The benefits of palliative care have been highlighted in a major way during the COVID-19 crisis.
Agencies that are able to safely manage chronically ill patients in the home are more valuable than ever. As that sort of care becomes more visible, and, in turn, easier to collect payment for, it has the potential to become another business line for home health care providers.
“We’re making sure that patients understand their medications and are just, in general, taking care of their illness,” Terri Maxwell, the chief clinical officer for Turn-Key Health, told Home Health Care News. “Because what we were really worried about were the sort of long-term consequences of people not accessing their primary care.”
Philadelphia, Pennsylvania-based Turn-Key Health is a community-based palliative care agency that serves health plans and their members, who usually have a serious or advanced illness.
That ability to avoid a decrease in health for those sort of individuals is part of the reason that CareCentrix — a large home-focused care management company — acquired Turn-Key Health in early May.
During the last few months, however, that proactive care has been even more vital, given the current state of the health care system.
“We didn’t want people to suddenly end up … in the emergency room in the middle of the worst time of the pandemic,” Maxwell said. “We really emphasized self-care. We did a lot of patient teaching and medication management over the phone. We were also using video to make sure that people were staying safe. And if they had a problem, they knew who to call and what to do.”
Increasingly, these types of services are reimbursable through Medicare Advantage (MA) plans, providing an opportunity for home health care agencies who already had the capabilities to step in.
More than 60 MA plans across the country are offering in-home palliative care as a supplemental benefit in 2020, according to an analysis by ATI Advisory.
Palliative care has continued to gain popularity in the U.S. due to its cost-saving benefits and also family health care decisionmakers taking a liking to the idea. Of those who were educated on palliative care and what it entails, 90% said they would be likely to consider the service if their loved one had a serious illness, according to a survey from national polling firm Public Opinion Strategies.
COVID-19 has made everyone feel a bit more helpless when dealing with the care for a loved one — from family members to other health care facilitators.
“One of the large provider groups that we work with in the South Florida area started referring us some more [patients] who they wanted us to keep a close eye on, as much as possible,” Maxwell said. “Because they normally see their patients really frequently. They were trying to get telehealth set up and everything, but they knew that there were some people that are at high risk, who could be potentially falling through the cracks without [additional support.]”
Palliative care will also likely get a boost from the distrust forming against other long-term health facilities during COVID-19, such as nursing homes.
What TurnKey Health offers is, in a lot of ways, a service that resembles the kind of visibility that family decisionmakers desire when placing a loved one in a nursing home. But it comes without the risks.
“I think that this is really an inflection point in the delivery of health care overall,” Maxwell said. “The [expansion] of just supporting people at home and preventing people from going to the hospital in the first place. So we sort of pride ourselves on the [idea that] we’re not a post-acute model. We’re a pre-acute model. We’re identifying people who are at risk for hospitalizations and have complex needs. And our goal is to go in and meet them, do very comprehensive assessments, understand what their needs are, understand what their goals are — and make sure that their treatment is aligned with their goals.”
The palliative care market is largely untapped, especially for home health care providers. Just like telehealth and other remote services, it’s growth is primed to accelerate during the public health crisis.
“Sometimes benefits are made available, but not necessarily adopted by health plans,” Maxwell said. “I’m hoping that there’s a greater adoption of the benefits that are now available.”
By Andrew Donlan | June 17, 2020
Source: Home Health Care News
Home care agencies have been trying to figure out how to partner with Medicare Advantage (MA) plans since the Centers for Medicare & Medicaid Services (CMS) announced the possibility back in 2018.
Anne Tumlinson, CEO of ATI Advisory, has the answers. She’s an expert on the economics of aging, a panelist at the upcoming Home Health Care News Virtual MA Summit and the latest guest on HHCN’s Disrupt podcast.
In our newest episode of Disrupt, Tumlinson breaks down the MA opportunities for home care providers by the numbers — from the number of plans offering in-home benefits to the financial considerations driving MA decisionmakers. Additionally, she briefs agencies on how the coronavirus is rocking the industry, what providers should say when pitching to plans and why home care’s future in MA is looking especially bright.
To hear that conversation and others, you can subscribe to Disrupt via Apple Podcasts, Google Play Music, SoundCloud or your favorite podcast app.
Tumlinson will dive even deeper into the financial considerations guiding MA decision makers at the Virtual MA Summit, which runs June 24 through 26. You can register here.
Until then, you can catch portions of HHCN’s conversation with Tumlinson below, edited for length and clarity.
