President Joe Biden focused on the ongoing COVID-19 pandemic during his first full day in office Thursday. In doing so, he once again drew attention to home-based care and getting the current “workforce crisis” under control.
“Our national strategy is comprehensive,” Biden said during an address from the White House. “It’s based on science, not politics. It’s based on truth, not denial — and it’s detailed.”
Since taking office, the president has signed 10 executive orders aimed at expanding COVID-19 testing and vaccine availability, with an ambitious goal of 100 million vaccine doses by April. The Biden administration unveiled a nearly 200-page pandemic preparedness plan on Thursday.
Wednesday saw more than 184,000 new cases of COVID-19 infection across the U.S., according to a New York Time database. More than 400,000 people have died since the pandemic began last year.
“Things are going to continue to get worse before they get better,” Biden said.
Biden’s pandemic preparedness plan is organized around seven goals, with the first goal focused on “restoring” trust with the American people. Protecting individuals most at risk — partly by expanding access to high-quality health care — is likewise a main goal under the plan.
“Specific actions include efforts to increase funding for community health centers, provide greater assistance to safety net institutions, strengthen home- and community-based services, expand mental health care, and support care and research on the effects of long COVID,” the plan states.
Dating back to his presidential campaign, Biden has proposed numerous investments in home- and community-based services as part of his plan to “Build Back Better.”
Wednesday’s pandemic plan notes that the U.S. Department of Health and Human Services (HHS) — including the Centers for Medicare & Medicaid Services (CMS) and the Administration for Community Living — will be tasked with identifying “opportunities” and “funding mechanisms” to provide greater support for individuals receiving care at home.
The plan also says that the administration will pay “particular attention” to “the home care workforce crisis.”
Washington, D.C.-based LeadingAge was among the first aging services organizations to voice support for Biden’s COVID-19 response.
“This virus has raged out of control for nearly a year, while our community has desperately called for help,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement. “So to have the new administration lay out plans on Day 1 to put COVID at the top of its agenda is welcome and hopeful news.”
To better track vaccination progress for seniors in congregate settings, in the community and in their homes, the Biden administration is also floating the idea of new reporting measures.
For example, to increase incentives to vaccinate Medicare beneficiaries, the plan explains, CMS will evaluate how to incorporate quality measures for COVID-19 immunizations into its value-based purchasing programs, including Medicare Advantage Star-Ratings, the physician quality payment program and accountable care programs.
One of the executive orders Biden signed directs cabinet agencies to invoke the Defense Production Act to scale up production of materials needed for vaccine shots.
“In the midst of the virus spiking and community spread, we’ve been on the battlefield trying to protect older adults and workers with limited support,” LeadingAge’s Sloan said. “We hope this means the cavalry is coming, especially on testing and vaccine initiatives.”
Another executive order empowers HHS, the Department of Defense and others to provide “targeted surge assistance” to critical care and long-term care facilities, including nursing homes and skilled nursing facilities (SNFs), plus assisted living facilities and more.
The new pandemic plan follows a couple of key HHS and CMS leadership announcements made earlier in the week.
The new administration on Wednesday tapped Liz Richter to lead CMS on an interim basis during the presidential transition. The agency’s website now lists Richter, who has worked at CMS in various capacities since 1990, as acting administrator.
Former CMS Administrator Seema Verma submitted her resignation last week with an effective date of Jan. 20.
The president on Tuesday nominated Dr. Rachel Levine to serve as assistant health secretary. Levine is currently the Pennsylvania health secretary, and a pediatrics and psychiatry professor at Penn State College of Medicine.
Biden already nominated California Attorney General Xavier Becerra to serve as HHS secretary, though he — along with the administration’s eventual pick for CMS chief — must eventually be confirmed by the Senate.
Dr. Micky Tripathi will lead the ONC as the new national coordinator for health information technology, while agency veterans Liz Richter and Norris Cochranwill serve as interim leaders for CMS and HHS, respectively.
“Nobody knows what the future holds” has been one of the biggest lessons learned during the COVID-19 emergency.
But even as the home health industry plays its part in responding to new infection spikes across parts of the country, it has never been more important to stay ahead of the curve. To remain competitive in coming months and beyond, agencies must identify the key trends that will help or hurt their businesses.
Yes, the coronavirus will continue to shape home-based care in 2021, especially when it comes to technology adoption, policy and outside investment. The Patient-Driven Groupings Model (PDGM) will likewise come back into the spotlight.
Each January, Home Health Care News tries to predict some of the top trends for the coming 12 months. That task may never be more complicated than it is right now.
Investment in home-based care will reach new heights.
This prediction probably goes without saying, but investment in home health care will reach new heights in 2021, with interest driven by private and public payers alike.
Prior to 2020, home health operators spent years trying to explain the value of their services to private payers and Medicare Advantage (MA) plans. Despite those outreach efforts, most providers have still struggled with non-competitive rates and strict limits around utilization.
But to keep high-risk populations healthy, payers had to increasingly turn to home health care during the COVID-19 emergency, giving providers an improved bargaining position. In one success story, for example, LHC Group Inc. (Nasdaq: LHCG) was able to grow its non-Medicare episodic admissions by about 35% in 2020, with the majority of those admissions coming at a Medicare-equivalent rate.
“Last year, we had been more engaged with our payers than ever before,” LHC Group President Joshua Proffitt noted at a recent investor conference.
In a November survey of 76 health plan executives from CareCentrix and KRC Research, 97% of respondents said they believed more care at home is better for both their organizations and their members. A similarly high percentage said they believed treating members at home is more cost effective than facility-based care.
As more private payers invest in home health care, “total cost of care” will become the most important metric for providers to track.
From a public perspective, federal and state-level policymakers will also aggressively search for new ways to invest in home- and community-based care. That could simply mean allocating more money for home health agencies as part of the annual payment update, but it could also mean updating post-acute care policies to shift more patients away from skilled nursing facilities (SNFs).
“The tragic devastation wrought by the coronavirus on nursing home residents exposes America’s over-reliance on institutional long-term care facilities,” CMS Administrator Seema Verma said in a September announcement. “Residential care will always be an essential part of the care continuum, but our goal must always be to give residents options that help keep our loved ones in their own homes and communities for as long as possible.”
Along with payers, private equity groups will maintain their laser-sharp focus on home health investments in 2021.
There will be a turf war over the home.
More money flowing into home-based care and a brighter spotlight will naturally breed more competition. As a result, traditional home health agencies will need to find their footing in a new, more crowded ecosystem.
The hospital-at-home model is a good example of this idea.
In response to acute care capacity challenges, the U.S. Centers for Medicare & Medicaid Services (CMS) launched a new hospital-at-home waiver in late 2020, granting hospitals “unprecedented” flexibility to care for patients in the home setting.
As of Jan. 13, there were at least 80 hospital participants in the initiative.
To work, hospital-at-home programs require hands-on care and other services, including remote patient monitoring. In many ways, the concept adds to what home health agencies already do, especially those with a history of caring for high-acuity populations.
The same could be said for emerging SNF-at-home programs.
Moving forward, home health operators will need to make sure they’re not being overshadowed by specialized hospital-at-home or SNF-at-home models. Cindy Krafft, owner and founder of Kornetti & Krafft Health Care Solutions, said it best during a recent HHCN webinar.
“I’m not a fan of ‘hospital at home’ or ‘SNF at home’ as a designation or evolution,” Krafft said. “I think home care is home care, and it doesn’t need to be ‘another setting came to your house.’ We’re already there. As we look at what other models can do for managing different types of patients, I think we’ve already shown what we can do.”
It’s not just hospital-at-home and SNF-at-home models. Seemingly countless home-focused health care startups are popping up, too, with in-home urgent care models particularly gaining lots of attention.
Home health operators have fought long and hard to “own the home.” In 2021, they’ll need to fight for that ownership.
Patient-acuity levels will continue rising, forcing agencies to become more specialized.
There is a common misconception that home health agencies only treat younger patients in relatively stable, good condition. That hasn’t been true for a long time.
First of all, individuals who utilize home health services are older than the broader universe of Medicare patients. Roughly one out of every four home health patients is over the age of 85, while just 10.9% of the overall Medicare population is over that age, according to the 2020 Home Health Chartbook.
At the same time, nearly half of all home health users suffer from five or more chronic conditions, such as asthma, arthritis, diabetes or heart disease. Just 22.4% of all Medicare beneficiaries suffer from that many chronic conditions all at once.
Home health users are additionally more likely to live alone and have two or more functional limitations.
These and other statistics reflect the high-acuity profile of most home health patients. In the wake of the COVID-19 pandemic and hospitals rushing individuals back home to preserve capacity, that profile is only growing more acute — and that’s a boon for providers.
“Where I see the most acceleration going forward is in higher-acuity home care,” Susan Diamond, home care business president at Humana Inc. (NYSE: HUM), told HHCN in December. “Physicians are starting to embrace the delivery of hospital-level and skilled nursing care in the home. In the past, physicians were more inclined to refer a patient to a facility setting.”
To keep up with rising acuity, home health agencies will need to become even more specialized, with dedicated programs addressing respiratory health, wound care, heart health and more.
Policymakers will take a sledgehammer to the traditional home health benefit.
The home health benefit under Medicare has been as rigid as a slab of concrete. But health care thought leaders are starting to chip away at that block in recognition of home health providers’ versatile capabilities.
At one time, home health care was a service people received after leaving the hospital or another institutional care setting. Today, home health agencies regularly help their patients stay out of the hospital or a SNF in the first place.
According to the most recent data on Medicare discharge patterns, roughly one-third of home health episodes are preceded by an institutional stay. That means two-thirds of all home health episodes — the vast majority — come from the community.
Home health care isn’t just becoming more “pre-acute.” As previously noted, it’s also becoming “more acute” — and an important cog in the hospital-at-home and SNF-at-home machines.
In 2020, the Medicare Payment Advisory Commission (MedPAC) started to reimagine the home health benefit to reflect this wider spectrum.
“I think one of the interesting challenges of home health is that it seems to be evolving into multiple types of care,” MedPAC commissioner Amol Navathe, co-director of the Healthcare Transformation Institute at the University of Pennsylvania’s School of Medicine, said at a December meeting. “We’ve heard already that there are developments in hospital-at-home, how many of the [alternative payment models] models like bundled payments are starting to shift patients from SNF to home health, which perhaps means that the acuity of patients in the home health care setting is also evolving, to some extent.”
With more attention on in-home care than ever before, policymakers will look to take a sledge hammer to the existing rigid home health benefit.
It may not happen in 2021, but soon the home health benefit will look very, very different.
These are just a few of the quotes HHCN gathered in 2020 touting the value of telehealth and virtual visits.
Despite the tragedy and devastation brought on by the coronavirus, the public health emergency accelerated the pace of home health innovation by a decade. To preserve personal protective equipment (PPE) and minimize exposure risks, operators across the industry have turned to telehealth with resounding success.
LHC Group, for example, went from about 176,000 telehealth and virtual visits in the first quarter of 2020 to more than 261,000 in Q2. The Los Angeles-based American Homecare Health Services used telehealth to help grow its patient census by about 10% while operating in one of the biggest COVID-19 hotspots in the country.
For the most part, this home health shift has been financed out of agencies’ own pockets. As things still stand as of January 2021, Congress has not yet given CMS the green light to directly reimburse for in-home virtual care.
But that may soon happen.
In October, U.S. Senators Susan Collins (R-Maine) and Ben Cardin (D-Md.) introduced the Home Health Emergency Access to Telehealth (HEAT) Act, a bipartisan bill to provide Medicare reimbursement for audio and video telehealth services furnished by home health agencies during the COVID-19 pandemic and future public health emergencies. A companion bill was also introduced in the House.
While neither piece of legislation has made it out of committee, this kind of common-sense issue is the perfect bridge for a deeply divided government. In light of the recent Washington, D.C., turmoil, lawmakers will want to quickly show American voters that they can still work together — and there’s no better, nonpartisan way to do that than by passing the HEAT Act.
Once that happens, it will be arguably the most important domino to fall in ushering in a new age of telehealth.
That ‘historic’ M&A activity we predicted for 2020? It’s still coming.
Two years ago, home health M&A experts believed the implementation of PDGM and changes to Requests for Anticipated Payment (RAPs) would lead to a “historic” number of transactions. Smaller agencies wouldn’t be able to survive all the cash-flow disruptions coming at one time, they speculated.
Well, that wave of deals never really materialized. New operational flexibilities, government stimulus money and other COVID-19 lifelines created a “sugar high” for some of the operators that may have otherwise sought to exit the market.
“The disruption from the implementation of PDGM and impact from the reduction (and in 2021 the full elimination) of the RAP was largely mitigated by Cares Act funds that helped to support the broader health care space,” Kusserow said. “Once the Public Health Emergency is over and there is no more Cares Act or additional government support, the impact that we thought we would see in 2020 will play out in 2021 – fewer players with more market share.
There have already been signs of that playing out as the industry has stabilized from COVID-19’s impact.
Overall, the fourth quarter of 2020 saw at least 17 deals for home health assets, data from M&A advisory firm Mertz Taggart shows. That’s the most home health deals in a single quarter since Q3 of 2018.
As healthcare spending continues to rise, so too does the inherent risk for bad actors to take advantage. Today, the United States is estimated to spend nearly 18 percent of its GDP, or $3.6 trillion, on healthcare, and is expected to increase to one-fifth of GDP within the next decade, according to the latest data. This alone provides ample motivation for fraud and abuse. While the full extent of healthcare fraud is difficult to measure,
The National Health Care Anti-Fraud Association (NHCAA) conservatively estimates that 3 percent – $68 billion – of all healthcare spending is lost to fraud each year. Others, such as the Federal Bureau of Investigation (FBI), estimate fraud accounts for up to 10 percent of healthcare expenditures.
Unfortunately, the COVID-19 pandemic has only accelerated the motivation for fraud and abuse amid the increased fear, confusion, and a relaxed regulatory environment. From fake cures to malware and illegitimate charities, fraudsters are taking advantage. Telehealth, which has experienced exponential growth aided by regulatory accommodations to facilitate its widespread adoption, is an area of particular concern. In turn, states and healthcare organizations must optimize their program integrity operations and telehealth strategy to stay protected amid healthcare’s new normal.
Greater Access Brings Greater Risk
The pandemic-driven expansion of telehealth has been profound in terms of enabling care access and continuity while reducing the risk of infection. When the Centers for Medicare and Medicaid Services (CMS) temporarily expanded telehealth coverage at the start of the pandemic, adoption soared to unprecedented levels.
