▶ 0:24:57e e
▶ 0:25:42okay CU I thought it had something to do with that one but it
▶ 0:28:57for e
▶ 0:29:44the subcommittee will come to order good afternoon thank you for to our Witnesses for being here today to discuss a crucial issue before us ensuring access to Quality post Secure Care for Seniors in terms of Medicare millions of Americans rely on post-acute care to recover from serious illnesses surgeries and injuries in fact 40% of Medicare beneficiaries who are hospitalized use Post Acute Care
▶ 0:30:14Services following their Hospital stay quality Post Acute Care can often result in patients better better outcomes in a better life for example patients dis just discharg to a nursing home have a lower rate of death and a lower rate of Hospital readmissions than those receiving care in a less uh specialized c c 58% of home health patients report improvements in their ability to engage in daily life activities longterm
▶ 0:30:45long-term uh care hospitals offer specialized services and impatients rehab facilities can help patients recover from injuries some of these providers are even uh Le in Innovation like tella Health which is very big to allow post Secure Care patients to receive Quality Health Care at home just two weeks ago congresswoman Carol Miller introduced the bipartisan hospice recertification flexibility act this
▶ 0:31:15important legislation will allow hospice providers to use tah Health to recertify their hosp stay from uh the comfort of their home and I look forward to seeing this flexibility become a real realityy we must focus on ensuring that uh patients receive the high the right care the right place at the right time and the right price our our Medicare program has changed over the past decade and we are here to make sure that patients have suff sufficient
▶ 0:31:45access to care at the same time we must conduct oversight to make sure these services are delivered timely I commend uh representative Panetta and and Van DY for working together to ensure these programs operate as in as intended to conduct oversight in terms of hospice providers strengthening our poster cure care system is critical to improving outcomes and reducing health care cost I look forward
▶ 0:32:16to the hearing today to discuss uh the importance of the the issue and I'm glad to recognize the gentleman a good friend from Texas Mr dogget for his opening statement well thank you thank you Mr chairman thank you for your consistent courtesy and professionalism uh this hearing is focused on what happens to Americans after they've been treated at the hospital uh we have a number of important uh portions of the health care industry here to discuss different aspects of postacute care
▶ 0:32:46but I don't believe you can talk about access to postacute care in America today without talking about Medicaid it is the primary payer for this care it covers 2third of all nursing home residents 60% of all Home and Community Based Services it pays for the long-term support for 9.3 million seniors and individuals with disabilities and that care is on The Chopping Block $ 880 billion proposed to be taken out
▶ 0:33:17principally from Medicaid in the Commerce Committee the plan that Republicans are offering for skilled nursing homes is one to take the nurses out of the nursing homes as they promise to pay for some of these uh actions by repealing the extremely modest minimum nursing staff standards that were adopted by the Biden Administration after giving private Equity back nursing home operators cart Blan to reduce care and slash Staffing
▶ 0:33:47in the fashion of musk Department of government evisceration Republicans will be cutting a significant amount of the financial backing for each of the different aspects of Healthcare represented today after repealing the minimum Staffing requirements Republicans intend to cut the funds that pay for nurses and ensure that our most vulnerable loved ones are not left on the hook for a nursing home stay that can cost 100,000 a year this postacute care plan amounts to
▶ 0:34:17a prescription for a mountain of medical debt and a preventable death sentence for some people last week I heard from one concerned austinite who resides in a nurs Nur in home her closest family member lives in Florida and she has no means to travel back and forth there uh and pay for her nursing home if Medicaid is slash she understandably told me quote I'm very afraid many adult children have written me concerning a a loved one a parent
▶ 0:34:48with Dementia or Alzheimer's again unable to personally provide the 247 care that is necessary these are folks who don't know how they'll get by without Medicaid similarly I've heard from the parents of children with a variety of complex medical conditions and disabilities who require home health aids costly therapies and eventually may need to reside in Assisted Living they seek assurance that their children will live with Dignity Health and the
▶ 0:35:18support that they deserve the only thing I'm sure of is that if enacted the Republican budget plan will harm each of these families the independent Congress pressional budget office confirmed this last week after setting aside Medicare spending which Republicans have promised not to touch through though million trillions they would add to our national debt endangers the stability of those programs also uh it was pointed out by the Congressional budget office that aside from this
▶ 0:35:48direct Medicare spending 93% of the funds under the jurisdiction of the Commerce Committee which has been told to cut almost a trillion dollars in order order to finance more tax breaks out of this committee 93% is Medicaid and of the remainder 7% is Chip so Health Care is on The Chopping Block particularly Post hosp Acute Care no matter how you slice it this budget demands cuts that will harm so many Americans all to further
▶ 0:36:18enriching a handful with who are already doing quite well under this budget we don't just have to worry about what happens after the hospital there will be acute need everywhere widespread I look forward to hearing from each of our Witnesses though I'll be interrupted by a quick trip to the floor on another bill from ways of means that was scheduled unfortunately at this time because millions of people are at risk from this Medicaid cut thank you Mr chairman thank you I now introduce our
▶ 0:36:48Witnesses first I will recognize Mr Arrington who will introduce the first witness I want to thank the chairman I will say you you did a pretty good head fake just then you said you wanted your good friend from Texas to make an introductory remarks so I hit my little button over here and turns out your friend from Texas is Lloyd doet yeah uh and then you stuck me down here in the corner so um this is what happens when you're the budget chairman in a budget reconciliation year you end up in the corner
▶ 0:37:19get over it will you yeah uh um I I have the the privilege and honor honor of introducing a very close friend of mine and a fellow West Texan in Dana Madison and the Madison family she's joined by her husband Ronnie if you had waved everybody the Madison family uh they don't get any better than than the Madison in West Texas and I think you'll find that Dana represents the very best
▶ 0:37:49of our people out west of I35 in the great state of Texas they work hard they're committed to serving their patience they're committed to Excellence they love the country they want America to win they want us to have the best most efficient uh Health Care system and they understand that ecosystem and how to make it work better to provide greater access better quality care and bend the curve on spending and so I'm uh
▶ 0:38:19delighted she's here today I expect that she'll give some very insightful counsel to this committee and uh Dana it's an honor to serve and represent you and the Madison family they they have a fstar rated home health uh agency uh five star from the CMS and they've been in this business almost 40 years Dana is a nurse so she's been practicing medicine for about that amount of time so anyway you you you know how to pick them
▶ 0:38:49Mr chairman and you got a winner in uh in the Madison family God bless and go west Texas yeah Mr Smith from Nebraska will introduce our next witness thank you Mr chairman I'm pleased to welcome Mr Paul donil the CEO of of Madonna Rehabilitation hospitals with locations in Lincoln and Omaha Nebraska Madonna has served Nebraskans from across the state since 1958 and its Cutting Edge and world-class treatment and technologies
▶ 0:39:19have made it a national destination for rehabilitation their Lincoln campus is a state-of-the-art facility and one of the only locations in the country to combine skilled nursing Inpatient Rehab and long-term acute care services Under One Roof spanning the full Continuum of postacute Care Mr donelli thank you for for being here today sharing your Insight and certainly your entire team that like I said offers worldclass treatment uh for so many folks and we certainly look forward to your testimony thank you
▶ 0:39:51again thank you Mr Smith Jonathan fleece is President CEO of impact health which provides home health care and Hospice Services to more than 23,000 patients in my area Mr fleece also serves on the board of Florida Hospice Association I have enormous respect for his intellect he does a lot of great things in our community my wife's had opportunity to be in board and participate but really appreciate you taking the time and coming up here I know you're a busy guy
▶ 0:40:22uh So Lisa Lisa greybird is a vis visiting research professor at Marquette University Eric Carlson is a director of long-term services at Justice and aging I want to thank you for joining us today your written statements will be made part of the hearing record and you will have five minutes to deliver your oral comments and try to keep it if you can to five minutes um so with that Dr Madison you're now recognized
▶ 0:40:58thank you good afternoon chairman Buchanan ranking member doet and distinguished members of the subcommittee my name is Dana Madison it is an honor and a privilege for me to be here today representing the Home Health industry I'm the administrator of our family-owned agencies that serve both urban and rural patients in the Texas Panhandle and the west Texas region I've been a registered nurse for 41 years I have a bachelor's of nursing an MBA in healthcare and a doctorate and nurse practice leadership
▶ 0:41:29from Texas Tech University Health Science Center I served as the president of the Texas Association for home care and hospice from 2010 to 2012 have served on the board of directors and currently co-chair the Medicare committee I started my first Home Health agency in LEC Texas 31 years ago most patients had traditional Medicare coverage and reimbursement was cost-based the balance budget Act of 1997 dramatically changed the reimbursement model for home healthcare it created the interim payment system
▶ 0:41:59that went into effect in 1998 the cost based reimbursement methodology was further Complicated by an annual capitation per patient over the next year in Texas alone 70% of the agencies closed and Nationwide about 30% in January of 2000 the pro prospective payment system went into effect with the goal of aligning reimbursement with patient needs CMS also implemented a new assessment tool Oasis Baseline for measuring
▶ 0:42:29outcomes it also included a small rural add-on payment for Rural patients which was helpful but rarely covered the cost of the windshield time of our staff it is not uncommon for our staff to drive over 400 miles a week to see their patients this rule add-on was taken away phased out in 2022 2020 will forever be remembered for the covid-19 pandemic and resulting public health emergency but there were other challenges in January a new payment
▶ 0:42:59system the pdgm started based on a 60-day period of care pdgm changed reimbursement to two 30-day increments with minimum service requirements claims volume doubled and we had to add administrative staff January 2020 also marked the beginning of the public health emergency our employees were taking care of up to 80 covid patients a day in their homes cost skyrocketed for both scarce labor and supplies but we were determined to do our part to to free
▶ 0:43:30beds of the hospitals for the sicker covid patients in my opinion Home Health met and exceeded expectations in helping this country through the emergency finally in March of that same year rcd began in Texas which required pre-authorization for all traditional Medicare patients we had to administrative staff once again in 2023 CMS introduced home health value based purchasing under this we're graded on Improvement in functional scores rehospitalization and customer
▶ 0:44:00satisfaction and can receive up to a 5% bonus or a 5% decrease in payments this has the potential to eliminate Home Health agencies that are not producing good patient outcomes Medicare Advantage plans cover approximately 50% of the Medicare eligible patients that we serve most of these plans reimburse at a rate below our cost and many are limiting or care these plans do offer services not covered by traditional Medicare and one plan offers
▶ 0:44:30up to 20 hours of unskilled care per week which helps the patients stay at home I'm very passionate about what we do and the positive impact that Home Health has on the overall health care System the average patient that we serve is a 79y old female that lives on a limited income my husband and I come to Washington several times a year and have for the last 20 years to represent our patients we have never asked for an increase in reimbursement but simply a reduction in reimb and reimbursement cuts
▶ 0:45:01and regulations for the past two years CMS has implemented a permanent payment cut in reimbursement because they contend that o Home Health was overpaid in 2020 and 2021 during the covid pandemic medpac annually reports to Congress that Home Health margins are 20% I ask Congress to instruct CMS and medpac to include all cost for all Medicare eligible patients to show the true picture of Home Health margins which are closer on average to
▶ 0:45:315% nationally I will conclude with these takeaways on average a 60-day period of care with Home Health costs less than one visit to the emergency room most senior citizens in America want to receive care in their home our country continues to have a critical nursing shortage that was exacerbated by the pandemic the utilization of telea health and Home Healthcare must become reimbursable and I believe that Home healthc Care is both costeffective and
▶ 0:46:01can be at the Forefront to help our country meet the challenges of our aging population now and in the future thank you very much thank you Mr Dilli you are recognized chairman Buchanan ranking member doet members of the subcommittee thank you for the opportunity to participate in today's hearing I also want to thank Congressman Smith for his leadership and and strong support of Madonna my name is Paul Don jully and I am president and CEO of
