit of a rude awakening. This is normal for them, but it’s technically a rejection that will go away at some point.

However, some of the exemptions have become permanent options for home health providers.

“If occupational therapy is part of a referral with another therapy, they can initiate care acceptance into the service,” Craft said. “It was a rejection, but now it has shifted to permanence for our setting. Additionally, issues around who can sign home health orders, the role of the nurse practitioner, and the like have also moved from opt-out to permanent.”

Telehealth remains in first place

For providers, the use of telehealth and virtual care has also served as a lifeline amid the pandemic.

“CMS’ easing of face-to-face rules in the early days of the public health emergency helped save lives when the pandemic hit,” Brent Korte, chief home care officer at EvergreenHealth Home Care, told HHCN in an email. “Allowing face-to-face virtual visits in all circumstances has streamlined access to home health care and prevented patients from staying in overcrowded hospitals.” It also helped increase access to home health care and greatly improved the timeliness of care. This helps reduce duplicate care and even unnecessary visits when patients need to make an in-person visit.

Although home health does not receive reimbursement for telehealth services, the public health emergency has created new flexibility for providers regarding HIPAA controls.

Tricia Chrisman, vice president and COO of CommonSpirit Health at Home, believes both patients and providers will experience the long-term effects if permanent changes are not implemented.

“Without permanent changes to Medicare coverage for telehealth services, most Medicare beneficiaries who do not live in rural areas will lose access to telehealth coverage,” she told HHCN. “Additionally, providing telehealth as an integrated and clinically appropriate part of the home patient’s care plan has helped reduce overall mileage and increase nursing capacity, offsetting some of the financial constraints of reduced volumes and, more recently, increasing reimbursement rates for mileage.”

Unfortunately for providers, legislative efforts surrounding the use of telehealth in home settings have failed.

Plus, home health stakeholders have largely shifted their focus to responding to the proposed payment rule and its potential impact on the industry, according to Kraft.

“There are people looking at the numbers who are concerned that the cut in payments as it is now could put a third of agencies in the red and put them in the red,” she said. “Whereas there used to be a lot of discussion about telehealth and legislation, I think right now the industry is more focused on this payment issue: ‘It doesn’t matter if I get reimbursed for telehealth if I’m out of work.’

One positive side of the proposed payment rule, however, is that it requires the use of G-codes for telehealth.

“It allows them to better track usage, and maybe in the future if they see that there’s telehealth usage, that could become part of a payment methodology down the road,” Kraft said.

Extension hospital at home

The end of PHE could also mean a major blow to providers offering higher precision services in the home environment.

In 2021, the US Centers for Medicare and Medicaid Services (CMS) introduced its Acute Hospital Care at Home Waiver Program. The introduction of this exemption allowed approved hospitals and health systems to provide hospital services at home and be reimbursed for the cost of providing care.

Currently, 107 systems and 242 hospitals in 36 states are authorized to provide hospital home services under the waiver program.

Previously, reimbursement was a major obstacle limiting the widespread adoption of the hospital-at-home model in the US

Even now, there is no permanent fee-for-service mechanism in Medicare to pay for hospital home care.
Wanting to continue the waiver program, lawmakers introduced the “Hospital Services Modernization Act” in March. The legislation would extend the exemption by two years.

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