According to a McKinsey report, providers have seen 50 to 175 times more patients through telehealth appointments compared to any year prior. At the same time, once-strict regulations governing telehealth services have been relaxed during the COVID-19 emergency, and the federal government has proposed to make permanent many of the regulatory changes initially meant to temporarily increase access to telehealth.
In parallel and perhaps unsurprisingly, there is a growing sentiment that telehealth is here to stay. According to a recent CynergisTek survey, 70 percent of consumers plan to continue using telehealth post-pandemic. From a provider perspective, new research from Bain & Company found that more than 80 percent of providers will continue to use telehealth as much or more than they do now.
All this considered, we must acknowledge the inherent risks of this technology. Telehealth has a poor track record for fraud, waste and abuse, with some of the largest healthcare fraud schemes involving telehealth providers. This September, for example, the Department of Justice announced the largest case of healthcare fraud in history, involving more than 300 individuals who submitted over $6 billion in fraudulent claims, with telehealth accounting for $4.5 billion of those claims.
With providers struggling to meet fluctuating demand amid unprecedented revenue shortfalls, improper billing practices — both intentional and inadvertent — are, to some degree, inevitable. Factor in hundreds of new telehealth codes and coding considerations as well as the overall stress on the healthcare system, and it is clear we must examine existing risk mitigation measures through a new, post-pandemic lens.
Strategies for Mitigating Telehealth Fraud & Abuse
For healthcare organizations and, specifically, special investigation units (SIUs) tasked with combatting fraud and abuse, the shift to telehealth adds an additional layer of complexity. Fortunately, there are strategies healthcare organizations can implement to successfully navigate the evolving landscape while strengthening the integrity of their operations for healthcare’s new normal.
Data visualization is a key component of an effective fraud investigation. Charts and graphs provide a clear representation of trends and outliers, including connections that could indicate a kickback or collusion scheme. Critical to the success of these tools, however, is the quality of the data that underlies them. Collecting sample data based on the appropriate modifiers and conducting thorough background research provides an accurate portrayal of events from which SIUs can clearly identify and pursue potential fraud schemes.
Integrating qualitative research into telehealth strategies is a great way to capture fraud at the source. When appropriate, conducting interviews with patients can validate whether services were in fact rendered as billed. For instance, a provider may bill for audio-only services as if they were delivered in an audio-visual capacity, resulting in an unjustifiably higher reimbursement rate. Similarly, using data visualization techniques to identify suspect trends, such as blanket billing or an implausibly high volume of services during a known low-demand period, can inform pointed questions for patients.
As we traverse this unprecedented territory, being on high alert for potential indicators of fraud and abuse is critical to protecting healthcare organizations and consumers. If something doesn’t make sense, whether clinically or in the context of the larger healthcare landscape, it is worth investigating. Understanding the limitations of telehealth and other key considerations surrounding its use will help to ensure we are maximizing the benefits of these services while mitigating their inherent risks.
Healthcare providers and patients alike have embraced telehealth during the COVID-19 crisis and, in doing so, confirmed what advocates have been saying for years — that telehealth promotes greater access to care. While ultimately good news for stakeholders across the healthcare spectrum, the environment we find ourselves in today has also created new avenues for fraudsters to take advantage. As telehealth becomes an inseparable part of the healthcare ecosystem, we are quickly learning how to identify telehealth fraud schemes, and, more importantly, strategies to mitigate the risks they post to integrity and security in the space.
About Gary Call, M.D.
Gary Call, M.D., is senior vice president and Chief Medical Officer at HMS, where he leads the company’s clinical program development and execution. Dr. Call has more than 25 years of experience in the practice of medicine and managed care. Dr. Call graduated from the University of Washington School of Medicine and completed his residency training at the University of Utah. He is a board-certified family physician.
The agency has finalized a rule that allows it to provide immediate Medicare coverage for FDA-approved products that are deemed “breakthrough devices.” The new coverage process would enable seniors to get access to these devices more quickly, but some provider and payer groups are concerned that this could cause patient harm.
In somewhat of a surprise move, U.S. health care policymakers unveiled plans last week to expand the Home Health Value-Based Purchasing (HHVBP) Model, a nine-state Medicare demonstration designed to better align reimbursement to quality of care.
Despite backing from most of the home health industry, the HHVBP Model — first implemented in 2016 — had seemingly hit a speedbump in recent years. Apart from a handful of minor modifications, the model only remained active in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee.
With more than one-quarter of its home health agencies currently located in HHVBP states, the Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED) has been among the biggest supporters of value-based purchasing. The company has persistently urged the Center for Medicare & Medicaid Innovation (CMMI) to expand the model for over a year.
“There’s still a perception out there that there is a high level of fraud in home health care — and that’s simply not true,” Amedisys CEO and President Paul Kusserow told Home Health Care News. “I think having to prove ourselves on the quality front and being willing to take risk on quality is absolutely the right thing for us.”
So far, even just the limited HHVBP Model has been able to achieve overwhelmingly positive results.
Since implemented, the model has contributed to a 4.6% improvement in home health agencies’ quality scores, in addition to average annual Medicare savings of $141 million, federal statistics show. On top of those points, agencies in HHVBP states have been able to significantly lower the costly utilization of hospitals and skilled nursing facilities (SNF).
“This has been extremely good,” Kusserow said.
As part of its push for an expanded HHVBP Model, Amedisys brought in Washington, D.C.-based research and consulting firm The Moran Company. The home health giant asked Moran to dig deeper into past results and explore what a nationwide rollout would eventually look like.
After cranking the numbers, the research firm estimated that a 50-state HHVBP Model would result in about $6.3 billion in savings over a 10-year period, using Congressional Budget Office (CBO) scoring methodology.
“We engaged in a very long dialogue [with CMMI] and exchanged a lot of data to push this forward,” Kusserow added.
Inside the advocacy process
Besides the whopping $6.3 billion in savings, Moran also determined that a nationwide rollout of the Home Health Value-Based Purchasing Model would lead to better post-acute care outcomes for Medicare beneficiaries and more ways for the U.S. Centers for Medicare & Medicaid Services (CMS) to identify high- and low-quality providers.
In many ways, the advocacy efforts around HHVBP were so effective because they were driven by “the power of a good idea,” according to David Kemmerly, the chief legal and government affairs officer at Amedisys. Instead of having to artfully persuade CMS and CMMI to expand the model, his team’s job was more about giving policymakers the objective information they otherwise lacked.
“They have to go make their case with the actuaries before they can expand something,” Kemmerly told HHCN. “So we helped arm CMS with the data and information they needed.”
It took more than facts and figures, however.
To help advance HHVBP, Kusserow communicated regularly with CMMI Director Brad Smith, the former CEO of home-based palliative care provider Aspire Health who joined the CMS Innovation Center in early 2020. Kusserow and Smith had already “known each other a long time,” thanks to their shared experiences in Nashville, Tennessee, and standing as Rhodes scholars.
“When [Smith] went to Washington, he called me up and said, ‘What should I be thinking about?’” Kusserow said. “Obviously, he was asking a lot of people that. I said, ‘I really think there’s something to value-based purchasing in home health. I’d really like you to look at it.’”
At first, CMMI decision-makers were concerned about home health provider buy-in.
While Amedisys and others sought to advance HHVBP, others were slightly skeptical, especially early on. More than a few home health operators believed HHVBP was just another piece of government regulation, with others too preoccupied with the Patient-Driven Groupings Model (PDGM) to worry about alternative payment mechanisms.
On its end, Amedisys worked hard to boost the industry’s understanding and acceptance of HHVBP, Kemmerly said.
“There’s a bit of politics involved,” he noted. “[Smith] asked us early on, ‘Where is the industry on this? And can you bring the industry to the table?’”
CMMI and CMS are committed to expanding the Home Health Value-Based Purchasing Model, but there are plenty of questions left to answer and improvements that can be made.
On a basic level, it’s still unclear whether policymakers will try to expand HHVBP through a standalone proposal or through the annual rulemaking cycle. Additionally, it’s not yet known whether that future expansion will be national or more incremental, possibly adding another dozen or so states to the current nine-state mix.
Scott Levy, the senior vice president of government affairs at Amedisys, was in the trenches for most of Amedisys’ advocacy battle on HHVBP. In all likelihood, CMS will pursue a 50-state expansion and implementation through the annual rulemaking cycle, Levy speculated.
“I’m just merely reading between the lines, but our discussions [with CMS] and our data presented to them was all based on the idea of a nationwide expansion,” he told HHCN.
Along with answers to those questions, Amedisys is also pushing for improvements to the HHVBP Model itself.
In 2020, home health providers were exposed to 6% upside and downside risk, depending on their quality performance. That figure increases to 7% and 8% in 2021 and 2022, respectively.
But it’s almost impossible to come close to that full upside or downside as the model is currently structured.
“The upside has been good for us. It’s generally quite positive,” Kusserow said. “But we feel the curve is too clustered toward the center. It is very hard to get the full rewards or to get the full penalties.”
In 2018, the payment adjustment in HHVBP ranged from a 1.5% penalty for providers in the lowest-10th percentile to a 1.5% bonus for providers in the highest-10th percentile, according to an investment note from Bank of America. CMS previously stated that the average adjustment was a 0.85% bump in 2018.
“Companies out there with good technology, good tracking systems, good checklists, good verification processes and very good clinical operations are the ones that are going to continue to do well and thrive under this, for sure,” Kusserow said.
A possible complication to HHVBP expansion plans could have been the transition to a new Biden administration, which is guaranteed to bring changes to CMMI, CMS and throughout the U.S. Department of Health and Human Services (HHS).
Yet the team at Amedisys doesn’t see that as an issue, considering the model’s origins.
“[HHVBP] was actually rolled out by the Obama administration,” Levy said. “It was proposed during the fall of 2015 for a January 2016 implementation.”
In a wide-ranging discussion at J.P. Morgan’s Annual Healthcare Conference, former CMS Administrator Andy Slavitt talked about the future of the ACA, telehealth and Medicare Advantage with a Democrat-led House, Senate and presidency.
Home health providers are getting one of their biggest wishes granted.
The U.S. Department of Health and Human Services (HHS) announced Friday that it is expanding the Home Health Value-Based Purchasing (HHVBP) Model. First implemented in 2016, the HHVBP Model is currently active in just nine states: Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee.
HHS Secretary Alex Azar has already signed off on an expansion, the department noted. Friday’s announcement did not specify the extent of the expansion, but clarified that HHS would execute the implementation through rulemaking no earlier than Jan. 1, 2022.
“The CMS Office of the Actuary has certified, based on its independent assessment of the model’s performance over the first three years of the Model, that an expansion would reduce, or not result in any increase in, net Medicare spending,” the announcement stated.
This is a developing story. Please check back later for additional updates.
With just a dozen days left in power, the Trump administration on Friday approved a radically different Medicaid financing system in Tennessee that for the first time would give the state broad authority in running the health insurance program for the poor in exchange for capping its annual federal funding.
The approval is a 10-year “experiment.” Instead of the open-ended federal funding that rises with higher enrollment and health costs, Tennessee will instead get an annual block grant. The approach has been pushed for decades by conservatives who say states too often chafe under strict federal guidelines about enrollment and coverage and can find ways to provide care more efficiently.
The approval, however, faces an uncertain future because the incoming Biden administration is likely to oppose such a move. But to unravel it, officials would need to set up a review that includes a public hearing.
Meanwhile, the changes in Tennessee will take months to implement because they need final legislative approval, and state officials must negotiate quality of care targets with the administration.
TennCare, the state’s Medicaid program, said the block grant system would give it unprecedented flexibility to decide who is covered and what services it will pay for.
It said the new arrangement would allow the state to keep part of the money it saves from operating the program more efficiently. Trump administration officials said the approach adds incentive for the state to save money, unlike the current system, in which increased state spending is matched with more federal dollars. If Medicaid enrollment grows, the state can secure additional federal funding. If enrollment drops, it will get less money.
“This groundbreaking waiver puts guardrails in place to ensure appropriate oversight and protections for beneficiaries, while also creating incentives for states to manage costs while holding them accountable for improving access, quality and health outcomes,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “It’s no exaggeration to say that this carefully crafted demonstration could be a national model moving forward.”
Opponents, including most advocates for low-income Americans, say the approach will threaten care for the 1.4 million people in TennCare, which includes children, pregnant women and the disabled. Federal funding covers two-thirds of the cost of the program.
Michele Johnson, executive director of the Tennessee Justice Center, said the block grant approval is a step backward for the state’s Medicaid program.
“No other state has sought a block grant, and for good reason. It gives state officials a blank check and creates financial incentives to cut health care to vulnerable families,” she said.
Democrats have fought back block grant Medicaid proposals since the Reagan administration and most recently in 2018 as part of Republicans’ failed effort to repeal and replace major parts of the Affordable Care Act. Even some key Republicans opposed the idea because it would cut billions in funding to states that would make it harder to help the poor.
Implementing block grants via an executive branch action rather than getting Congress to amend Medicaid law is also likely to be met with court challenges.
The block grant approval comes as Medicaid enrollment is at its highest ever level.
More than 76 million Americans are covered by the state-federal health program, a million more than when the Trump administration took charge in 2017. Enrollment has jumped by more than 5 million in the past year as the economy slumped with the pandemic.
Medicaid, part of President Lyndon B. Johnson’s “Great Society” initiative of the 1960s, is an entitlement program in which the government pays each state a certain percentage of the cost of care for anyone eligible for the health coverage. As a result, the more money states spend on Medicaid, the more they get from Washington.
Under the approved demonstration, CMS will work with Tennessee to set spending targets that will increase at a fixed amount each year.
The plan includes a “safety valve” to increase federal funding due to unexpected increases in enrollment.
“The safety valve will maintain Tennessee’s commitment to enroll all eligible Tennesseans with no reduction in today’s benefits for beneficiaries,” CMS said in a statement.
Tennessee has committed to maintaining coverage for eligible beneficiaries and existing services.
In exchange for taking on this financing approach, the state will receive a range of operating flexibilities from the federal government, as well as up to 55% of the savings generated on an annual basis when spending falls below the aggregate spending cap and the state meets certain quality targets, yet to be determined.
The state can spend that money on various health programs for residents, including areas that Medicaid funding typically doesn’t cover, such as improving transportation and education and employment.
The 10-year waiver is unusual, but the Trump administration has approved such long-term experiments in recent years to give states more flexibility.
Tennessee is one of 12 states that have not approved expanding Medicaid under the Affordable Care Act that’s left tens of thousands of working adults without health insurance.
“The block grant is just another example of putting politics ahead of health care during this pandemic,” said Johnson of the Tennessee Justice Center. “Now is absolutely not the time to waste our energy and resources limiting who can access health care.”
State officials applauded the approval.