▶ 0:46:31Madonna Rehabilitation hospitals our services include long-term care hospitals Inpatient Rehab hospitals and Skilled Nursing Facility Services excuse me can you speak into the mic thank you thank you I'd like to share a patient story 73-year-old Randy lamir came to Madonna after spending two weeks at a South Dakota Hospital Randy was hit by a car while riding his bike and arrived at Madonna requiring a tracheo and a ventilator to breathe he had also sustained a severe brain trauma and required a
▶ 0:47:02craniotomy after 3 months in our eltech Randy was transferred to our Rehab Hospital 5 months after arriving Randy walked out of Madonna and returned home to South Dakota with his wife Gloria of 54 years this story is a real life example of the different and distinct levels of post cute care offered at Madonna and how patients move between them efforts to advance an advanced unified post acute payment system have proven very difficult and complex there have been beneficial reforms
▶ 0:47:32specifically to the rehab hospital and sniff Payment Systems however L eltac Payment Systems have not been similarly reformed with changes instead focusing on payment criteria resulting in financial concerns and closures alarmingly the number of eltec decreased from 438 in 2015 to 341 in July 2024 an additional 17 closed in 2024 or announced that they would in 2025 the bulk
▶ 0:48:02of elac closures occurred when CMS implemented a new dual payment criteria system as required by Congress the Dual system criteria likely misses patients who had benefit from an elac a financial strain for elac like Madonna is the high cost outlier fixed lost amount threshold elx can get an extra payment to offset Financial loss associated with extremely high cost cases but over the last two years the amount a hospital must lose before they are eligible for
▶ 0:48:32the payment has doubled from about $38,000 in fiscal year 23 to $77,000 in fiscal year 25 one or two $770,000 losses is potentially financially devastating especially for independent small and Rural El taacs the National Association of long-term hospitals is immensely grateful to congresswoman Miller Congressman Hearn and congressman boil for introducing legislation to provide relief and stability to the industry specifically no
▶ 0:49:02asks the committee swiftly consider a legislation to reform the method for determining the high cost outlier fixed lost threshold expand the standard rate to additional High Acuity patients and provide the ability to directly admit patients to an eltech from a critical access Hospital such legislation cannot be offset by reductions within the industry between 2016 and 202 22 Medicare fee for service ltech spending decreased accumulative $1 billion there's
▶ 0:49:33simply no juice left to squeeze Congress should also urge CMS to continue to refine the postacute care payment system to ensure that payments reflect the uniqueness of each setting the case complexity and Associated High resource use I'd like to briefly discuss Medicare Advantage maate plans prior authorization and denial practices are limiting access to postacute care many ma plans deny nearly one half of the prior authorization requests for eltech and Earth admission and thereby trigger a resource intensive
▶ 0:50:03appeals process which further delays delays enroles from transferring to the next appropriate level of care we are deeply concerned that cms's proposed neutral contractor sides with ma plans nearly 100% of the time during the appeals process n and the American Medical Rehab providers Association make the following recommendations there must also be clear consistent enforcement by CMS to uphold existing Medicare Advantage rules we urge greater Congressional
▶ 0:50:33oversight particularly as how planed behavior is reviewed by an entity that is designated to function as an in as an independent manner in closing I want to convey the urgency my ltac colleagues and I feel as we watch our industry shrink absent Swift congressional action we expect closures to continue and for patient access to be limited I fear Randy's outcome would have been very different had he lacked the access to specialized services like
▶ 0:51:03those offered at madon thank you again for the opportunity to testify and I'm pleased to answer your questions and thank you Mr fleece you are now recognized good afternoon chairman Buchanan ranking member doet and the distinguished members of the subcommittee thank you for having me chairman m Canon please accept my heartfelt gratitude for your leadership to the State of Florida and the United States of
▶ 0:51:33America I'm Jonathan fleece president and CEO of impath Health one of the nation's largest not for-profit homebased care organizations which is proud to serve and honored to serve one in five Floridians receiving Hospice today impath is also a proud member of the National Alliance for care home I hold a ba degree from emmer University and a jurist doctorate degree from St Louis University
▶ 0:52:03School of Law with a certificate in health law studies it has been a privilege to be serving in healthcare for over 30 years losing my daughter at Birth shaped my mission to ensure that no family navigates serious illness or loss alone that passion leads me to advocate for patient centered care every day in 2011
▶ 0:52:33I co-authored the new health age the future of healthc care in America with futurist David H examining how Healthcare must evolve to expand homebased Care Solutions that too is why I am here today to speak for millions of Americans who rely on homebased care and the policy that make it possible at impath we witness and deliver profound Care at home every
▶ 0:53:04day for one senior patient with Advanced cancer choosing hospice was not giving up it was choosing to live to live fully on her terms she bravely forwent aggressive treatments that would have kept her in and out of the hospital away from family and instead embraced care that is focused on comfort and dignity at home hospice helped her avoid countless ER visits
▶ 0:53:35her husband of 60 years had the support that he needed to make confident decisions knowing that expert care was just a phone call away instead of Phil spending her final moments in a hospital bed she was home spending time with her grandchildren often surrounded by them with love her choice gave her quality of life and spared her family the financial burden of medical interventions that could
▶ 0:54:05never have changed her ultimate outcome but homebased care isn't just for those actively dying it supports people managing chronic illness recovering from surgery navigating terminal diagnosis patients want it families need it and taxpayers benefit keep keeping patients at home prevents costly hospitalizations and reduces strain on the Health Care system today
▶ 0:54:35in a time of Financial and Workforce challenges we should be expanding access to care at home not it we call this at impath Full Life Care a holistic patient centered approach that provides the Right Care at the right time in the place they call home but today access to this type of care is risk hospice providers face immense pressure thin margins
▶ 0:55:05excessive Audits and ineffective fraud enforcement Bad actors exploit gaps in oversight while high quality providers face excessive scrutiny the flawed hospice special Focus program built on incomplete data risks destabilizing trusted providers instead instead of targeting those who truly abuse the system put bluntly there are hospice programs in the United States that receive medicare
▶ 0:55:36dollars today but refuse to submit their quality and Survey survey data to CMS that practice should not be tolerated and fuels greater Fraud and Abuse by allowing some hospices to profit while avoiding transparency and Regulatory scrutiny as a CEO I understand that Financial strength and balanced budgets are essential for both organizations and Nations to thrive as Congress navigates today's budget
▶ 0:56:06challenges in closing I urge you to consider invest in homebased care data shows it improves outcomes and reduces Medicare spending two expand pay for performance reward the highquality providers and hold those who evade accountability responsible three enhance proven value-based models care these are not just policy decisions they are Urgent threats to
▶ 0:56:36access quality and patient Choice decisions here will shape the future of Care at home let's protect and expand access before it's too late thank you and I stand ready to answer your questions thank you Mrs gyberg you're recognized chairman Buchanan ranking member dogget and members of the the subcommittee I am Lisa greybert a visiting research professor in the College of Nursing at Marquette University in Milwaukee Wisconsin it is truly an honor to sit on this side of the dis
▶ 0:57:07as I have spent many hours behind you as a former staffer of this the most powerful Committee in the US Congress I have dedicated the past 20 years of my career to improving the Medicare program and I applaud the committee for addressing this important topic of postacute care the Medicare program is on an unsustainable path the part A or Hospital Insurance trust fund is projected to be insolvent in six years one factor driving cost is spending across the postacute Baseline on an annual basis
▶ 0:57:38approx approximately 60 billion in taxpayer dollars are spent to deliver services to Medicare patients in these four unique settings this Baseline has been very profitable for providers in 2022 the marginal profit was 27% for home Health 27% for nursing homes 39% for rehab hospitals and 18% for long-term care hospitals the average across the co Post Acute Baseline is
▶ 0:58:0927% in 2013 Congress initiated a public transparent policy process whereby the chairman and ranking members of the ways and means and finance committees posed 64 questions to stakeholders the main goal of the impact act after multiple rounds of consensus building the impact Act was signed into law a year later via unanimous consent in the house and in the Senate the main goal of the impact Act was to establish a unified postacute care prospective payment system
▶ 0:58:39or a PPS Congress mandated the centers for Medicare and Medicaid services or CMS to deliver the operational specifications of a payment system that was ready for implementation to lend credibility to the effort the trumpet Administration included a unified pack PPS in its fiscal year 2021 budget proposal the reform would have saved $80 billion in the 10-year budget window if it had been
▶ 0:59:09implemented in 2022 CMS submitted the unified pack PPS technical prototype to Congress in summary the unified pack PPS is ready for enactment and I strongly urge Congress to give CMS the authority to implement justifying regulatory relief within the postacute care space given the average 27% marginal profit will be challenging for example the 60% rule around the 13 conditions for rehab
▶ 0:59:40hospitals may be a prime target of repeal if coupled with a unified pack PPS as policy makers you should consider your role as masters of the art of the deal on behalf of the US taxpayer I implore you to negotiate a favorable outcome in exchange for any regulatory relief what is an example of a favorable outcome you guessed it a unified pack PPS although we have readily available information about
▶ 1:00:10fee for service postacute care margins the Medicare Advantage margins remain elusive however my economic intuition tells me we can reasonably assume poost acute care providers do not enjoy an average 27% Medicare margin profit from ma plans unlike feif for service Medicare ma plans cannot exert monopsony power over postacute providers during the negotiation process empirical evidence supports the spillover of fee for service payment
▶ 1:00:40rates to ma to address the Gap in managing postacute profits ma plans may be using other tools in their toolbox including authorization the HHS Office of the Inspector General found that Rehab Hospital discharges are among the top Services subject to prior authorization by Ma plans the oig also found that 75% of audited rehab hospital stays were not overturned on appeal in addition to the lack of
▶ 1:01:10medical necessity the 39% fee for service Rehab Hospital marginal profit may be related to the use of prior authorization of these Services gaining greater transparency into how MA plans use prior is essential for a better understanding of how lack of payment reform on the fee for service side impacts Medicare Advantage authorizing a unified pack PPS could result in an equilibrium that reduces the use
▶ 1:01:40of prior authorization by Ma plans in conclusion I strongly recommend that this committee move ahead with legislation that gives CMS the authority to implement a unified pack PPS thank you for the opportunity to share my perspective within the subcommittee I look forward to continuing to work with you on these issues thank you Mr Carlson you are now recognized thank you chairman Buchanan ranking member dogget and subcommittee members I appreciate the opportunity to testify
▶ 1:02:11on these important topics my name is Eric Carlson I work as director of long-term services and supports advocacy for justice and aging I have specialized in long-term care Medicaid and related issues for over 30 years in today's post cute environment two issues have special urgency they are number one maintaining adequate funding for the Medicaid Program and number two implementing Nursing Facility Staffing standards that were announced by CMS last year like to address threats to
▶ 1:02:41Medicaid first the current house budget resolution calls for the Energy and Commerce Committee to reduce funding by $880 billion over 10 years a CBO analysis shows that cuts of that magnitude would have to be taken largely from Medicaid resulting in catastrophic consequences for the program and the older Americans and persons with disabilities that it serves for many older Americans postacute care is not a matter of weeks or months they have ongoing chronic
▶ 1:03:11conditions Alzheimer's disease most common example and that require daily Hands-On assistance as well as health care and other services only Medicaid covers these services on an ongoing basis and Medicaid is flexible enough to allow needed services to be provided either in a nursing facility or at home crucially Medicare does not pay for these services so Medicare beneficiaries rely on Medicaid for long-term care of the persons covered by Medicaid for long-term care over
▶ 1:03:4260% are Medicare beneficiaries without Medicaid many older Americans would be in a hopeless situation nursing home care costs over $100,000 per year in the expense of either nursing home care or at home care can consume a person's life savings in very short order continued funding of Medicaid with its current structure is is essential for ensuring that older Americans can access needed long-term care and then moving to the second
