This article is a part of your HHCN+ Membership
As the second Trump administration begins to reshape federal health care priorities, home-based care leaders are cautiously optimistic but sounding the alarm on certain key areas such as reimbursement and labor stability.
Budget neutrality adjustments have been a “tragedy,” Medicaid budget cuts still loom large for patients and caregivers, Medicare Advantage (MA) plans require accountability and audits and surveys are set to only increase. While concerns shadow in-home care providers looking to improve access to care, light can still be seen through the darkness. The 80/20 rule is likely to be repealed and demographic changes mean more patients require in-home care than ever before, according to experts on the latest episode of HHCN+ TALKS.
Home Health Care News sat down with Dr. Steven Landers, CEO of The National Alliance for Care at Home; Jeanette Weinz, Brand Leader of Executive Home Care; and David Jackson, CEO of Choice Health at Home to discuss the current and potential pressures facing home-based care providers, as well as the path forward for the industry.
A replay and transcript of that TALKS episode for HHCN+ members is below. The transcript is lightly edited for style and clarity.
HHCN: I’m Morgan Gonzales, associate editor of Home Health Care News.
We’re discussing home-based care under the second Trump administration, including policy shifts, potential budget cuts and the path ahead for providers. Thank you all so much for being here with me today. Let’s get started.
Steve, since February, what are the most significant policy proposals or actions you’ve seen that could impact home-based care under the second Trump administration?
Dr. Steven Landers: Thanks, Morgan. In some ways, it’s early in the Trump administration for this second go round. But at the same time, the administration and Congress (have) been moving at rapid speed, and so there’s so much happening. It’s hard to boil it down to one single thing, but I think that what’s happening right now in Congress related to reconciliation and the implications for the Medicaid program are quite serious with respect to home-based care, because although direct cuts to home and community services and Medicaid are not implicated, the type of pressure we expect to see on state budgets from this proposal, in the past … has led to challenges with access to home- and community-based care. So we’re concerned. We’ve been weighing in aggressively to try and see some mitigation of some of those risks.
Of course, we are any day now going to see a proposal for the Medicare home health payment system for 2026 and we’re looking out for, will CMS moderate under the Trump administration this cycle of behavioral adjustments, which have been hanging over the home health system’s head? Or will those adjustments be moved forward aggressively? That could also be damaging to Medicare home health services, which are crucial for post-acute care and for preventing hospitalization in the first place.
We’ve got a hospice rule that is going to be finalized. And no shortage of other issues around telehealth, Medicare Advantage, you name it.
(Editor’s note: CMS released the proposed 2026 home health payment rule on June 30, drawing sharp concern from Landers.)
Thanks for setting that scene. Jeanette, I’ll turn to you to start this next one. How do you feel six months into this administration, more nervous, more optimistic, or the same as you did in January?
Jeanette Weinz: I am … cautiously optimistic. I think that there are a lot of changes coming down the pipeline. I couldn’t have said it better than Steve. He gave a great explanation of it, but I think that there will be things that are changing regarding the Medicare and the Medicaid waiver system. I am hoping that it will be looked at more specifically, so that we will be able to get more positivity around understanding the home care system. We see it now in the hospitals, realizing that how home care partners with home health is saving them money. I’m hoping that will come out more and we’ll be able to see that.
I am saying optimistic. But I also have other things on the other side, such as elderly ones living longer and wanting to live at home. So there are two different sides to it. I’m hoping the next couple of years that that will really pick up and they’ll really recognize home care.
David Jackson: I think, like Jeanette, I’m cautiously optimistic.
Steve touched on this. Any time you gain visibility (is a positive), so a completed reconciliation bill gives you visibility, and right now, when things are rumbling around in D.C., you don’t really have visibility, because deals are being made. (Editor’s note: The Senate passed the tax-and-spending bill on July 1.) Where I get optimistic is, the consumer wants healthcare at home. There’s no question. There is a lot of rhetoric around that. So it becomes a question of, how best can we convey and advocate for how we can best do that?
The scary part, sometimes, for me, in this industry and where I’ve become very cautious, is people understanding the indirect ramifications of, say, mass cuts to the Medicaid program, especially for my company which serves the southwestern United States. We’re going to talk all about a lot of topics that impact the southwestern states, but to Steve’s point, ramifications that impact rural access hospitals could then subsequently impact rural access health care providers and post-acute care. There’s a snowball to that.
