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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

NAHC Submits Formal Comments on Medicare Proposal to Bundle Payments for Joint Replacement Services

September 11, 2015 10:57 AM

On Tuesday, September 8, the National Association for Home Care & Hospice (NAHC) submitted comments to the Centers for Medicare & Medicaid Services (CMS) on its proposal to establish a pilot program that “bundles” payments for lower hip and knee joint replacements (see previous NAHC Report article here for a summary of the proposed rule). In a letter to CMS Acting Administrator Andy Slavitt, NAHC called the proposed rule a “positive step,” and also provided a number of comments and recommendations to improve it. “With the significant growth in joint replacement services, innovative approaches to care and the financing of that care should be explored thoroughly,” NAHC stated. “At the same time, we support CMS’s recognition that innovations be approached carefully to ensure that there are no unintended adverse consequences. In line with such caution, NAHC offers the following comments that are intended to constructively improve the proposal.”

NAHC submitted the following comments and recommendations:

Beneficiary Protections

The proposal requires that the hospitals and other physicians included in the Comprehensive Care for Joint Replacement (CCJR) Model provide notice to beneficiaries regarding their freedom to choose any qualified provider, a list of the post-acute care options, an explanation of the CCJR model, and proposed cost-sharing and quality information. NAHC expressed support for the proposal’s protection of the beneficiary’s right to choose the course of care and provider. However, NAHC provided several revisions for CMS to strengthen the proposed beneficiary protection:

  • Revise the timing of the required notice to the beneficiary to a point prior to admission to an anchor hospitalization. NAHC noted that, “by the time a patient is admitted to a hospital, the course of action as well as the likely path of post-acute care may have already been designed.” Instead, notice should be provided prior to admission. NAHC stated: “The notice can be provided by the admitting physician regardless of whether that physician is participating in CCJR Sharing. Alternatively, since the surgery is generally elective, the hospital involved can convey the notice prior to admission once the surgery is scheduled.”
  • Devise a model notice regarding freedom of choice, including an explanation of the CCJR model and all of the care provider types that are included in the bundle. Such a model notice, NAHC stated, will “achieve a level of accuracy and consistency that will not occur with individual notice formats and contents devised by each hospital.”
  • Institute a “structured monitoring program to ensure compliance with the patient notice requirements,” including: A) Submission of any model notice format and content to the monitoring entity in advance of its use; B) Certification of assurances of compliance by the hospital/physician; C) Auditing of compliance within the first 30-60 days of implementation of CCJR; D) Annual auditing of compliance thereafter.

Access to Care

While “a payment model that financially rewards a hospital for reducing care costs has the potential to create barriers to care access,” NAHC expressed support for the CMS proposal to “monitor compliance” and “integrate the QIOs [Quality Improvement Organizations] into the process as an entity available to handle beneficiary complaints” in order to protect beneficiaries’ access to care. NAHC provided additional recommendations for CMS to protect access to care:

  • Provide appeal rights to any Medicare beneficiary comparable to those appeal rights available to Medicare Advantage enrollees. While adverse payment determinations are subject to appeal under the usual Fee-for-Service (FFS) rules, the potential for adverse care decisions exists in the CCJR model. Given that beneficiaries may face care steering that is counter to their interests, appeal rights are the best mechanism to protect those interests.
  • Establish a structured auditing system to monitor providers for compliance with the patient-centered care planning expected in the model. Such audits should be conducted by an outside party and should occur in the early stages of the new model and periodically thereafter.
  • Inform CCJR patients of the hotlines available to convey grievances on care at each level of service during the episode.

Provider Participation and Payment

In addition to supporting the proposal’s allowance for all Medicare-qualified providers to participate in the program’s post-hospital services along with the beneficiary’s freedom to choose a provider, NAHC expressed support for “maintaining the existing payment model for provider services along with direct provider payment. In addition, the payment reforms intended with the CCJR model are best managed through a shared-savings, payment reconciliation approach for both the episode initiators and other participants.” Furthermore, NAHC stated its support for “continuing the existing Medicare coverage standards for home health services and hospice care” with the “exceptions noted in regulatory waivers” (see “Regulatory Waivers” below).