▶ 1:04:12issue of particular urgency today This concerns Decades of inadequate Staffing and nursing facilities finally last year the federal government issued a rule to establish reasonable Min minimum Staffing standards ards but there's legislation in both houses of Congress to eliminate those standards before they even come into effect and also to prohibit CMS and perpetuity from issuing similar standards from a resident perspective insufficient Staffing means that a resident
▶ 1:04:42develops a bed store because staff isn't available to help them move or they become malnourished because AIDS aren't there to help them meet these are real world consequences the hundreds of thousands of Nursing Facility deaths during Co highlighted long-standing problems Studies have found in nursing facilities with poor Staffing suffered higher covid death rates and studies for decades have concluded that low Staffing correlates with a variety of bad outcomes including bed Source Falls weight loss and infections
▶ 1:05:12a related Staffing problem has been the relatively limited use of registered nurses the federal Nursing Facility law has required registered nurse staffing for only eight hours a day while Studies have shown improved resident outcomes from higher levels in the aftermath of the many many co Nursing Facility deaths CMS commissioned to study issued a proposed Rule and then finalized a rule with new minimum Staffing standards these standards require a registered nurse Around the Clock also facility must provide
▶ 1:05:43at least 3 point three and a half hours of direct care assistance per resident per day which must include approximately 2 and a half hours of care per resident per day from an aid just put this in the context briefly the nurse this nursing Aid Staffing requirement translates effectively to one aid for 10 residents so it's not an extravagance it's really a minimum standard to ensure that aids are not overwhelmed by the time intensive chores
▶ 1:06:13that they must complete most important context is that these standards will save lives researchers at the University of Pennsylvania estimate a savings of 13,000 lives annually there have been a lot of um provider attacks for the provider Lobby on this this this regulation I mentioned the pending Federal legislation but there are also several accommodations that providers have already been given an extensive
▶ 1:06:43phase in period from until 2026 and 2027 which for Rural agent areas is extended to 2027 and 2029 they hardship exemptions for providers who face labor shortages as long as there's a goodfaith effort to meet standards by the provider and CMS has developed a nursing facility Staffing campaign to increase the availability of AIDS and registered nurses in conclusion
▶ 1:07:14if you're talking today about ensuring access to postacute care the highest priorities are protecting our current system on behalf of justice and aging I urge Congress to retain the Medicaid Program with adequate funding in its current form and to retain the vital Nursing Facility Staffing requirements thank you for this opportunity and thank you thank all our panelists for the testimony we now Pro proceed to the questions and answer session
▶ 1:07:44Mr Smith from Nebraska you're now recognized thank you again to our panel or our entire panel certainly members for paying attention here today I think these are important topics and I'm glad that we can uh convene and and discuss these it's uh I think important to remember that America is a big country different needs in different places uh yes I represent a a rural district and Rural means different things in different places Across America and uh in fact means different things in different places
▶ 1:08:14across my own District that um Nebraska as a whole which my district is most of the uh land area of Nebraska um we only have three long-term care hospitals in the entire state they're all in the East the population certainly is weighted that way but that doesn't mean we don't exist in other parts of the state and so I it is my hope that we can pursue policies that are more flexible that actually meet the needs uh that that
▶ 1:08:44exist in in more parts of our country than than we currently do uh you know it's comeing to my attention that even small oversights in our current policies can have a a very significant impact on an individual's ability to access postacute care for example patients with primary imuno deficiencies are typically unable to receive necessary IV IG treatments because facilities are simply unable to absorb those high costs of their special therapies with a standard
▶ 1:09:14Skilled Nursing Facility payment that's why I introduced the the pi postacute access care access act last Congress to include these treatments in a limited list of high cost outliers which are paid outside of the standard Skilled Nursing Facility payment uh I I want to mention that I frequently hear from Nebraska hospitals about their frustrations with delays discharging patients ready to leave the hospital because of their inability to gain access to an appropriate
▶ 1:09:45postacute care site some of those delays are caused by administrative issues such as prior authorization but in many cases this is because there just aren't any skilled nursing fac facility beds available nearby for a patient who really needs one one way to address this lack of access would be to look at new innovative ways to expand the universe of Hospital discharge options I'm currently working on a new bill which would create a skilled nursing facility at home option modeled after the successful the success of the
▶ 1:10:15ongoing Hospital atome demonstration since the co pandemic we've seen just how much new technologies have expanded the ability of patients to receive care in their home homes instead of the traditional facilities uh we hear a lot about various things we we heard earlier reference about uh uh nursing care uh Staffing uh mandates by uh by the previous administration I would say those were political decisions very expensive ones I I might add and it has really stressed
▶ 1:10:45uh if not caused the closure uh of many nursing facilities or certainly would if allowed to continue but I'm concerned that the stresses on on facilities especially in rural areas um the federal government ought not make it even more stressful especially with unfounded uh mandates that that come out of Washington I I think we can do better than that American people expect us to do better but miss grabert uh you mentioned the impact of a unified postacute payment
▶ 1:11:16system could have on the postacute landscape how would such a system make it easier to provide a skilled nursing facility at home option for our seniors thank you for the question Mr Smith I do think that what you've described as a perfect model that fits Under the Umbrella of regulatory relief that can be done in tandem with a postacute Care univi Pack PPS it's a model that would Thrive under such a system okay thank you uh Mr Dilli uh again thank you for your
▶ 1:11:46participation here today um legislation was proposed last Congress to address several key concerns of long-term care hospitals which included a number of different provisions such as admitting patients from critical access hospitals concerns with the high cost outlier payments ensuring access for patients with certain complex conditions and other payment modifications which of these do you think would have the greatest impact on your ability to continue serving long-term acute care patients at Madonna
▶ 1:12:16uh thank you for the question Congressman Smith uh both of those issues would allow greater access for individuals to come and receive services in a long-term care hospital uh the high cost outlier issue is one that is impacting uh both access for patients to come into an ltech but also the ability for an acute care hospital to manage their ICU in other beds
▶ 1:12:47currently when an individual is on a ventilator say and requires additional high cost services like dialysis for instance um losing $77,000 before receiving an outlier payment because that patient has stayed so long because of the care that they need would deter that alac from admitting them and as a result that patient might have to stay longer in the acute care hospital and hopefully transition
▶ 1:13:18out of receiving the dialysis service before they could M into the elac so addressing the high cost outli provision would allow greater access but so would uh uh allowing patients to come directly from a critical access Hospital both are important very good thank you again thanks for enre panel I yield that Mr doet I yield to you thank you very much thanks to each of our Witnesses uh Dr Dilli uh I've uh been out to a long-term care hospital
▶ 1:13:48I think similar to the one uh that you operate uh with uh Dr Prettyman who's here with you today and seeing firsthand the big challenges you have to provide quality care to people that really need uh Extended Care uh and I was alarmed by your written testimony I didn't get to hear all of the oral that the discharge rates for to long-term hospitals are uh about 40% lower for those enrollees
▶ 1:14:18that have Medicare Advantage versus those in traditional Medicare when someone is not not approved by their Medicare Advantage plan to come to a long-term care hospital of the type you direct uh what happens to them what what care do they get one of two things can happen they can continue to receive services in the short-term acq care hospital which often does not provide the comprehensive services
▶ 1:14:49that a long-term care hospital provides with dedicated respiratory staff interdisciplinary teams and an integrated care plan or they can stay in the hospital for a period of time and then decrease to a a facility that is less intense that might not have those resources in place to meet their needs and languish there or uh perhaps transfer back to the uh short-term acq care hospital because of the lack of that
▶ 1:15:19care I think Medicare Advantage is a real problem for taxpayers since they get overpaid uh as has been pointed out by the independent uh medpac uh and it's a problem in terms of quality of care in this situation and others uh perhaps they've been able to maintain this position where they don't save taxpayers any money they cost us billions of dollars in providing lesser Care by the fact that they spent invested in this Congress $330 million in lobbying
▶ 1:15:49expenses between 2020 and 2024 uh Dr m M we have visited previously about the challenges that Home Health Care faces in Texas uh I know you're aware that if uh Texas legislature that is already pretty stingy with his Medicaid Program has to cut it even more because more responsibility is shifted to the state uh that just like the Medicare issue will impact what you're able to do with home health care and I suppose
▶ 1:16:20overall my my feeling is uh Mr Smith referenced the legislation last year it's entirely unclear to me especially on the long-term care hospitals why it is we're having a hearing in March when I thought we were going to get legislation up for consideration last fall but I suppose that's the the troubling position we're in of inattention to these issues uh certainly Mr Carlson I'm pleased that you focused on the nursing home standards uh you
▶ 1:16:50have emphasized uh the impact and I want to explore that with you a little more it's been referred to as a political decision and I suppose that's right there was a political decision that it was worthwhile as predicted and estimated with these standards that we could save about 13,000 lives a year by properly Staffing our skilled nursing homes uh the conditions have become so Bleak that the average nursing home is today turning over more than half of their staff every year we don't have
▶ 1:17:20a true Workforce shortage we have a shortage I believe of decent working conditions wages and fair treatment of care workers nursing homes have the funds to create better working conditions again referring to medpac uh their 2023 report found that skilled nursing homes have profits that exceeded 10% or 22 consecutive years and were as high as 177% uh and that's with uh them finding that one out of five facilities
▶ 1:17:50have more than 100% of their cost fully met by Medicaid uh I just ask you whether there are sufficient workers out there to meet these minimum Staffing standards uh despite the claims of the industry to contrary thank you the first of course is the context of this is really important and necessary to make sure that residents get the care that they deserve as I mentioned in the testimony there have been numerous accommodations
▶ 1:18:21written in the regulation to make sure that this is practicable the standard selected is not um as high as certainly some people advocated for it's a standard that's already met by 60% the overall standard is a standard that's already met by 60% of the facilities in the country there's a significant phase in Period that allows facilities until for Rural facilities until um 2027
▶ 1:18:52and 2029 to f um meet these meet these standards and um and also as I think you rightly point out this is a retention issue to a significant extent um there's a vicious cycle in nursing facilities sometime where you're short staffed and then terrible working conditions and then people leave and you're short staffed the idea behind this regulation is to staff appropriately so it's a good environment for
▶ 1:19:22residents and for staff members and then and then finally I'll note that there as I mentioned there is a hardship exemption if facilities try and make their very best effort there there's a demonstrated labor shortage in that region and the facility shows that they have offered prevailing wages they are Exempted from penalties for this provision so in these multiple ways the um the standards recognize reality in Balance the the need to to provide good care
▶ 1:19:53with the other factors that have to be dealt with and understood thanks to each you Mr Kelly you're recognized thank you chairman thank you all for being here today uh what I really like to do when we get in these uh these hearings I'd rather have people that actually do the work than people that read a couple pages and then say I'm I'll come up with a really great question and the business I'm in uh the most expensive part of everything we do is paperwork and it's like redundant
▶ 1:20:23Time After Time After Time time so Dr Murphy and I were talking as we were sitting here you I said doc you know what I'd rather do I'd rather seed my time to you but you know the way we break this up in five minute increments I don't want him to lose the the consistency with it so uh these are models and and quite frankly you folks are in this business I don't know how you do it you're being mandated by people who have no idea what they're mandating uh for you to to uh access nursing uh people that need to be there and by the way there's not enough of them to do that and a lot of them left