I said it on a committee the other day, this current bill would alter three different hospital systems that we service in rural America by almost $48 billion. Just three small rural access hospitals. I mean, they don’t exist in that environment. So that’s where I’m cautious.
I’m also really bullish on some of the rhetoric that’s coming out around holding MA plans accountable. I think that’s probably the most impactful potential administrative impact this administration or subsequent administrations could have is clarity around Medicare Advantage and holding them accountable to provide the care that they’re supposed to provide to the beneficiaries.
Landers: I feel deeply optimistic about the implications of investing in home care for America. For an aging country, which is tripling the number of people 85 and older from 2020 to 2060, has affordability issues with its public programs, (and) has a public who wants independence and wants autonomy as they age, care at home is the right solution.
I have to say I’m not satisfied. I do not feel comfortable. I can’t say that I was particularly satisfied in November or earlier, but I’m certainly not now that our decision makers are investing and embracing care at home to the extent that it needs to be as a strategic resource for the country. I think that if I distill all the noise that I’m hearing, I think there are some things that are promising that might lead to some improvements, and some things I’m really worried about.
So let’s say that in the very near term, very mixed feelings, but long term, I just want to keep imploring everybody in our community to speak up, tell that story and make sure that our voices are heard, because we need to make more progress faster, I believe.
Jeanette and David, I’ll ask you what policies or regulations would make the biggest difference for your businesses and the patients or clients that you serve. David, could you take that one to start?
Jackson: I believe sometime (around) 19 months ago, Medicare Advantage overtook traditional Medicare as the large payer for home health care services. We should have transparency around the cost and the payments that we’re receiving from those plans. There’s an entire chapter of it from MedPAC discussing MA plans, and yet we can’t even report that on our cost reports, as providers. That lack of transparency, to Steve’s point, how do congressmen and women make rational decisions without seeing the impact of over 50% of the payers for health care at home? It doesn’t make sense.
So creating transparency around that, and then also just improving the authorization process. If you think about the meeting that was about a week and a half ago (that said that) everyone’s going to voluntarily start talking about authorizations, I would like to see more consequences for failure to authorize care for a 90-year-old female living alone in her home.
I wrote two stories about the prior authorization news. I think that’ll be really interesting to watch how that pans out. Jeanette, what about you, same question?
Weinz: I agree with exactly what he says. I feel like sometimes people or insurance companies undervalue what home care does. As he said, it really needs to be thought about, regarding the reimbursement on it.
Sometimes it’s very hard for us to be able to recruit caregivers, and not just caregivers, awesome caregivers, ones that we can put into the home. What we get reimbursed and what we can pay is really such a slim margin that a business cannot stay in any (state) of, I wouldn’t even say profit, I would just say covering their operational costs.
I believe, as he says, the second thing is really looking at our labor market. Are there things that we can do, such as immigration. Is there some way to have that type of a visa, a work visa? We have to be open to that. As they say, out of 100 resumes you get, you could only hire two for caregivers. Isn’t that crazy? So we definitely need to be thinking about those two different things, as far as how that’s going to impact home care going forward.
The House passed the budget reconciliation bill that included significant cuts to the Medicaid budget. It’s looking like those cuts could be even deeper. What’s the long-term impact on the home-based care industry if these budget cuts, or even more significant ones, pass and get implemented? Steve?
Landers: It looks like the Senate language is changing, so I don’t want to comment too deeply on where they end up. But overall, we’re looking at significant pressure on state budgets. The implications then are (that) the states are going to have to figure out how they manage those pressures. The concern is that one of the ways to manage that will be to reduce access to services, add co-payments, or cost sharing, things that harm access to home- and community-based care. So I think there is a lot to be concerned about.
I think another story is that as the states are under more pressure, they have to reevaluate their strategies in the long run. Now they have a hard time being strategic, because the political pressure by all the different groups is so strong. When states, at times, have had to think about their future strategically, they’ve done things like rebalancing and trying to shift more care into home and community settings. We’re going to have to make sure at a state level that we remind the decision makers that their home- and community-based platform is a value creator. It’s something that saves them money in their budget in the long term, versus a burden.
Another thing that’s not talked about enough in this conversation about the reconciliation and Medicaid pressures, and also some of the changes to the Affordable Care Act exchanges in this law, is that a lot of caregivers are going to be impacted. This is not my research, and so don’t hold me to the exact number, but (there is a stat) that 40% of personal care workers in the United States are Medicaid beneficiaries, or (on) a Medicaid-like exchange product on the Affordable Care Act exchanges.
