Category: ATI Advisory

Patients discharged from hospitals are increasingly headed to home health agencies, a new analysis from ATI Advisory shows.

In May 2019, of the 801,464 patients discharged from short-term acute care hospitals (STACHs), 11% were sent to home health agencies. In May 2020, of the 558,296 patients discharged from STACHs, 19% went to home health agencies.

The analysis took into account Medicare fee-for-service claims data incurred from January through May, then paid through June.

On a basic level, these latest figures confirm the role home health agencies have played during the COVID-19 pandemic. They also support comments made by the several home health executives who have said their referral partners have turned to in-home care more readily than in the past.

Yet it’s unclear if the shift toward home health is here to stay, according to Anne Tumlinson, founder and CEO of ATI Advisory.

“We don’t know yet how permanent this disruption in post-acute care discharge patterns will be,” Tumlinson told Home Health Care News in an email. “If it holds, it will be positive for home health when the pandemic eases and if hospital volumes return – even when the waivers go away. In other words, if they hold onto the size of their slice of the pie and the pie increases, that’s good for the industry overall.”

Of the 104,886 patients diagnosed with COVID-19 that were discharged from STACHs from January to May of 2020, 8% went to home health agencies. In comparison, 25% went to skilled nursing facilities (SNFs), with another 29% discharged directly home without services.

Of the 3.21 million STACH discharges to take place from January through May 2020, 17% were for home health care, according to the ATI Advisory analysis.

“I would say that we are very lucky that the Patient-Driven Payment Model (PDPM) and Patient-Driven Groupings Model (PDGM) were in place because they allow for the appropriate reimbursement for what is probably a more complex patient population overall,” Tumlinson said.

The ATI Advisory analysis is also noteworthy from a SNF-diversion perspective.

In May 2019, for instance, SNFs received 19% of all patients. But in May 2020, SNFs only received 15%.

Agencies have been bullish on SNF-to-home diversion since the outset of the COVID-19 pandemic. Still, SNFs are hopeful that the SNF-to-home trend will subside once the pandemic eases.

While these trends look good for home health agencies, they’re not necessarily indicative of the status quo moving forward.

Additionally, the analysis only takes into account Part A reimbursement for home health agencies — community-admits are not considered in the data.

“We would caveat this analysis by saying that it’s the claims data from just the first three months of the pandemic,” Elizabeth Burke, an analyst at ATI Advisory, told HHCN in an email. “We’ll have a better understanding of what this all means as we examine the data over time – when the next few quarters come in.”

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A number of major Medicare Advantage (MA) carriers are expanding their supplemental benefit offerings shaped around in-home care next year. UnitedHealthcare, the insurance arm of UnitedHealth Group (NYSE: UNH), is among them.

Overall, UnitedHealthcare partners with more than 1.3 million physicians and care professionals across the U.S., plus another 6,500 or so hospitals and other care facilities. In 2020, UnitedHealthcare had more MA enrollees than any other group.

“We know the majority of older adults want to stay in their homes and communities as they age, and UnitedHealthcare continues to design plans that place the home at the center of health care support and delivery,” Steve Warner, senior vice president of Medicare Advantage in UnitedHealthcare’s Medicare & Retirement division, told Home Health Care News.

America’s largest health insurers — UnitedHealthcare, Humana Inc. (NYSE: HUM), Aetna, Blue Cross Blue Shield plans and others — have built out their home strategies in a variety of ways.

In some cases, that has meant the launch of internal in-home primary care and remote monitoring programs to better track members’ social determinants of health. In others, it has meant partnering with in-home care providers to offer the types of new supplemental benefits that the U.S. Centers for Medicare & Medicaid Services (CMS) has increasingly signed off on over the past few years.

“The interconnectedness of the health care system means that every touchpoint along a consumer’s health care journey is important,” Warner said. “Particularly for high-risk individuals and others who depend on a variety of needs being addressed from home, the people who provide these services are an integral piece of a shared community of support.”