▶ 1:20:53hospitals and went into visiting nurses for obvious reasons but I if I can I want to seed my time to Dr Murphy he spends his whole life on this and it is a business model it's a failing business model and uh I mean what I said people who don't know what they're doing are setting mandates for you that's a terrible model it's a terrible business model it's probably part of the reason why we're in the situation we're in today but Dr Murphy I would like to seed my time to you thank you um representative Kelly you know I find it interesting on our some of our documents I've been in medicine
▶ 1:21:23now for 30 5 years and I'm looking at some of the documents here and I know this is absolute Greek to my fellow um colleagues who don't know this who this what this is what a sniff is what a long-term care facility and truth be told it's a little Greek to me because whenever I'm in a hospital and most in my field Urology we do mostly outpatient stuff but we still um sometimes do long-term if we have to do cancer therapy somebody needs long-term care or we consult on somebody that needs long-term care and then
▶ 1:21:53if you look at the the tyranny of what our government has done in the rule after rule after law after law no wonder the medical system in the United States is screwed up no wonder it is because if you have so many different um regulations when I was Chief of Staff of our Medical Center thousand bed level one Trauma Center we we had during my tenure three different rules about how an outpatient
▶ 1:22:23person would would be um categorized whether they're overnight whether they have to stay two nights in a hospital whether they can go to a sniff or you literally have to keep them in a hospital an extra two days just so that they'll qualify for some of these things and this is where I am beyond a static that we have a president and a government that is actually willing to step back and look at this nonsense because frankly uh before I came to Congress when I once I got here I said I would go down to CMS which by the way nobody's been in
▶ 1:22:54the parking lot for the last four years that I'd go down and fire a third of the people because it is Rule after rule after rule created so that they have something to enforce and I say this not only on the hospital side but I also say it on the physician side in our practice we have grown and grown and grown individuals to try to put laws or to try to enforce regulations that were put forth by the government you you look at all of these things there's no stability in this whatsoever and if you look at the number
▶ 1:23:24of folks who are now employed by the hospital that are our administrators and you compare the growth of them versus the growth of actually the people who take care of this why is this Delta occur it is because of CMS it is because of government and Mr Carlson I'll go back you know you talked about the home uh mandate there's so many disqualifiers if we could find the nurses in any corner of the country we'd be happy to do this but we have beds at our in
▶ 1:23:54institution that are closed that are desperately needing to be opened because we have folks sitting in our emergency room for 36 hours waiting for beds because we don't have nurses it's fine I'd want that higher level of care but we literally number one can't find them and two can't afford them I'll go back to some of the um you know other remarks that were made you know in North Carolina from April to September uh of last year at least 360 patients were medically cleared for discharge
▶ 1:24:25but did not have appropriate postacute care placement so what happens they sit in the hospital they sit in the hospital and what happens not only do they get nosocomial infections they get infections from other people ding ding ding it rings up the bill Miss grabert I have a question for you in a second you know look I think Medicare Advantage is making a steal on everything here I'll agree with Mr blogett on the other side of the Das here Medicare Advantage will start with a great intention but is absolutely determined that they're going to steal
▶ 1:24:55the taxpayer dollar Handover Fist and United Healthcare is the number one offender from what's Happening um from my vantage point and I think uh a lot of the federal agencies also the average weit time for the patients that I talked about Mr chairman continue can I continue okay uh average wait time uh for the patients was 73 days 73 days for these 360 people 51% of the patients waited over a month 25% three months three 3 months to 2 years
▶ 1:25:26guys I love the concept of home health because I think that's where care is done best if at all possible uh Miss Graber I was astounded by the numbers that you gave about the profit margins of some of those and I look at the the problems here we're trying to actually get the Physicians to not get cut more and more from pay uh that have happened over the last 20 years 62% of medical benefic Medicare beneficiaries were waiting for a Skilled Nursing Facility placement 44%
▶ 1:25:56had serious mental or substance use disorder so the system is broken for all those crying out that we can't do this to Medicaid we can't do this this system is broken one to three years we're going to have a financial insolvency of our country Medicaid desperately needs to be reformed all the cuts and all the scare tactics from the other side of the aisle patients are still going to be cared for but I if the Biden Administration finally would let us audit the Medicare Medicaid roles
▶ 1:26:26which they didn't do for 4 years we would get people off the Medicaid roles that don't deserve eligibility our psychiatric hospitals in North Carolina had the longest weight times whatsoever 197 excess days so we have a problem with getting people from the hospital to the care that they need for every three Medicare beneficiaries waiting in a hospital two out of the three are involved in involved in a Medicare Advantage plan the largest three ma
▶ 1:26:57PL plans denied prior authorization Quests for postacute care level at higher levels than did any other types of care so yeah maybe our our um uh free for service Medicare needs to be fixed but good Lord our Medicare Advantage plan needs the uh the wrath of God to come down and fix that system Miss greybert in your view let me ask you this if you're a hospital administrator if you're a physician if you're a nurse administrator what do we
▶ 1:27:27do to streamline both uh discharges and prior authorization requirements because there's an entire cottage industry that we have to alert our our our our nurse managers when we think that patient's going to be able to leave I mean heck as soon as I put scalpel down it's like when is the patient leaving so tell me how we streamline that process thank you so much for the question one of the things that you mentioned I believe you referenced the three-day state requirement in an inpatient facility that's required
▶ 1:27:57before Medicare coverage into a Skilled Nursing Facility I think this is a perfect example of something that is in statute that is really causing some of these issues on an impatient basis um so I I totally share your concern regarding this specific rule to repeal that rule could be very cost prohibitive so what you need to take what what do you mean can you explain that the the reason the rule is in place is because it prevents switching
▶ 1:28:27of benefits between Medicare Medicaid and so to control fee for service utilization that rule is in place to push down utilization so we keep people in the hospital longer yes so there at more risk for DBT nosocomial infections etc etc that is the unintended consequence of the policy that's and that costs more money because it makes people sicker and get some guess what they stay in the hospital yes and your point is well taken the way that the Congressional budget office unfortunately looks at that they only I don't even say CBO
▶ 1:28:57around here because I don't believe anything they say sorry about that the way that they sort of consider that they they probably would assign a pretty cost prohibitive score to repeal that rule because that is their perspective on that particular policy you may want to also consider the revenue to go along with that to offset it and that's why I describe things like the 3day say as regulatory relief you could possibly generate the revenue from a unified pack PPS right but that's when people are given drgs they're paid
▶ 1:29:28for this diagnosis they're staying in the hospital it could be 3 days it could be 300 days the hospitals still get stuck with that bill so how do we cut down the the regulation how do we cut down the the burdens some administrative paperwork we take a an axe to it and this is where CMS again this is what this government has done and this is Republican and Democrat problem this is what's happened in every agency and this is why I'm so glad we're finally having a reset of our government is to look back and
▶ 1:29:58say this is ridiculous because it's add upon add upon add upon add upon and things just don't make sense for patients or the people who care for them anymore I I'm glad I appreciate everybody's um remarks today um I hope we get to the point where we're not just making remarks but we're actually fixing what is an badly badly broken American Medical system thank you Mr chairman I'll y back Mr Thompson you're recognized thank you Mr chairman thank you for calling today's uh hearing and I want to thank the witnesses
▶ 1:30:28uh for being here today although I think it's ironic that we're holding a hearing today on long-term care facilities while the House Republicans are in the process of cutting $880 billion from Medicaid 63% of all long-term care patients rely on Medicaid coverage to pay for their care these cuts to Medicaid will hurt 26 long-term care facilities in my district uh which provide
▶ 1:30:58services for 8,000 patients half of whom rely on Medicaid and it's not just patients who will suffer from these Cuts long-term care facilities support 8500 jobs pay $548 million in salary and contribute $183 million in federal and state taxes as soon as the Republican budget was announced I met with Health Care Professionals in each of the five counties
▶ 1:31:28that I represent what they told me should concern everyone on this dis and every American they said that the Medicaid Cuts in the Republican budget would hurt people on Medicaid and also veterans people on Medicare and people with private insurance these drastic Medicaid Cuts will mean 54,000 fewer people will be covered by medic aade or chip also known as the Children's Health Initiative Program
▶ 1:31:59in California rural Hospital closures uh will lead to longer Drive times and more preventable deaths in emergency cases the large hospitals that are able to stay open uh will cut special Specialists leading to fewer local treatment options for Medicaid recipients as well as people with insurance I also heard that longer uh larger systems will pull back on support for long-term
▶ 1:32:29assistance and programs to help keep people in their homes without Medicaid funded equipment some people with disabilities will be unable to get out of bed and go to work some will not be able to stay in their homes which will mean a higher cost uh to taxpayer these Republican Medicaid Cuts would cause a $2 billion reduction in E economic activity in my district alone that hurts Main Street Mr chairman I know that
▶ 1:32:59members on this Das will object and say that Medicaid and Medicare and Social Security aren't mentioned once in the Republican budget but as you know you can't cut $880 billion do without touching those programs and along those lines I'd like unanimous consent to enter into the record uh this news article where uh where Mr musk is talking about going after and cutting Social Security
▶ 1:33:29and um these are all life-saving programs and they're being dismantled the health and the economic impacts are going to be felt in every congressional district and by every American can I get you yeah without OB objection uh Mr Carlson please uh expand on how Medicaid Cuts in the Republican budget would impact people who were on Medicare private coverage or our veterans who use the private Health Care system
▶ 1:34:00thank you the important thing to note is that Medicare is not comprehensive I'd like to focus on that that it doesn't cover long-term long-term service and supports on a long-term basis there's some Nursing Facility coverage but as mentioned only after a hospitalization of at least three nights and only for a particularly intensive level of Nursing Care so Medicare doesn't cover these long-term service supports that people need either in a nursing facility or
▶ 1:34:30particularly as you note in for at home care it's it's worth noting that at home care is particularly at risk from the cuts are proposed these Home and Community Based Services are not mandatory under Medicaid they're optional programs and those they're so they're particularly vulnerable to Cuts like this if the if the cuts of the of the magnitude that are being proposed were to come into effect States would have to look at
▶ 1:35:01their Medicaid programs and make drastic drastic cuts and it's very likely that those would fall heavily on the Home and Community Based Services programs that are that are optional and these are the programs that provide Care at home they provide home modifications they provide personal care assistance they provide hom delivered meals they Pro provide daycare so all of that care in particular would be at at extreme risk if if Cuts Like This were to
▶ 1:35:31go into effect thank you very much and I I just can't tell you in Strong Enough terms how concerned upset and um and uh and unnerved uh constituents are across the country about this proposal thank you you back Miss Chu you recognized Mr Carl while the topic of today's hearing suggests interest in improving healthc Care for Seniors Republicans are charging ahead
▶ 1:36:01with their Reckless plans to cut as much as $880 billion dollar from Medicaid Medicaid's the primary source of payment for long-term services and supports in this country it's impossible to ensure quality Care while gutting the very program that pays for long-term care services for roughly 9.3 million older adults and people with disabilities without Medicaid
▶ 1:36:32most older adults who need help with daily activities would not be able to afford home-based or nursing facility care Medicaid also helps older adults pay their Medicare cost sharing and covers vital benefits that Medicare does not such as dental vision hearing and non-emergency medical transportation over 900,000 older adults and people with disabilities receive coverage for essential long-term services and supports through Medicaid or medical in California
▶ 1:37:02including atome care and Care in institutional settings at $83,000 per year for out-of-pocket home care and 147,000 annually for nursing home stays long-term care is unaffordable without Medicaid Medicare only pays for limit Lim mited days of rehab after a hospital stay or for inom skilled nursing care if the beneficiary meets the strict definition of being Homebound