And so if some of those people through this community engagement or work requirements, if the burden on them increases, or they’re not able to keep up with it – because you know, a lot of these caregivers are working for maybe small employers that are not hitting the employer mandated or under the 30 hours a week – this could put a lot of pressure on some of our caregivers that are in marginal situations themselves, which is not going to make things easier for care recipients. When caregivers are stressed, the people who need the care suffer also.
Jeanette, did you want to add anything there? I think I saw you nod your head.
Weinz: What he said was great, but I want to say, one of the things that he didn’t mention is they don’t realize that when they do those cutbacks, what it does to the other part of the health care system. So it means more hospital admissions, more skilled nursing facilities. They don’t balance that out. They don’t look at what it affects. So I think it’s something that they should look at, the pros and the cons of doing something like that.
Jackson: I would just add on, it’s more about the gap of people that will not be covered. And then Medicaid expansion states. There’s a gap in supplementation that is the reason that several rural facilities are even in place. I think Steve said it best in opening comments, like it’s about these indirect ramifications, that if you think the private sector insurance programs are going to just create coverage for people, it’s just not. There’s a gap of people that aren’t going to be covered.
It’s the indirect effects that make it very difficult to predict, because these people are not covered, and then when that person walks through the ER, we take care of them. That’s just what happens in health care. So the spending is going to continue to be incurred, and then they’re going to try to kick them out into the post-acute care system without a payer. It just creates, like several different ramifications that are hard to predict … To Steve’s point, think about our caregivers, think about the large groups of people who are going to struggle to become enrolled in some other type of healthcare program. It’s not easy. It’s not easy to navigate.
Medicare Advantage has proliferated in recent years, and Dr. Oz is now heading up CMS. He has in the past advocated for “Medicare Advantage for all,” so I’m tracking his approach to it, but it could continue to expand. What would the impact be on home health providers if something doesn’t change? David, could you start?
Jackson: I think when Oz was nominated, obviously his past history with Medicare Advantage, and our industry’s past history of Medicare Advantage, created a lot of concern. It’s interesting, the events of the last 12 months have pushed everything under a significant amount of bipartisan scrutiny. So there’s this moment in time where we could really push back and say, ‘Hey, we create so much value. We are the three sectors that actually save more dollars than are spent on us, considerably.’
So when you think about that, anything that we can do to create transparency to our policymakers so that they can understand the ramifications (of the) very cumbersome authorization process, lack of authorizations, and more of a commodity-driven visit approach … We want to be paid on our value. We love to be paid episodically with some type of value-based kicker.
Everyone’s like, “Hey, we’re going to try to negotiate.” My company is a great example of, we’ve created immense scale in the Southwest, but you can’t negotiate with Walmart or Amazon. When you talk about United Healthcare, they own so much of everything that it’s not really a fair negotiation. We have to consider that in health care and understand, how are we going to hold these groups accountable, these four massive organizations that we’re calling a diversified, free market delivery system?
Steve, did you want to add on anything there?
Landers: The big picture of the growth of Medicare Advantage is that it has had incredible implications for all health care and home health. It’s one of these things that I still, after 20 years working in this field, I’ve not totally figured out. Because on paper, it would seem like a match made in heaven. Managed care, and people that have the expertise of helping keep people healthy in the community rather than in costly hospitals or institutions, it should be the best partnership going in all of health care because of the alignment.
I think we need to realize that there is a lot of pressure and a lot of scrutiny on the plans right now, for many different reasons, but these plans are popular with beneficiaries, at least when they’re choosing and electing their benefits. They might have lower cost sharing, or they might have lower premiums, or be attracted to some supplemental benefits that have been offered. And these beneficiaries often are not particularly high income. This model is very attractive because they might just not have a lot of resources.
I think we’ve got to keep trying to understand and figure out, whether that’s through policy making and through other conversations, how to make this partnership work, because it’s not working, by and large.
There have been too many examples of utilization management models that have just been burdensome, and the negotiation challenges.