“It’s a legacy accomplishment,” said Tennessee Gov. Bill Lee, a Republican. “This new flexibility means we can work toward improving maternal health coverage and clearing the waiting list for developmentally disabled.”
“This means we will be able to make additional investments in TennCare without reduction in services and provider cuts.”
KHN chief Washington correspondent Julie Rovner contributed to this report.
HIT Consultant sat down with Mike McSherry, CEO, and co-founder of Seattle-based digital prescription platform Xealth to discuss digital health lessons learned in 2020 and what we can expect in 2021. As Xealth’s CEO, Mike also works with Duke Health, UPMC, Atrium Health, and The Froedtert & the Medical College of Wisconsin health network where he uses his background in digital health to connect patients and care teams outside of traditional care settings.
HITC: In 2021, How can digital health reduce race and minority disparities in healthcare?
McSherry: The U.S. has struggled with health disparities, which this pandemic has widened. Many of these disparities can be linked to access, which digital health can assist with – telehealth makes care virtual from any location, clinical decision support can reduce human errors, remote patient monitoring helps keep patients home while linked to care.
Digital health removes hurdles related to transportation, taking time off work, or finding childcare in order to travel in-person for an appointment. It brings care to the patient instead of the other way around, making access simpler. Care through these pathways is also more cost-efficient.
There are still hurdles to overcome. Broadband is widespread but not everywhere and inclusive design of these tools should be considered. How digital tools, including wearables, are built should address differences in gender and ethnicity, especially as these tools are used more frequently in clinical trials, so as not to inadvertently perpetuate disparities.
HITC: Why some hospitals are offering digital health tools to staff but not patients?
McSherry: There are a few factors at play when hospitals offer digital health tools to staff but not patients. One, most health systems are not currently deploying system-wide digital health initiatives, leaving the decisions to individual departments or providers. This can lead to inconsistent patient experiences and more data siloes as solutions are brought in as one-offs.
The second issue is reimbursement. A hospital acting as an employer offering digital health tools as part of its benefits package is different than a patient, who must rely on their health insurance, whether it is a public or private plan. The fact healthcare organizations see digital health tools as a perk shows their value. Now, it is time for CMS and commercial payers to consistently enable their use to help providers care for patients and incorporate digital health as clinicians see fit.
HITC: How hospitals can remain competitive in 2021, especially after tighter margins from COVID-19?
McSherry: Large tech companies, like Google and Amazon, and huge retailers, including Walmart and Best Buy, are looking to deliver the promise of health care that has so far eluded the industry. Venture capital money has been pouring in for funding innovation, with digital health funding hitting a new high in 2020.
These initiatives are all racing to control health care’s front door and if hospitals don’t innovate as well, they run a very real risk of having patients turn elsewhere for care. Payers are also building digital front doors and telling members to go there. People have long expressed their desire to have the same consumer experience in health care that they receive in other industries. The technology is there. It needs to be incorporated with the correct care pathways.
One silver lining during the COVID-19 pandemic is that it showed fast-moving innovation can happen in health care. We worked with hospitals to stand up workflows around telehealth in four days and remote patient monitoring in seven days – an amazing pace. The key is to keep this stride going once we are on the other side of this crisis.
Providers are becoming more digitally savvy to engage patients and deliver holistic care. Hospitals should support this.
HITC: What will be Biden’s impact on COVID-19, how hospital leaders should respond, and what it means that we have a divided congress?
McSherry: Under the current administration, telehealth rules have been relaxed, at least temporarily, along with cross-state licensure so providers are better able to build a front door strategy, helping organizations roll out remote patient monitoring and chronic care management apps. Biden has been a proponent of digitalization in health care and will have a broader engagement. This could lead toward more funding and more covered lives.
A divided Congress will not make much easy for the Biden administration, however, getting on the other side of this pandemic as quickly and as safely as possible is best for everyone. Biden has shown he will make fighting COVID-19 a top priority.
HITC: Will remote patient monitoring become financially viable for hospital leaders in 2021?
McSherry: Why does a diabetic patient need to have every check-in be in-person or a healthy, pregnancy met every few weeks with an in-person visit as opposed to remote monitoring for key values and a telehealth check-in in place of a couple of those visits? Moving forward, hospitals will see the benefit of remote monitoring in terms of lower overhead, along with better patient engagement, outcomes and retention.
To make this work, providers must share risk, and determine digital strategies around attracting patients and then manage them in a capitated way with more digital tools because of the cost efficiencies.
HITC: How do we foster tighter physician-patient relationships?
McSherry: Patients trust their doctors, period. The struggle is going to be more obvious as more people do not have a PCP and turn to health care with a bandage approach to take care of an immediate concern. That will lead to entire populations without that trusted bond who are sicker when they finally do seek care, due to the lack of continuity and engagement early on.
By connecting with people now, where they are comfortable, there is a tighter physician-patient relationship by making it more accessible and reciprocal.
UNC Health is throwing its hat in the hospital-at-home ring. The North Carolina-based health system announced Monday that it has plans to launch an acute hospital care at home program in partnership with Medically Home.
UNC Health is a state-owned integrated health care system based in Chapel Hill. The organization is made up of 12 hospitals, 350 clinics and various clinical programs from the University of North Carolina School of Medicine.
Meanwhile, Medically Home is a Boston-based company that brings acute-level care into the home. As part of its model, Medically Home sends clinicians into the home, along with technology, equipment, medication and supplies.
UNC Health will offer its acute care at home program to patients at two of its hospitals by mid-year. The plan is to eventually roll out the program at UNC Health’s 10 other hospitals over time.
As part of the new program, certain COVID-19 patients will now be able to receive medical services — including IV therapies, oxygen treatments and ultrasounds — in their homes. The program will also be for some non-COVID patients with conditions such as heart failure, pneumonia, COPD, cellulitis and more.
UNC Health physicians and nurses will monitor these patients 24/7 through Medically Home’s technology platform.
The program’s model of care is predominantly a 30-day length of stay, split between an acute phase and a restorative phase.
Generally, patients will be able to enter the program through two mechanisms, Matt Smith, UNC Health’s vice president for well care and specialty services, told Home Health Care News.
“One would be through the emergency department,” he said. “They would have an opportunity, through various screenings of acceptability for the program. The other option that we’re putting forward to utilize this infrastructure is a model of an early discharge. In that case, a patient would be able to be discharged early from the hospital, after they’ve stabilized, and would finish out the remainder of their stay in the home.”
Last year saw a number of health care organizations roll out hospital-at-home or similar programs in an attempt to lessen the capacity issues the COVID-19 emergency created.
UNC Health may be the latest health system to launch a hospital-at-home program, but even prior to the public health emergency, relieving capacity issues was top of mind.
“This came just from being a large academic health system in a growing area and in a state where there are laws and regulations around how many hospital beds you can build,” Smith said. “We looked at it as, if patients are clinically comfortable and able to be effectively cared for in the home, as an alternative care environment, it was best to build an infrastructure and offer that.”
In November, the U.S. Centers for Medicare & Medicaid Services (CMS) announced “unprecedented” flexibilities that would open doors for health organizations offering hospital-level care for patients in their homes.
Since then, CMS has approved at least 56 hospitals and health systems under its hospital-at-home initiative.
While UNC Health isn’t part of the new CMS initiative, Smith believes it’s a step forward.
“I think it only helps to think through the ability to care for more patients in this model,” he said. “The [ability] to leverage [hospital-at-home] and have it in communities is a great thing. It just helps support the initial direction we had taken.”
UNC Health does have plans to eventually apply for CMS’s waiver.
For now, UNC Health is looking to the future of its own hospital-at-home program. The health system is in talks with other North Carolina hospitals about offering the service in prospective partnership arrangements.
“We’re happy to explore this model with others,” Smith said. “Patients are often transferred to Chapel Hill or from other communities because of the care that can be provided. There are already existing partnerships in terms of the coordination of patient care. I think where we can save costs together is by creating a coordinated care team that can really do the same things for those communities.”
Ultimately, Smith believes that expanding these services locally is a net positive for patients and the organizations that would potentially partner with UNC Health.
“The more that this care model is out there, the better it is for patients. And the better it is for all of our health systems working within that,” he said.
The U.S. Centers for Medicare & Medicaid Services (CMS) has approved a handful of new hospitals under its rapidly growing hospital-at-home initiative, Administrator Seema Verma announced on Monday.
Originally unveiled at the end of November, CMS’s “Acute Hospital Care at Home” initiative is designed to give hospitals “unprecedented” and “comprehensive” regulatory flexibilities to treat certain patients from inside their own homes. The CMS program builds off the success and learnings of the existing hospital-at-home models pioneered by Johns Hopkins, Mount Sinai and others.
The agency cleared at least five new hospitals for its initiative, according to a Twitter message from Verma.
The list includes St. Charles Hospital, St. Catherine of Siena Medical Center and Good Samaritan Hospital Medical Center, all three of which are part of the Catholic Health Services family. It also includes Claiborne Memorial Medical Center and Michigan Medicine, the latter of which is part of the University of Michigan.
Tina Haynes — CEO of Claiborne Memorial Medical Center, a hospital in southern Louisiana that serves about 16,000 patients — said her team was able to handle the first and second COVID-19 surges fairly well.
The current surge has been a different story, however.
“With this latest surge, our entire region is having some big capacity issues,” Haynes told Home Health Care News. “We began to see we were going to have trouble with having places to put people, to treat people. And if we couldn’t treat them, we were going to have trouble finding places to transfer them.”
The most recent additions bring the hospital-at-home initiative’s grand total to at least 56 hospitals across the U.S.
Just six hospital groups were cleared when CMS first revealed the waiver program less than two months ago.
“CMS made a terrific decision in recognizing the value of hospital-at-home care for the public health emergency,” Dr. Bruce Leff, a hospital-at-home expert and the director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine, told HHCN at the time. “Hospital-at-home is well proven to provide high-quality hospital-level care in patients’ homes for many acute conditions — and patients and their families love it.”
There currently isn’t a publicly available list of hospital-at-home participants posted online, but Monday’s news from Verma suggests the initiative is growing faster than some health care insiders expected.
That could be a promising development for home health and home care agencies, both of which typically play active roles in hospital-at-home models.
To participate in CMS’s initiative, hospitals must apply for a designated waiver via an online portal, with existing hospital-at-home operators eligible for “an expedited process.”
Among their requirements, participating hospitals will need to provide in-person physician evaluation before starting care in the home. Additionally, a registered nurse is required to perform evaluations on each patient — in person or remotely — daily.
On its end, CMS will collect monitoring data on a monthly or daily basis from participants, depending on their experience level. That data is meant to shed light on patient volumes, unanticipated mortality rates, escalation rates and more.
During the waiver-application process, prospective participants are required to explain how they’re able to meet their patients’ pharmacy, respiratory and other needs in the home setting. Participants must also outline, for example, which diagnostic studies are available to their patients while hospitalized in the Acute Hospital Care at Home initiative.
Claiborne Memorial Medical Center is new to the hospital-at-home model, Haynes noted.
“We decided, well, to keep being able to treat the patients in our parish, which is what we’re here for, we needed to start thinking outside the box,” she said. “We started looking at this waiver as a way to free up some in-patient bed space for the most acutely ill. We started asking ourselves, ‘How could we use this waiver program to our advantage?’”
Specifically, Claiborne plans to use its hospital-at-home program to care for mostly stable COVID-19-positive patients who still need to complete remdesivir therapy.
“We’re looking at a very narrow patient population,” Lee Jones, a registered nurse and director of quality for Claiborne, told HHCN.
In general, CMS is working to advance hospital-at-home efforts to boost acute care capacity during the COVID-19 pandemic.
As of Monday, an estimated 71.34% of all in-patient beds were occupied by a patient, U.S. Department of Health and Human Services (HHS) data shows. An estimated 17.74% of in-patient beds were occupied specifically by a COVID-19 patient.
Hospitals across the country are struggling with in-patient capacity, with no singular geographic hotspot.
While many of the participants are part of larger health systems in densely populated metropolitan areas, Claiborne is proof that the hospital-at-home concept can be put to work in rural regions as well, Haynes added.
“We’re very small and rural, but you can do these kinds of things and provide care for rural communities,” she said. “You don’t have to be in a big metropolitan market to make things happen. You can think outside the box when you put your mind to it. There are ways to make things happen and free up beds to be able to provide care for different patient populations.”
Prior to the pandemic, telehealth was a limited ad-hoc service with geographic and provider restrictions. However, with both the pandemic restrictions on face to face interactions and a relaxation of governmental regulations, telehealth utilization has significantly increased from thousands of visits in a week to well over a million in the Medicare population. What we’ve learned is that telehealth allows patients, especially high-risk populations like seniors, to connect with their doctors in a safe and efficient way. Telehealth is valuable for many types of visits, mostly clearly ones that involve mental health or physical health issues that do not require a physical exam or procedure. It’s an efficient modality for both the member and provider.
With the growing popularity of telehealth services, we may see permanent changes in regulatory standards. Flexible regulatory standards, such as being able to use platforms like FaceTime or Skype, would lower the barrier to entry for providers to offer telehealth and also encourage adoption, especially among seniors. Second, it’s likely we’ll see an emergence of providers with aligned incentives around value, such as in many Medicare Advantage plans, trying very hard to encourage utilization with their members so that they get the right care at the right time. In theory, the shift towards value-based care will allow better care and lower costs than the traditional fee for service model. If we are able to evolve regulatory and payment environments, providers have an opportunity to grow these types of services into 2021 to improve patient wellness and health outcomes.
Dr. Salvatore Viscomi, Chief Medical Officer, GoodCell
2021 will be the year of patient controlled-health
The COVID-19 pandemic brought the realities of a global-scale health event – and our general lack of preparedness to address it – to the forefront. People are now laser-focused on how they can protect themselves and their families against the next inevitable threat. On top of this, social distancing and isolation accelerated the development and use of digital health tools, from wellness trackers to telehealth and virtual care, most of which can be accessed from the comfort of our homes. The convergence of these two forces is poised to make 2021 the year for patient-controlled health, whereby health decisions are not dictated by – but rather made in consultation with – a healthcare provider, leveraging insights and data pulled from a variety of health technology tools at people’s fingertips.
Anish Sebastian, CEO of Babyscripts
Telemedicine was the finger in the dyke at the beginning of pandemic panic, with healthcare providers grabbing whatever came to hand — encouraged by relaxed HIPAA regulations — to keep the dam from breaking. But as the dust settles, telemedicine is emerging as the commodity that it is, and value-add services are going to be the differentiating factors in an increasingly competitive marketplace. Offerings like remote patient monitoring and asynchronous communication, initially considered as “nice-to-haves,” are becoming standard offerings as healthcare providers see their value for continuous care beyond Covid.