▶ 1:37:32and most non-skilled long-term services and support such as personal care or routine care are paid for privately or provided by unpaid caregivers until individuals deplete their savings and eventually become eligible for Medicaid long-term services and supports which is why cuts to Medicaid are so damaging for Americans who need long-term services and support and this includes people like uh my constituent Chi kuang
▶ 1:38:03from montree Park California when he heard about Republicans plans to cut Medicaid he called my office and said I am a 74 year-old who's worked for 40 years as a warehouse worker after Decades of hard work I now rely on Medicaid and Medicare for life-saving medication and medical care as especially after undergoing hip and spine surgery I also heard from people like Bailey from alhamra California who said my daughter
▶ 1:38:33has a rare genetic disorder and many health problems I'm worried about what will happen to the help that I'm receiving for her through Medicaid without this it will be impossible for me to take care of her alone Mr Carlson I I've read the documents of justice and aging uh and I um am very interested in what it has to say about the interaction between
▶ 1:39:04Medicare and Medicaid how would Republicans Medicaid Cuts affect the ability of seniors who rely on both Medicare and Medicaid like chiwang to afford their health care how would these Cuts affect people with disabilities like Bailey's daughter in accessing long-term care services thank you I can make some additional points to the answer that I made a a second ago as as you noted Medicaid helps people pay Medicare premium so the the Medicare Savings
▶ 1:39:34programs that's that's something that that's used by 10 million older Americans to cover the significant expense that the Medicare requires the for example the part B premiums which are $185 a month so there's significant expense that medic Medicaid helps with that otherwise many people can't can't cover I'll note also that Medicaid given the the really high long-term care expenses that you note is a Lifeline for people
▶ 1:40:04really from a a multiplicity of income levels you can have significant life savings and be middle class or thereabouts or above and if you find yourself in a need for nursing facility care paying private pay at $100,000 a year you spend down to Medicaid levels very quickly so Medicaid is just a rock bottom safety net program that provides something that no other program provides for the folks like your
▶ 1:40:34constituents that you mentioned people um older people and individuals with disabilities who need this kind of long-term service and supports whether it be in a facility or at home um Medicaid is the only thing that's available for them they can't afford it otherwise Medicaid specifically pays when other when otherwise people can't afford it and so the cuts that were that have been proposed here would be devastating for the Medicaid Program
▶ 1:41:05and devastating for the people that rely upon it thank you I yeld back Mr Hearn you recognized thank you chairman I really appreciate you doing this today holding this meeting and I appreciate all the witnesses being here as well postacute care is an integral part of the Health Care System it's where patients have the chance to really heal and get back home to resume their daily lives one piece of the system is longterm care hospitals also known as L tax L tax for the for the sickest patients go as you all know spending an average
▶ 1:41:35of about 26 days there there are two l taac in my district back in Oklahoma not in the whole state of Oklahoma and I'm concerned about the rate of closures we've been seeing in the elac industry in the past few years while I applaud the work of Congress and what they did in 2013 to address overpayments and misalign Inc in the ltac system we are now a decade out and it's time to look how we can modernize and improve the work that was done that's why alongside my colleague across the aisle representative Bo introduced
▶ 1:42:05HR 1924 the securing access to care for seniors and critical condition Act of 2025 this bill ensures the sickest of patients are getting the care they need without unnecessary delays and that LX are getting paid the appropriate amount for these patients by helping clarify what con institutes an ltac payment the goal of this legislation is to get patients the setting of care they need when we know they need it Mr gyar thanks thanks first of all
▶ 1:42:35for being back I'm I'm sure you're happy to be back in this room at least for a moment anyway so thank you for all your work over the past under the former chairman I know you have a lot of experience in this space and can you tell us what Cong can Congress can do to ensure uh we get patients to the correct place of care whether it be an eltac an earth or sniff you gotta love the names or any other place of care they need as quickly as we can get their healing process started and what are some of the unnecessary delays we are sitting
▶ 1:43:05in getting these patients to where they need to go thank you for the question Mr Hearn and congratulations on the bill that you introduced just last week for regulatory relief for long-term care hospitals a bipartisan bill on my yes very a very nice achievement and it's a classic example of what I would classify as regulatory relief the same type of policies I'm talking about that would be essential to pair with a unified postacute care prospective payment system so I do think those things could
▶ 1:43:35go together very nicely and I think specifically long-term care hospitals could Thrive under a revised payment system so I encourage you to think about that type of Reform impairing that with the wonderful bill that you introduced last week thank you much Mr delli I appreciate all the suggestions for improving the ltac payment system and that's why I've introduced my bill to provide a small bit of certainty for the industry however I want to ask you about the current statutory provision that specifically grandfathers just
▶ 1:44:05a few L tax from some of changes that have happened over the last few decades and do you believe that we should address these grandfather Provisions as we look to modernize ltac payments my understanding of the grandfathered hospitals they have shrunk I think there's eight or less maybe in the country right now those eltechs are not exempt from these payment requirements or the criteria for admission into
▶ 1:44:35the eltech they really Center on the hospital within Hospital Provisions about common ownership and common control so I don't think dealing with that would have any impact on allowing greater access into the term care hospital one thing that I do think would allow greater access into the long-term hospital is dealing with this Medicare Advantage issue and I'll use this patient example we have two patients that look
▶ 1:45:06exactly alike both on ventilators both have stayed in an ICU for three days one has Medicare Advantage one has traditional fee for service Medicare our staff go in and evaluate those patients the fee for service Medicare patient we can bring right in no delay because they meet the criteria that has been set by CMS by Congress the Medicare Advantage patient we need to get prior authorization we need to go through uh they're usually denied
▶ 1:45:36because they say they can receive care in the short-term acq care hospital they go through an appeal process now you might say that impacts us but think about that family and we have often had this input coming from family members they visit with each other they're in the room right across from each other and one will say how come that patient can go to Madonna but my family member can't well it's because you have a Medicare Advantage plan and they're delaying your admission and they're denying it so I think that is the key Crux of of what could
▶ 1:46:06happen short term to address this problem thank you and obviously preauthorization is a whole other subject for another day and really appreciate your thoughts on that thank you so much I you back Mr Evans you're recognized thank you thank you Mr Carson post accure care is very expensive in all of its forms those who receive it often have even more complex cases can
▶ 1:46:37you speak to issue I'm sorry could you repeat the question please sir post Secure Care is very expensive in all its forms those who receive it it often has even more care you speak to that thank you yeah there there's a great deal of complexity and um Medicaid is an important provision
▶ 1:47:07that allows people to get to where they where they need to to be there's been discussion here about levels of care in different parts of the of the Health Care system for lowincome folks or people who spend down to to um Medicaid Eligibility levels Medicaid is essential for providing the the care that is needed whether it be in a a nursing facility at whatever level it could could be a more intensive
▶ 1:47:37type of of care the kind of care that's been referenced here and it can also be the type of long-term assistance at home for example that individuals might need on an ongoing basis Medicaid working along with Medicare for for many people allows the the bases to be covered as it as it were to to so the individual can get the medical care the The Physician care for example or the hospital care
▶ 1:48:07that he or she needs but also the the long-term care that might be necessary as well can you please elaborate further in how much even those enrolled make care often still rely on Medical Aid to meet their needs while and post procurement needs thank you as as mentioned earlier that those indiv um the people who receive Medicaid funded
▶ 1:48:38long-term care 60% Medicare beneficiaries so the the programs are is in a practical matter for those people the programs are set up to work together it was mentioned often times when people approach Medicare eligibility they just assume well now I'm covered I'm 65 um Medicare will will cover me but that's not true as it was mentioned by some of the other Witnesses even that Medicare won't cover a a nursing
▶ 1:49:08facility care unless you have a qualifying three-day stay in a hospital there there various Provisions like that that limit the ability of the Medicare program to meet the the needs of of real people and specifically the Post Acute the topic of our conversation here today in long-term service and supports Medicaid is essential to fill that role because um Medicare will not and for older
▶ 1:49:38people and for other adults with disabilities Medicaid is is essential because um it's it's the only program for those folks um who are unable to pay privately that allows them to to cover the long-term service and supports um items that they that they need to to live a full life Mr chairman I'd like to thank you thank thank you uh pursuant
▶ 1:50:09to the committee's practice we will now move two to one questioning I recognize Miss Miller thank you Mr chairman and thank you all for being here today rural patients like my constituents back in West Virginia are disproportionately left without critical support that they need to recover after major illnesses but it also is from surgery this lack of access to essential care not only affects their recovery
▶ 1:50:39but it also increases their risks of complications leading to longer hospital stays and a diminished quality of life one way to address this critical Gap is to expand tea health usage in postacute care settings I introduced the hospice recertification flexibility act which passed out of this committee last year my bill would allow hospice providers to use tah Health to conduct face-to-face
▶ 1:51:09visits required for recertification Mr Dilli not only do patients suffer from a lack of proximity to necessary care but their families and spouses are also deeply affected for caregivers and loved ones the inability to regularly visit or assist in the recovery process can lead to emotional financial and logistical strain with these challenges in mind will you speak about the impact
▶ 1:51:39of lack of access to care in rural areas upon your patients spouses and families and the challenges that they face visiting their loved ones thank you for that question it is a very real issue for family members we recognize that treating patients in postacute care is not just treating that patient it's treating the entire family it's making them comfortable and confident to take their family member back home
▶ 1:52:10once they finish their episode of care and and so I know we've tried to Institute various ways to make it easier for those family members to access the care we pride provide at Madonna we provide some family housing we have the ability for family members to stay in the patients rooms they have access to amenities um that would support their their relocation for brief periods of time you know to our vicinity um
▶ 1:52:40I think that the part of the the bill that Congressman Hearn talked about and that you also co-sponsored is making it uh helpful and useful for folks to uh come to an eltac and for that eltac to receive payment for them um admitting directly from that critical access hospital and so that would hopefully help um the patients and and their families receive the care that they need thank you long-term care
▶ 1:53:10hospitals are critical for patients who require Extended Care the cost to treat the complex medical needs that the ltch patients require can be significant the reimbursement system for the ltchs is structured to help manage these costs but recent changes to the high cost outlier threshold have introduced new Financial challenges by raising this threshold the amount of reimbursement ltchs can receive
▶ 1:53:41for treating particularly costly cases has decreased this puts additional strain on providers and it affects the level of care available to patients I introduced the patient access to long-term care hospitals act which will provide adequate reimbursements for ltchs my bill also caps the high cost outlier amount to $50,000 with this in mind Mr Dilli what has been the impact
▶ 1:54:11of the increase in the high cost outlier threshold for ltchs on providers such as yourself and the patients you treat well from a provider and patient perspective the prior to the increase the significant increase in the high cost outlier threshold when for instance when it was $27,000 I know from a financial standpoint we were able to allow more patients
▶ 1:54:41who would enter into the facility who we knew would become high outliers because that fixed loss amount was such that we could manage that and still still make a a relatively small margin within our long-term care hospital and at that time it was it was close to 4% when that doubled and it went to 58,000 or $557,000 what we saw was that we had to provide more scrutiny
