Home health deserts are increasing at an alarming rate across some rural states as home health companies close or reduce services due to financial challenges.
Home health companies in Maine, Nebraska and Minnesota say a proposed Medicare rate cut, low Medicare Advantage reimbursements and workforce shortages are forcing them to make difficult business decisions — leaving many communities with limited access or no access to post-acute care in the home. But the Medicare Payment Advisory Commission, which advises Congress, has downplayed access problems in rural areas and said federal reimbursements are adequate to support services there.
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Approximately 800 home health providers have closed over the past five years, according to the National Alliance for Care at Home, a trade group that represents the industry. Alliance CEO Dr. Steve Landers mostly blames a Medicare home health payment model that went into effect in 2020 for reducing Medicare reimbursements and causing financial stress for providers.
“While closures are significant, we are also getting reports that providers are restricting the territory they serve as a first step to addressing their financial stresses,” Landers said in an email. “This appears to be especially concerning in rural areas where no other provider is available to step in.”
That scenario is playing out in Maine. Andwell Health Partners, one of the state’s largest providers of home-and community-based services, is ending home health service in the coming weeks for 58 of the 144 communities it serves in the southern and western parts of Maine, said Kenneth Albert, the nonprofit’s president and CEO.
Albert said the prospect of a 1.7% Medicare rate cut next year and low Medicare Advantage reimbursements forced Lewiston, Maine-based Andwell to cut home healthcare offerings to communities in remote parts of the state.
“In some of these regions, it takes two hours to get there,” Albert explained. “Sometimes I have to send a nurse, a physical therapist and a CNA. When you look at all of the disciplines, that is six hours of windshield time. The math just does not work.”
Albert believes about 45 of the communities Andwell is exiting will be left with no home health provider.
The Maine Home Care Association fears Andwell’s decision to cut service could foreshadow possible service cuts from the state’s 21 other Medicare-certified home health providers. In an email, The association estimated the proposed 1.7% Medicare rate cut will cost its members more than $1.6 million next year.
“Service area reductions are a difficult but necessary choice to reduce the overall cost of care to align with Medicare payment reductions,” the association said. “Medicare beneficiaries in Maine are disproportionately impacted due to our aging population and vast rural geographic regions.”
That could create challenges for health systems, such as Northern Light Health, that refer some patients to Andwell for home healthcare. Northern Light Health operates 10 Maine hospitals and a home health business in about two-thirds of the state. A spokesperson for the Brewster, Maine-based health system said it is still trying to determine how Andwell’s decision to exit certain communities will impact both its hospitals and home health business.
Maine isn’t the only rural state grappling with home health deserts.
In Nebraska, ten home health organizations representing about 9% of the state’s providers have gone out of business over the past five years, said the Nebraska Home Care Association. As a result, two-thirds of the state’s 93 counties have either no home health organization offering services or only one. A single home health provider in a county might not offer services to the entire area, said Janet Seelhoff, the association’s executive director.
In regions where there is little or no access to home healthcare, it can be a struggle to find post-acute care for patients following hospital discharge, said Callaway District Hospital and Medical Clinics CEO Brett Eggleston. His hospital is located in Custer County which is served by two home health providers. But Eggleston said many of the hospital’s patients come from surrounding counties that have no home health providers.
“You have to see if the family has the resources to care for them safely [at home] and if they don’t, a lot of times they’ll end up having to be placed in a skilled nursing facility for a short period of time until they are able to be released safely to home,” Eggleston said.
Seelhoff thinks the Preserving Home Health Access Act could help secure access in rural states. The legislation, introduced in the House last year, would prevent the Centers for Medicare and Medicaid Services from cutting Medicare home health rates.
“We have been meeting with our congressional delegation and we are doing everything we can to get that bill across the finish line,” Seelhoff said.
But it could be a hard sell. The Medicare Payment Advisory Commission has favored lower payment rates to home health providers for the past eight years. In an August comment letter to CMS Administrator Chiquita Brooks-LaSure supporting the proposed Medicare rate cut, the commission said home health payment levels were well above the cost of providing care. The commssion raised no concerns about home health deserts, stating that 98% of Medicare beneficiaries live in zip codes with at least two providers.
Still, some providers fear continued reimbursement cuts will force more home health agencies out of business, creating new care deserts and more problems for them.
Hillcrest Health Services in Bellevue, Nebraska has been flooded with home health referrals over the past few years as other providers have gone out of business or limited patient access in the eight Nebraska counties where it offers services, said Reggie Ripple, vice president of home and community based services. He said the nonprofit had to turn away about 1,600 patients last year and is on track to turn away about twice as many patients this year.
“I don’t have enough staff to take care of [the patients] I have today,” Ripple said. “There is only so much we can do. People are absolutely going to have access issues.”
But providers in some areas are stepping in to fill care voids where they can.
In May, Evangelical Lutheran Good Samaritan Society began offering home-based care in International Falls, Minnesota after the small Canadian border town lost its only home health provider, said president and CEO Nate Schema in an email.
Schema said community leaders asked the Sioux Falls, South Dakota-based nonprofit to step into the vacancy because it had already operated a senior living community in International Falls for six decades. He said Good Samaritan Society obliged because it made a longstanding commitment to the health and well-being of the people who lived there.
“We were proud to be able to step up and expand home health and hospice services to help fill the growing need in the area,” Schema added.