HHCN: While many home care agencies want to work with MA plans, only a few are. In 2019, about 3% of MA plans offered in-home support services. Your team released some new data for 2020, pre-coronavirus, but what does that figure look like today?
Tumlinson: Today, there are 223 plans offering the new supplemental benefit in-home support services. That’s the category referring to in-home personal care services.
That is an increase over the previous year, which was only about 80. So the good news is we’re definitely seeing an increase from 2019, when these benefits could first be offered.
At the same time, this is also the first year plans could offer a whole new set of benefits much more focused on social-support needs. They’re called Special Supplemental Benefits for the Chronically Ill (SSBCI). It’s a category that lets plans offer benefits not related to health care at all — food, produce, meal, pest control, transportation, social-needs benefits.
Between the non-medical primarily health-related benefits and new non-medical services, we have 619 plans that are doing one and/or the other. That’s not a high percentage of the about 3,000 or 3,500 plans, but the fact that there are 619 plans doing this at all, to me, is like a small miracle.
Are all of those plans working with home care providers to offer those services?
It varies tremendously.
We’re definitely seeing the approach where somebody in the health plan has reached out specifically to a home care provider in their market — or two or three — to say: “Hey, we want to offer this benefit. Are you guys equipped to deliver it, and can we start to talk about what that relationship would look like?”
It might be a regional plan, like Geisinger or SCAN Health Plan. They want to work with regional local providers with whom they can build long-lasting relationships and can be collaborative to their approach to collecting data and information.
Another model we see [is from] some of the larger insurance companies like Humana (NYSE: HUM), Anthem (NYSE: ANTM) and WellCare (NYSE: WCG).
Some [larger plans] haven’t done anything, really. They just put these benefits in their benefit package, and they haven’t really built out a contracted network yet. It’s still a really immature set of relationships where there’s a lot of floundering around.
Model No. 3 is where there’s an intermediary that’s serving kind of like an aggregator. We have a relationship with a company called healthAlign. A couple health plans have contracted with them to essentially find all of the different home care providers and aggregate them in one platform to play the go-between role in terms of contracting and things like that.
That’s my favorite kind of model.
How has the coronavirus shaken up the MA industry?
It’s a little hard to say right now.
Many MA plans are in this very weird position where their costs are way down for medical care because doctors’ offices and everything else has been closed. They’re kind of sitting there with the pot of money they’re supposed to be spending that they haven’t been able to spend.
Secondly, they’ve been given this incredibly broad flexibility from CMS around these supplemental or non-medical benefits, which previously only a handful of them had been offering as formal benefits.
But now CMS is saying: “If you need to change that in the middle of the year, which is normally not allowed, [you can]. We get it. You did your benefit packages way back before anybody knew what COVID-19 was, and now you’ve got a bunch of people stuck at home, who need things like meals, groceries and in-home support services. We’re going to allow you health plans to make those changes in your benefit packages … so that you can meet your member needs and redirect the resources.”
But the third thing is there’s an enormous amount of uncertainty, so it’s really hard, especially for larger plans, from a financial standpoint, to say, “Let’s start buying in-home support services.”
They don’t know if three or four months from now there’s going to be this huge pent-up demand for all these elective procedures. So there’s some hesitation on their part to jump in with both feet and start paying for things that they haven’t been paying for before.
My opinion is given how long we expect this pandemic to dramatically affect our lives, it’s going to dramatically change the way that MA plans and health care, in general, are delivered — and these flexibilities will be more and more deployed.
It looks really good for home care right now. That is the bottom line.
I know there’s not a lot of data on those mid-year MA flexibilities, but this essentially means that MA plans could be adding new home care benefits right and left right now, right?
This all sounds really good for home care, but I don’t want to sound flippant because I know there are a lot of challenges to delivering home care as a result of the virus. But I think there will be a need.
What other recommendations would you have for providers looking to get involved with MA plans?
You’ve got to attack this in a variety of ways.
Look at the local health plans. Who in your market is a real leader at a community level? It could be a hospital, a health system, a physician group.
I always give the example of Geisinger or SCAN Health Plan. They’re a little bit less bureaucratic, and they’re a lot more focused on meeting the needs of [the] community.
Those are going to be the organizations that are more receptive to working with you. There’s fewer people to deal with, and you can find the decisionmakers and get in front of them.
If you’re part of a national organization, … think about, at your corporate level or at a regional level, what is going to be your strategy or your approach?
You’ve got power in numbers. You’ve got a quasi-network. How do you organize yourself in a way that gives you something to take to those conversations?
