AAHCM Work for Nurse Practitioners and Physician Assistants
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AAHCM Works with National Coalition to Allow NPs and PAs to Certify Home Health Services

A mantra that was heard during the growth of managed care in the 1990s was “the right care in the right place at the right time.” We hear this mantra repeated today; however, now it is in the context of the move to “value-based payment” and “population health management.” We know that having access to services is fundamental to the right care in the right place at the right time. A significant access issue is that nurse practitioners (NPs) and physician assistants (PAs) are not authorized by Medicare to certify home health services.

In general, once a benefit is established in the Medicare program, the Centers for Medicare and Medicaid Services (CMS) defers to state scope of practice regulations in determining whether a category of medical professionals should be recognized (that is “covered and paid”) for rendering services related to that benefit. State scope of practice is not the issue in this situation. As we know, NPs and PAs can order similar Medicare services in other settings, recertify hospice services, render the face-to-face services required for home health certification, and render Care Plan Oversight (CPO—home health and hospice); however, they cannot certify home health services themselves.

The history of the home health benefit itself reflects that Medicare was concerned with the ability to assure that services in the home were indeed medically necessary. Fast forward to the present: Since the 1980s, when the home health benefit was broadened, we are finding that providers need to be able to provide the right care in the right place at the right time—this time on the path to population health management. How can this be accomplished when a critical portion of medical professionals are not able to certify home health so as to enable the care? Plus, there is a shortage of post-acute providers and, in particular, a growing shortage of primary care providers.

Issues of access become even more important in the context of the aging U.S. population. The Medicare Payment Advisory Commission (MedPAC) projected a more than 50% increase in the number of Medicare beneficiaries to more than 80 million in 2030. The Census Bureau projects that by 2030, the proportion of U.S. residents older than 65 will have nearly doubled from 2010 (20% vs. 13%). The fast-growing cohort of those age 85 and above will double by 2036 and triple by 2049. The number of Medicare beneficiaries with multiple costly, chronic diseases is growing, with those having four or more conditions making up three quarters of the total national healthcare expenditures. With these demographic and diagnostic drivers comes an increased demand for home health.

In a recently released analysis, the CMS Office of the Actuary projected that the annual growth rate for home health spending will be higher than any other category that Medicare tracks and is predicted to increase by 6.7% in 2020. Spending on home health is projected to be nearly $173 billion in 2026.

According to findings published in Health Affairs, total national health spending is projected to increase an average of 5.5% each year between 2017 and 2026, at which point it will account for 19.7% of the U.S. economy. This is faster growth than the economy as a whole; during this same time period, total U.S. gross domestic product is anticipated to only increase 4.5% per year. Policymakers and payers have long viewed these growth projections and the “crowding out” effect as excuses for not paying for other nonhealth-related services.

At the same time, Americans have answered multiple surveys voicing a desire to age in place and receive care in the home rather than in institutional settings. Therefore, providing care in the most appropriate, cost-effective, and efficient setting is paramount. Of note, the Trump administration has not turned away from the move to value-based payment. In fact, the Department of Health and Human Services (DHHS) Secretary Alex Azar has reinforced this policy objective in recent speeches and has stated that “value-based transformation has been a frustrating process…this administration and this President are not interested in incremental steps.”

Two of Secretary Azar’s priorities are

  • using innovative models within Medicare and Medicaid to drive industry change
  • removing regulatory burdens that impede progress to value-based transformation.

A bit of good news within this macro context is that we have learned from Academy members’ participation in models such as ACOs and Independence at Home, as well as other settings, that the growth of home health also can accompany an increase in home-based primary care and a reduction in more expensive and traumatic facility utilization.

What is the Academy doing to remedy the issue that NPs and PAs cannot currently certify home health services?

The Academy has joined with the American Association of Nurse Practitioners (AANP), AARP, Gerontological Advanced Practice Nurses Association (GAPNA), Elevating Home (VNAA and hospice organizations), and Optum Health to further a shared goal of allowing NPs and PAs to order home health services. Earlier this Congressional session, the Home Health Improvement Act legislation (S. 445 and H.R.1825) was introduced with several co-sponsors; however, the legislation has stalled, partly due to an unfavorable Congressional Budget Office (CBO) Medicare savings score.

Why has CBO failed to produce a favorable savings score? In 2014, a study was developed to evaluate whether NP/PA certification would save Medicare money. This was an effort to gain CBO support for certification authority legislation. The study by the consulting firm of Dobson, DaVanzo, and Associates projected an increasing ratio of NP and PA certification of home health to an end state ratio of 70% NP/PA and 30% MD certification. The study then projected savings by multiplying the 15% reduction in payment that NPs/PAs receive by projecting utilization to produce a 10-year (2015—2024) savings estimate of $252.6 million. The study did not rigorously explore more timely access to care and thus reduced facility utilization.

However, we understand that rather than accepting this savings projection, CBO took the view that physicians who are no longer certifying home health would then occupy their available professional time and produce other offsetting spending, making NP/PA certification an excessive Medicare program cost. The Academy also has experienced this negative view of savings in CBO consideration of IAH. When analyzing IAH, CBO seems to only want to count the cost of practices that did not save money under the demonstration and to not consider the savings of the practices that did save money. With this knowledge, we realize that an updated effort and perspective is required to influence CBO.

The Academy is in discussions with our NP/PA certification colleagues to design a study demonstrating that increased access and timeliness to home health services through NP/PA certification will contribute to decreased hospitalizations and produce cost savings for Medicare (well beyond the 15% payment differential for professional services).

As you may know, the Academy Public Policy Committee also is working on alternative payment model designs to support your practice. Approaches could be explored here to have NP/PAs recognized and paid for home health certification. In the interim, Academy members are encouraged to contact their Representatives and Senators to support the Home Health Improvement Act.

With your help and support, we will add the NP and PA certification bricks on the path to the right care at the right place at the right time.