An area that I think we ought to be paying attention to also is that just given some of the things that have come up here with hospice, which is an important home-based care model that has been a special managed care program outside of Medicare Advantage, it has its own sort of care manager model and a special status. In the current Congress, there have been a few moments of floating the idea of, quote, unquote, “carving in” hospice to Medicare Advantage. So one thing we’ve been paying very close attention to, and putting a lot of energy in, is pushing back on that. Because we believe it’s a terrible idea right now to bring hospice into the Medicare Advantage plans, especially when there’s so many other challenges happening. And at the same time, hospice is a high performing part of our health system, it just doesn’t seem to be the right thing to do.
We got a question from the audience. The question says, “The gap that you were referring to is what concerns me. Many of the people kicked off of receiving health care through Medicaid will now want to get insurance through us, their employer.” What are your thoughts regarding the potential of this happening? He says he has several hundred caregivers, and paying their health insurance would be a significant blow to profits. Anything to add to respond to that question?
Landers: To the extent that caregivers are dependent on Medicaid, they almost by definition would be fitting into some of these working or able-bodied populations that are going to have more scrutiny of their eligibility, in terms of them meeting work requirements and the documentation requirements that are going to be more frequent. I think that those pressures will impact parts of the workforce.
I think one thing we’ve got to keep doing – going back to this conversation that David was really eloquent about, about the payers and negotiations – hopefully, our businesses can get reimbursed at a level where we can afford to provide insurance and the benefits that are needed for these individuals. But I don’t have any answer to that question other than I fear that those pressures will occur.
Jeanette, do you have anything to add there?
Weinz: No. I agree with Steve regarding the pressures of that, because when they are not on Medicaid, they’re going to be looking for us for full-time benefits. As you know, as a home care company, we don’t really have those type of margins, unless you’re doing your $5 million office a year. So I see a lot of my franchises want to start with Medicare Advantage. Once they start that, they’re very excited about it, but it’s not sustainable. Because then they figure out what their margins are on that piece of it. So there’s definitely something that has to be done with Medicare Advantage, for their pricing, their reimbursement to go up on that, so we can afford these things.
Landers: Morgan, can I just add, I appreciate what Jeanette said, there’s just one other piece I wanted to add to this. Which is that, we also have to look at other things that could improve the cost of employment. The Trump administration has been very open about wanting to support deregulation. They’ve had some requests for information that we’ve been very proactive on. For example, the Fair Labor Standards Act companionship exemption. We’ve asked them to restore that exemption. That would be an aspect of deregulation that might be able to help with the affordability of the workforce. (Editor’s note: The Department of Labor has since put forward a proposal to restore the exemption.)
We’ve asked for them to reevaluate some of the OSHA standards that don’t seem to apply or weren’t written with care at home in mind, but are implicating care at home from a regulatory standpoint. Heat-related work injury standards are one of the areas we’ve been really aggressively pushing.
Of course, we still have standing out there – not for implementation until 2030, but it’s still been hanging out there – the quote, unquote “80/20 rule,” which I know we will touch on. In the sense that maybe there are pressures on employers because of what happens with health insurance, we also need to keep looking at opportunities for deregulation and reasonable accommodation by the government so that we can be viable employers.
Talking about Medicare Advantage, talking about cost pressures, I hear a lot about diversifying payer sources and service lines, improving efficiencies. What can providers actually do to mitigate some of the low rates and increasing MA prevalence? What is a top tip or two?
Jackson: At Choice, I’ve been very focused on building three distinct service lines: personal care, home health and hospice. We want to pursue excellence in the home and enhance lives (of) people that we get to take care of every day through those three sectors.
I think about that in times like this. You know, Jeanette and I both use the phrase cautiously optimistic, and, as Steve alluded, we have the coolest job taking care of the greatest generation in their homes. It’s so important. And diversity is one way to hedge against regulatory stroke of the pen risk. You’ll see states, to Steve’s point, as they start to grapple with insufficient funds, they’ll move dollars around. And it can have unintended consequences that these congressmen and women that are dealing with this, they just can’t anticipate.
We are price-takers in almost every realm of what we do, outside of private duty home care. And in that realm, we have our own economic pressures, and our caregivers have those pressures.
So one of the things that we’re trying to embrace outside of that diversification in the home is also really every support group that we have that services our caregivers and our clinicians is focused around what can we use AI for to enhance what we’re doing? That means, in every back office, how can we look at our FBA financial functions, our human resources functions, our scheduling components, like, what can we do to strengthen and support that back arm of what we’re doing?
