Senator Susan Collins Joins Other Lawmakers, Asks CMS to Ditch PDGM’s 4.36% Behavioral Adjustment

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Senator Susan Collins (R-Maine) has sent a letter to the U.S. Centers for Medicare & Medicaid Services (CMS) on behalf of home health providers, urging the agency to reconsider the 4.36% behavioral adjustment baked into the Patient-Driven Groupings Model (PDGM) this year and in 2021. 

Collins isn’t alone. U.S. Representative Vern Buchanan, a Republican from Florida, recently did the same. 

“I write to request that you revisit the calculation of the ‘behavioral assumption’ rate reduction in the home health payment system and consider eliminating the proposed 4.36% reduction for 2021,” Collins wrote in the letter. “At a time when skilled and compassionate home-based care is more important than ever … I am concerned that continuing this payment rate reduction in 2021 could affect continued access to home health care services.”

In August, the Partnership for Quality Home Healthcare (PQHH) released an analysis of PDGM, which found that government spending on home health care is 21.6% lower than what CMS had projected headed into this year.

That analysis, which was conducted by health economics and policy consulting firm Dobson DaVanzo & Associates, found that the behavioral adjustment was at the root of the underspending issue. 

Since PQHH has alerted politicians to its findings, Collins — a consistent home health advocate and behavioral adjustment skeptic — and other politicians have taken notice and begun to take action. 

Collins wrote that while she appreciated the initial reduction of the behavioral adjustment to 4.36% by CMS, she was still concerned with the idea that the agency would be continuing with the adjustment in 2021 despite having clear evidence as to how it affects home health agencies — particularly during the public health emergency.

“As the sponsor of the Home Health Payment Innovation Act of 2019, I continue to believe that CMS should base these behavioral adjustments on observed evidence, rather than on assumptions of potential provider behavioral changes, and that any necessary rate increases or decreases should be phased in to limit the risk of disruption in care,” Collins wrote. 

The Dobson DaVanzo & Associates analysis showed a drop in home health spending, but was based on Medicare claims data from the first four months of PDGM.

Since then, however, things have changed for the industry, which both Buchanan and Collins pointed out in their letters. 

The Bipartisan Budget Act of 2018 requires PDGM to be budget neutral.

On Friday, PQHH expressed its appreciation for Collins and other lawmakers speaking out on this issue in a release.

“The Partnership applauds Senator Collins for her continued leadership on Medicare home health issues, including efforts to ensure Medicare’s new payment model does not impede the delivery of home health to our vulnerable patient population, especially as we continue to navigate the challenges of the COVID-19 crisis, ” PQHH Executive Director Joanne Cunningham said in the release. “We hope CMS will consider the concerns flagged by Senator Collins – as well as other lawmakers in Congress – and eliminate the 4.36 percent cut in their final payment rule for 2021.”

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