On its end, UnitedHealthcare says it’s doing more than ever to support health and wellness from the comfort, safety and convenience of the home.

In 2021, most of its plans, for example, will include HouseCalls, a program that offers Medicare and Medicaid members a yearly in-home visit with a licensed clinician. The company expects to complete nearly 1.7 million HouseCalls visits for members in 2020.

HouseCalls has been particularly valuable during the COVID-19 pandemic, too, with the number of home visits in the third quarter growing by nearly 30% year over year, according to UnitedHealth Group CFO John Rex, who addressed the topic during an Oct. 14 earrings call.

“We continue to deepen our engagement with those seniors most in need, increasing the distribution of remote digital sensor kits to collect and monitor vital health data and address gaps in care generated by the pandemic,” Rex said at the time.

‘Health is more than medical care’

Apart from its HouseCalls program, at least six UnitedHealthcare plans are offering in-home support services under the “primarily health-related” supplemental benefit pathway in 2021, according to state-level data compiled by Washington, D.C.-based research and consulting firm ATI Advisory.

In comparison, only two UnitedHealthcare plans offered in-home support services supplemental benefits this year.

Geographically, the two UnitedHealthcare plans offering in-home support services in 2020 covered slightly more than two dozen counties. Next year, the six plans doing so will cover more than 250 counties, according to ATI Advisory’s data.

“They have made a very significant, clear increase in the coverage,” ATI Advisory CEO Anne Tumlinson told HHCN. “I think it speaks a lot to the power of these benefits.”

Overall, 429 MA plans will offer in-home support services across 36 states and Puerto Rico next year. Many more will also likely offer home-focused supplemental benefits through the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway in 2021.

These trends in supplemental-benefit design are, in part, linked to the realization that a large chunk of a person’s health is ultimately impacted by functional ability and social factors, including access to food, friends and transportation.

“We know that health is more than medical care, and that factors outside a doctor’s office play a significant role in influencing a person’s health and well-being,” Warner said. “This reality factors into how we design our plans and support older adults.”

UnitedHealthcare isn’t just coordinating and covering services that take place within its members’ homes.

At times, it’s even helping to provide the home in the first place.

“At an enterprise level, UnitedHealthcare continues to make significant investments in affordable housing as part of the company’s ongoing efforts to remove social barriers to better health for people in underserved communities,” Warner said.

Since its affordable housing initiative kicked off in 2011, the company has worked with a range of advocates to invest more than $500 million in developments that increase access to housing, health care and social services.

Telehealth is ‘here to stay’

The U.S. tallied 91,530 new COVID-19 infections on Election Day, adding to the skyrocketing cases numbers reported in the past week.

The COVID-19 pandemic is changing the health care landscape, Warner recognized, but it isn’t altering UnitedHealthcare’s commitment to helping members access the care they need. That’s true whether they reside in a clinical setting or at home, he added.

To maintain that commitment, UnitedHealthcare has turned to more telehealth solutions.

“In just one month earlier this year, for example, more than 12% of our UnitedHealthcare Medicare members had a telehealth visit with their doctor – up from just a fraction of a percent last year,” Warner told HHCN.

In 2021, all standard MA plans from UnitedHealthcare will offer telehealth visits with a $0 copay.

“As in-person visits resume, telehealth utilization is moderating, but remains significantly higher than the pre-COVID baseline,” Warner said. “We believe higher utilization and increased comfort level in embracing telehealth is here to stay.”

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With hundreds of plans reportedly offering in-home support services in 2021, the coming year is certain to bring more Medicare Advantage (MA) opportunities for home care agencies.

But some home care operators will have more opportunities than others due to geographic variability across the MA landscape. To find leads, agency leaders will need to understand what’s going on in their market and identify plans to go after.

“We’re seeing a few states sort of rise to the top, with a number of plans offering in-home supports under Medicare Advantage,” Tyler Cromer, a principal at Washington, D.C.-based research and advisory firm ATI Advisory, told Home Health Care News.