We found, very quietly in the home health care sector, we found that through improved authorization processing, even automating how we’re moving on authorizations … we’re trying to go at that in a way to enhance what we’re doing, so that anything that we can accomplish in negotiation with payers or at the federal level, as we think about Medicare reimbursement, is upside. If you’re not doing that right now, our most precious resource is caregivers and clinicians, and there’s just simply not enough of them.
I mean, one of the cool things is (that) 2030 demographics look great. So many people to get to take care of. There are not enough caregivers and clinicians, and there are rate pressures. So we need to find a way to enhance that through using AI. That’s the way, outside of diversification, that we’re attacking that.
I’m really excited about AI. I’m also scared that I can no longer tell which photos and videos are AI-generated. It’s getting really good. Jeanette, in terms of actions that you can take to prepare for some of the pressures that we’re talking about, what about EHC?
Weinz: It is a huge priority for me now. I have franchises. So, franchises in home care means I’ve got to get them up and going as soon as possible. We have implemented a much more strategic training, focusing on the sales training, the network, and then we also have a couple of other different programs (that I won’t describe here), but they’re really helping them out.
So they’re working with getting them out the door. Because, as we know with the pressures, they have to work outside the box. They have to be out there branding themselves.
We are just home care. We don’t do Medicaid, we do some Medicaid waiver, but definitely we have to work outside the box and be out there branding, making those relationships. Ours is a little bit, I wouldn’t say different, but we really focus on the community, the relationships, the training, so that it can get them to have more of that private-pay sector, and that is helping us to keep our margins.
But we know in certain states it’s great to do … the VA. We see all of that. So I really think that, as a national company, you have to think of every location as separate, (in terms of) what things can they do. But we really try to focus on making that person better, so that they can get out there and get those private pay sales more, and then balance the other different types of programs that you have.
Steve, anything you want to add before we move on?
Landers: The cloud, the technology, the efficiencies and logistical improvements that can be had is critical to keep up in this environment. I’ve been traveling to a lot of the state home care and hospice association meetings. We’ve got our financial summit coming up in July. I’ve become more and more impressed by the business partner environment, the entrepreneurs that have new solutions on the technology front for this sector. Not just new folks, but even the existing companies you see, Homecare Homebase, Axxess, you see so many investing in innovation and partnering with some of these products that support logistics.
I’d say one other thing that hasn’t come up yet: some of the various audit programs that we know about, you PICs, RACs, cert issues. They’re investing more in these initiatives.
There’s going to be a differentiator for those companies. It’s something we all have to worry about. We’re giving a lot of feedback about what will work and won’t work for providers. But I think that, I hope that, to the extent that there are any sham operations or marginal operations in our sector, that this initiative finally ends some of that stuff. I think we’ll see some of the other players and more serious companies be able to take on a bigger role.
We’ve talked about, a bit tangentially, the Trump administration has a reputation of being pro-business. So I’m curious, are there inclinations that dealmaking in the home-based industry will change?
Jackson: People anticipate a more active M&A front in 2025 (and) interest rate movement, which now there’s some anticipation around (that happening in) September, as we look at the different financial analysts and how they’re viewing it. From a regulatory perspective, typically, Republican administrations are seen as a little bit more advantageous for M&A activity, and so I think a lot of people were overly anxious about that. That means that there are some big companies moving through. We’ll see some transactions. There are a few that should be announced here in the next few weeks.
As those markers come out there, what I’m hearing in the industry is showing some significant success. I’m talking about the larger middle market groups, regional providers, trading hands.
With some clarity from the reconciliation bill, you’ll start to see the publics perform better on the markets, and that typically leads to more M&A in the market. If you see fed rates start to drop in Q4, we should see heightened activity off of the last two and a half years, just because of interest rate pressures that subdued.
Thanks. David. Jeanette, Steve, do you want to add (thoughts) about dealmaking?
Weinz: We have franchise owners that get the funding, and as soon as we put their numbers together, it is getting much easier for them to be funded because of how our industry is growing, giving them the statistics of that. But anything that the presidency does regarding helping out those independent, smaller companies would help a lot. Not only help them, but also help out the services all together, home care, so that they’re able to provide more and more owners that can provide more services. So it’s a win-win for everybody if this is something that happens.
Jackson: I was just going to comment on what Steve said in regards to M&A. The audit environment, especially in hospice right now, is pretty significant. I think organizations that have high clinical compliance need to have a robust audit and loss prevention program. You need to be looking at programs that help you improve the compliance of a clean claim … I think you have to be perfect there.