Finally, you have to have something to say about who you are when you make that approach, really making sure that you understand what is valuable to these health plans. “How can we as an agency be helpful in delivering [these services]?” And what are the benefits to you in offering them?
On the flip side, what are MA decisionmakers taking into account when they’re creating plans?
It’s a long process in deciding what’s going to go into a benefit package. We’re in June 2020, … and their [plan] decisions are all made for 2021.
In a month or two, if they haven’t already, [plans] are going to start thinking about what’s going to go into their packages for 2022.
How much extra money are they going to have under their bids and how are they going to divide that up? A lot of it goes into what other plans are doing in that market and how they can be competitive.
At the end of the day, what Medicare Advantage plans really want to do is be very, very competitive on enrollment. That’s No. 1. “How can we structure our benefit package to be attractive, both in terms of attracting new members and retaining current members?”
And then, “How can we do this in a way that doesn’t … increase spending in any way, shape or form above and beyond what we estimate it will?” They want to feel comfortable that they know what they’re doing when they price [supplemental benefits].
Finally, they care a lot about what we call coding — information that can help their care managers manage their population better. And then also, you know, what kind of information can help in the coding that they need to get paid well by CMS.
Finances are obviously an important part of the equation. We’ve heard from some providers working with MA plans that the payments they’re getting aren’t always great.
That’s exactly right.
[Imagine] for illustrative purposes every health plan getting $1,000 per member, per month.
Let’s just call that the benchmark right now. Then the plan says, “Hey, I think we can do this for $900 per member per month.”
CMS says: “That’s awesome. Of that difference of $100, you get to take $50 of it and do whatever you want with it.”
Not anything, but all that fun stuff that’s going to help you attract enrollees like lowering the cost of the plan premium, lowering out of pocket costs, offering supplemental benefits.
This is not a lot of money relative to the rest of the spend. Within that, they have to prioritize. This is very hypothetical right now, but there’s really a small amount of dollars available designated for the category that we’re talking about.
In many ways, this opportunity [for home care providers] is more strategic and symbolic than it is financially a big win.
The actuaries have to price the risk. They think, “Hey, how about if we pay $4 for every 15 minutes.” They don’t really know what they’re doing, so the rates are not great. Not always, but in many instances.
The last thing I’ll say about all this is that the policy environment is very fluid right now. This is an election year. We have a huge pandemic going on. Nursing homes are under fire. Medicare’s never been more flexible.
Going into next year maybe, there are going to be some proposals on the table to make the pot of money available for home care from public paying sources bigger because there’s a recognition that people really do need these services to stay home and to stay out of nursing homes.
Overall I’m hopeful that will go up. That’s why it’s so important to strategically position yourself with these payers now.
By Bailey Bryant | June 17, 2020
Source: Home Health Care News
John Stagliano never was much of a hospital guy.
“Anytime he ever went was when something bad happened,” said his son, also named John Stagliano. “I guess he had that, ‘Nothing ever good is gonna be coming from there,’ kind of thing.”
That made it all the more difficult when the elder Stagliano contracted the novel coronavirus at the end of February. At 82, he was statistically at a high risk for the disease to become serious, and potentially fatal. But despite his children’s pleading, he would not be admitted to the hospital.
“He just didn’t want to be there,” said his son John.
So he got his father set up to receive fairly intensive care in the basement of the Exton home the elder Stagliano shares with his wife, Catherine Stagliano. A home health care team through Penn Medicine brought an oxygen machine down to what the family calls the “man cave” and set up an app so his kids could monitor their father’s heart rate, temperature and other vital signs remotely.
For about two weeks, Catherine Stagliano, also 82, trekked up and down the steps to the basement, bringing her husband food and caring for him in the man cave.
Until, predictably, she started feeling sick, too.
For older adults, staying healthy often involves rotating in and out of skilled nursing facilities after an injury, a fall, or a joint replacement surgery. Sometimes, those short-term stays become long-term ones, in the same facility.
If the Staglianos hadn’t made a fuss, they would have likely ended up receiving care in a hospital for COVID-19 and then been discharged to a skilled nursing facility once they were stable — the same facilities that have been ground zero for the coronavirus pandemic. In Pennsylvania, two-thirds of COVID-19 deaths have happened there.
As families watch nursing homes struggle to contain the virus, many have started to consider bringing health care for their loved ones into their own homes.