To help home care operators with their MA strategies, ATI Advisory recently released its 2021 Medicare Advantage Supplemental Benefits State Report. Broadly, the report maps out where MA plans are operating while highlighting the supplemental benefits they’ll offer next year, including in-home support services.

It currently focuses on the 738 plans that will offer “primarily health-related” supplemental benefits in 2021.

“After going through this research process a few times with different organizations last year, we decided, this year, we’re going to package all the data up and put it on our website,” ATI Advisory CEO Anne Tumlinson told HHCN. “We learned that it’s actually kind of challenging for individual agencies and even corporate leadership to navigate government data this way. That’s our expertise.”

While the report comes at a cost, ATI Advisory shared key state-level takeaways with HHCN.

Of the 738 plans offering primarily health-related supplemental benefits next year, 429 will offer in-home support services, doing so across 36 states and Puerto Rico. Florida and California will have the most plans offering in-home support services in 2021, with 103 and 57, respectively.

“There are probably no surprises there, given the size of their population,” Cromer said. “And each has a lot of Medicare Advantage plans.”

Texas, Michigan and Ohio round out the top-five states for in-home support services, with 36, 31 and 24 plans offering in-home support services.

Meanwhile, in-home support services are newly available in six states in 2021, ATI Advisory data shows. Those states are Alabama, Iowa, Minnesota, Nevada, Oklahoma and Utah.

In terms of carriers, Anthem Inc. (NYSE: ANTM) and Centene are the leaders in the space, with each offering in-home support services and other expanded primarily health-related benefits in over 100 plans. Generally, 14% of all Medicare Advantage organizations will offer in-home support services in at least one of their plans next year.

“We’re actually seeing just more coverage of in-home support services geographically, across the country,” Cromer said. “We’re seeing real growth in this space, particularly around in-home support.”

When it comes to hunting for MA opportunities, home care operators need to take a two-pronged approach.

First, Tumlinson said, they must look internally to identify their value — and how they measure it.

“Do you have a digital platform for collecting information? Do you have electronic visit verification? What kind of data do you have on your employees? What can you say about your quality?” she said. “You want to look at all of those things and what makes you a strong operator relative to your competition.”

While looking inward, home care leaders must also conduct their own market intelligence to figure out the MA plans they want to appeal to.

Then, it’s all about shaping an agency’s Medicare Advantage pitch. If an MA plan is interested in working with an agency, it will then assist with final steps like credentialing and more.

“Once you’re in a conversation with a plan about how to be part of their network of providers, either they or some other third-party intermediary will assist with making sure that you’re a credentialed provider for the purposes of being in-network, that you’re set up to submit claims and things like that,” Tumlinson said. “Those pieces are hard, but they’re all problems you can solve.”

“The relationship is the hardest part,” she added.

Updated data from the Centers for Medicare & Medicaid Services (CMS) shows that MA penetration has reached 40% of the total Medicare-eligible population for the first time in history. There were about 25.4 million MA beneficiaries nationwide for the month of October, with a total Medicare-eligible population of 62.4 million.

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The U.S. Centers for Medicare & Medicaid Services (CMS) last month released new Medicare Advantage (MA) figures highlighting a massive expansion of plans offering home-focused supplemental benefits in 2021.

The agency shared additional data on Wednesday — and it now appears the ongoing home care MA movement is even bigger than originally anticipated.

“These benefit offerings are growing,” Tyler Cromer, a principal at Washington, D.C.-based research and advisory firm ATI Advisory, told Home Health Care News. “And they’re growing substantially.”

CMS’s Medicare Advantage preview from September revealed that 738 plans are offering supplemental benefits under the “primarily health-related” pathway in 2021, a 46% increase compared to the nearly 500 plans that did so in 2020.

The preview similarly showed that 920 plans are offering benefits under the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway next year, a nearly four-fold increase compared to the 245 plans that did so this year.