In terms of M&A, that is going to be one thing that investors consider as they look at targets and assets, is how compliant is this business, and it creates value for everyone, from your investors to your patients.
Jeanette, you mentioned Medicaid waivers. CMS has already cut some funding for services previously covered by in-home, non-medical waivers. What will the impact of reduced funding here have on the home care industry in your eyes?
Weinz: It’s going to really trickle down. What we provide for them is really their daily living, helping them with daily living activities. And so therefore, if it’s cut, then the home care company is only going to have to make the decision. Is it going to be based on the reimbursement, the amount, or actually the client? And then it’s going to be, are they going to start turning away more and more individuals because they can’t sustain the reimbursement for it, so it is not going to be something that’s going to be good for home care itself.
There’s been growing concern around the PDGM payment model and home health, especially regarding the budget neutrality adjustments carried over from the Biden administration. Do you think the current administration would bring any changes to this approach? David, do you want to start?
Jackson: (Given) what the Alliance has done historically – and then there have been some great EMR vendors that have provided a lot of data around this, around the flaws and the budget neutrality component, looking at how we’re looking at the spend – I really would be interested in what Steve has to say.
I feel like in that specific sector, home health, seems like my whole career has been subsequent cuts, and we bring so much value. I do think there are people that are starting to realize it. Like I said, as we started this conversation, the consumer wants this provision in the home, and so it’s a little bit counterintuitive to continue to reduce this low-cost delivery of care, when you’re trying to decrease overall spending.
So I’m hopeful around the fact that we might see some clarity around the entire model, any potential take-backs related to prior years. I’d just like to get clarity on that so we can move forward, but I’d be interested in what Steve has to say about it.
Landers: This has been a tragedy. I think there’s no better way to put it. Congress, in 2018 in the Bipartisan Budget Act, developed a method to redesign home health payments, and the goal was to do this in a budget-neutral fashion. It actually wasn’t even viewed as a cost saver. As you know, if Congress can get a cost-saver to pay for something else, they take it whenever they can. In this case, they did not intend that to be the case. However, this gets handed off to the administrative folks in Medicare and in the sausage making somehow here, we’ve seen a home health program that’s gotten decimated, for lack of a better way to put it.
We’re talking about tens of millions fewer visits, delays in care, people being referred and not being admitted at higher rates, agency closures. Oh, by the way, I want to remind everyone, I think you know, somebody being referred to home health and not admitted, it’s a life and death situation. Mortality rates are increased when older folks are sent home from a hospital with a home health referral, and then they don’t get (that service). It’s incredibly dangerous. We have agency closures, more prominent issues with access (especially) in rural areas, in other high-poverty communities.
This has been a decimation, not a budget-neutral redesign of the system. The idea of matching the payments to different diagnoses and that type of thing, I don’t think any of us have any real major problem with that. But the fact that we’ve seen payments cut in the face of the highest wage and labor inflation in the history of the health care industry, at least the modern history of it, I know I’ve never seen anything like this in my career. The real dollar payments for home health have just plummeted out of CMS. This administration, we’ve been giving them information about the access issues, about the way the law was developed, and the intent of the law.
We’re of course going to have a much more intense conversation about this after they issue a preliminary or proposed payment rule in the next several days, and we’ll see where they stand.
We’re going to learn, you know, really, what they’re thinking with this first payment proposal. Although it is the first proposal of the new administration, and some of the work was probably done by the past (administration), and so we’ll have to balance our evaluation from that standpoint. But these behavioral adjustments are just not tenable, especially when the all-payer environment is not being assessed and looked at. Where MedPAC, who’s been advising Congress, various folks on the Hill,
they seem to want to turn a blind eye toward the other part of the book of business, for the home health agencies, which (is) largely Medicare Advantage, sometimes Medicaid as well. The margin profile there has just been negative, as best we can tell.
So it just doesn’t fit. I know I gave a long answer to a short topic, but all I can say is that this is our life’s work. We’ve got to turn the tides on these trends here. With respect to Medicare home health, it’s a wonderful program. It can provide so much value. Again, going back to the waste, fraud and abuse topic with this administration, there are likely places they could – not by nixing good care because of a missed signature, like David said – but there are examples of some true, unqualified and inappropriate operations. That’s really where we should be going, rather than across-the-board cuts. And using technology to gain efficiencies, new roles for telehealth, and that’s where the conversation should be going, not on these across-the-board cuts.