The trend isn’t new. As the baby boomer generation ages, hospital systems, government agencies and insurers have been shifting long-term care away from costly institutions and toward the home for at least a decade. Many experts predict that the risks posed by COVID-19 may accelerate that process, whether the system is ready for it or not.
Is telemedicine the ‘new normal’?
The pandemic is already shifting the day-to-day logistics of seeing a doctor.
As soon as models began to predict that hospital systems could be overwhelmed by a surge of COVID-19 patients, the federal Centers for Medicaid and Medicare Services changed its policies surrounding telemedicine, allowing health systems to bill for remote appointments that previously would not have been eligible for reimbursement. That meant more people were able to receive care at home who would have otherwise created crowded hospitals and taken up valuable bed space.
At health systems around the Philadelphia region, doctors started treating more people virtually, at home, for a variety of illnesses, from addiction medicine to cancer treatment — as well as those with COVID-19, like the Staglianos.
“This situation … is shining a much brighter spotlight,” said David Baiada, CEO of Bayada Home Health Care, the largest long-term provider of at-home care in Pennsylvania. “It’s also creating innovation,” such as the remote monitoring of symptoms and increased use of telemedicine.
As people are discouraged from visiting the hospital for routine care, they’re also getting used to accessing it from home and could be more willing to keep doing so even after the pandemic lifts — especially if the loosened Medicare regulations remain in place.
“It’s going to be really hard to go back from that because now we’ve seen that it’s possible to do this and patients like getting telehealth and care at home,” Rachel Werner, head of the University of Pennsylvania’s Leonard David Institute of Health Economics, said of the relaxed telehealth restrictions. “In the next year or two, I think we’re going to find that nursing homes are going to have to close because there just won’t be as much demand for the care that they provide. I think we’ve probably turned a corner on that.”
Penn Medicine went to such great lengths to keep people out of the hospital that by mid-May the numbers of patients being treated at home and in the hospital were roughly the same. Traditional care at home was supplemented with multiple telemedicine visits a day and a lot of communication with family members. Still, said Nina O’Connor, chief medical officer for Penn’s home health care, the model asks a lot of family caregivers.
“At-home care does depend on informal caregiving from family members or friends,” said O’Connor. Though loved ones may have had more time than usual during the pandemic as shutdowns rendered many jobless, there is no guarantee that will continue to make the model sustainable, she noted.
“That is a real barrier, one that we haven’t completely overcome,” she said.
John and Catherine Staglioni, both 82., pose for a photo during a trip to Key West over the Thanksgiving holiday. Both were treated for COVID-19 at home in Exton, Pa. (Provided by John Staglioni)
John Stagliano said he was grateful his parents could remain at home, but he ultimately would have preferred if they had been in a setting where they had 24/7 monitoring.
“If they’re OK, the home care’s fine,” he said. “However, if they start not being able to take care of one another, then it becomes a problem. And all the home health care’s not gonna help you with that.”
While both parents were sick, Stagliano moved from his home in Reading to stay with his brother who lives nearby, so he could make the 10-minute drive to their house if necessary. He is able to work from home, so he had some flexibility. Even so, the care took a toll.
“My stress level was ridiculous,” Stagliano said.
Financial tides have begun to turn
Though the bulk of the residents at any given nursing home may be there for the long term, it’s the patients discharged from the hospital to recover after operations like joint replacements, or short-term illness like COVID-19, that come with higher reimbursement rates. Many nursing homes subsidize the care of their long-term patients through those short-term patients, who stay for just a few weeks.
The operations of nursing homes depend on both streams of patients, but the risks posed by COVID-19 could change both for the foreseeable future.
The notion of shifting more elder care into the home was brewing long before the coronavirus tore through nursing facilities. By 2050, the U.S. population over age 65 is expected to be nearly double what it was in 2012. Pennsylvania is particularly old, with 19% of its population over 65, compared to the national median of 14%.
“There are a lot of old people coming here soon, and we’re gonna have to figure out what to do with that and how to pay for it,” said Kirstin Manges, a national clinician scholar who studies post-acute care for older adults and a registered nurse by training.
Because of the anticipated rising costs that come with caring for more older adults, government officials and health system operators have been thinking about how to reduce the costs of elder care for more than a decade. Plus, people overwhelmingly want to stay at home.
“People express the desire to be able to age in place as much as possible, in their homes and in their communities,” said Kevin Hancock, deputy secretary of the state Department of Human Services’ Office of Long-Term Living. “That view has underwritten the development of long-term care services really for about the last 25 years.”
