In the News

Insurers Prep for Trump Admin Friendly to Medicare Advantage and Mergers, Hostile to Medicaid and ACA

Fierce Healthcare / By Noah Tong

President Donald Trump has won back the White House, and with his win, many health plans are seeing their stocks rise.

Likely expecting a more relaxed regulatory environment that loosens requirements on Medicare Advantage plans and encourages more mergers, some health insurers are reaping initial benefits.

At the time of publication, CVS Health’s stock is up 11.24%, Humana is up 8.56% and UnitedHealth Group 6.03% higher. Elevance Health is seeing a modest 1.23% gain.
Today, CVS recorded $87 million in profit for the third quarter and beat the Street’s expectations. This year, the company has brought in $3 billion in profit, down from $6.3 billion at this time in 2023.

President Joe Biden has faced criticism from insurer-backed trade groups that portray him as an opponent to private insurance plans because of new federal rules seeking to hold Medicare Advantage plans to stronger standards. This caused the country’s top insurers to report, along with staggering profits, struggles tied to increased utilization and stricter federal requirements.

President Trump, on the other hand, is likely to be more favorable to MA plans. Although he distanced from Project 2025 on the campaign trail, the Heritage Foundation-led plan is closely tied to officials that will almost certainly be in or advising his transition team and second term.

The 922-page document explicitly calls for making MA the “default enrollment option” and eliminating “burdensome policies that micromanage MA plans.” It also says the current risk adjustment model should be “reconfigured.”

MA supporters say the program delivers high-quality care and more robust benefits not offered under traditional Medicare.

Critics say the program is costly and hands the keys over to insurers to impose harsh prior authorization and step therapy decisions on a whim. Some experience trouble switching from an MA plan back to traditional Medicare and others say they are faced with ghost networks, where a host of seemingly-available providers are not covered after all.

And despite some support from J.D. Vance and a select group of Republicans, it’s unlikely Federal Trade Commission Chair Lina Khan will remain at her post in a Trump administration. Although pharmacy benefit reform may continue, because it appears to be a rare bipartisan agreement in Congress, other healthcare mergers and acquisitions could get greenlit that may not otherwise seen the light of day in a President Kamala Harris administration….

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AARP's New CEO Vows to Protect Social Security and Medicare, and Ensure Older Adults Age 'On Their Own Terms'

Fortune | By Alexa Mikhail

It’s a salient time for the AARP, the non-profit that has been advocating for the over 110 million American adults aged 50 and over, and championing policies and resources to improve their lives since 1958.

The reality of a rapidly growing population of older adults (10,000 Americans turn 65 each day), has laid bare the lack of solutions in place to support people physically, mentally, and financially as they age. Against this backdrop, there’s new uncertainty about how changes to health care policies and safety nets under a Trump presidency will affect the lives of older adults.

To lead the non-profit into these headwinds, the AARP, which has 38 million paying members, announced Tuesday the appointment of Dr. Myechia Minter-Jordan as its CEO.
“This is an important time for the country, and we know that older adults have acutely felt the strain of inflation, cost of living, and healthcare costs over the past several years,” Minter-Jordan tells Fortune. “Our top priority will always be to work with Washington and states around the country to protect Social Security and Medicare, and expand ways to support financial security and well-being so people can age with dignity and on their own terms,” she says.

Minter-Jordan, who has previously held roles as president and CEO of CareQuest Institute for Oral Health and CEO and chief medical officer of The Dimock Center in Massachusetts, replaces Jo Ann Jenkins, who was appointed in 2014.

Also among her top priorities, is what she calls one of the biggest concerns for AARP members: advancing support for the 48 million American caregivers who are “often with great financial and emotional stress and without adequate support.” To do so, she plans to push for policies like the bi-partisan national Credit for Caring Act in addition to tax credits for caregivers.

“We look forward to working with national and state officials to make these happen,” she says.

When it comes to how Minter-Jordan plans to work with companies, she draws attention to the data and a need to address ageism at work at scale. One-fifth of workers 65 and older were employed in the U.S. last year—and as people live longer, the workforce age gap is only widening.

Older workers are integral for the strength of businesses. Research shows that older workers are more loyal to companies, and that intergenerational teams are more productive and meet or exceed management’s expectations compared to teams that do not have a wide age range. Despite this, older workers don’t feel supported in workplaces and many struggle to find jobs.

“[Businesses] must invest in supporting older workers, who in turn, are a valuable asset to their productivity,” Minter-Jordan says.

Those 50 and older are a powerful group politically and economically: they turned out in record numbers to vote in the Nov. 5 elections, and also spent a combined $8.3 trillion in 2018—a number expected to jump to nearly $27 trillion by 2050.

The Flu Vaccine Might be Less Effective this Year

Medscape | By Ralph Ellis

The CDC says the influenza vaccine being used this flu season might be less effective than the one used last flu season, based on reports of how well the vaccine is working in five South American countries.