Thanks a lot, Steve, I’ll stick with you. Trump campaigned and is largely carrying through on stringent immigration policies. How will these policies impact the home-based care industry?
Landers: I’m a … geriatric medicine doc, and so I like to think about demographics and aging and what’s going on in that regard. And the demographics are challenging. We’re seeing rapid increases in our population of older people, and basically a flat population of the younger age groups of the traditional caregiving years.
The numbers don’t match up that well, and we’re already seeing crises with waiting lists in certain programs, and I’ve even heard of private pay referrals being turned down for lack of caregivers in different places in our country. Certainly those home health referrals that need to be seen on a Friday night or first thing Saturday morning are under great pressure. Where are the caregivers going to come from? I don’t know any one specific immigration policy – security and rationality are important – but big picture, if we don’t have any immigrants, given our demographics, we could struggle a lot with caregiving.
Jeanette, do you have any thoughts there?
Weinz: It is a huge issue, and it will be even more of an issue. Especially now with a lot of the immigration, the strategic things that they’re doing, it’s really causing issues to reduce the legal way of coming in. We see a lot of this on different areas. One in four of our employees, our caregivers, are actually foreign born. We see a lot of it in cities like Chicago, on the East Coast and the West Coast. Our numbers in those offices are down because with the live-ins and other different types of client hours, we had a lot of these individuals that were supplying the care for that. It’s very hard to be able to recruit. One of the things that we say is, would you rather lose a caregiver or client? You would rather lose the client than the caregiver, because it’s so hard to get caregivers out there.
So there needs to be something done there, whatever that is. There needs to be some type of carve-out, target situation regarding eligibility, so that we’re able to keep immigrants in the country more to be able to help out with personal care or home care services.
David, do you see any impacts for your neck of the woods?
Jackson: In the Southwest U.S.? Yeah. We provide care in places like South Texas and Tucson. Throughout the Southwest, you see the ramifications of immigration policy, and we’re talking about a 30-year issue. We’ve seen different presidents handle different applications of policy.
At Choice, one of our pillars is empathy. We have some really great Spanish-speaking programs that we provide to our health and home and personal care clientele … even in the hospice benefit. I’m pretty excited, education in Spanish for Spanish-speaking individuals in the South, it’s just really important.
We do see some fear there, and I hate to see that in the people that we are taking care of. So I’m just hopeful that we can return to a place where there shouldn’t be fear of people living in houses in the United States.
Thanks, David, and I’d like to discuss the future of the 80/20 rule. Steve, you mentioned that earlier. I’ve heard from some sources that some of Trump’s actions could implicate the 80/20 rule. What do you think is the fate of the 80/20 rule?
Landers: I think it’s going to be repealed during this administration, exactly when I can’t pinpoint. It will have to happen through notice and comment rulemaking. Because it doesn’t immediately come into effect, I think there are other things waiting in line that are more urgent priorities, but certainly this type of mandate is not in line with this administration’s governing philosophy.
I think the whole access rule probably gets repealed. There are things in there that I think our community would want to maintain, but ultimately, that 80/20 piece is just so damaging and unworkable that I think it’ll be good news when it gets put to bed.
Jeanette, you want to add (anything)?
Weinz: I really don’t have anything to add, except you’re right. You think about 80% to the caregiver, 20% to the owner of the company. And that’s really not sustainable at all.
David, before we move on, any thoughts there?
Jackson: I’ve heard the same thing. Steve, and our thoughts have been that that would be repealed. There were some good things in there, it was a mixed bag. I think the whole of health care should get concerned anytime they start trying to tell us how to spend the money inside the P&L. That, to me, is a little bit of a scary concept, and there could be ramifications at all levels of care. One of those things where good intentions probably just didn’t (equate to) quite common sense.
Steve, from a policy standpoint, do you expect any shifts to the HHVBP model under this administration?
Landers: We are just starting to see implications in payment for the national expansion year 2025. The overall concept is promising, and our agencies have saved Medicare a lot of money by doing more to help keep people out of the hospital. They’re not getting those monies back, but they’re doing a lot of great work.
I think that there are some questions we have about how it’s being implemented. One of the things we’ve seen is that there are agencies that are getting quality bonuses in this that are not participating in the home health quality reporting system, which doesn’t seem to make sense that the VBP system wouldn’t flag that and somehow address that.
