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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton

Abt Explores Hospice Payment Options, Utilization in Technical Report for CMS

June 6, 2013 03:53 PM

Abt Associates, the Centers for Medicare & Medicaid Services’ (CMS) hospice payment contractor, has been conducting analysis of utilization and cost data to help inform discussions on ways to modify the current payment structure so that it better reflects actual costs incurred during a hospice length of stay. 

Hospice payment reform was mandated by the Affordable Care Act (ACA) to occur no earlier than October 1, 2013.  In a presentation at the National Association for Home Care & Hospice (NAHC) March on Washington earlier this year, an Abt representative discussed findings from their study related to:

  • Trends in Hospice Cost Reports           
  • Trends in General Inpatient Utilization (GIP)
  • Impact of the Face-to-Face Requirement on Hospice Benefit Periods

More recently, CMS posted online a copy of a hospice payment technical report, “Medicare Hospice Payment Reform:  Hospice Study Technical Report,” that contains study findings for the topics listed above, as well as Part D utilization while enrolled in hospice and discussion of payment reform options; these topics are covered as part of this article.


Part D expenditures for hospice patients are of interest to CMS because per diem hospice payment amounts are supposed to cover all care costs - including medications - for the terminal and related conditions for which a patient elects hospice. 

Previously, the Office of the Inspector General (OIG) had found that in 2009, “Medicare Part D was billed $33.6 million for prescription analgesic, antinausea, laxative, and antianxiety drugs, as well as prescription drugs used to treat COPD and ALS, that likely should have been covered under the per diem payments made to hospice organizations.”

Abt expanded on the OIG’s work, focusing on analgesics. They found that in 2010 112,555 hospice beneficiaries, 14.6 percent of those enrolled in Part D, received analgesic prescriptions through Part D.  Total value for the medications is estimated at more than $13 million. Abt found that over four-fifths of this cost was paid by Part D.


As part of the technical report, Abt provides a simulation of a potential tiered model for hospice payment and discusses rebasing of hospice payment rates as one possible component of payment reform.


Using data for 2011, Abt constructed a tiered payment model for routine home care (RHC) days that represents a modified version of the U-shaped payment model first advocated by the Medicare Payment Advisory Commission in 2009.  

According to Abt, “The general approach is to determine the average resource use for several different groups of hospice episodes…these groups correspond to the characteristics such as: where the hospice day is in relation to the start and end of the episode, whether a beneficiary is an extremely short stay hospice user, and whether the beneficiary received visits as recorded on the claim at the end of life.”

This tiered model is applicable for hospice stays that end in death. Future work could yield a somewhat different approach for hospice care that ends in live discharge.

Abt created seven potential payment “groups” or categories based on average daily resource use - each hospice day of care would be classified according to the category that best fits.  Rates are set based on the relative costs of care for that day within the length of stay. 

For the simulation, Abt established a relative or “implied weight” for each of the seven groups; the implied weight is equal to the ratio of the average resource use for the specific group divided by the total average resource use across all RHC days in the analysis.  Payment for each day in the group would be equal to the RHC base rate multiplied by the implied weight.   

Following are the seven groups with their associated “implied weight”:

  • Group 1: RHC care that occurs between days 1 and day 5 of a beneficiary’s lifetime length of stay. Implied weight:  2.30
  • Group 2: RHC care that occurs between days 6 and day 10 of a beneficiary’s lifetime length of stay. Implied weight:  1.11
  • Group 3: RHC care that occurs between days 11 and day 30 of a beneficiary’s lifetime length of stay.  Implied weight:  0.97
  • Group 4: RHC care that occurs on day 31 or later of a beneficiary’s lifetime length of stay. Implied weight:  0.86
  • Group 5: RHC care that occurs during the last 7 days of a beneficiary’s lifetime length of stay and the beneficiary is discharged dead. Beneficiary receives visiting service - nursing, aide, MSS, therapy - during the last 2 days of life if the last two days of life are RHC or the last two days of life are not RHC. Implied weight: 2.44
  • Group 6: RHC care that occurs during the last 7 days of a beneficiary’s lifetime length of stay and the beneficiary is discharged dead. Beneficiary does not receive visiting service - nursing, aide, MSS, therapy - during the last 2 days of life. Last 2 days of life are RHC. Implied weight:  0.91
  • Group 7: RHC care when the beneficiary’s lifetime length of hospice is 5 days or less, each day of hospice is RHC, and beneficiary is discharged deceased. Implied weight:  3.64

According to the report, “There is little meaningful change in average daily resource following 30 days in hospice (when the beneficiary is no tin the last 7 days of life).”  Presumably it is for this reason that Group 4 is open-ended.

Abt includes a summary table on page 49 of the report that provides insight into actual reported resource use for hospice days categorized according to the seven groups used in the simulation.  Abt also discusses applicability of budget neutrality for the first year of payment reform, and provides an impact table (page 51) of how the tiered model in the simulation would impact different hospice subgroups.  Abt is continuing its analysis in this area.

It should be noted that MedPAC recently put forth a potential “initial payment reform” step that includes a tiered approach to payment that has fewer tiers than has been simulated by Abt.  For discussion of MedPAC’s model, please see: NAHC Report, April 5, 2013.


Abt suggests that better alignment of payment rates and actual costs through rebasing of hospice payment rates could be one component of payment reform efforts.  Hospice base payment rates were initially set in 1983 based on the hospice demonstration agencies’ costs -- a sample of 26 hospices.  Since that time limited changes have been made but hospice care and the population served has changed considerably. Abt provides an approach under which the three labor components of RHC - nursing, home health aide, social services/therapy - which comprise nearly 70 percent of the original base payment rate, could be rebased. 

The data necessary to rebase the six other components included in RHC are not available at this time. Abt’s methodology for rebasing the labor components would result in a considerable reduction in payments for RHC – the rebased RHC rate in 2011 would have been $130.54, as compared with the actual rate for 2011 of $146.63. 

In a proposed rulegoverning the FY2014 Hospice Wage Index and Payment Rate Update (see NAHC Report, April 30, 2013), CMS discussed options for payment reform and addresses work on rebasing conducted by Abt but states that they do not have a proposal at this time to rebase hospice payments but have indicated that it is one of several approaches to hospice payment reform that could be considered in the future.  CMS notes that rebasing, as part of payment reform, would need to be done in a budget neutral manner – any savings achieved through the reduction of the RHC rate would need to be redistributed within the payment system.

Watch for future updates on CMS’ efforts to reform the hospice payment system in NAHC Report, Hospice Notes, and on the NAHC member listserv.




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