The seasonal flu vaccine cut the risk of hospitalization for high-risk groups by 35% in Argentina, Brazil, Chile, Paraguay, and Uruguay, the CDC said. Last flu season, the vaccine had a 51.9% effectiveness in those countries.

Vaccine effectiveness "might be similar in the Northern Hemisphere" if similar flu viruses circulate, according to the federal health agency.

How well the vaccine works in South America, where the flu season runs from April to September, provides an idea of how well the vaccine will work in North America, where the flu season usually runs from October to April.

During the past flu season in North America, the CDC estimated the vaccines were 41%-44% effective in preventing flu-related hospitalization in adults and 52%-61% effective for children.

This year's flu vaccines for the United States, all trivalent (protecting against three viruses), will target the three strains expected to circulate — H1N1, H3N2, and influenza B (Victoria). Health officials say that everyone 6 months and older should get a flu vaccination.

An estimated 75 million people in the US got the flu between October 2023 and April 2024, according to the CDC, resulting in 900,000 hospitalizations and between 17,000 and 100,000 deaths.

The data about the South American nations came from a research network coordinated by the Pan American Health Organization.

SOURCES:

CDC: "Interim Effectiveness Estimates of 2024 Southern Hemisphere Influenza Vaccines in Preventing Influenza-Associated Hospitalization — REVELAC-i Network, Five South American Countries, March-July 2024."

CDC: "Interim Estimates of 2023-24 Seasonal Influenza Vaccine Effectiveness — United States."

Severe Acute Respiratory Infections Network (SARInet) plus: "Acerca de SARInet plus."

President's Message

Posted: November 5, 2024

It has been and will be a busy week or so in our home health and physical therapy world. And this is on top of our normal day-to-day!

Most notable for the home health world is that the 2025 PPS Final Rule was released on Friday evening. Once again, your advocacy efforts have made a difference. CMS reduced the so-called behavioral adjustment by half, which resulted overall in a small increase in the PPS base rate (about $20) for 2025. You can find more details about the Final Rule below, and watch out for more information later this month!

Wednesday, November 6, is the early bird registration deadline for CSM 2025 in Houston, Texas. Please join us for three days of amazing home health focused CE programs (a total of eighteen hours) along with our Annual Business Meeting with free food and drink! In addition to being a great way to get a lot of CE, it is an even better way to become more acquainted with your APTA Home Health family! Please also consider registering for our pre-conference course on Wednesday, February 12, in Houston. This one-day course, titled, “Innovative Approaches in Physical Therapy for Empowering Patients Who Use Opioids: A Lab Based Course,” discusses opioids from soup to nuts—prevention, harm reduction, emergent treatment of overdose, and downstream sequelae. Much of this is presented with a hands-on approach including training in use of Narcan and some wound care techniques.

Elections for APTA’s Board of Directors begin on Thursday, November 7. This process is undertaken by the House of Delegates. Naturally, APTA Home Health’s delegates will be participating. APTA Membership will be notified of the election results on November 18, following the conclusion of the election process. Due to APTA’s Bylaws and the large number of slated candidates who already sit on APTA’s Board, it is quite possible that additional rounds of voting will be necessary on November 12 and possibly after that. This accounts for the planned release of results on November 18. The current candidates can be viewed on APTA’s website. Please reach out to our Delegates, Eva Norman and Rachel Botkin, if you have any feedback regarding these candidates.

Finally, our nation’s presidential election is today. For most, if not all of us, someone that we know—a family member, a friend, a colleague—fought for our democracy. If you haven’t already, please honor their service and sacrifice by voting today. If you are reading this and are one of the fine people that have fought to uphold our democracy and our nation, thank you.

Sincerely,

Phil Goldsmith
President
APTA Home Health

Medicare Calendar Year 2025 Home Health Prospective Payment System Final Rule

Last Friday, the 2025 home health final rule, effective January 1, 2025, was released.

Though the rule comes with more devastating cuts, they aren’t as deep as those first proposed by CMS. To quote the announcement directly, “in response to commenter concerns, we are finalizing a -1.975 percent (half of the proposed -3.95 percent) permanent adjustment for CY 2025.” Advocacy does make a difference.

The following synopsis of major provisions was provided by Federal Health Policy Strategies.

Key Takeaway

The CY 2025 Final Rule includes a significant reduction to home health payments for CY 2025. However, similar to CY 2023 and CY 2024, CMS limits the size of this reduction for CY 2025. This results in an estimated 0.5 percent increase in estimated aggregate payments in contrast to the Proposed Rule’s 1.7 percent decrease in aggregate payments for home health providers. However, for the third consecutive year, the Final Rule applies a substantial reduction that eliminates much of the benefit of the annual payment update.