Care Planning

Existing hospital discharge planning “has, on occasion, been focused on getting the patient out of the hospital rather than any extended planning relative to post-hospital care.” However, under the CCJR model, “post-hospital care planning takes on a wider and time-extended responsibility” and the “process of discharge planning must evolve if it is to fit the needs in the CCJR model.” Specifically, NAHC recommends that CMS:

  • Revise hospital discharge rules to incorporate the new responsibilities triggered by a 90-day CCJR episode. The modification of that rule should include a requirement that discharge planning involve an interdisciplinary team that incorporates expertise in all post-acute care capabilities.
  • Require that the episode initiator ensure the availability of and offer Advance Care Planning discussions, along with the opportunity to complete an advance directive.

Scope of CCJR Post-Hospital Services: Hospice Care

The CMS proposal includes hospice care in the bundle of post-acute care services subject to the CCJR model,but plans to exclude “unrelated” services that are defined as services for “acute clinical conditions not arising from existing episode-related chronic clinical conditions or complications of LEJR surgery; and chronic conditions that are generally not affected by the LEJR procedure or post-surgical care” from the bundle. However, the proposed rule does not include a rationale for differentiating hospice admissions “that are related to or unrelated to the purpose for and consequences of LEJR surgery.” NAHC recommends that CMS:

  • Disclose in detail its rationale for inclusion of hospice in the CCJR bundle. While the other included services are obviously appropriate, hospice services are unique and have been generally excluded from past bundling innovations.
  • Provide complete data on CCJR episode hospice spending and utilization to better understand the impact of including hospice in the CCJR bundle.
  • Establish detailed guidance on how to determine if the post-surgical hospice services are related or unrelated to the joint replacement surgery.
  • Establish a data acquisition system on hospice use in the final CCJR model.

Target Price

The proposed rule’s calculation of the Target Price measure that will be applied in determining any shared savings to the hospital episode initiator does not take into account over 900,000 claims from all Medicare provider sectors that are backlogged awaiting assignment to and adjudication by Administrative Law Judges (ALJ). Nor does the process for reconciliation in CCJR shared savings consider the pending ALJ appeals. Regarding the calculation of the Target Price, NAHC provided the following recommendations for CMS:

  • Include an estimate of the impact of the pending ALJ appeals on the Target Price. It is more reasonable to use an estimate based on historical reversal rates than to adjust the Target Price as appeal decisions are issued.
  • Include a mechanism in the reconciliation process to take appeal reversal into consideration where claims audits deny post-hospital services coverage in such areas as home health services.
  • Establish standards to address potential changes in provider specific prospective payment systems.


The proposal includes gainsharing standards that are “needlessly complex.” Therefore, NAHC provided the following comment: “Drop the gainsharing standards. Alternatively, simplify them significantly using deference to the hospital plan as a starting point.”

Regulatory Waivers

In addition to the regulatory waivers CMS included in the proposal, NAHC recommends modifications to the waivers as well as additional regulatory waivers for consideration by CMS:

  • Home Health Services “Homebound” and “Incident to” Services Direct Supervision Requirements.While CMS proposal would waive the “direct supervision” requirement for services “incident to” physician services, it rejects a waiver of the “confined to home” (homebound) requirement for coverage of home health services. However, CMS fails to recognize that the two overlap. NAHC recommends that CMS: 1) Establish a homebound waiver to fit the circumstances described in the “incident to” waiver. 2. Issue a clarification that specifically permits a hospital or community physician or non-physician practitioner to contract with an HHA for home nursing visits under the “incident to” waiver. This clarification should also provide that the Medicare home health agency Conditions of Participation do not apply to such visits.
  • Telehealth Services. NAHC supports the proposed waivers of the originating site and geographic service area for coverage of telehealth services. NAHC further recommends that CMS “waive the requirements of the telehealth services benefits as proposed along with a waiver of the requirement that such services be performed by physicians or non-physician practitioners and permit the provision of telehealth services by HHAs through licensed clinicians to individuals who are not receiving Medicare-covered home health services.”
  • Waiver of the physician certification requirements for home health services. “A waiver of the limitation requiring physician certification would permit the patient to maintain the connection with the primary practitioner without the need to insert a new physician into the patient’s care,” NAHC stated.  
  • Waiver of federal antikickback and patient gift rules related to pre-op counseling and home assessments by home health agencies. NAHC stated: “Certain orthopedic surgeons had found that such pre-op services improved the transition of patients to the home following joint replacement surgery, including reduced length of stay at the hospital and improved rehabilitation at home. However, with the OIG concerns set out in the referenced Advisory Opinion, such services have been effectively halted within home health services.”

To read the full letter containing NAHC’s recommendations, please click here.




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