However, Medicaid-funded care through Social Security was initially set up to pay for nursing home stays, not care in the community.
Nationally, 87% of state Medicaid spending on long-term care went to nursing homes in 1990, according to a report from the Kaiser Family Foundation.
That started to shift after the passage of Americans with Disabilities Act in 1990. Lobbyists and advocates continuously made the point that home care is safer, more humane and more cost-effective than institutionalized long-term care.
The industry has adapted to challenges: Stymied by a limited stock of ADA-compliant housing, home health and government agencies have expanded their scope to focus on housing development, too. Philadelphia-based Liberty Resources has built 103 units through its own development arm, and priority is given to individuals transitioning out of nursing home care.
Pennsylvania has come a long way. By 2018, the state Department of Human Services had launched Community Health Choices, a program to codify and streamline community care for people with disabilities over age 21 and seniors who received Medicaid. The state also has a department dedicated to transitioning individuals out of nursing home care into their homes.
In Pennsylvania, 62% of the people now drawing those federal funds for long-term care receive that care outside of a nursing home. The funding is now split around 50-50, between institutional and community-based care.
Preliminary numbers for January through April of this year do not show an increase in the number of people moving out of institutional settings compared to previous years, so it’s too soon to know whether the pandemic will accelerate that shift.
By Nina Feldman, Laura Benshoff | June 12, 2020
The Patient-Driven Groupings Model (PDGM) and its unintended ripple effects were supposed to be the dominant story this year for the nation’s 12,000 or so Medicare-certified home health care providers. But the coronavirus has rewritten the script for 2020, throwing most of the industry’s previous projections out the window.
While PDGM — implemented on Jan. 1 — will still shape home health care’s immediate future, several other long-term trends have emerged as a result of the coronavirus and its impact on the U.S. health care system.
These trends include unexpected consolidation drivers and the sudden embrace of telehealth technology, the latter of which is a development that will affect home health providers in ways both profoundly positive and negative. Unforeseen, long-term trends will also likely include drastic overhauls to the Medicare Home Health Benefit, a revival of SNF-to-home diversion and more.
Now that providers have had roughly three full months to adapt to the coronavirus and transition out of crisis mode, Home Health Care News is looking ahead to what the industry can expect for the rest of 2020 and beyond.
‘Historic’ consolidation will still happen, with some unexpected drivers
Although the precise extent was often up for debate, most industry insiders predicted some level of consolidation in 2020, driven by PDGM, the phasing out of Requests for Anticipated Payment (RAPs) and other factors.
That certainly appeared to be true early on in the year, with Amedisys Inc. (Nasdaq: AMED), LHC Group Inc. (Nasdaq: LHCG) and other home health giants reporting more inbound calls related to acquisition opportunities or takeovers of financially distressed agencies.
In fact, during a fourth-quarter earnings call, LHC Group CEO and Chairman Keith Myers suggested that 2020 would kick off a “historic” consolidation wave that would last several years.
“As a result of this transition in Q4 and the first few months of 2020, we have seen an increase in the number of inbound calls from smaller agencies looking to exit the business,” Myers said on the call. “Some of these opportunities could be good acquisition candidates, and others we can naturally roll into our organic growth through market-share gains.”
Most of those calls stopped with the coronavirus, however.
Although the vast majority of home health agencies have experienced a decline in overall revenues during the current public health emergency, many have been able to compensate for losses thanks to the federal government’s multi-faceted response.
For some, that has meant taking advantage of the approximately $1.7 billion the U.S. Centers for Medicare & Medicaid Services (CMS) has distributed through its advanced and accelerated payment programs. For others, it has meant accepting the somewhat murky financial relief sent their way under the Provider Relief Fund.
In addition to those two possible sources of financial assistance, all Medicare-certified home health agencies have benefitted from Congress’s move to suspend the 2% Medicare sequestration until Dec. 31.
Eventually, those coronavirus lifelines and others will be pulled back, kickstarting M&A activity once again.
“We believe that a lot of the support has stopped or postponed the shakeout that’s occurring in home health — or that we anticipated would be occurring around this time,” Amedisys CEO and President Paul Kusserow said in March. “We don’t believe it’s over, though.”
Not only will consolidation happen, but some of it will be fueled by unexpected players.
With the suspension of elective surgeries and procedures, hospitals and health systems have lost billions of dollars. Rick Pollack, president and CEO of the American Hospital Association (AHA), estimated that hospitals are losing as much as $50 billion a month during the coronavirus.