Daniel Kivatinos, COO and Co-Founder of DrChrono
Telehealth visits are going to supersede in-person visits as time goes on.
Because of COVID-19, the world changed and Medicare and Medicaid, as well as other insurers, started paying out for telehealth visits. Telemedicine will continue to grow at a very quick rate, and verticals like mental health (psychology and psychiatry) and primary care fit perfectly into the telemedicine model, for tasks like administering prescription refills (ePrescribing) and ordering labs. Hyperlocal medical care will also move towards more of a telemedicine care team experience. Patients that are homebound families with young children or people that just recently had surgery can now get instant care when they need it. Location is less relevant because patients can see a provider from anywhere.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Virtual Healthcare is Here to Stay (House Calls are Back)
This new normal however is going to put significant pressure on the data support and servicing requirements to do it effectively. As more services are offered to patients outside of established clinical locations, it also means there will be more opportunity to collect data and a higher degree of dependence on interoperability. Providers are going to have to up their game from just providing and recording facts to passing on critical insight back into these interactions to maximize the benefits to the patient.
Sarahjane Sacchetti, CEO at Cleo
Virtual care (of all types) will become a lasting form of care: The vastly accelerated and broadened use of virtual care spurred by the pandemic will become permanent. Although it started with one-off check-ins or virtual mental health coaching, 2021 will see the continued rise in the use and efficacy of virtual care services once thought to be in-person only such as maternity, postpartum, pediatric, and even tutoring. Employers are taking notice of this shift with 32% indicating that expanded virtual health services are a top priority, and this number will quickly rise as employers look to offer flexible and convenient benefits in support of employees and to drive productivity.
Omri Shor, CEO of Medisafe
Digital expansion: The pandemic has accelerated patient technology adoption, and innovation remains front-and-center for healthcare in 2021. Expect to see areas of telemedicine and digital health monitoring expand in new and novel ways, with increased uses in remote monitoring and behavioral health. CMS has approved telehealth for a number of new specialties and digital health tools continue to gain adoption among healthcare companies, drug makers, providers, and patients.
Digital health companions will continue to become an important tool to monitor patients, provide support, and track behaviors – while remaining socially distant due to the pandemic. Look for crossover between medical care, drug monitoring, and health and wellness – Apple
Watch has already previewed this potential with heart rate and blood oxygen monitoring. Data output from devices will enable support to become more personalized and triggered by user behavior.
Kelli Bravo, Vice President, Healthcare and Life Sciences, Pegasystems
The COVID-19 pandemic has not only changed and disrupted our lives, it has wreaked havoc on the entire healthcare industry at a scale we’ve never seen before. And it continues to alter almost every part of life across the globe. The way we access and receive healthcare has also changed as a result of social distancing requirements, patient concerns, provider availability, mobile capabilities, and newly implemented procedures at hospitals and healthcare facilities.
For example, hospitals and providers are postponing elective procedures again to help health systems prepare and reserve ICU beds amid the latest COVID-19 resurgence. While level of care is always important, in some areas, the inability to access a healthcare provider is equally concerning. And these challenges may become even more commonplace in the post-COVID-19 era. One significant transformation to help with the hurdle is telehealth, which went from a very small part of the care offering before the health crisis to one that is now a much more accepted way to access care. As the rise in virtual health continues to serve consumers and provide a personalized and responsive care experience, healthcare consumers expect support services and care that are also fast and personalized – with digital apps, instant claims settlements, transparency, and advocacy. And to better help serve healthcare consumers, the industry has an opportunity to align with digital transformation that offers a personalized and responsive experience.
Brooke LeVasseur, CEO of AristaMD
Issues pertaining to the COVID-19 pandemic will continue to be front-and-center in 2021. Every available digital tool in the box will have to be employed to ensure patients with non-COVID related issues are not forgotten as we try to free up in-person space and resources for those who cannot get care in any other setting. Virtual front doors, patient/physician video and eConsults, which connect providers to collaborate electronically, will be part of a broadening continuum of care – ultimately aimed at optimizing every valuable resource we have.
Bret Larsen, CEO and Co-Founder, eVisit
By the end of 2021, virtual care paths will be fairly ubiquitous across the continuum of care, from urgent care and EDs to specialty care, all to serve patients where they are – at home and on mobile devices. This will be made possible through virtualized end-to-end processes that integrate every step in patient care from scheduling, waiting rooms, intake and patient queuing, to interpretation services, referral management, e-prescribe, billing and analytics, and more.
Laura Kreofsky, Vice President for Advisory & Telehealth for Pivot Point Consulting
2020 has been the year of rapid telehealth adoption and advancement due to the COVID pandemic. According to CDC reports, telehealth utilization spiked as much as 154% in late March compared to the same period in 2019. While usage has moderated, it’s clear telehealth is now an instrumental part of healthcare delivery. As provider organizations plan for telehealth in 2021 and beyond, we are going to have to expect and deliver a secure, scalable infrastructure, a streamlined patient experience and an approach that maximizes provider efficiency, all while seeing much-needed vendor consolidation.
Jeff Lew, SVP of Product Management, Nextech
Earlier this year, CMS enacted new rules to provide practices with the flexibility they need to use telehealth solutions in response to COVID-19, during which patients also needed an alternative to simply visiting the office. This was the impetus to the accelerated acceptance of telehealth as a means to both give and receive care. Specialty practices, in particular, are seeing successful and positive patient experiences due to telehealth visits. Dermatology practices specifically standout and I expect the strong adoption will continue to grow and certainly be the “new normal.” In addition, innovative practices that have embraced this omni-channel approach to delivering care are also establishing this as a “new normal” by selectively using telehealth visits for certain types of encounters, such as post-op visits or triaging patients. This gives patients a choice and the added convenience that comes with it and, in some cases, increases patient volume for the practice.
Under the Trump administration, federal health care policymakers have long been vocal about the ability of Medicare Advantage (MA) to lower costs and improve outcomes among vulnerable populations.
A recent report from the Washington, D.C.-based Better Medicare Alliance (BMA) and consulting firm Avalere Health is now putting hard numbers on that claim, particularly around home health services and post-acute care.
“The hallmark features of Medicare Advantage — risk-adjusted capitated payment, strong value-based performance incentives and flexibility in benefit design — enable health plans to offer care management interventions that meet complex care needs of vulnerable beneficiaries in ways that produce robust positive outcomes and greater value for high need, high cost beneficiaries,” the report states.
To study cost and outcomes differences between MA and traditional fee-for-service (FFS) Medicare, Avalere and BMA analyzed data tied to more than 1.4 million MA enrollees and 7.9 million FSS beneficiaries. Researchers pulled data from 2015 to 2017.
Broadly, the findings show that MA enrollees spend far fewer days on home health services compared to their FSS peers. For every 1,000 individuals, home health days on service were nearly 20% lower in MA than in traditional Medicare, with an even greater difference among certain subpopulations.
For every 1,000 individuals under the age of 65 living with a disability, for example, home health days on service were about 27% lower in MA than FFS. For every 1,000 individuals living with a major complex and chronic condition, home health days on service were again 27% lower.
The smallest gap in home health agency days came in the frail elderly subpopulation, according to the report. For every 1,000 frail and elderly individuals, home health days on service were about 10% lower in MA than in traditional Medicare.
“The data … show that home health utilization is lower for all three populations in Medicare Advantage compared to traditional FFS Medicare,” the report notes. “One possible explanation is that inappropriate use of these services is minimized in Medicare Advantage relative to traditional FFS Medicare, but further research is needed to evaluate differences in use of home health services.”
High-need, high-cost MA beneficiaries had lower rates of post-acute utilization across all settings compared with those in traditional Medicare. Skilled nursing facility (SNF) days were 16% to 41% lower in MA, for instance.
In general, differences in post-acute care costs were similarly aligned with differences in utilization of post-acute care.
Across all populations, home health agency costs were about 38% lower in Medicare Advantage compared to FSS Medicare.
The Congressional Budget Office (CBO) forecasts that 47% of all Medicare enrollees will be Medicare Advantage beneficiaries by 2029.
“This study finds that overall Medicare Advantage delivered robust positive outcomes for high-need, high-cost beneficiaries compared to similar populations in traditional FFS Medicare,” the report continues. “Higher utilization of preventive screenings, preventive therapy and post-acute care follow-up in Medicare Advantage suggests that care management results in higher quality of care for this vulnerable population.”
Healthcare data security has been a growing concern for CIOs for the last year or so, as hackers are increasingly targeting health information. Now, with a global pandemic forcing a shift to telemedicine and remote work, and new rules from the ONC and CMS introducing more regulatory burden, healthcare CIOs have more to manage than ever. Fortunately, it is possible to roll out new capabilities while simultaneously improving cybersecurity by following these three rules:
Rule 1: Think Like an Attacker
The coronavirus pandemic has forced healthcare providers everywhere to roll out new capabilities, processes, and workflows, such as telemedicine systems and new patient check-in procedures. These measures are being taken in addition to the necessary work being done to comply with the new mandates from ONC and CMS regarding patient data accessibility. Though these changes need to be implemented quickly, it’s important to follow cybersecurity best practices to avoid providing new openings for attackers.
When a hacker sees new systems and processes being implemented, they are thinking about:
– What software is being introduced? Are there known vulnerabilities or frequently unpatched exploits associated with it?
– How are new endpoints being added and are they secure?
– Since the new ONC and CMS rules require publicly exposed FHIR APIs, how can those be attacked? Are there social engineering exploits that can provide a way around security?
– Are there ways to perpetrate identity fraud if a patient does not need to be physically present to receive healthcare?
This approach should lead to a cybersecurity plan that puts measures in place for each identified risk. By thinking like the adversary, it is possible to identify and lock down the possible attack vectors.
Rule 2: Minimize the Attack Surface
Every way into an organization’s network needs to be secured, monitored, and maintained. The best way to make this process as efficient and fool-proof as possible is to minimize the number of ways into the network.
This is especially difficult in light of the ONC and CMS rules, which require that clinical systems must share data through publicly available FHIR APIs. At first, this seems like a mandate to radically expand the organization’s attack surface. Indeed, this is precisely what happens if the straightforward approach of exposing every clinical system through public APIs is followed.
A different approach, which provides the same capabilities and compliance with the rules, would be to route all API traffic through a central hub. Attaching all the clinical systems to a single point of API access provides a number of benefits:
– Most importantly, compliance is achieved while minimizing the new attack vectors.
– All traffic between clinical systems and the outside world can be monitored from a single place.
– The API hub can act as a façade that makes legacy systems compliant with the new rules, even if those systems lack native FHIR API capabilities.
The API hub need not be an expensive new component of the network architecture. Most healthcare organizations are already using a clinical integration engine to move HL7, XML, and DICOM traffic among their internal systems. The same technology can serve as an API hub. This is especially effective if a new instance of the integration engine is placed in an isolated part of the network without full access to other systems.
Rule 3: Have an Expert Review the Defenses
Even for healthcare organizations with cybersecurity experts on staff, it can be worthwhile to bring in a cybersecurity consultant to cross-check new implementations. Novel threats are constantly shifting and emerging, making it nearly impossible for internal IT staff to keep up with the looming threats of ransomware hacks, while also adequately carrying out the day-to-day responsibilities of their jobs. For that reason, it makes sense to bring in a professional who focuses exclusively on security. It is also often useful to have an independent review from someone who is looking at the implementation from an outsider’s perspective. Independent consultants can provide the necessary guidance, risk assessments, and other security support, to set healthcare organizations up for success and operate more securely.
Expanding an organization’s IT capabilities often means more exposure to risk, especially when implementations are subject to time constraints. However, given the value and importance of the data that’s being generated, transmitted, and stored, it is imperative not to let cybersecurity fall out of focus. By following best practices around design, implementation, and testing healthcare organizations can rise to meet the current challenges of the pandemic, address the mandates of the interoperability rules, and simultaneously improve data security measures.
About Scott Galbari, Chief Technology Officer
As Chief Technology Officer for Lyniate, Scott leads the development and delivery of all products and services. Scott has been in the healthcare IT domain for the past twenty years and has experience in developing and delivering imaging, workflow, nursing, interoperability, and patient flow solutions to customers in all geographies. He was most recently the General Manager for multiple businesses within McKesson and Change Healthcare and started his career as a software developer.
About Drew Ivan, Chief Product & Strategy Officer
Drew’s focus is on how to operationalize and productize integration technologies, patterns, and best practices. His experience includes over 20 years in health IT, working with a wide spectrum of customers, including public HIEs, IDNs, payers, life sciences companies, and software vendors, with the goal of improving outcomes and reducing costs by aggregating and analyzing clinical, claims, and cost data.
A federal appeals court has ruled against hospital groups in their legal challenge to the CMS regulation that would require hospitals to make pricing information publicly available. The rule is set to take effect Jan. 1.
As we close out the year, we asked several healthcare executives to share their predictions and trends for 2021.
Kimberly Powell, Vice President & General Manager, NVIDIA Healthcare
Federated Learning: The clinical community will increase their use of federated learning approaches to build robust AI models across various institutions, geographies, patient demographics, and medical scanners. The sensitivity and selectivity of these models are outperforming AI models built at a single institution, even when there is copious data to train with. As an added bonus, researchers can collaborate on AI model creation without sharing confidential patient information. Federated learning is also beneficial for building AI models for areas where data is scarce, such as for pediatrics and rare diseases.
AI-Driven Drug Discovery: The COVID-19 pandemic has put a spotlight on drug discovery, which encompasses microscopic viewing of molecules and proteins, sorting through millions of chemical structures, in-silico methods for screening, protein-ligand interactions, genomic analysis, and assimilating data from structured and unstructured sources. Drug development typically takes over 10 years, however, in the wake of COVID, pharmaceutical companies, biotechs, and researchers realize that acceleration of traditional methods is paramount. Newly created AI-powered discovery labs with GPU-accelerated instruments and AI models will expedite time to insight — creating a computing time machine.
Smart Hospitals: The need for smart hospitals has never been more urgent. Similar to the experience at home, smart speakers and smart cameras help automate and inform activities. The technology, when used in hospitals, will help scale the work of nurses on the front lines, increase operational efficiency, and provide virtual patient monitoring to predict and prevent adverse patient events.
Omri Shor, CEO of Medisafe
Healthcare policy: Expect to see more moves on prescription drug prices, either through a collaborative effort among pharma groups or through importation efforts. Pre-existing conditions will still be covered for the 135 million Americans with pre-existing conditions.