We are very much wanting to see any kind of questionable, potentially even sham operations in this space be addressed appropriately. That doesn’t add up. That might be the case, that people would be not fitting in the quality reporting program, but somehow getting a bonus … And of course, anything that involves self-reported coding and risk adjustment. We’re continuing to pay attention to other risk adjusters, truly accounting for how sick people’s patients are. And making sure there’s nothing being manipulated in this system.
David, what would you like to see happen there?
Jackson: To Steve’s point, there’s just so much data available, I’d like to see them hone in on that. Our average agency rating, we have extreme focus on this, is in the mid-fours, 4.4, I keep (saying), we’re going to keep working on improving all of our agencies’ performance.
From a quality perspective, there are some places where we’re accepting more critical patients, and it seems like the agencies, it’s almost like you’re being penalized for taking on a different type of population. So we’ll see heavy hospital discharge(s) make it very difficult for us to perform. So I think Steve’s right, we need to grab the wheel on this and say, “Hey, here’s what makes sense.” I would love to get paid this way in Medicare Advantage. As much as we can show off, we want to show off.
We’re rapidly running out of time, but I really did want to hit on a little bit of the palliative care and hospice element that, Steve, I know you mentioned. Could you shed some light on the status of the Palliative Care and Hospice Education and Training Act, and just generally give us an update on the policy landscape for palliative and hospice care?
Landers: We’ve been excited to support that initiative to enhance caregiver education and access to palliative care. Palliative is a wonderful approach … Comprehensive palliative care models make such an impact, and they just have not grown because policy making has not … accommodated them.
One of the things that’s on the edges of this, that’s really struck me was, we had this Medicare choices demonstration program with concurrent care within some hospices, and people being able to get hospice-like services even if they were still getting curative treatments. They got into hospice earlier, they had better end of life experiences that saved the system money. But … for whatever reason, Congress and CMS are not advancing these policies so that they scale.
In our sector, for innovation to scale, it often requires accommodating public policy. I can’t tell you how many times I’ve seen things that benefit patients, that save the system money, but don’t scale because we don’t have (an accommodating) policy and supportive policy. Palliative is one of those areas where we just need to see that grow.
Of course, hospice is a national treasure. It’s one of the best things in health care, beloved. There are some problems in hospice that need to be fixed, but by and large, it’s a wonderful program where we’ve been looking out for threats to hospice, things that would weaken access or hurt the program. We’d love to see some modernization. Concurrent care top of the list, (and) home-based respite care models that improve payment models for people with dialysis needs and other complex care needs, so that that works better in hospice. So there’s a lot of work to be done.
Let’s end on something that is a tailwind for the industry. What’s something that you each think has positive movement right now? Jeanette, can you start, please?
Weinz: Being positive … is really going out there and having individuals recognize that home care can play such a huge part in keeping a person at home, or wherever they lay their head at night. So I feel that that’s extremely positive. The more that we educate and the more that we partner with home health care companies, I think that it’s really going to benefit people. People live longer, so they’re going to be able to enjoy their life longer. We are really concentrating on helping individuals have the best life possible.
David would like to go next?
Jackson: By about 2031, one in five Americans will be 65 or over. I know there are probably providers out there that are really struggling right now, and I think everyone should continue to advocate, but the consumers are coming. There’s this massive wave of people that we are going to have the privilege of trying to care for. That coupled with what Jeanette said. No one is arguing anymore, this is where the consumer wants to be. Those one in five people, that’s where they want to be, is home. To Steve’s point, I think you have to have an economic structure that makes those programs viable for them to proliferate. So I think we’ve got the first two check boxes, consumer growth, and then everyone, this is where they want to be, and that gets me excited about the industry. Everybody should hang on.
Thanks. Steve, would you like to take us home?
Landers: I’ve seen through my work over the last several months just a lot of energy and commitment to advocacy. We are not that big of a sector in the whole health care system. It’s imperative that everybody includes as part of their job description speaking up, telling the story, engaging with their legislators, and with our associations, state and national, to make a difference.
I’m seeing grassroots participation, political action being stronger. It’s not strong enough, we’ve got to keep going, but there’s some momentum there, and we’ve got to keep investing, because if we don’t speak up, somebody’s going to jump in. There are a lot of people with other ideas, and we’ve got to tell our story, because it’s a winning one.
Many thanks to our speakers for sharing your insights today. Thank you all, and thanks to our attendees for coming.