“I think it’s fair to say that hospitals are facing perhaps the greatest challenge that they have ever faced in their history,” Pollack, whose organization represents the interests of nearly 5,000 hospitals, told NPR.
To cut costs, some hospitals may look to get rid of their in-house home health divisions. It’s a trend that may already be happening, too.
The Home Health Benefit will look drastically different
With a mix of temporary and permanent regulatory changes, including a redefinition of the term “homebound,” the Medicare Home Health Benefit already looks very different now than it did three months ago. But the benefit will likely go through further retooling in the not-too-distant future.
Broadly, the Medicare Part A Trust Fund finances key services for beneficiaries.
While vital to the national health care infrastructure, the fund is going broke — and fast. In the most recent CMS Office of the Actuary report released in April, the Trust Fund was projected to be entirely depleted by 2026.
The COVID-19 virus has only accelerated the drain on the fund, with some predicting it to run out of money two years earlier than anticipated. A group of health care economics experts from Harvard and MIT wrote about the very topic on a joint Health Affairs op-ed published Wednesday.
“COVID-19 is causing the Medicare Part A program and the Hospital Insurance (HI) Trust Fund to contend with large reductions in revenues due to increased unemployment, reductions in salaries, shifts to part-time employment from full time and a reduction in labor force participation,” the group wrote. “In addition to revenue declines, there was a 20% increase in payments to hospitals for COVID-related care and elimination of cost sharing associated with treatment of COVID.”
Besides those and other cost pressures, Medicare is simultaneously expanding by about 10,000 new people every day. The worst-case scenario: the Medicare Part A Trust Fund goes broke closer to 2024.
There are numerous policy actions that can be taken to reduce the financial strain on the trust fund. In their op-ed, for example, the team of Harvard and MIT researchers suggested shifting all of home health care under Part B.
In 2018, Medicare spent about $17.9 billion on home health benefits, with roughly 66% of that falling under Part B, which typically includes community-based care that isn’t linked to hospital or nursing home discharge. Consolidating all of home health care into Part B would move billions of dollars away from Part A, in turn expanding the Trust Fund’s lifecycle.
“Such a policy change would move nearly $6 billion in spending away from the Part A HI Trust Fund but would put upward pressure on the Part B premium,” the researchers noted.
Of course, all post-acute care services may still undergo a transformation into a unified payment model one day. However, the coronavirus has devastated skilled nursing facility (SNF) operators, who were already dealing with the Patient-Driven Payment Model (PDPM), a payment overhaul of their own.
Regulators may shy away from introducing further disruption until SNFs have a chance to recover, a process likely to take years — if not decades.
Previously, the Trump administration had estimated that a unified payment system based on patients’ clinical needs rather than site of care would save a projected $101.5 billion from 2021 to 2030.
Telehealth will be a double-edged sword
The move toward telehealth was a long-term trend that home health providers were cognizant of before COVID-19, even if some clinicians were personally skeptical of virtual visits. But because the virus has demanded social distancing, telehealth has forced its way into health care in a manner that would have been almost unimaginable in 2019.
In late April, during a White House Coronavirus Task Force briefing, President Donald Trump indicated that the number of patients using telehealth had increased from about 11,000 per week to more than 650,000 people per week.
Meanwhile, MedStar Health went from delivering just 10 telehealth visits per week to nearly 4,000 per day.
Backed by policymakers, technology companies and consumers, telehealth is likely here to stay.
“I think the genie’s out of the bottle on this one,” CMS Administrator Seema Verma said in April. “I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back.”
The telehealth boom could mean improved patient outcomes and new lines of business for home health providers. But it could also mean more competition moving forward.
For telehealth to be a true game-changer for home health providers, Congress and CMS would need to pave the way for direct reimbursement. Currently, a home health provider cannot get paid for delivering virtual visits in fee-for-service (FFS) Medicare.
Sen. Susan Collins (R-Maine) has floated the idea of introducing legislation that would allow for direct telehealth reimbursement in the home health space, but, so far, no concrete steps have been taken — at least in public. With a hyper-polarized Congress and a long list of other national priorities taking up the spotlight, it’s impossible to guess whether home health telehealth reimbursement will actually happen.
While home health providers can’t directly bill for in-home telehealth visits, hospitals and certain health care practitioners can. That regulatory imbalance could lead to providers being used less frequently as “the eyes and ears in the home,” some believe.
A new SNF-to-home diversion wave will emerge
Over the past two decades, many home health providers have been able to expand their patient census by poaching patients from SNFs. Often referred to as SNF-to-home diversion, the approach didn’t just benefit home health providers, though. It helped cut national health care spending by shifting care into lower-cost settings.