The Biden administration has made this a central element of this platform, so coverage will remain for those covered under ACA. Look for expansion or revisions of the current ACA to be proposed, but stalled in Congress, so existing law will remain largely unchanged. Early feedback indicates the Supreme Court is unlikely to strike down the law entirely, providing relief to many during a pandemic.
Brent D. Lang, Chairman & Chief Executive Officer, Vocera Communications
The safety and well-being of healthcare workers will be a top priority in 2021. While there are promising headlines about coronavirus vaccines, we can be sure that nurses, doctors, and other care team members will still be on the frontlines fighting COVID-19 for many more months. We must focus on protecting and connecting these essential workers now and beyond the pandemic.
Modernized PPE Standards Clinicians should not risk contamination to communicate with colleagues. Yet, this simple act can be risky without the right tools. To minimize exposure to infectious diseases, more hospitals will rethink personal protective equipment (PPE) and modernize standards to include hands-free communication technology. In addition to protecting people, hands-free communication can save valuable time and resources. Every time a nurse must leave an isolation room to answer a call, ask a question, or get supplies, he or she must remove PPE and don a fresh set to re-enter. With voice-controlled devices worn under PPE, the nurse can communicate without disrupting care or leaving the patient’s bedside.
Voice-controlled solutions can also help new or reassigned care team members who are unfamiliar with personnel, processes, or the location of supplies. Instead of worrying about knowing names or numbers, they can use simple voice commands to connect to the right person, group, or information quickly and safely. In addition to simplifying clinical workflows, an intelligent communication system can streamline operational efficiencies, improve triage and throughput, and increase capacity, which is all essential to hospitals seeking ways to recover from 2020 losses and accelerate growth.
Michael Byczkowski, Global Vice President, Head of Healthcare Industry at SAP,
New, targeted healthcare networks will collaborate and innovate to improve patient outcomes.
We will see many more touchpoints between different entities ranging from healthcare providers and life sciences companies to technology providers and other suppliers, fostering a sense of community within the healthcare industry. More organizations will collaborate based on existing data assets, perform analysis jointly, and begin adding innovative, data-driven software enhancements. With these networks positively influencing the efficacy of treatments while automatically managing adherence to local laws and regulations regarding data use and privacy, they are paving the way for software-defined healthcare.
Smart hospitals will create actionable insights for the entire organization out of existing data and information.
Medical records as well as operational data within a hospital will continue to be digitized and will be combined with experience data, third-party information, and data from non-traditional sources such as wearables and other Internet of Things devices. Hospitals that have embraced digital are leveraging their data to automate tasks and processes as well as enable decision support for their medical and administrative staff. In the near future, hospitals could add intelligence into their enterprise environments so they can use data to improve internal operations and reduce overhead.
Curt Medeiros, President and Chief Operating Officer of Ontrak
As health care costs continue to rise dramatically given the pandemic and its projected aftermath, I see a growing and critical sophistication in healthcare analytics taking root more broadly than ever before. Effective value-based care and network management depend on the ability of health plans and providers to understand what works, why, and where best to allocate resources to improve outcomes and lower costs. Tied to the need for better analytics, I see a tipping point approaching for finally achieving better data security and interoperability. Without the ability to securely share data, our industry is trying to solve the world’s health challenges with one hand tied behind our backs.
G. Cameron Deemer, President, DrFirst
Like many business issues, the question of whether to use single-vendor solutions or a best-of-breed approach swings back and forth in the healthcare space over time. Looking forward, the pace of technology change is likely to swing the pendulum to a new model: systems that are supplemental to the existing core platform. As healthcare IT matures, it’s often not a question of ‘can my vendor provide this?’ but ‘can my vendor provide this in the way I need it to maximize my business processes and revenues?
This will be more clear with an example: An EHR may provide a medication history function, for instance, but does it include every source of medication history available? Does it provide a medication history that is easily understood and acted upon by the provider? Does it provide a medication history that works properly with all downstream functions in the EHR? When a provider first experiences medication history during a patient encounter, it seems like magic.
After a short time, the magic fades to irritation as the incompleteness of the solution becomes more obvious. Much of the newer healthcare technologies suffer this same incompleteness. Supplementing the underlying system’s capabilities with a strongly integrated third-party system is increasingly going to be the strategy of choice for providers.
Angie Franks, CEO of Central Logic
In 2021, we will see more health systems moving towards the goal of truly operating as one system of care. The pandemic has demonstrated in the starkest terms how crucial it is for health systems to have real-time visibility into available beds, providers, transport, and scarce resources such as ventilators and drugs, so patients with COVID-19 can receive the critical care they need without delay. The importance of fully aligning as a single integrated system that seamlessly shares data and resources with a centralized, real-time view of operations is a lesson that will resonate with many health systems.
Expect in 2021 for health systems to enhance their ability to orchestrate and navigate patient transitions across their facilities and through the continuum of care, including post-acute care. Ultimately, this efficient care access across all phases of care will help healthcare organizations regain revenue lost during the historic drop in elective care in 2020 due to COVID-19.
In addition to elevating revenue capture, improving system-wide orchestration and navigation will increase health systems’ bed availability and access for incoming patients, create more time for clinicians to operate at the top of their license, and reduce system leakage. This focus on creating an ‘operating as one’ mindset will not only help health systems recover from 2020 losses, it will foster sustainable and long-term growth in 2021 and well into the future.
John Danaher, MD, President, Global Clinical Solutions, Elsevier
COVID-19 has brought renewed attention to healthcare inequities in the U.S., with the disproportionate impact on people of color and minority populations. It’s no secret that there are indicative factors, such as socioeconomic level, education and literacy levels, and physical environments, that influence a patient’s health status. Understanding these social determinants of health (SDOH) better and unlocking this data on a wider scale is critical to the future of medicine as it allows us to connect vulnerable populations with interventions and services that can help improve treatment decisions and health outcomes. In 2021, I expect the health informatics industry to take a larger interest in developing technologies that provide these kinds of in-depth population health insights.
Jay Desai, CEO and co-founder of PatientPing
2021 will see an acceleration of care coordination across the continuum fueled by the Centers for Medicare and Medicaid Services (CMS) Interoperability and Patient Access rule’s e-notifications Condition of Participation (CoP), which goes into effect on May 1, 2021. The CoP requires all hospitals, psych hospitals, and critical access hospitals that have a certified electronic medical record system to provide notification of admit, discharge, and transfer, at both the emergency room and the inpatient setting, to the patient’s care team. Due to silos, both inside and outside of a provider’s organization, providers miss opportunities to best treat their patients simply due to lack of information on patients and their care events.
This especially impacts the most vulnerable patients, those that suffer from chronic conditions, comorbidities or mental illness, or patients with health disparities due to economic disadvantage or racial inequity. COVID-19 exacerbated the impact on these vulnerable populations. To solve for this, healthcare providers and organizations will continue to assess their care coordination strategies and expand their patient data interoperability initiatives in 2021, including becoming compliant with the e-notifications Condition of Participation.
Kuldeep Singh Rajput, CEO and founder of Biofourmis
Driven by CMS’ Acute Hospital at Home program announced in November 2020, we will begin to see more health systems delivering hospital-level care in the comfort of the patient’s home–supported by technologies such as clinical-grade wearables, remote patient monitoring, and artificial intelligence-based predictive analytics and machine learning.
A randomized controlled trial by Brigham Health published in Annals of Internal Medicine earlier this year demonstrated that when compared with usual hospital care, Home Hospital programs can reduce rehospitalizations by 70% while decreasing costs by nearly 40%. Other advantages of home hospital programs include a reduction in hospital-based staffing needs, increased capacity for those patients who do need inpatient care, decreased exposure to COVID-19 and other viruses such as influenza for patients and healthcare professionals, and improved patient and family member experience.
Jake Pyles, CEO, CipherHealth
The disappearance of the hospital monopoly will give rise to a new loyalty push
Healthcare consumerism was on the rise ahead of the pandemic, but the explosion of telehealth in 2020 has effectively eliminated the geographical constraints that moored patient populations to their local hospitals and providers. The fallout has come in the form of widespread network leakage and lost revenue. By October, in fact, revenue for hospitals in the U.S. was down 9.2% year-over-year. Able to select providers from the comfort of home and with an ever-increasing amount of personal health data at their convenience through the growing use of consumer-grade wearable devices, patients are more incentivized in 2021 to choose the provider that works for them.
After the pandemic fades, we’ll see some retrenchment from telehealth, but it will remain a mainstream care delivery model for large swaths of the population. In fact, post-pandemic, we believe telehealth will standardize and constitute a full 30% to 40% of interactions.
That means that to compete, as well as to begin to recover lost revenue, hospitals need to go beyond offering the same virtual health convenience as their competitors – Livango and Teladoc should have been a shot across the bow for every health system in 2020. Moreover, hospitals need to become marketing organizations. Like any for-profit brand, hospitals need to devote significant resources to building loyalty but have traditionally eschewed many of the cutting-edge marketing techniques used in other industries. Engagement and personalization at every step of the patient journey will be core to those efforts.
Marc Probst, former Intermountain Health System CIO, Advisor for SR Health by Solutionreach
Healthcare will fix what it’s lacking most–communication.
Because every patient and their health is unique, when it comes to patient care, decisions need to be customized to their specific situation and environment, yet done in a timely fashion. In my two decades at one of the most innovative health systems in the U.S., communication, both across teams and with patients continuously has been less than optimal. I believe we will finally address both the interpersonal and interface communication issues that organizations have faced since the digitization of healthcare.”
Rich Miller, Chief Strategy Officer, Qgenda
2021 – The year of reforming healthcare: We’ve been looking at ways to ease healthcare burdens for patients for so long that we haven’t realized the onus we’ve put on providers in doing so. Adding to that burden, in 2020 we had to throw out all of our playbooks and become masters of being reactive. Now, it’s time to think through the lessons learned and think through how to be proactive. I believe provider-based data will allow us to reformulate our priorities and processes. By analyzing providers’ biggest pain points in real-time, we can evaporate the workflow and financial troubles that have been bothering organizations while also relieving providers of their biggest problems.”
Robert Hanscom, JD, Vice President of Risk Management and Analytics at Coverys
Data Becomes the Fix, Not the Headache for Healthcare
The past 10 years have been challenging for an already overextended healthcare workforce. Rising litigation costs, higher severity claims, and more stringent reimbursement mandates put pressure on the bottom line. Continued crises in combination with less-than-optimal interoperability and design of health information systems, physician burnout, and loss of patient trust, have put front-line clinicians and staff under tremendous pressure.
Looking to the future, it is critical to engage beyond the day to day to rise above the persistent risks that challenge safe, high-quality care on the frontline. The good news is healthcare leaders can take advantage of tools that are available to generate, package, and learn from data – and use them to motivate action.
Steve Betts, Chief of Operations and Products at Gray Matter Analytics
Analytics Divide Intensifies: Just like the digital divide is widening in society, the analytics divide will continue to intensify in healthcare. The role of data in healthcare has shifted rapidly, as the industry has wrestled with an unsustainable rate of increasing healthcare costs. The transition to value-based care means that it is now table stakes to effectively manage clinical quality measures, patient/member experience measures, provider performance measures, and much more. In 2021, as the volume of data increases and the intelligence of the models improves, the gap between the haves and have nots will significantly widen at an ever-increasing rate.
Substantial Investment in Predictive Solutions: The large health systems and payors will continue to invest tens of millions of dollars in 2021. This will go toward building predictive models to infuse intelligent “next best actions” into their workflows that will help them grow and manage the health of their patient/member populations more effectively than the small and mid-market players.
Jennifer Price, Executive Director of Data & Analytics at THREAD
The Rise of Home-based and Decentralized Clinical Trial Participation
In 2020, we saw a significant rise in home-based activities such as online shopping, virtual school classes and working from home. Out of necessity to continue important clinical research, home health services and decentralized technologies also moved into the home. In 2021, we expect to see this trend continue to accelerate, with participants receiving clinical trial treatments at home, home health care providers administering procedures and tests from the participant’s home, and telehealth virtual visits as a key approach for sites and participants to communicate. Hybrid decentralized studies that include a mix of on-site visits, home health appointments and telehealth virtual visits will become a standard option for a range of clinical trials across therapeutic areas. Technological advances and increased regulatory support will continue to enable the industry to move out of the clinic and into the home.
Doug Duskin, President of the Technology Division at Equality Health
Value-based care has been a watchword of the healthcare industry for many years now, but advancement into more sophisticated VBC models has been slower than anticipated. As we enter 2021, providers – particularly those in fee-for-service models who have struggled financially due to COVID-19 – and payers will accelerate this shift away from fee-for-service medicine and turn to technology that can facilitate and ease the transition to more risk-bearing contracts. Value-based care, which has proven to be a more stable and sustainable model throughout the pandemic, will seem much more appealing to providers that were once reluctant to enter into risk-bearing contracts. They will no longer be wondering if they should consider value-based contracting, but how best to engage.
Brian Robertson, CEO of VisiQuate
Continued digitization and integration of information assets: In 2021, this will lead to better performance outcomes and clearer, more measurable examples of “return on data, analytics, and automation.
Digitizing healthcare’s complex clinical, financial, and operational information assets: I believe that providers who are further in the digital transformation journey will make better use of their interconnected assets, and put the healthcare consumer in the center of that highly integrated universe. Healthcare consumer data will be studied, better analyzed, and better predicted to drive improved performance outcomes that benefit the patient both clinically and financially.
Some providers will have leapfrog moments: These transformations will be so significant that consumers will easily recognize that they are receiving higher value. Lower acuity telemedicine and other virtual care settings are great examples that lead to improved patient engagement, experience and satisfaction. Device connectedness and IoT will continue to mature, and better enable chronic disease management, wellness, and other healthy lifestyle habits for consumers.
Kermit S. Randa, CEO of Syntellis Performance Solutions
Healthcare CEOs and CFOs will partner closely with their CIOs on data governance and data distribution planning. With the massive impact of COVID-19 still very much in play in 2021, healthcare executives will need to make frequent data-driven – and often ad-hoc — decisions from more enterprise data streams than ever before. Syntellis research shows that healthcare executives are already laser-focused on cost reduction and optimization, with decreased attention to capital planning and strategic growth. In 2021, there will be a strong trend in healthcare organizations toward new initiatives, including clinical and quality analytics, operational budgeting, and reporting and analysis for decision support.
Dr. Calum Yacoubian, Associate Director of Healthcare Product & Strategy at Linguamatics
As payers and providers look to recover from the damage done by the pandemic, the ability to deliver value from data assets they already own will be key. The pandemic has displayed the siloed nature of healthcare data, and the difficulty in extracting vital information, particularly from unstructured data, that exists. Therefore, technologies and solutions that can normalize these data to deliver deeper and faster insights will be key to driving economic recovery. Adopting technologies such as natural language processing (NLP) will not only offer better population health management, ensuring the patients most in need are identified and triaged but will open new avenues to advance innovations in treatments and improve operational efficiencies.