Budget Neutrality/Permanent Adjustments: The provisions of the law governing implementation of the Patient-Driven Groupings Model (PDGM) required that the change to the new home health payment model be budget neutral. CMS is required conduct an annual process to examine payments for years 2020 through 2026 to determine whether payments have been budget neutral. As part of the process established by CMS, the agency had proposed a -4.067 percent permanent adjustment for CY 2025. In prior years’ Final Rules, CMS had already applied a -3.925 percent permanent adjustment to the 30-day payment rates for CY 2023 and a -2.89 percent permanent adjustment for CY 2024. For CY 2025, CMS will again limit the reduction in the Final Rule and apply a permanent adjustment of -1.975 percent.
Temporary Adjustments: CMS is also required to apply temporary adjustments for past periods to account for over or under payments and ensure budget neutrality retrospectively. While CMS determined the need for temporary adjustments for CY 2020 through CY 2023 totaling approximately $4.5 billion (including an additional $973 million based on the most recent 2023 data), the Agency did not propose to make such adjustments and, therefore, the Final Rule does not include them. CMS notes that the law provides discretion on the timing of the temporary adjustments.
Routine Annual Payment Update: The Final Rule provides for an annual payment update of 2.7 percent which is based on a market basket increase of 3.2 percent minus a 0.5 percent productivity adjustment. This is slightly better than the proposed rule. As noted above, the positive benefit of the annual update is significantly offset by the decrease associated with the final CY 2025 permanent adjustment. As a result, the 30-day period payment rate for CY 2024 of $2038.13 increases slightly to $2,057.35 for CY 2025.
Impact Analysis: According to the Final Rule, the overall economic impact related to the changes in payments under the HH PPS for CY 2025 is estimated to be $85 million (0.5 percent). The $85 million increase in estimated payments for CY 2025 reflects the effects of the CY 2025 finalized home health payment update percentage of 2.7 percent ($460 million increase), an estimated 1.8 percent decrease that reflects the effects of the permanent behavior assumption adjustment ($305 million decrease) and an estimated 0.4 percent decrease that reflects the effects of an updated outlier FDL ($70 million decrease). The estimated 1.8 percent decrease related to the finalized behavior assumption adjustment includes all payments, while the finalized -1.975 percent BA adjustment only applies to the national, standardized 30-Day period payments and does not impact payments for 30-day periods which are LUPAs.
Case Mix Weights/ Low Utilization Payment Adjustments (LUPAs)/Outliers: For CY 2025, CMS is finalizing its proposal to recalibrate the PDGM case-mix weights, including functional impairment levels and comorbidity subgroups, and update the LUPA thresholds using the latest available data from CY 2023, consistent with its past practice. In addition, using the 2023 data, this rule updates the fixed-dollar loss ratio (FDL) used for determining outlier payments to 0.35 so that outlier payments as a percentage of estimated total payments will not to exceed 2.5 percent, as required by law. This results in a net reduction in payments of 0.4 percent for CY 2025.
Wage Index: For CY 2025, CMS is finalizing a routine update to the wage index based on its existing policy and regulations, as proposed. CMS will use the FY 2025 pre-floor, pre- reclassified hospital wage index data as the basis for the CY 2025 home health wage index. This update is based on FY 2021 hospital cost report data. In addition, CMS will implement revised geographic delineations as a result of updates by the Office of Management and Budget (OMB) using the latest census data. This policy is consistent with its Final Rule policies for other post-acute payment systems. These changes can impact a provider’s wage index resulting in an increase or decrease in payment. As it did in the Proposed Rule, CMS notes that its standard policy applying a 5 percent cap on decreases in an area’s wage index value from year to year is sufficient to mitigate any significant adverse payment impacts associated with this change.
Quality Reporting Program (QRP):CMS is finalizing several proposed changes to the QRP for CY 2025. These include collection of four new items as standardized patient assessment data elements in the social determinants of health (SDOH) category, and modification of one item collected as a standardized patient assessment data element in the SDOH category. These will be effective beginning with the CY 2027 Home Health QRP. The four new assessment items focus on living situation, food security, and utilities. In addition, CMS is also finalizing a modification to the current transportation item beginning with CY 2027. CMS is also changing all-payer data collection to begin with the start-of-care OASIS data collection timepoint instead of the discharge timepoint.
Conditions of Participation (CoPs): CMS also finalized changes to the Home Health CoPs intended to reduce avoidable care delays. As proposed, CMS is adding a new standard that would require home health providers to develop, implement, and maintain through an annual review, a patient acceptance to service policy that is used for prospective patients referred for home health care. Under these requirements, home health providers must make certain information publicly available, including the scope of services offered by the HHA, including any service limitations related to types of specialty services, service duration, or service frequency.
Medicare Provider Enrollment: CMS also finalized a proposed change to its broader enrollment regulations. This change will add providers and suppliers that are reactivating their Medicare billing privileges to the categories of new providers and suppliers subject to additional oversight. Accordingly, CMS may impose a provisional period of enhanced oversight for 30 days to one year for such new providers and suppliers and may conduct prepayment medical review, cap payments, and take other actions.