At first, the stream of SNF residents being shifted into home health care was like water being shot from a firehose: In 2009, there were 1,808 SNF days per 1,000 FFS Medicare beneficiaries, a March 2018 analysis from consulting firm Avalere Health found. By 2016, that number plummeted to 1,539 days per 1,000 beneficiaries — a 15% drop.
In recent years, that steady stream has turned into a slow trickle, with more patients being sent to home health care right off the bat. In the first quarter of 2019, 23.3% of in-patient hospital discharges were coded for home health care, while 21.1% were coded for SNFs, according to data from analytics and metrics firm Trella Health.
Genesis HealthCare (NYSE: KEN) CEO George Hager suggested the initial SNF-to-home diversion wave was over in March 2019. Kennett Square, Pennsylvania-based Genesis is a holding company with subsidiaries that operate hundreds of skilled nursing centers across the country.
“To anyone [who] would want [to] or has toured a skilled nursing asset, I would challenge you to look at the patients in our building and find patients that could be cared for in a home-based or community-based setting,” Hager said during a presentation at the Barclays Global Healthcare Conference. “The acuity levels of an average patient in a skilled nursing center have increased dramatically.”
Yet that was all before the coronavirus.
Over the last three months, more than 40,600 long-term care residents and workers have died as a result of COVID-19, according to an analysis of state data gathered by USA Today. That’s about 40% of the U.S.’s overall death toll.
CMS statistics place that number closer to 26,000.
In light of those figures and infection-control issues in congregate settings, home health providers will see a new wave of SNF-to-home diversion as robust as the first. As the new diversion wave happens, providers will need to be prepared to care for patients with higher acuity levels and more co-morbidities.
“[That’s going to change] the psyche of the way people are going to view SNFs and long-term care facilities for the rest of our generation,” Bruce Greenstein, LHC Group’s chief strategy and innovation officer, said during a June presentation at the Jefferies Virtual Healthcare Conference. “You would never want to put your parent in a facility if you don’t have to. You want options now.”
One stat to back up this idea: Over 50% of family members are now more likely to choose in-home care for their loved ones than they were prior to the coronavirus, according to a survey from health care research and consulting firm Transcend Strategy Group.
Separate from SNF-to-home diversion, hospital-to-home models will also likely continue to gain momentum after the coronavirus.
There will be a land grab for palliative care
Over the past two years, home health providers have aggressively looked to expand into hospice care, partly due to the space’s relatively stable reimbursement landscape. Amedisys — now one of the largest hospice providers in the U.S. — is the prime example of that.
During the COVID-19 crisis, palliative care has gained greater awareness. Generally, palliative care is specialized care for people living with advanced, serious illnesses.
“Right now, we are seeing from our hospital partners and our community colleagues the importance of palliative care, including advanced care as well as appropriate pain and symptom management,” Capital Caring Chief Medical Officer Dr. Matthew Kestenbaum previously told HHCN. “The number of palliative care consults we’re being asked to perform in the hospitals and in the community has actually increased. The importance of palliative care is absolutely being shown during this pandemic.”
As community-based palliative care programs continue to prove their mettle amid the coronavirus, home health providers will increasingly consider expanding into the market to further diversify their services.
Currently, just 10% of community-based palliative care programs are operated by home health agencies.
Demand will reach an all-time high
The home health industry may ultimately shrink in terms of raw number of agencies, but the overall size of the market is very likely to expand at a faster-than-anticipated pace.
In years to come, home health providers will still ride the macro-level tailwinds of an aging U.S. population with a proven preference to age in place — that hasn’t changed. But because of SNF-to-home diversion and calls to decentralize the health care system with home- and community-based care, providers will see an increase in referrals from a variety of sources.
In turn, home health agencies will need to ramp up their recruitment and retention strategies.
There’s already early evidence of this happening.
Last week, in St. Louis, Missouri, four home-based care agencies announced that they were hiring a combined 1,000 new employees to meet the surge in demand, according to the St. Louis Dispatch.
Meanwhile, Brookdale Senior Living Inc. (NYSE: BKD) similarly announced plans to hire 4,500 health care workers, with 10% of those hires coming from the senior living operator’s health care services segment.
Bayada Home Health Care likewise announced plans to ramp up hiring.