Prior to the pandemic, there was already an increasing level of focus on the use of real-world data (RWD) to advance the discovery and development of new therapies and understand the efficacy of existing therapies. The disruption caused by COVID-19 has sharpened the focus on RWD as pharma looks to mitigate the effect of the virus on conventional trial recruitment and data collection. One such example of this is the use of secondary data collection from providers to build real-world cohorts which can serve as external comparator arms.
This convergence on seeking value from existing RWD potentially affords healthcare providers a powerful opportunity to engage in more clinical research and accelerate the work to develop life-saving therapies. By mobilizing the vast amount of data, they will offer pharmaceutical companies a mechanism to positively address some of the disruption caused by COVID-19. This movement is one strategy that is key to driving provider recovery in 2021.
Rose Higgins, Chief Executive Officer of HealthMyne
Precision imaging analytics technology, called radiomics, will increasingly be adopted and incorporated into drug development strategies and clinical trials management. These AI-powered analytics will enable drug developers to gain deeper insights from medical images than previously capable, driving accelerated therapy development, greater personalization of treatment, and the discovery of new biomarkers that will enhance clinical decision-making and treatment.
Dharmesh Godha, President and CTO of Advaiya
Greater adoption and creative implementation of remote healthcare will be the biggest trend for the year 2021, along with the continuous adoption of cloud-enabled digital technologies for increased workloads. Remote healthcare is a very open field. The possibilities to innovate in this area are huge. This is the time where we can see the beginning of the convergence of personal health aware IoT devices (smartwatches/ temp sensors/ BP monitors/etc.) with the advanced capabilities of the healthcare technologies available with the monitoring and intervention capabilities for the providers.
Simon Wu, Investment Director, Cathay Innovation
Healthcare Data Proves its Weight in Gold in 2021
Real-world evidence or routinely stored data from hospitals and claims, being leveraged by healthcare providers and biopharma companies along with those that can improve access to data will grow exponentially in the coming year. There are many trying to build in-house, but similar to autonomous technology, there will be a separate set of companies emerge in 2021 to provide regulated infrastructure and have their “AWS” moment.
Kyle Raffaniello, CEO of Sapphire Digital
2021 is a clear year for healthcare price transparency
Over the past year, healthcare price transparency has been a key topic for the Trump administration in an effort to lower healthcare costs for Americans. In recent months, COVID-19 has made the topic more important to patients than ever before. Starting in January, we can expect the incoming Biden administration to not only support the existing federal transparency regulations but also continue to push for more transparency and innovation within Medicare. I anticipate that healthcare price transparency will continue its momentum in 2021 as one of two Price Transparency rules takes effect and the Biden administration supports this movement.
Dennis McLaughlin VP of Omni Operations + Product at ibi
Social Determinants of Health Goes Mainstream: Understanding more about the patient and their personal environment has a hot topic the past two years. Providers and payers’ ability to inject this knowledge and insight into the clinical process has been limited. 2021 is the year it gets real. It’s not just about calling an uber anymore. The organizations that broadly factor SDOH into the servicing model especially with virtualized medicine expanding broadly will be able to more effectively reach vulnerable patients and maximize the effectiveness of care.
Joe Partlow, CTO at ReliaQuest
The biggest threat to personal privacy will be healthcare information: Researchers are rushing to pool resources and data sets to tackle the pandemic, but this new era of openness comes with concerns around privacy, ownership, and ethics. Now, you will be asked to share your medical status and contact information, not just with your doctors, but everywhere you go, from workplaces to gyms to restaurants. Your personal health information is being put in the hands of businesses that may not know how to safeguard it. In 2021, cybercriminals will capitalize on rapid U.S. telehealth adoption. Sharing this information will have major privacy implications that span beyond keeping medical data safe from cybercriminals to wider ethics issues and insurance implications.
Jimmy Nguyen, Founding President at Bitcoin Association
Blockchain solutions in the healthcare space will bring about massive improvements in two primary ways in 2021.
Firstly, blockchain applications will for the first time facilitate patients owning, managing, and even monetizing their personal health data. Today’s healthcare information systems are incredibly fragmented, with patient data from different sources – be they physicians, pharmacies, labs, or otherwise – kept in different silos, eliminating the ability to generate a holistic view of patient information and restricting healthcare providers from producing the best health outcomes.
Healthcare organizations are growing increasingly aware of the ways in which blockchain technology can be used to eliminate data silos, enable real-time access to patient information, and return control to patients for the use of their personal data – all in a highly-secure digital environment. 2021 will be the year that patient data goes blockchain.
Secondly, blockchain solutions can ensure more honesty and transparency in the development of pharmaceutical products. Clinical research data is often subject to questions of integrity or ‘hygiene’ if data is not properly recorded, or worse, is deliberately fabricated. Blockchain technology enables easy, auditable tracking of datasets generated by clinical researchers, benefitting government agencies tasked with approving drugs while producing better health outcomes for healthcare providers and patients. In 2021, I expect to see a rise in the use and uptake of applications that use public blockchain systems to incentivize greater honesty in clinical research.
Alex Lazarow, Investment Director, Cathay Innovation
The Future of US Healthcare is Transparent, Fair, Open and Consumer-Driven
In the last year, the pandemic put a spotlight on the major gaps in healthcare in the US, highlighting a broken system that is one of the most expensive and least distributed in the world. While we’ve already seen many boutique healthcare companies emerge to address issues around personalization, quality and convenience, the next few years will be focused on giving the power back to consumers, specifically with the rise of insurtechs, in fixing the transparency, affordability, and incentive issues that have plagued the private-based US healthcare system until now.
Lisa Romano, RN, Chief Nursing Officer, CipherHealth
Hospitals will need to counter the staff wellness fallout
The pandemic has placed unthinkable stress on frontline healthcare workers. Since it began, they’ve been working under conditions that are fundamentally more dangerous, with fewer resources, and in many cases under the heavy emotional burden of seeing several patients lose their battle with COVID-19. The fallout from that is already beginning – doctors and nurses are leaving the profession, or getting sick, or battling mental health struggles. Nursing programs are struggling to fill classes. As a new wave of the pandemic rolls across the country, that fallout will only increase. If they haven’t already, hospitals in 2021 will place new premiums upon staff wellness and staff health, tapping into the same type of outreach and purposeful rounding solutions they use to round on patients.
Kris Fitzgerald, CTO, NTT DATA Services
Quality metrics for health plans – like data that measures performance – was turned on its head in 2020 due to delayed procedures. In the coming year, we will see a lot of plans interpret these delayed procedures flexibly so they honor their plans without impacting providers. However, for so long, the payer’s use of data and the provider’s use of data has been disconnected. Moving forward the need for providers to have a more specific understanding of what drives the value and if the cost is reasonable for care from the payer perspective is paramount. Data will ensure that this collaboration will be enhanced and the concept of bundle payments and aligning incentives will be improved. As the data captured becomes even richer, it will help people plan and manage their care better. The addition of artificial intelligence (AI) to this data will also play a huge role in both dialog and negotiation when it comes to cost structure. This movement will lead to a spike in value-based care adoption
– Healthcare technology company Forcura names the five
most significant trends for the post-acute care industry in 2021.
The post-acute care (PAC) sector saw some of its most
profound challenges this year, from deadly COVID-19
outbreaks in skilled nursing facilities (SNFs) to a suddenly accelerated need
for the services provided by home health and hospice. The biggest question now
is that what does the post-acute care future hold for all of us?
Forcura, a healthcare technology company that enables safer patient care transitions along the care continuum recently released their report, What Happened and What’s Next in Post-Acute Care,” which synthesizes the top takeaways for the post-acute care industry in 2020, and explores the five themes it projects will be the leading business influencers on the sector in 2021 and for years to come.
The report names these as the five most significant drivers
for the post-acute care industry in 2021:
1. Interoperability: The Industry Inches Closer to a
In its guide to “Interoperability in Healthcare,” HIMSS
as “the ability of different information systems, devices and applications
(systems) to access, exchange, integrate and cooperatively use data in a
coordinated manner, within and across organizational, regional and national
boundaries, to provide timely and seamless portability of information and
optimize the health of individuals and populations globally.”
Individuals and organizations have worked tirelessly for
years to create a technological foundation that will make care transitions
safer and more holistic. They’ve made incredible progress…with patients and PAC
providers beginning to reap the benefits of increased data sharing.
2. Healthcare will be Increasingly Built Around the
Service providers talk about the “user experience” and now
users are finally seeking better care experiences. People are becoming savvier
and more demanding about their healthcare in the same ways they have done so in
consuming other services. While technology is certainly a component of the move
towards patient centricity, it is a tool that enables or enhances care
delivery. Post-acute care is poised for the shift to patient centricity.
3. Payment Models and Reimbursement Plans Remain in Play
The post-acute care industry will continue to be shaped by
regulatory and financial forces. By being proactive, fully understanding the
impacts of payment models (like unified payments), learning from the lessons of
acute care payment reform, and choosing the right partners, PAC providers
should be able to more confidently control their bottom lines in the coming
4. New Business Models are Not Your Parents’ PAC
PAC companies themselves also are beginning to explore new
options for their business operations. Post-acute care is being asked to
deliver better patient outcomes and greater value – and it’s time to respond.
Driven in part by the explosion of home-based health care services from legacy
players and new entrants, PAC organizations will be scrambling to retain as
much patient share as possible. By diversifying, providers can reduce the
vulnerability experienced by single service line agencies.
5. Healthcare for All Remains Elusive
COVID-19 has revealed some harsh realities about the ongoing
effects of structural inequity…to no one’s surprise. Some steps towards equity
are occurring. Research led by Oregon Health & Science University shows
that a new national care program for hip and knee joint replacements seems to
reduce health outcome disparities for Black patients. The CMS Comprehensive
Care for Joint Replacement model is a bundled payment model designed to reduce
spending and improve outcomes for all joint replacement patients. “Although
Black patients were discharged to institutional post-acute care more than white
patients, the gap narrowed under the new bundled payment model. Readmission
risk decreased about 3 percentage points for Black patients under the new
model, and stayed roughly the same for Hispanic and white patients.”
“Everyone realizes that 2020 is historic for the unprecedented disruption and lives lost to the COVID-19 public health crisis” says Forcura founder and CEO, Craig Mandeville, “and operating in-the-moment has been a necessity. It has also possibly reduced the time the industry has to plan for what else is around the corner.” Craig continues, “Our original research and conversations from our CONNECT Summit clearly point to five market drivers that everyone should factor into their strategic initiatives. We’re proud to offer this report and believe it will guide health industry companies to focus more on patients and better secure their bottom lines.”
A recent Advisory Board briefing examined the annual Centers for Medicare & Medicaid Services (CMS) Readmission penalties. Of the 3,080 hospitals CMS evaluated, 83% received a penalty for payments to be made in 2021, based on expected outcomes for a wide variety of treated conditions. While CMS indicated that some of these penalties might be waived or delayed due to the impacts of the Covid pandemic on hospital procedure volumes and revenue, they are indicative of a much larger issue.
For too long, patients discharged from the hospital have been handed a stack of papers to fill prescriptions, seek follow-up care, or take other steps in their journey from treatment to recovery. More recently, the patient is given access to an Electronic Health Record (EHR) portal to view their records, and a care coordinator may call in a few days to check-in. These are positive steps, but is it enough? Although some readmissions cannot be avoided due to unforeseen complications, many are due to missed follow-up visits, poor medication adherence, or inadequate post-discharge care.
Probably because communication with outside providers has never worked reliably, almost all hospitals have interpreted ‘care coordination’ to mean staffing a local team to help patients with a call center-style approach. Wouldn’t it be much better if the hospital could directly engage and enable the Primary Care Physician (PCP) to know the current issues and follow-up directly with their patient?
We believe there is still a real opportunity to hold the patient’s hand and do far more to guide them through to recovery while reducing the friction for the entire patient care team.
Strengthening Care Coordination for a Better Tomorrow
Coordinating and collaborating with primary care, outpatient clinics, mental health professionals, public health, or social services plays a crucial role in mitigating readmissions and other bumps along the road to recovery. Real care coordination requires three related communication capabilities:
1. Notification of the PCP or other physicians and caregivers when events such as ED visits or Hospitalization occur.
2. Easy, searchable, medical record sharing allows the PCP to learn important issues without wading through hundreds of administrative paperwork.
3. Secure Messaging allows both clinicians and office staff to ask the other providers questions, clarify issues, and simplify working together.
There are some significant hurdles to improve the flow of patient data, and industry efforts have long been underway to plug the gaps. EHR vendors, Health Information Exchanges (HIEs), and a myriad of vendors and collaboratives have attempted to tackle these issues. In the past few decades, government compliance efforts have helped drive medical record sharing through the Direct Messaging protocol and CCDAs through Meaningful Use/Promoting Interoperability requirements for “electronic referral loops.” Kudos to the CMS for recognizing that notifications need to improve from hospitals to primary care—this is the key driver behind the latest CMS Final Rule (CMS-9115-F) mandating Admission, Discharge, and Transfer (ADT) Event Notifications. (By March 2021, CMS Conditions of Participation (CoPs) will require most hospitals to make a “reasonable effort” to send electronic event notifications to “all” Primary Care Providers (PCPs) or their practice.)
However, to date, the real world falls far short of these ideals: for a host of technical and implementation reasons, the majority of PCPs still don’t receive digital medical records sent by hospitals, and the required notifications are either far too simple, provide no context or relevant encounter data, rarely include patient demographic and contact information, and almost never include a method for bi-directional communications or messaging.
Delivering What the Recipient Needs
PCPs want what doctors call the “bullet” about their patient’s recent hospitalization. They don’t want pages of minutia, much of it repetitively cut and pasted. They don’t want to scan through dozens or hundreds of pages looking for the important things. They don’t want “CYA” legalistic nonsense. Not to mention, they learn very little from information focused on patient education.
An outside practitioner typically doesn’t have access to the hospital EHR, and when they do, it can be too cumbersome or time-consuming to chase down the important details of a recent visit. But for many patients—especially those with serious health issues—the doctor needs the bullet: key items such as the current medication list, what changed, and why.
Let’s look at an example of a patient with Congestive Heart Failure (CHF), which is a condition assessed in the above-mentioned CMS Readmission penalties. For CHF, the “bullet” might include timely and relevant details such as:
– What triggered the decompensation? Was it a simple thing, such as a salty meal? Or missed medication?
