The National Alliance for Care at Home’s (the Alliance) new chief government affairs officer, Denis Fleming Jr., sees an unprecedented upswell of bipartisan support among lawmakers for home-based care — an environment he describes as the “greatest opportunity” yet for providers.

At the same time, Fleming is closely watching rising threats to access to care, including the nationwide moratoria on Medicare home health and hospice enrollment and negative temporary adjustments to the home health payment rate.

The Alliance named Fleming its chief government affairs officer in July. Fleming has held leadership roles at home health and hospice provider Almost Family, hospice, home care and facility-based care provider LHC Group and at healthcare giant UnitedHealth Group (NYSE: UNH).

Fleming is advocating for improved home health payment rates, an end to the home health and hospice moratoria and the elimination of the Medicaid 80/20 rule.

Home Health Care News sat down with Fleming to discuss the state of home health at the federal level, the legislation that could reshape the home-based care industry and how providers can advocate for their industry.

Below is that conversation, edited for length and clarity.

Your work experience includes roles at the LHC Group and UnitedHealth Group. How will those experiences shape your advocacy strategy?

I have the good fortune of having perspective over nearly 15 years and seeing a lot of changes in the industry. And from my perspective, this opportunity we have right now is probably the greatest one we’ve had in the 15 years I’ve been in the industry, and I’ll say that for a couple of reasons.  

One, when you look at the home health rule that we had proposed this year with the 2.4 percent increase, that was the second-biggest increase the industry’s had in 14 years. Within the home health rule, there’s that 3% negative temporary adjustment cut. It’s a prospective cut. Now that concerns us, and we’re advocating to try to get that moderated or even to be dropped from the final rule. 

What we saw in that rule just doesn’t happen out of the blue or overnight. It’s been years of work by the Alliance and Alliance members.

We continue to worry about the erosion of the [home health payment] rate over time, despite being very appreciative of the increase this year. We’ve seen almost a 9.4% erosion of the base rate over the last four years, which puts constraints on access and workforce, and the challenges of competing with other hospital systems in different areas. 

On the plus side, both of the home health and hospice rules had palliative care RFIs. That could be a long-term exciting opportunity: the expansion of a palliative care benefit that would reimburse providers for that important care segment.

Now, there are challenges in these rules. There are the provider enrollment provisions. If you look at our comment letter, we spend maybe 40% of our letter expressing concern about provider enrollment. That, for example, can provide for retroactive revocation of your ability to do your job and your provider number for administrative errors. It doesn’t give you an opportunity to try to cure administrative errors or any sort of administrative or due process opportunity to present additional data, it has some other aspects to it that concern us.

Can you say more about now being the greatest opportunity for home health?

It’s [lawmaker support] on a bipartisan basis. But let’s take, for example, the letter that the Senate Democrats released, [advocating to make] home care available and affordable. They’re asking for ideas. They want some interesting, big ideas. So what can we suggest and propose?  

We could maybe look at the Choose Home legislation that the industry got behind. We got that filed. We had bipartisan sponsorship. There are other bills out there, like Representative Dingell’s bill that … establishes the personal care benefit at 20 hours per week, which is paid for with a premium increase.

There have been other efforts over the years. Representative Pallone’s bill a couple of years ago, which he could possibly reintroduce, the Better Care Better Jobs Act, that nationalized the personal care benefit that was non-means-tested.  

Choose Home, as we worked on it in the past, is just an example of something that could be refined or presented to Congress and to both parties. … That bill went through a lot of effort, so I think a lot of confidence comes from the fact that Congress is reaching out to us, which they haven’t done in some time, saying ‘We think there’s more value for care in the home than ever before.’

The other bills that you’re seeing out there, which are maybe at an unprecedented level, are six or seven that deal with home health and hospice and expanding personal care services. Those are all indicators that give me some hope.

[Still,] legislation, as many things as there are filed, the chances of being passed at times can be limited because Congress often is divided, and different proposals cost different amounts of money and have to be scored. But patients sometimes can win the day.

What are the biggest roadblocks for providers to achieve this opportunity?

That leads us right into a discussion about the nationwide moratorium, which is, as far as I can recall, unprecedented. We’re in favor of discovering and preventing overutilization and getting bad actors out of the business, whether it be home health or hospice. But historically, both MedPAC and CMS have approached their concerns about overutilization and program integrity on a targeted basis.

We’re concerned that the nationwide moratorium is just taking a hammer to the problem when a scalpel is needed. It’s a broad-brush approach that limits and constrains access in business development and projects that people have underway for new locations for hospice and home health.

What are your top three policy priorities right now?

The overarching priority would be improving patient and family access to care. Improving access, stability, and predictability in the payment rate underlies that and is a function of the workforce and how that needs to be addressed, because home health often competes with other sector providers in an area.

The next one probably would be the moratoria. To do our best, as we’ve been doing recently, to try to persuade CMS not to extend those home health and hospice moratoria on a nationwide basis, which we’re concerned already is and will continue to erode access over time.

A third one would be … workforce. Because we’ve got to have the people to perform the work.

Finally, I’d have to mention, on Medicaid HCBS, the 80/20 rule. We’re hopeful. There’s been a great effort by the Alliance to try and have that not implemented. That is over at OMB currently, and it’s left CMS. So that’s one of the final steps in the agency review process to withdraw it. Fingers crossed we will see some news on that in the near future.

Any parting thoughts to share with home health providers?

We want to try to put a priority and premium on external engagement. And the best example of that is, we’re going to make an effort, as best we can, to encourage our members to do home visits with members of the General Assembly and the states and members of Congress.