“We are absolutely hiring more people now than ever,” Bayada CEO David Baiada previously told HHCN. “The need for services — both because of societal and demographic evolution, but also because of what we anticipate as a rebound and an increase in the demand for home- and community-based care delivery as a result of the pandemic — is requiring us to continue to accelerate our recruitment efforts.”
The bottom line: The coronavirus may have presented immediate obstacles for home health providers, but the long-term outlook is brighter than ever.
By Robert Holly | June 10, 2020
Source: Home Health Care News
The COVID-19 pandemic has ushered in a new era of telehealth for primary care, and patient-centered care is now easier than ever. This has been the model promoted as early as 1967 by the American Academy of Pediatrics. The idea is that the patient and not the physician or the hospital is at the center of a wheel. Each health provider in the care team, including preventive, acute, and chronic care, is at the end of a spoke in the wheel. Each provider contributes to the care of the patient, but the patient is the ultimate decision-maker. Data shows that chronic medical conditions are managed better in this model.
Why isn’t patient-centered care just standard of care? One of the major barriers is how we have traditionally paid for health care: Under the fee-for-service model, the provider only received payment for a procedure or visit. But patient-centered care requires many time-consuming duties that are not patient visits, such as reviewing the medical record, reading and responding to email and phone calls, and monitoring tests. Under the fee for service model, those activities were not compensated.
The transition from fee-for-service to a more integrated form of patient compensation has been much too slow. As a result, physicians have been incentivized to fill their schedule with office visits. Many of these visits are not needed; they benefit physicians and the health care facility more than patients. Now that telehealth visits are being reimbursed at close to or equal to what office visits were, we can come closer to putting the patient at the center
A few years ago, at my hospital, the department of general medicine switched from fee-for-service to a “panel-based” model to compensate their primary care physicians. That means primary care physicians are now paid a fee per patient rather than per visit or procedure. My job is to manage my panel of patients and not to fill my schedule. For example, I get paid the same whether I manage a patient’s diabetes via the phone or in person. If I get an email from a patient with a question about their glucose monitoring regimen, it’s part of my job to answer. Under fee-for-service, I might spend 30 minutes answering that email without any compensation.
The old system incentivized my staff to call that patient into the office for a visit they may not really need just so I could get paid. Now, the incentive is to make contact based on patients’ preference and clinical need rather than physician need. With the panel management model, the financial interest of physicians is aligned with the patient’s health: the incentive is on what is necessary, not just what is doable.
We needed telemedicine before COVID, but the virus made it clear just how much and how quickly. Due to overwhelming need and demand, many of the old barriers to reimbursement have been lowered or eliminated. CMS and commercial insurance companies have issued policy changes expanding coverage and access so patients can get their care while staying at home. Health care systems have rapidly expanded the technological infrastructure to integrate telehealth with electronic health records. Additionally, many states are waiving in-state licensure requirements, allowing patients to “see” providers out of state. With this change, providers in Boston are now able to practice telemedicine for those who live outside Massachusetts and get paid at the same rate.
Telehealth won’t eliminate every barrier to patient-centered care. Many physicians are still skeptical about changes. They were trained in an era when the physician alone cared for the patient — some fear to lose the unique patient-doctor bond when other team members are involved in the care. The team approach requires patients to trust other physicians besides their own and be comfortable sharing sensitive and personal information with team members. As an ‘old school’ primary care physician in practice for 25 years, I was a late adapter to team care and telehealth. But I was always a proponent of patient-centered care. Now I see how interconnected they are.
As medical care is now more complex and fragmented, I have come to realize that team care is the best way to care for our patients because they have better access to us. For example, they can see a nurse practitioner instead of me with shorter waiting times. Furthermore, a nurse, social worker, case manager, mental health ‘coach’ or collaborator can more effectively educate patients, provide access to behavioral health services, and give tips on self-management support. I see physicians in my practice draws on the expertise of a variety of provider-team members. In sum, everyone gets more of what they need.
The recent changes in regulations in telehealth reimbursement need to be made permanent. Physicians should not be financially penalized for doing what is best for the patient. The old fee for service model is clearly not working: despite leading the world in medical expenditure, we are at the bottom on many health measures when compared with other advanced countries.
Our health care system, led by Centers by Medicare and Medicaid Services, needs to instead incentivize quality, improved outcomes, and patient satisfaction. Paying for telehealth and promoting non-face to face visits is one small step in practicing patient-centered care. Putting our patients first should not only be a slogan but a true mandate.
By Dr. Li Tso, opinion contributor — 06/09/20 11:00 AM EDT
Source: The Hill