– What was the cardiac Ejection Fraction?
– What were the last few BUN and Creatinine levels and the most recent weight?
– Was this left- or right-sided heart failure?
– What medications and doses were prescribed for the patient?
– Is she tending toward too dry or too wet?
– Has she been postural, dizzy, hypotensive?
Ideally, the PCP would receive a quick, readable page that includes the name of the treating physician at the hospital, as well as 3-4 sentences about key concerns and findings. Having the whole hospital record is not important for 90 percent of patients, but receiving the “bullet” and being able to quickly search or request the records for more details, would be ideal.
Similar issues hold true for administrative staff and care coordinators. No one should play “telephone tag” to get chart information, clarify which patients should be seen quickly, or find demographic information about a discharged patient so they can proactively contact them to schedule follow-up.
Building a Sustainable, Long-Term Solution
Having struggled mightily to build effective communications in the past is no excuse for the often simplistic and manual processes we consider care coordination today.
Let’s use innovative capabilities to get high-quality notifications and transitions of care to all PCPs, not continue with multi-step processes that yield empty, cryptic data. The clinician needs clinically dense, salient summaries of hospital care, with the ability to quickly get answers—as easy as a Google search—for the two or three most important questions, without waiting for a scheduled phone call with the hospitalist. X-Rays, Lab results, EKGs, and other tests should also be available for easy review, not just the report. After all, if the PCP needs to order a new chest x-ray or EKG how can they compare it with the last one if they don’t have access to it?
Clerical staff needs demographic information at their fingertips to “take the baton” and ensure quick and appropriate appointment scheduling. They need to be able to retrieve more information from the sender, ask questions, and never use a telephone. Additionally, both the doctor and the office staff should be able to fire off a short note and get an answer to anyone in the extended care team.
That is proper care coordination. And that is where we hope the industry is collectively headed in 2021.
About Peter Tippett MD, PhD: Founder and CEO, careMESH
Dr. Peter S. Tippett is a physician, scientist, business leader and technology entrepreneur with extensive risk management and health information technology expertise. One of his early startups created the first commercial antivirus product, Certus (which sold to Symantec and became Norton Antivirus). As a leader in the global information security industry (ICSA Labs, TruSecure, CyberTrust, Information Security Magazine), Tippett developed a range of foundational and widely accepted risk equations and models.
About Catherine Thomas: Co-Founder and VP, Customer Engagement, careMESH
Catherine Thomas is Co-Founder & VP of Customer Engagement for careMESH, and a seasoned marketing executive with extensive experience in healthcare, telecommunications and the Federal Government sectors. As co-founder of careMESH, she brings 20+ years in Strategic Marketing and Planning; Communications & Change Management; Analyst & Media Relations; Channel Strategy & Development; and Staff & Project Leadership.
The Patient-Driven Groupings Model (PDGM) was supposed to define home health care in 2020.
Instead, this year was almost entirely shaped by COVID-19, a point that’s reinforced by the most widely read stories on Home Health Care News. Of the top-10 stories on HHCN in 2020, eight were related to coronavirus coverage.
From the first outbreak in Kirkland, Washington, to the latest developments in government support for health care providers, HHCN was on top of it all. Reflect back on this unprecedented year in home health care by browsing through the content below.
There have been several different federal COVID-19 stimulus packages passed since spring, with the House and Senate often locked in tense political debates on the details. HHCN’s top story of 2020 was an inside look at a May House proposal — the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act.
While nothing came of the Democrat-backed bill, it did highlight the growing recognition of front-line health care workers. Specifically, the proposed relief package included a $200 billion fund for essential-worker hazard pay.
As of Thursday, lawmakers were reportedly close to signing off on a roughly $900 billion relief deal that would include another round of stimulus checks and other much-needed financial benefits for Americans. Liability protections for businesses — something Republicans have pushed for — are likely not included in the deal.
Going into this year, one of the main storylines of PDGM was the reimbursement overhaul’s impact on in-home therapy services.
After the Patient-Driven Payment Model (PDPM) was implemented in the skilled nursing facility (SNF) space in October 2019, many operators opted to cut or furlough therapy staff. Some industry experts expected home health agencies to do the same.
Certainly, some providers did shift their therapy strategies. But it’s almost impossible to identify whether home health therapy cuts were tied to PDGM or the ongoing public health emergency.
Early on, home health providers had to adapt to care for a surge of COVID-19-positive patients. Quickly, though, it became clear they would have to respond to other challenges as well.
Among those challenges: the influx of non-COVID patients that were getting discharged from hospitals faster to maintain acute care capacity. By not recovering in the hospital for longer, patients discharged to home health care in 2020 have been weaker and more deconditioned than in the past.
A similar trend has emerged — higher patient acuity levels — as referral sources looked to avoid congregate care settings like SNFs.
On one hand, labor experts predicted that a depressed economy and the closure of certain businesses would lead to a larger worker pool for in-home care agencies. On the other, initially robust unemployment benefits meant some caregivers could get paid more by opting out of work.
In conversations with HHCN, most home health and home care executives have said the recruitment and retention of workers remains extremely difficult.
Although COVID-19 outbreaks started to surface in mid-March, home-based care agencies didn’t start feeling pandemic pressures until mid- to late-April. Leading up to that time, operators scrambled to secure enough personal protective equipment (PPE) and educate their patients on the safety of their services.
In April, CMS announced that it was sending a first tranche of $30 billion to all Medicare-reimbursed health care organizations, with funding coming from the Public Health and Social Services Emergency Fund under the CARES Act. More tranches followed, with HHS releasing another $1.1 billion in direct aid to nursing homes on Wednesday.
In September, CMS announced the availability of up to $165 million in supplemental funding to states operating Money Follows the Person (MFP) demonstration programs. While that news was exciting, it was related comments from Administrator Seema Verma that really piqued home-based care agencies’ interest.
The tragic devastation wrought by the coronavirus on nursing home residents exposes America’s over-reliance on institutional long-term care facilities,” Verma said at the time. “Residential care will always be an essential part of the care continuum, but our goal must always be to give residents options that help keep our loved ones in their own homes and communities for as long as possible.”
Staffing continues to be a challenge for home-based care providers. Even as unemployment rose to record-highs during the COVID-19 crisis and demand for home-based care skyrocketed, providers found it hard to find qualified workers.
But one undeniable tailwind was how spotlighted home care careers became during the public health emergency. President-elect Joe Biden outlined a plan to boost the caregiver workforce, politicians vied for home-based care on both sides of the aisle, and everyday Americans become more aware of what home-based care workers did on a daily basis.
“One positive thing that I think came out of COVID — and I think this is just a real positive thing for the whole industry — is home care careers are suddenly on the map,” Brandi Kurtyka, the CEO of myCNAjobs told HHCN. “Senior care just got the biggest ‘Got Milk’ campaign that we’ve ever seen.”
Efforts have certainly stalled since, but when the initial relief packages came out in March, home-based care providers could not get enough of the details — of which there were many.
When the record-breaking $2 trillion stimulus package known as the CARES Act passed, providers were granted monetary and regulatory relief. It was the first shoe to drop in a litany of changes ultimately made to the home-based care space.
It created the Provider Relief Fund and made temporary, beneficial changes to reimbursement. But it also created a more virtual industry, rendering face-to-face requirements and other traditionally in-person practices as relics of the past.
This is the story that kicked everything off — the first time that HHCN reported on the coronavirus in 2020. “People have been asking me, ‘Where are we with the coronavirus?’” National Association for Home Care & Hospice (NAHC) President William A. Dombi was quoted saying. “It’s scary.” Those fears would soon turn out to be well founded.
National home health spending soared to a whopping $113.5 billion in 2019, according to a new analysis from the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary published Wednesday in the journal Health Affairs.
While that figure marked another all-time high for home health care, the U.S. government still spent far more on nursing care facilities and hospital care last year.
That may change in 2020 due to the ongoing COVID-19 pandemic and a need to decentralize health care services, though it’s probably still too soon to draw any long-term spending conclusions.
Overall 2019 health care spending in the United States was $3.8 trillion, up 4.6% compared to the previous year, the CMS Office of the Actuary estimates. The share of the economy devoted to health care spending, as measured by the GDP, was 17.7%.
“Health care spending in 2019 increased at about the same rate as it had in 2018 and was similar to the average annual growth since 2016,” Anne Martin, an economist in the CMS Office of the Actuary and first author of the Health Affairs article, noted. “This relative stability in health care spending growth over the last four years preceded the COVID-19 pandemic in 2020. The full impact of the pandemic on the health care sector is still not known, but it will certainly have profound consequences on the provision and consumption of health care in 2020 and perhaps beyond.”
National spending on home health care services has grown by at least 5% annually since 2015. From 2018 to 2019, spending increased by 7.7% — the biggest year-over-year jump since at least 2013.
Wednesday’s analysis does not go into the reasons driving that substantial increase, but there are several likely factors.
On a demographic level, the country’s universe of Medicare beneficiaries is becoming more medically complex, with older individuals often living with four or more chronic conditions and functional limitations. At the same time, more and more hospitals and community-based referral sources are opting to send their patients to home health providers instead of skilled nursing facilities (SNFs).
Accountable care organizations (ACOs), health plans and others are similarly recognizing the value of home-based care more than ever.
These and other trends have only accelerated during the public health emergency in 2020.
“The biggest thing that we will see in home health care is that we’re given a seat at the ‘big kids’ table,’” Beau Sorensen, COO at First Choice Home Health & Hospice, told Home Health Care News earlier this week. “The recognition from COVID-19 that the country needs to move away from keeping people in congregate living and post-acute settings, combined with the expertise that we have developed through decades of caring for people at home, will lead to a much larger role for home health and hospice in the care continuum.”
Total Medicare spending grew by 6.7% in 2019 to $799.4 billion. Comparatively, that accounted for 21% of total national health care expenditures.
Meanwhile, total Medicaid spending grew by 2.9% to 613.5 billion. That accounted for 16% of total national health spending.
Government spending on hospital care hit an estimated $1.2 trillion last year, according to the CMS Office of the Actuary. Put differently, roughly one out of every three dollars spent on health care in 2019 was tied to hospital-based care.
Spending on “nursing care facilities and continuing care retirement communities” was an estimated $172.7 billion in 2019 — nearly $60 billion more than spending on home health care. While home health expenditures grew by more than 7% from 2018 to 2019, however, spending in this area only grew by 3.3%.
At the beginning of the month, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the 2021 Medicare Physician Fee Schedule.
Since then, the rule has drawn criticism for the payment cuts CMS made to home-based primary care visits, a move that experts believe will jeopardize access to care for seniors and chronically ill patients. That’s especially true considering the ongoing public health emergency, when in-home care has never been more important.
Similar to the home health payment rule, CMS’s Medicare Physician Fee Schedule mandates how much Medicare physicians get paid for providing care in 2021.
Under the rule, home-based primary care saw an 8% to 10% payment cut to visits. One of the many organizations that has been critical of the cut is the American Academy of Home Care Medicine (AAHCM).
About 2 million seniors are permanently homebound, according to AAHCM. For seniors who fall under this category and certain others, receiving care outside of the home can be difficult — or impossible.
“One concern if this doesn’t get reversed or reconsidered by policymakers is that with the effective rate cuts to home-based medical care providers, the exact patients who we are trying to protect by not having to go to a clinic, hospital or urgent care facility will be impacted,” Theresa Soriano, president of AAHCM, told Home Health Care News. “If you are reducing rates by 10%, you’re going to threaten the ability of these largely small practices to be able to provide care quickly and on a large scale.”
Soriano also noted that home-based primary care providers are often delivering care to those who are most at risk for adverse health complications if they were to contract COVID-19.
Chicago-based AAHCM is a professional and advocacy organization that represents physicians, nurses, physician assistants, social workers and other health care professionals dedicated to working in the field of home-based medical care.
CMS’s payment cut to home-based primary care visits could also spell trouble for smaller providers and have long-term implications for the industry as a whole.
“Many of my colleagues are extremely worried that smaller practices — those that are not affiliated with large health systems or [similar] entities — will really struggle, and may either have to downsize or even close,” Soriano said. “This is not urban or rural — all parts of our country are being served by home-based medical care.”
Soriano pointed out that the recent rate cut was accompanied by a rate increase for primary care providers that don’t work in the home setting, which may speak to an oversight on CMS’s part.
“Office-based primary care is effectively seeing an increase in their reimbursement, which is appropriate and right,” she said. “We want people to be getting the care they need, but considering that the care we are providing is in an arguably safer setting, we just believe that there was a … lack of recognition that home-based medical care is primary care and should not be seeing a rate cut but the same increase,” she said.
In order to combat CMS’s decision, AAHCM has thrown its support behind legislation under consideration which would delay the cuts. The organization considers this a temporary solution.
Moving forward, Soriano believes that it’s important for providers to reach out to Congressional representatives, as well as CMS.
“Something that we are doing is reaching out to our state representation, both on the Senate and House side,” she said. “And to CMS, to make them aware that primary care and home-based medical care are related. Home-based medical care is a subset of primary care and needs to be recognized in the same way.”
In April 2019, the U.S. Centers for Medicare & Medicaid Services (CMS) rolled out a new suite of direct-contracting payment models, with the goal of accelerating the shift to value-based care.
Since then, exactly 51 direct-contracting entities (DCEs) have signed up for either the ”global” or “professional” options. Among them is Huntington Beach, California-based Landmark Health, an in-home medical care provider that cares for tens of thousands of complex patients each year.
“We, as an organization, have been interested in a model like this for traditional Medicare beneficiaries for a long time,” Chris Johnson, vice president of corporate strategy and development for Landmark, told Home Health Care News.
Founded in 2014, Landmark has built its business model on delivering comprehensive in-home medical care to chronically ill older adults. Today, its physician-led multidisciplinary teams work alongside patients’ existing health care providers in 16 states and dozens of metropolitan areas.
Traditionally, Landmark has operated within the Medicare Advantage (MA) landscape, helping health plans bend the cost curve by reducing avoidable ER visits and hospitalizations. But thanks to the new direct-contracting model from CMS and its CMS Innovation Center, the company will soon be able to expand its reach to also care for fee-for-service Medicare beneficiaries.
And that will fundamentally transform Landmark, according to Johnson.
“We see this as something that allows legacy health systems and medical groups, as well as newer entrants like Landmark, to be able to bring new innovative models of care to the market,” he said. “We see it as something that will measure us and reward us on our ability to improve outcomes and reduce the overall cost of care for patient populations, without being beholden to the traditional fee-for-service payment system.”