▶ 1:55:12even though we continued to admit those patients who would go into high cost outlier status the financial impact of doubling it resulted in our overall eluk margin falling from that 4% to a minus 3% so when you're talking about a significant number of cases and for us at that time our high cost outlier threshold was about uh 30% so now
▶ 1:55:42it's it's we we have to limit that in order to just maintain Financial solvency which denies patients access to the care that they need at that point in time thank you for your answer I have to yield back I'm out of time thank you uh Mr Fitzpatrick you are now recognized thank you Mr chairman thank you all for being here today uh a key challenge facing uh my constituents back home in bucken Montgomery County in Pennsylvania has been the increasing staff shortages in the
▶ 1:56:12healthcare industry uh forcing many patients to be turned away from necessary care uh or alternatively uh to receive suboptimal care to meet their needs this is coupled with increased pressure on the professionals administer administering this very care um as has been brought up in this hearing Staffing for these specialized Post Acute Care Facilities is especially concerning um in my home state in Pennsylvania uh PA is projected to have the most dire shortage of staff for skilled
▶ 1:56:42nursing facilities by 2026 and reportedly nearly half of Pennsylvania Healthcare Association members plan to close or sell at least one of their snfs this year um Dr Madison in your professional experiences uh in home health can you speak to how staffing has changed in recent years and moreover um how have these potential challenges impacted your ability to treat your patients I certainly can thank you for the question in LEC Texas six years ago we did a study and at
▶ 1:57:12that one point we're a city of 260,000 we were a th RN short and 1 th000 LVN short and that's a backfill hole that you I mean that's a hole that you can never back fill in enough so we are dealing with it right now um tella Health would help with that tremendously if we could do tella Health visits one particular nurse could make 20 visits a day instead of the normal eight that they make for those for those patients that don't need to be actually have hands on care that day I think tella Health would be a great way to take care of those patients
▶ 1:57:42we also lost a lot of nurses during covid because they did not want to be subjected to some of the viruses and stuff that are out there and then also you have disabled nurses that can no longer handle the hospital care work that's demanded of them we could put them to work also and uh Mr Dilli um in your experiences an observation are you able to speak to how Staffing concerns have impacted your administration of care yes um
▶ 1:58:13like Texas and the state of Nebraska in 2025 is forecasted to have a shortage of RNs of over 5,000 and so you you can't absorb that and so I think what we find within my state is uh holding beds that could potentially be opened if we had adequate staff um it's widespread not only in the postacute sector but in the acute Hospital sector as well so it does impact the provision of
▶ 1:58:43care and patients access to it and moving on to long-term uh care hospitals these hospitals play um an essential role in caring for our seniors with serious conditions uh miss grber several years ago Congress created the criteria for ltch eligibility requiring a patient to have an ICU stay or 96 hours on a ventilator for an ltch to receive a higher payment uh what was the rationale of this
▶ 1:59:16change thank you for the question I believe part of the rationale behind it was that the medicare payment advisory commission had recommended to Congress to put patient criteria into place for long-term care hospitals medpac recommended an 8-day ICU stay and when Congress legislated it they codified a three ICU day so I believe that that was some of the background behind how Congress got to the 2013 policy got it back to you Mr Dilli
▶ 1:59:47are there patients who might benefit from an ltch care uh who do not meet this criteria um how would this change impact their care uh well thank you for that follow-up question because yes we can understand the reason to create criteria but we believe that 3day in the ICU stay went too far there are other patients who have who are critically and chronically ill who could benefit from the services that a long-term care hospital provides
▶ 2:00:17that haven't maybe been in the ICU there are certain hospitals for in One hospital in our market right now has 25 patients waiting in the emergency room waiting for a patient bed some of those patients can get into a a unit within the hospital that can deal with their critical chronic condition instead of the ICU but because they're not in the ICU because of the bed availability they're not then eligible to come to the elac
▶ 2:00:47so we think they should be expanded thank you Mr anelia are you back Mr Mr horo you are recognized thank you chairman Buchanan and to the ranking member uh Medicaid as we're discussing today is the primary payer for long-term care here in the United States covering 61% of total spending it's the backbone of our long-term care system supporting millions of seniors and individuals with disabilities as well as the dedicated professionals
▶ 2:01:18who care for them but let me be clear despite desite some mistruths circulating from my colleagues on the other side of the aisle the impacts of the 2025 budget reconciliation plan I call it the screw America Bill uh are indisputable House Republicans are proposing to slash billion from Medicaid and eliminate critical tax credits that help Working Families
▶ 2:01:48afford their health care all while Del delivering a $4.5 trillion doll tax credit cut to billionaires to Big corporations and DET Tech tycoons the consequences of these proposed cuts are not hypothetical they are catastrophic any cuts to Medicaid will only intensify the existing challenges in the long-term care sector direct care jobs will become even harder to fill further straining the
▶ 2:02:18system providers will be forced to reduce work hours and in some case shut down entirely destabilizing the long-term care Workforce and undermining Health Care Quality workers themselves will be at risk of losing their own Medicaid coverage and other essential supports further plunging them into instability now my constituents are very concerned just this past week
▶ 2:02:48weekend I held a town hall to give an update dat on what's Happening Here on Capitol Hill and to listen directly to my constituents the first question from that town hall what is being done to protect workers in nursing homes from Medicaid cuts that is not an abstract policy debate it is real real workers real families and real lives that are on the line Mr Carlson my question is simple
▶ 2:03:19if $880 billion in Medicaid cuts become a reality what do you anticipate will happen to the long-term care Workforce if Cuts were made of of that magnitude then um long-term care providers couldn't operate the way they can now you can imagine you can imagine closures that it because of the prevalence of Medicaid to fund long-term servic and
▶ 2:03:49supports drastic cuts to to Medicaid would first the consequences fall in the state which is unable to to to make payments that are necessary to maintain the system and then the consequences fall on the on the providers because they no longer have the funding to provide necessary services on an individual basis on an Institutional level um a lot of nursing facilities and also home Community Based Services providers rely extensively
▶ 2:04:20on Medicaid PA 50% of the reimbursement 2/3 depending on the or above if you're talking about some home community based service providers they they just couldn't operate any longer so knowing that reality what should lawmakers be doing right now to protect these workers and to stabilize the critical Workforce that's needed in healthcare yeah well on behalf of justice and aging that um the Urgent issues in access to postacute care at the topic of today's
▶ 2:04:50of today's hearing ing is protecting the Medicaid Program in in rejecting these Cuts in recognizing the the importance of Medicaid and maintaining the current funding and structure of the program and this is the fact that even before this house Republican reconciliation proposal was made families were long uh voicing concerns about the quality of care in nursing homes especially the lack of adequate Staffing to meet
▶ 2:05:21residents needs in fact in 2024 the centers for Medicare and Medicaid services took action and set minimum Staffing standards to ensure that every facility has a nurse on site research from the University of Pennsylvania shows that the rule improves Care Quality reduces abuse and saves an estimated 30 thou 13,000 lives annually but now Republicans have indicated their desire to roll back these critical
▶ 2:05:52protections once again to fund tax breaks for big corporations and the wealthy so how is rolling back protections and standards going to improve quality Mr Carlson again the position of Justice in aging is that it's counterproductive I I'll note that this has been a problem for for decades that the standard of the federal government has just been sufficient sufficient Staffing which hasn't enough to
▶ 2:06:22establish a decent quality of care and you can talk to individual Nursing Facility residents and hear stories all day long about just not enough staff and how that leads to bad outcomes and a and a bad quality of care just point out the standard there's a phase in Period right it hasn't even come into effect yet and so what we would advocate of course is that let these standards be implemented they're they're important there are accommodations to um
▶ 2:06:52allow for changes under certain circumstances and they should be maintained thank you I yield back Mr kostov you're recognized thank you Mr chairman thank you for holding today's hearing and I do want to thank the witnesses also for appearing today Mr flee if I could with you in your opening testimony you talked about the work uh Workforce shortages in the health care sector and how those shortages are affecting
▶ 2:07:22access to care can you tell me in your experience how common is it for somebody to enter the workforce as a CNA to pursue a higher level of nursing like becoming a a licensed practical nurse or or nurse thank you Congressman kustoff for that great question I will share as the CEO of uh hospice and homebased Care Organization that employees over 3,400
▶ 2:07:53workers a day that those healthcare workers are my first and formost attention every day and after the great resignation in healthc care uh that occurred during the pandemic uh The Runaway inflationary pressures that have hit healthc care uh since uh and going on forward since then uh the pressures to hire retain and recruit staff are M we are
▶ 2:08:23absolutely reinvesting in Workforce Development as an organization at impath and certainly always U very grateful for congress's support uh for funding uh Workforce Development efforts but it is a major health care crisis uh in the United States today across the entire system is adequate Staffing and healthc Care thank you Mr Don Jilly if I could with you if a Skilled Nursing Facility receives certain highlevel deficiency gencies or fine up
▶ 2:08:53to a certain dollar amount as I understand facility probably can't offer or will not be able to offer CNA classes for a certain period I think it's two years so hypothetically if Madonna were to lose that ability to hold CNA classes how would that affect your ability to be able to staff your your facility how would you be affected well it would impact negatively our ability to have the CNA
▶ 2:09:23staff that we need in order to provide the patient care we're known for so it it's important and we would hopefully not find ourselves in that position sure um the district that I represent is a mostly rural District in West Tennessee so in my district there are number of counties where the local nursing facility might be the only place that they could uh somebody could obtain or take
▶ 2:09:54CNA classes so would you say it's it's fair to say that for for a nursing home maybe like the kind that I just described that losing the ability to hold those CNA classes would inhibit or impair their ability to be able to improve the quality of service yes I would say it it thank you very much uh Dr Madison I know that medic Medicare reimbursement for remote patient monitoring
▶ 2:10:24Services is subject to price modification based on average cost to operate in a given geographic area and this takes into account factors like employees wages office space equipment and the cost of offering remote monitoring not necessarily cheaper in rural areas like the kind that I represent and in fact it might even present additional cheap challenges like connectivity or or
▶ 2:10:54Broadband or longer travel times to set equipment can you talk about um how Home Health Services like yours offer rural RPM if reimbursement for these Services was in line with the national average does that make sense the way I ask that I can I can tell you as a home health agency that we're currently offering remote patient monitoring um we offered blood pressure weight and gluc for our patients we do not get reimbursed at all for those
▶ 2:11:24Services currently um but we feel like it's necessary in order to provide better care um especially because we can see if there's an issue a lot faster um and it the devices that we use we've not had trouble with conductivity it's Bluetooth and um it's much easier than it was 10 years ago I me put it that way good thank you Dr Madison thank you to the witnesses and Mr chairman I yield back Mr Moore you're recognized
▶ 2:11:54thank you Mr chairman Miss greybert uh the University of Utah and my district has provided data that indicate that of the patients that require Specialized postacute Care the majority require either home health care or skilled nursing facilities medpac has long indicated that there is sufficient access to home health care but many people are saying that access measure is flawed could you shed some light on this should medpac adopt a new measure of of access if so what elements should this measure
▶ 2:12:26incorporate thank you for the question Mr Moore no I don't think medpac's measure of access for home health is flawed I support medpac's methodology um the uh is there is there any ways to you know as as we look at the the approach to this any ways that you would suggest we improve this certainly I think access to care issues are always something in the Medicare program that we need to pay attention to I don't have a specific recommendation for you
▶ 2:12:56today but I'm happy to follow up with your staff after today's hearing thank you and like my colleague I represent several rural counties U Mr fleece um particularly in Northern Utah and many cases tella health is the best option for Medicare patients how would uh how does empath empath Health employ teleah Health Services to improve quality what are some of the best practices that may be employed elsewhere this is obviously a big topic that we're we're going through here in um in Congress and we've had multiple