The latest data from last week offers deeper insights around the primarily health-related pathway, according to ATI analyst Elexa Rallos.

“These data show all of the benefits that the entire universe of Medicare Advantage plans offers,” Rallos told HHCN. “We’re able to go in and really dig into which plans are offering what, then pull all the information on a high level about the availability of these benefits.”

So what’s the big news for home care operators? Of the 738 plans operating in the primarily health-related MA pathway in 2021, 430 are offering “in-home support services,” or services that typically fall under a home care agency’s core business mix.

For context, just 223 plans offered in-home support services through the primarily health-related MA pathway in 2020.

“When we are able to dig into the data a little bit more, we’re able to see that there’s almost a two-fold increase in in-home support services,” Cromer said. “There’s also more than double the number of plans offering home-based palliative care compared to 2020. There’s a lot of growth here — and that growth is being driven by services provided in the home.”

To Cromer’s point, just 61 MA plans offered home-based palliative care under the primarily health-related pathway last year. More than 130 will do so in 2021, a trend that illustrates older adults’ overwhelming preference to age in place and avoid facility-based care.

“I think, again, that reflects the desire to meet Medicare beneficiaries where they are,” Cromer added. “The idea is to give them services that really add value and allow them to stay at home, to live their lives the way they want to.”

Limited benefits

Anthem Inc. (NYSE: ANTM) and WellCare are the leading MA plans offering in-home support services in 2021, according to ATI’s analysis. Both Anthem and WellCare offer in-home support services in more than 100 plans, Rallos noted.

Martin Esquivel, VP of product management and strategic initiatives for Anthem, previously discussed the insurance giant’s approach to supplemental-benefits design with HHCN.

“We recognize that beneficiaries that experience limitations in [ADLs] are at … greater risk for a fall, greater risk of social isolation and more likely to have access-to-care issues,” Esquivel said in October 2019. “Helping create a stable, safe environment in the home, we see that as a first step toward helping beneficiaries down a path toward a more comfortable, sustainable health care experience.”

In addition to those offering in-home support services and home-based palliative care in 2021, 127 plans will offer adult day health services, 176 will offer therapeutic massage and 95 will offer some type of service aimed at caregiver support.

In terms of geography, the MA plans offering in-home support services under the primarily health-related pathway next year operate in 36 states and Puerto Rico. On a county level, there appears to be a particularly strong concentration in New York, Michigan, Indiana, Maine and a handful of other states.

Exactly 11 states have MA plans offering home-based palliative care in at least one county in 2021, according to ATI.

While home care operators should be excited about the spike in plans offering in-home care benefits, they should also remember that most plans are working with limited resources. That means benefits aren’t always robust or equivalent to what home care agencies do for their typical, private-pay client.

“These are limited benefits … that MA plans are providing with limited dollars,” Cromer said. “Benefits we’re seeing are generally ranging from, let’s say, roughly 24 hours to 200 hours a year of services, or per discharge from the hospital.”

Stay tuned on SSBCI

ATI Advisory is currently working on an even deeper analysis of CMS’s Medicare Advantage data dump from Wednesday. Toward the end of this week, the firm hopes to share detailed information on what plans are doing state by state, county by county.

Part of that effort is to give home care operators a better understanding of what MA plans are doing in their individual markets.

As for the SSBCI pathway, which is arguably the even bigger opportunity for the home care industry, ATI Advisory likely won’t have anything new to share until early 2021. CMS releases its MA numbers as part of what’s called the “plan benefit package files,” updated quarterly.

“We expect an additional tranche of data to come out in early 2021,” Cromer said. “And that will include information about Special Supplemental Benefits for the Chronically Ill, along with some other information.”

CMS first introduced the primarily health-related flexibility under MA in 2018 for the 2019 plan year.

Broadly, “primarily health-related” can include services that diagnose, prevent or treat an illness or injury. It can also include services aimed at lessening or improving some sort of functional impairment that hinders an individual’s ability to perform activities of daily living.

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