▶ 2:13:26you know times where this is going to expire and we've done it temporarily like give me share a little bit about how you would approach this thank you very much Congressman Moore and impath health Prides itself at serving the rural communities across Florida uh tele medicine is a critical part of ensuring access to care whether it's recertification of hospice eligibility or ensuring that in crisis that we can get access from Communications perspective uh to
▶ 2:13:56all of our patients uh it's also Mission critical to our homebased care organizations uh those that are suffering chronic disease or post-acute uh to ensure that homebased care is there for the rural communities through tele medicine uh to reduce hospitalizations readmissions that homebased care has been proven uh to demonstrate and we are also always looking for additional infrastructure investment uh to ensure that not only do we have tele medicine from a policy perspective
▶ 2:14:27but we are able to connect to the rural communities whether that be through satellites or other technology that impath invests uh it's not just policy it's also infrastructure from a technology perspective that is Mission critical to reach the rural uh communities excellent thank you uh lastly Dr Dilli Post Acute Care Facilities Nationwide were operating at approximately 85% capacity back in say obviously before covid-19 exacerbated much of those resources can you shed some light on current postacute care capacity
▶ 2:14:58does our current postacute care infrastructure have enough beds for patients in need I think that for the most part beds are available why we're seeing shrinking access is not so much the bed availability it's the inadequate payment or the restrictive criteria that are in order to allow those patients to access and I'll cite the Medicare Advantage challenges as a
▶ 2:15:28prime example of that fact so thank you back Mr Sanchez do you're recognized thank you Mr chairman for holding this hearing and I want to thank our Witnesses for being here today postacute care is a critical part of the Care Continuum but it's often fragmented in its delivery so I'm encouraged to hear the witnesses ideas to help address some of these issues something that I personally care deeply about is long-term care more often
▶ 2:15:58than not caregiving is unpaid and it's provided by loved ones two-thirds of caregivers in the United States are women and I've worked for over 10 years to pass a caregiving tax credit and today my colleague Mr Carrie and I reintroduced the bipartisan credit for caring act I hope that we can pass this on a bipartisan basis to provide much needed relief for work Working Families because the only other way Working Families can afford long-term care is through Medicaid and Republicans are
▶ 2:16:28held B on pursuing an $880 billion cut in Medicaid to pay for the tax the tax cuts for the largest corporations and highest income earners in the United States the fact is that three out of every five nursing home residents rely on Medicaid Mr Carlson I want to thank you for your testimony on long-term care and your notes on Staffing standards in skilled nursing facilities I want to ask you and if you could answer briefly because got a lot
▶ 2:16:58of territory to cover what kind of impact would Medicaid Cuts have on access to Nursing Facility Care thank you for the for the question that um has been mentioned Nursing Facility residents you're talking about close to two-thirds of residents who are reimbursed by by Medicaid and so that's just obviously a tremendously big piece of reimbursement for for nursing facilities so any dramatic
▶ 2:17:29cuts to Medicaid funding as I mentioned earlier you know the consequences fall to the states they don't have enough money to do what they want to do what needs to be done to to cover the health care needs of so the individuals would be responsible can many of them afford that yeah I mean right then it falls on the the facilities aren't adequately reimbursed or the eligibility standards are are changed you know one way or another it becomes untenable for for for everyone the the
▶ 2:17:59providers it it's likely become untenable but I'm focused on the the patient what happens to the patient for the beneficiaries you know they either don't have coverage or that the the financial standards would be such that that they wouldn't that they couldn't afford to to to care they they wouldn't get the care just you get you get you get squeezed out they they wouldn't get the care they'd be squeezed out and what would that do to the nursing home industry in States like Alaska Georgia Louisiana or West Virginia
▶ 2:18:29those are states which which is even higher percentage of Medicaid benefit I think north of 70% so 880 billion cut in Medicaid would mean that those facilities and their patients who are no longer receiving the subsidies what happens to those facilities the impact is even bigger in those States because the percentage hit on nursing facilities is that much higher there's not enough there's not enough money for individuals there's not enough money for providers
▶ 2:18:59okay um thank you I want everyone to recall when my Republican colleagues on this committee voted to resend the minimum Staffing rule for nursing facilities last year our own chairman said in his opening statement during our markup last year quote without access to more staff nursing homes particularly those in rural areas will have no no choice but to reduce the number of residents they admit or shut down altogether let me repeat that without access to more staff
▶ 2:19:29nursing homes will shut down so let me ask are Republicans still outraged about rural Nursing Facility closures because a $880 billion cut in Medicaid will close many of those rural facilities so I urge you to stand up to oppose those cuts which will devastate those Ral facilities and the patients that they serve I also want to talk about access to issues in postacute care this is an issue that I've worked on on a bipartisan
▶ 2:20:00basis with Miss vany of this committee and I'd like to submit for the record our letter uh on Ma Network adequacy standards which still do not include irfs so ordered thank you Mr chairman I also consistently hear that patients experience long de delays in post-acute care due to Medicare advantages plans prior authorization practices Mr teli in your testimony you cite improper denials in coverage for more intensive post-acute
▶ 2:20:30care what causes delays in care when a patient transitions to the postacute uh to the Post Acute setting at an irf uh thank you for the question the the delays result from the process that has been set up by the Medicare ad Advantage plan like I said previously feif for service Medicare patients we can assess that patient and bring them in within one day if
▶ 2:21:00it's a patient who has Medicare Advantage we have to take that clinical information we have to provide it to the uh Medicare Advantage plan for approval to bring the patient in often what we see is an immediate denial and and how often are those prior authorization claims denials appealed and overturned Ed they're over oh appealed and overturned yes overturned what we find in our experience is that
▶ 2:21:30roughly maybe 40% of the ones that are initially denied and be overturned during appeal thank you and I yel back Mr stuie you're recognized thank you Mr chairman uh Mr fleece thank you for all the work that you've done in my district uh the number of Home Health Providers has declined significantly excluding California the number of agency serving beneficiaries has dropped by 17% since 2019 from 7,793 to
▶ 2:22:016,468 a publicly traded Home Health company recently announced the closure of multiple agencies particularly in rural areas citing reimbursement Cuts as the primary reason can you provide insight into the factors driving this widespread closure of Home Health agencies and do you believe current reimbursement policies are sustainable for providers thank you congressman stuie and we do thank you for your service to uh the district where impath Home Health uh serves uh as well as Tidwell hospice so thank you sir um
▶ 2:22:31ultimately homebased care is so much of the solution to many of the questions and many of the problems that have been identified today at this subcommittee ultimately as I co-authored in my book the new health age how we think about healthc care how we deliver health care and the economics of Health care must change uh and there are many many reasons behind that uh I concur that there are various models within the homebased care um environment
▶ 2:23:01that are driving especially smaller homebased care agencies out of business and even for larger not for-profit organizations like myself caring for 880,000 Floridians a year uh programs like pdgm programs like review Choice demonstration uh the complex Oasis tool that our staff are are forced and required to to comply with um while well- intended when when enacted uh certainly do require further
▶ 2:23:32uh consideration to reduce administrative burden um to ensure that homebased care uh and patient care survives and in all due respect in my final comment to one of my um panelists uh that's testifying today um I practiced healthc care law for 25 years and have been in healthcare for 30 serving as a CEO or president of this organization and I'm hard pressed hard pressed to find a lot of home care agencies as identified by medpac with 20 plus percent
▶ 2:24:02margins we are operating at a 2% that's 2% net operating margin across empath health and the care Continuum and our home healthc care division is operating at a net loss and under the new Home Health Payment Systems uh are payments covering provids cost absolutely absolutely not congressman and how inadequate are fee for service payments relative to cost inadequate and when Medicare Advantage is continuing to grow while there are good implementations
▶ 2:24:32and five-star rated Medicare Advantage plans across this country uh that that has been longstanding we need to continue to move towards a pay for performance model and also pay the four and five star hospice and Home Health agencies more so that we're paying for performance under under the model and can you speak to your experiences with prior authorization uh are are most of the requests approved uh how does this impact the care received so I would ask for the
▶ 2:25:03Congress here today to imagine one of your loved ones in either hospice or home health and and they are in need of postacute care every second every minute is critical to get them out of the hospital into a homebased care environment we both participated under the Medicare Advantage Carin pilot on the hospice side and we contract with Medicare Advantage plans today it adds hours days
▶ 2:25:33to the pre-authorization process and delays access and delays care oftentimes on the hospice side and sometimes even on the home care side patients literally die during the discharge planning process waiting for the authorization Congressman in the little bit of time I have remaining is there any issues you'd like to address that you haven't had the opportunity to address so far thank you so much Congressman one thing I can guarantee every Congress person here today is that we will all die
▶ 2:26:04if I compel you to take one takeaway today from this subcommittee hearing it's preserve the end of life care benefit that hospice has been known for for over 45 years in the Medicare benefit than thank you so much I yield back thank you for being here Mr fleece let me ask you um you've built an enormous organization Tampa Bay Area obviously the biggest part in Sarasota County my
▶ 2:26:35colleagues District uh but I've watched your growth your professionalism what is the key to your success uh I think you're one of the top facilities organizations in the country and uh so as you look back in your tenure and I remember about 20 years ago you gave me a copy of your book by the way time goes by so qu fast but what is what's been the key to your success or a couple of keys with your organization I it's one of the best best run organizations in the country thank you so
▶ 2:27:05much Congressman for that great question and I too am extremely proud of impath Health uh as we serve Central Florida Southwest Florida East Coast of Florida and as you stated uh over 12,000 patients a day uh in our in our care I think number one The Secret of our success is always put the patient first to everything that we do the staff are also Mission critical because if we are not investing in taking care of our staff we will
▶ 2:27:35not have workers to care for ultimately the patients as I have already stated we understand within our industry that we as a country are in challenging uh economic budget times it is critical that we look at this as a return on conversation Hospice Care has shown over and over and over again that it will ultimately reduce Medicare spending 25%
▶ 2:28:06of the Medicare spend is spent in the last 6 months of Medicare beneficiar 25% of that 25% 10 to 15% a small component is spent on hospice care if we look at this as a return on investment conversation there is so much that can be done around homebased care so that we are getting patients and families out of an Institutional environment where they do not want to die where they
▶ 2:28:36can be cared better for to reduce hospital readmissions so that we can continue to expand care in the home let you touched on performance to pay I know being in business 30 years before I got up here here uh that was a big premise of mine is trying to make sure we tied the behavior to what we were trying to incentivize people can you explain what you mean by that from your perspective yes uh Mr chairman chairman
▶ 2:29:06if you look at the current star rating system that is prevalent in Medicare today it is one that does not adequately pay for performance the the providers that are that are provid ing care for for patients today we would certainly Advocate that for those organizations that have higher star ratings that they get paid more under the reimbursement system that would be one model of a pay for performance we also stand proudly behind
▶ 2:29:37taking risk through our Pace programs programs for allinclusive care for the elderly where we are ultimately caring for those that would otherwise be in a nursing home and receive both the Medicaid and the Medicare care component for our Pace programs and we become responsible for that performance we become responsible for making sure that they have the right care right place right time and finally chairman Mr chairman I would Advocate that those that are
▶ 2:30:07not reporting their survey scores to avoid scrutiny be rooted out because much of the fraud and much of the profiteering that we are seeing in in America today that that we know the special Focus program was um proposed to to address are not submitting their survey scores that is a required so that those of us that are providing highquality care can continue to focus on our mission and the other my last
▶ 2:30:37question is on preventative care that's really my focus with this committee as much as I can uh don't get sick in the first place I mean you get sick at some point but my point is what you touched on to preventative care what does that mean with your organization with your patients uh people that use your facilities thank you Mr chairman so many of of what we are talking about today is how we can improve outcomes for reduced cost
▶ 2:31:08and ultimately that will be part of what Congress faces in its um upcoming budget discussions I I am sure one of the concepts around thinking and delivering Healthcare differently is the more that we focus on prevention versus being reactive and the more we focus on Wellness versus sickness there is a return on that investment that will help balance this nation's budget
▶ 2:31:38thank you and uh Mr smucker recognized thank you Mr chairman for holding this important hearing and I'd like to thank each of the witnesses for uh sharing your testimony today uh you've explained how important Post Acute Care is how vital of a role it serves in our nation's Health Care system with roughly 40% of Medicare beneficiaries receiving uh this type of care after impatient Hospital dayss which and we've also talked about
▶ 2:32:08how that helps them to recover and stay healthier for longer I've spoken to constituant in my district about the services that they've received uh through skilled nursing facilities home health patient rehabilitation facilities and other care settings and understand and agree with the importance of continuing to make improvements to the Medicare program so these Services continue to be accessible for all seniors I'd like to highlight uh a little bit the uh LX long-term care
▶ 2:32:38hospitals which serve the most complex patients who are in need of specialized care but are facing waves of closures I've heard that from folks in my district as well um and these are the hospitals that um or if if these closures continuous the most patients with the most severe conditions won't have the level of care that they need uh we've heard reports of Medicare Advantage plans delaying or denying coverage you've mentioned that earlier today for LTE
▶ 2:33:09uh ltech Services um and I why I believe that Ma has been a game changer and allowing seniors to uh that access to better more Comprehensive Health Coverage I'm concerned by some of the obstacles to care which could lead to costly complications complications for patients so Mr dunell um we've heard a little talk about prior authorizing uh authorization just a little bit ago but can you describe some of your experiences with prior
▶ 2:33:39authorization and talk about how those May create barriers to coverage and how that impacts the care that your patients receive yes thanks again for the the question um the delays once an assessment is done on a patient who has Medicare Advantage and working through the appeal process is time consuming timec consuming in intense it delays that patient's
▶ 2:34:10access and at times the the patient then and the hospital that's referring them may not want to work through that process with us and so as a result we'll discharge the patient to a less intense setting where they don't receive the care that they need or they stay in the acute care hospital and create throughput issues for that hospital because they can't discharge them so it literally could lead to patients
▶ 2:34:40being required to leave your facility and not receiving the care that is needed correct yeah I appreciate you sharing that I'd also like to touch on home health as well we know that patients recover quicker have better experiences when they receive care in their homes uh occupational therapy is one of the services that seniors can receive through the Medicare part A Home Health Benefit however as you know the outdated statute prevents occupational therapist from treating a patient
▶ 2:35:10in their home unless they're accompanied by another provider uh which creates a strain on medical providers and complicates this access to care yesterday introduced a bill with Mr doet and several other colleagues to streamline the process and allow occupational therapists to provide stolom services in the home health uh benefit Dr Madison you also noted in your written testimony that on average one 60-day period of care of Home Health costs less than one treatment in an
▶ 2:35:40emergency room so I would think there are huge cost savings here so H Dr Madison how would a bill like the one I've described uh stream line patient access to care um and can you expand on the financial implications this would have for the Medicare system yes sir we're paid for an episode of care irregardless of what services we provide however if OT could stand on its own then an OT could do provide all the services needed instead of a nurse having
▶ 2:36:10to do the admission and the discharge um so it would C can you give uh any sense on what kind of cost savings that would create it it would not because we get paid for an episode we get paid based on the diagnosis the function of the patient that kind of thing what it would save is the expenses that the agency is having to spend yes all right thank you Mr chairman I yield back Mr buer you're recognized Mr chairman thank you very much and thank all of you for hanging in here
▶ 2:36:40uh it's been really encouraging to hear many good ideas about how to provide better services to patients in those latter years of their life and I really want to thank you for being here to discuss supporting older Americans today more than ever Americans work into the later years and these changing conditions require new methods of support Al Le a bill to establish an older workers Bureau within the Department of Labor supporting our older workers ensuring they have the resources they need to succeed you probably know this is the fastest
▶ 2:37:10growing sector of our Workforce and those resources are needed to confront the unique challenges that older workers face things like work limiting health conditions or financially preparing for retirement and for many older Americans that difficult balance is only made possible because that we have critical Federal programs like Social Security and Medicare Mr Carlson I would like to thank you specifically for discussing the importance of Medicaid to older Americans which is so often overlooked
▶ 2:37:40and I'm deeply concerned that my Republican friends and colleagues are pushing a defunding bill that actively attacks older Americans we're expecting to vote on that bill in just a few minutes this is far from a clean bill the partisan measure STS away $1 13 billion from essential non-defense programs and services that includes cuts to critical medical research cuts to emergency programs and even specific cuts to Veterans medical benefits the bill would cut $280 million in research
▶ 2:38:11for treatments and cures for Alzheimer's despite the fact that 50% of Americans 85 and older will get Alzheimer's or or dementia it cuts research for heart disease kidney disease diabetes and many more serious health conditions that disproportionately affect older Americans it cuts more money from usda's commodity supplemental food program leaving 255,000 older Americans unable to participate denying them emergency assistance at a time when food prices are still rising
▶ 2:38:41and amidst nearly 23 billion in planned funding for the toxic exposures fund to care for veterans exposed to burn pits agent orange and and other toxic substances those veterans most of whom many of them were exposed to toxic substance in Vietnam are older Americans and they're disproportionately older and face severe Health impacts from their sacrifices for our country and this bill doesn't stop there because it lacks any guard rails it allows the Trump musk Vance Administration to continue continue to stop funding
▶ 2:39:12to impound funding or redirect funds away from even more programs for older Americans including home assistance Mental Health Care rural health care and cancer programs and that's not to mention the budget resolution that the House Republicans have passed to set up reconciliation to pay for pack Stakes for the wealthy they're looking for $2.5 trillion dollar in cuts and they charge the Energy and Commerce Committee here in the house the one that oversees Medica Aid with $880 billion of
▶ 2:39:42those cuts the nonpartisan Congressional budget office found that those cuts were not possible without touching Medica Aid which I look at 162,000 Virginia over 65 depend upon I held a Medicaid round table last week in Alexandria last Friday we had nursing home managers and owners there they said it was impossible for them to survive if Medicaid were cut so Mr Carlson a simple existential question put all this together is it possible to make cuts of this magnitude
▶ 2:40:13without undermining the care that older Americans rely upon the simple answer is no the program could not could not survive in a reasonable fashion given the cuts that have been well that's that's enough Mr chairman then I yield back yeah Mr suasi you're recognized thank you Mr chairman
▶ 2:40:43and thank you to the witnesses I know you've had a long day today Dr Madison and Mr dongi and Mr fleece m g Mr Carlson and I wasn't here for most of your testimony I watched some of it on TV but uh I appreciate I just wanted to come here and talk about a a bill that I'm working on that is pertinent to this issue uh as Mr Carlson mentioned in his written testimony there are 10,000 people turning 65 every day and in five years I don't know if that was in your testimony but in five years there'll be about six or 8,000 people turning 85
▶ 2:41:14every day and one of the number one causes of new homeless people in America is turning 8 years old and we've got a major storm coming in our country with long-term care uh especially you know we can't afford to put everybody in a nursing home we don't have enough nursing homes and Medicaid will go bust and my Republican colleagues have talking about saving money in Medicaid and I think I'm trying to posit an idea that can save a lot of Medicaid money but also make people's lives better in the process
▶ 2:41:44and that is to create a public private partnership on long-term care insurance insur my my I grew up in a house all four of my grandparents lived in my house growing up three were very sick Parkinson's Alzheimer's they called senility in those days uh colon cancer and my other grandfather lived to about 90s something pretty healthy and my mother was a nurse we all took care of my grandparents I remember taking my my grandmother to the bathroom you can imagine what that was like when you was a young young teenager and my parents didn't want us to go through that so they got long-term care
▶ 2:42:14insurance and they lived till 95 and '93 and they died at home and they had a great end of life but most people can't afford long-term care insurance only 3 to 4% of Americans have long-term care insurance and the insurance companies when broke when they issued a lot of insurance policies for long-term care uh originally because they didn't take into account the Actuarial tables that people would live a lot longer than the average of like a year and a half to two years after you couldn't do your two activities of daily living so we're going to have a major problem
▶ 2:42:44in our country it's already started it's going to get a lot worse where we have all these senior citizens that are living a lot longer that are going to need assistance with activities of daily living their kids have their families are smaller their kids have moved other parts of the country there's nobody to take care of their parents and the the solution right now is to spend down your assets or you know give them to your kids in some way or to your spouse and do spousal refusal and then stick you in a nursing home and have Medicaid pay for it it's not only a bad way to end your life it Mo puts a lot of people into poverty and it's a really
▶ 2:43:14a miserable way to exist so what I'm proposing is that the federal government needs needs to create a catastrophic CARE program whereby we will provide long-term care dollars to people if they live beyond a certain period of time so if you are a lower income person in the lowest 20th 20% of America you got to take care of yourself for a year between you and your family if you're a higher income person you got to take care of yourself for five years and a sliding scale in between that one year and five years and by taking care
▶ 2:43:44of that catastrophic care portion it'll incentivize the private sector to create Insurance products for long-term care that'll be much more affordable and they'll be out marketing it the way they Market Medicare Part B and things like that now they'll be out selling these products and letting people know that they've got to deal with this long-term care issue because nobody talks about it nobody talks about these end of life issues and as a result families are falling apart All Over America seniors
▶ 2:44:14are being left destitute because they haven't talked about this issue and it's never going to be the government's going to solve this problem we have to create a vehicle by which the private sector will be incentivized to go out and Market these products that will be affordable for people that they can get long-term care insurance so the question is how to fund it I believe the way to fund it I originally wanted to do a payroll tax but I'll never get my Republican colleagues to vote for a payroll tax so I think there's one of two ways one is to get the savings that we'll generate from Medicaid because I believe we can dramatically
▶ 2:44:45reduce Medicaid expenses by creating these long-term care products and number two is to when we we have there are ideas out there now how to fix the Social Security trust fund by investing money not Social Security trust funds but other money that will get a rate of return that will help to Supple supplement the Social Security trust fund anyway Mr Carlson do you agree that there's a major problem in our country with this explosion of seniors that's coming on board yes it's something clearly that has to be
▶ 2:45:15grappled with as you as you point out that often times these issues don't get the attention that they deserve and this it absolutely deserves the sort of attention that you're describing here Dr Madison do you think that chairman Vern Buchanan is a brilliant handsome wonderful guy that will work together with me on the wish program you know absolutely okay thank you very much I yield back thank you um I'd like to thank our Witnesses for appearing before us today please be advised that members have two
▶ 2:45:45weeks to submit questions to the answers later in writing those questions and your answers will be made part of the former he hearing record with that the subcommittee stands adjourned