Landmark officially announced its participation in the direct-contracting model on Nov. 23. Other DCEs, according to CMS records, include home-based care pioneers like Lifesprk, Oak Street Health, VillageMD and more.
“We’ve always been very interested in exploring ways that we can move from serving what today is traditionally a Medicare Advantage population into traditional Medicare as well,” Johnson emphasized.
‘A really big contract’
Since launching, Landmark has gained backing from General Atlantic and Oxeon Partners. It has similarly secured several prominent partnerships, including ones with Aetna, Blue Shield of California and Harvard Pilgrim Health Care.
The care provider’s foray into the direct-contracting model shouldn’t come as a surprise to those who are familiar with the company. In fact, innovation and alternative payment models are actually part of Landmark’s DNA.
Before current CEO Nick Loporcaro took over as CEO in September 2018, Landmark was led by founder Adam Boehler. In April of that year, Boehler left Landmark to run the CMS Innovation Center, a tenure that ultimately ended this year.
Overall, the implementation period for the global and professional direct-contracting options runs from Oct. 1 of this year through March 31, 2021.
Of CMS’s direct-contracting pathways, the professional option offers a lower risk-sharing arrangement, with participants being exposed to 50% upside and downside risk. It comes with “primary care capitation,” a capitated, risk-adjusted monthly payment for enhanced primary care services.
Meanwhile, the global option offers the highest risk-sharing arrangement, with participants on the hook for 100% savings and losses. It comes with two payment options: Primary care capitation or “total care capitation,” a capitated, risk-adjusted monthly payment for all services provided by participants plus the preferred providers they work with.
“You have full upside and downside risk for the total cost of care of the beneficiaries that you’re seeing,” Johnson said.
In some ways, direct-contracting is similar to how MA plans operate.
Broadly, CMS sets a base rate at the county level for different patient populations. Each DCE then has to work against the base rate, figuring out where they can improve patient care and curb overall spending.
“We almost think of this as just adding a new contract,” Johnson said. “It’s just that this is a really big contract.”
Landmark will start caring for patients under the direct-contracting model in April. When that time comes, it will have an opportunity to profoundly expand its business.
Currently, Landmark has about 12 million Medicare beneficiaries across its national footprint. Of those, more than 7 million are in traditional Medicare — people Landmark wouldn’t be able to reach without direct contracting.
“The reason we get really excited about it is, you know, part of our mission is to transform the care in the communities that we serve,” Johnson said. “As things stand today, we’ve really been limited. We’ve thought about ways that we could participate with traditional Medicare, but we just couldn’t make our business model work in the fee-for-service world.”
On top of the global and professional options, CMS also recently unveiled plans for a geographic direct-contracting model. With the initial performance period slated for January, the geographic option would pay participants for lowering total cost of care for Medicare beneficiaries in a given marketplace.
“The Geographic Direct-Contracting Model is part of the Innovation Center’s suite of Direct-Contracting models and is one of the Center’s largest bets to date on value-based care,” current CMS Innovation Center Director Brad Smith said in a statement.
CMS is considering 15 geographic regions in which to test the model, though ultimately the agency will select only a maximum of 10. The areas under review include: Atlanta, Dallas, Denver, Detroit, Houston, Los Angeles, Miami, Minneapolis, Orlando, Phoenix, Philadelphia, Pittsburgh, Riverside, San Diego and Tampa.
Each of these areas includes 150,000 to 700,000 beneficiaries.
The rule would require payers in the Medicaid, CHIP and QHP programs to build and maintain application programing interfaces to improve data exchange and the prior authorization process. But the rule does not include Medicare Advantage plans, which the American Hospital Association called “disappointing.”
A global health crisis has thrust us into a scenario in which lives quite literally depend on the ability to virtually connect. Telehealth has rapidly emerged as a vital tool, enabling continuity of care, allowing vulnerable individuals to access their physician from home, and freeing up resources for providers to treat the most critical patients. The acceptance of telehealth and expansion of covered services for the senior population demonstrate that this technology will endure long after COVID-19 subsides.
Prior to the pandemic, just 11% of Americans utilized telehealth compared to 46% so far this year, and virtual healthcare interactions are expected to top 1 billion by year’s end. While the technology has been a life-saver for many, usage depends heavily on the availability of audio-video capabilities, internet access, and technological prowess – potentially leaving vulnerable patients behind.
Seniors Face Physical, Technical and Socioeconomic Barriers to Telehealth
Despite telehealth’s surge, there is growing concern that the rapid shift to digitally delivered care is leaving seniors behind. Telehealth is not inherently accessible for all and with many practices transitioning appointments online, it threatens to cut older adults off from receiving crucial medical care. This is a significant concern, considering older adults account for one-quarter of physician office visits in the United States and often manage multiple conditions and medications, and have a higher rate of disability. This puts an already vulnerable population at a higher risk of severe complications from COVID-19.
Research published recently in JAMA Internal Medicine found that more than a third of adults over age 65 face potential difficulties accessing their doctor through telehealth. Obstacles include familiarity using mobile devices, troubleshooting technical issues that arise, managing hearing or vision impairments, and dealing with cognitive issues like dementia. Many of these difficulties stem from the natural aging process; it is imperative for provider organizations employing telehealth and telehealth vendors to improve offerings that consider vision, hearing, and speaking loss for this population.
While barriers associated with aging are a key factor within the senior population, perhaps the greatest challenges in accessing telehealth are socioeconomic. The rapid shift to digital delivery of care may have left marginalized populations without access to the technological tools needed to access care digitally, such as high-speed internet, a smartphone or a computer.
According to the JAMA study, low-income individuals living in remote or rural locations faced the greatest challenges in accessing telehealth. A second JAMA study, also released this summer indicated that “the proportion of Medicare beneficiaries with digital access was lower among those who were 85 or older, were widowed, had a high school education or less, were Black or Hispanic, received Medicaid, or had a disability.”
These socioeconomic factors are systemic issues that existed prior to the pandemic, and the crisis-driven acceleration of telehealth has magnified these pre-existing challenges and widened racial and class-based disparities. Recent initiatives at the federal level, such as the FCC’s rural telehealth expansion task force, are a step in the right direction, though more sustained action is needed to address additional socioeconomic challenges that are deeply rooted within the healthcare system.
Fortunately, Telehealth Hurdles Can Be Overcome
Recognizing that telehealth isn’t a “one-size fits all” solution is the first step towards addressing the barriers that disproportionately impact seniors and work is needed on multiple levels. Telemedicine consults are impossible without access to the internet, so the first step is to provide and expand access to broadband and internet-connected devices. With more than 15% of the country’s population living in rural areas, expanding broadband access for these individuals is especially crucial. In addition, older adults in community-based living environments need greater access to public wi-fi networks.
Access to mobile and other internet-connected devices is also essential. Products designed with large fonts and icons, closed captioning, and easy set-up procedures may be easier for older adults to use. For example, GrandPad is a tablet designed specifically for seniors and has an intuitive interface that includes basic video calling, enabling seniors to virtually connect with their caregivers.
To address affordability, the Centers for Medicaid and Medicare Services (CMS) allowed for mid-year benefit changes in 2020 to allow for payment or provision of mobile devices for telehealth. Many Medicare Advantage organizations are enhancing plans’ provisions of telehealth coverage and devices for 2021.
In addition to increasing access to broadband and internet-connected devices, providing seniors with proper educational resources is another crucial step. Even if older adults are open to using technology for telehealth visits, many will need additional training. Healthcare organizations may want to connect older patients with community-based technology training programs. Some programs take a multi-generational approach, pairing younger instructors with older students.
For example, Papa is an on-demand service that pairs older adults with younger ‘Papa Pals’ who provide companionship and assistance with tasks such as setting up a new smartphone or tablet.
From a socioeconomic perspective, careful consideration is needed to address the concerns that telehealth may reinforce systemic biases and widen health disparities. Providers may be less conscious of systemic bias toward patients based on race, ethnicity, or educational status.
In turn, providers must address implicit bias head-on, such as offering workplace training and incorporating evidence-based tools to adequately measure and address health disparities. This includes pushing for policies that enable widespread broadband access funding to better connect communities in need.
Health plans can support expanded access to care through benefit design, reducing costs for plan members. To match members and patients with the right resources and assistance, health plans and providers should launch outreach campaigns that are segmented by demographic group. Outreach initiatives could include assessments to determine each person’s ability and comfort level with telehealth.
The Path Forward
Without question, telehealth is playing a central role in delivering care during the current pandemic, and many of its long-touted benefits have been accentuated by the current demand. Telehealth, along with other digital monitoring technologies, have the potential to address several barriers to care for seniors and other vulnerable populations for whom access to in-person care may not be viable, such as those based in remote locations or with mobility issues.
In the post-pandemic era, telehealth can provide greater access and convenience, but if not implemented carefully, the permanent expansion of telehealth may worsen health disparities. Careful consideration and collaboration will be essential in embracing the value of telehealth while mitigating its inherent risks.
If implemented correctly, telehealth can provide continued access to care for our vulnerable aging population and can significantly improve care as well. Enhancing the ability to connect with healthcare providers anytime, anywhere can give seniors the freedom to gracefully age in place.
About Anne Davis
Anne Davis is the Director of Quality Programs & Medicare Strategy at HMS, a healthcare technology, analytics, and engagement solutions company, where she’s focused on the company’s Population Health Management product portfolio.
When 2020 began, no one anticipated that complying with the Merit-based Incentive Payment System (MIPS)—the flagship payment model of the Centers for Medicare & Medicaid Services (CMS) Quality Payment Program (QPP)—would look so different halfway through the year. Like many other things, the COVID-19 crisis has delayed, diverted, or derailed many organizations’ reporting efforts and capabilities. Lower procedure volumes, new remote work scenarios, and shifting priorities have taken attention away from MIPS work.
Despite the disruptions and uncertainties associated with the pandemic, healthcare organizations should not lose track of MIPS compliance and the program’s intent to improve care quality, reduce costs, and facilitate interoperability. Here are a few strategies for keeping a MIPS program top of mind.
Understand the immediate effects of the pandemic on MIPS reporting
Due to COVID-19, CMS granted several 2019 data reporting exceptions and extensions to clinicians and providers participating in Medicare quality reporting programs. These concessions were enacted to let providers focus 100% of their resources on caring for and ensuring the health and safety of patients and staff during the early weeks of the crisis. For the 2020 MIPS performance period, CMS has also chosen to use the Extreme and Uncontrollable Circumstances policy to allow requests to reweight any or all of the MIPS performance categories to 0%.
Clinicians and groups can complete the application any time before the end of this performance year. If practices are granted reweighting one or more categories but submit data during the attestation period, the reweighting will be void and the practice will receive the score earned in the categories for which they submit data
Seize the opportunity to improve interoperability
Interoperability is a key area that organizations were focused on before the crisis, and this work still warrants attention. If an organization is not on the front lines of the COVID-19 response, it should use this time to shore up communications with other entities so, once things return to “normal,” it will be well prepared to seamlessly exchange information with peer organizations.
Establishing processes for sending and receiving care summaries via direct messaging is important for practices to earn a high score in the Promoting Interoperability category. Direct messaging is a HIPAA-compliant method for securely exchanging health information between providers, which functions as an email but is much more secure due to encryption. A regular pain point organizations face is being unable to obtain direct messaging addresses from peer organizations, including referral partners.
To assist providers in this area, the Office of the National Coordinator for Health Information Technology (ONC) and CMS has created a mandatory centralized directory of provider electronic data exchange addresses published by the National Plan & Provider Enumeration System (NPPES). The NPPES directory is searchable through a public API and allows providers to look up the direct messaging addresses for other providers. To meet current interoperability requirements, providers must have entered their direct messaging address into the system by June 30, 2020. If they haven’t done so, the provider could be publicly reported for failure to comply with the requirement, which could constitute information blocking.
Take time now to ensure direct messaging addresses have been entered correctly for all members of your practice. This is also a good time to begin reaching out to top referral sources to make sure they are also prepared to send and receive information.
Look for ways to streamline quality reporting
Over the next few months, the focus will return to quality measure reporting. As such, it’s wise to take advantage of this time to ensure solid documentation and reporting methods. Electronic medical records (EMRs) can be helpful in streamlining these efforts.
For example, dropdown menus with frequently used descriptions and automated coding can enable greater accuracy and specificity while easing the documentation process for providers. Customizable screens that can be configured to include specialty-specific choices based on patient history and problem list can also smooth documentation and coding, especially if screen layouts mirror favored workflow.
Regarding MIPS compliance in particular, it can be helpful to use tools that offer predictive charting. This feature determines whether a patient qualifies for preselected MIPS measures in real-time and presents the provider with data fields related to those items during the patient encounter—allowing the physician to collect the appropriate information without adding additional charting time later on.
With respect to reporting, providers may benefit from using their certified EMR in addition to reporting through a registry. At the beginning of the MIPS program, providers could report through both a registry and EMR directly and would be scored separately for their quality category through each method. They would then be awarded the higher score of the two. This method had the potential to leave some high-scoring measures on the table.
Beginning in 2019, providers reporting through both registry and EMR direct are scored across the two methods. CMS uses the six highest scoring measures between the two reporting sets to calculate the provider’s or group’s quality score, potentially resulting in a higher score than the provider would earn by reporting through either method alone.
A knowledgeable partner can pave the way to better performance
COVID-19 has impacted healthcare like no other event in recent history, and it’s not surprising that MIPS compliance has taken a back seat to more pressing concerns. However, providers still have the opportunity to make meaningful progress in this area. By working with a technology partner that keeps up with the current requirements and offers strategies and solutions for optimizing data collection and reporting, a provider can realize solid MIPS performance during and beyond this unprecedented time.
About Courtney Tesvich, VP of Regulatory at Nextech
Courtney is a Registered Nurse with more than 20 years in the healthcare field, 15 of which have been focused on quality improvements and regulatory compliance. As VP of Regulatory at Nextech, Courtney is responsible for ensuring that Nextech’s products meet government certification requirements and client needs related to the regulatory environment.
The new Geographic Direct Contracting Model aims to improve quality of care and slash costs for Medicare beneficiaries across an entire region. It involves setting up risk-sharing arrangements where participants will be responsible for the total cost of care for beneficiaries in the region.
– San Francisco-based digital health startup Pair Team
emerges out of stealth with $2.7M in seed funding backed by Kleiner Perkins,
Craft Ventures, & YC.
– Pair Team provides both a remote team and AI that automates workflows, provides infrastructure & improves medical practices — efficiencies and billing as you’d expect, but all driving toward value-based, quality patient care.
– Pair’s wrap-around technology tripled the rate of annual wellness visits and increased revenue by 15% for clinics in 2020.
Pair Team (“Pair”) announced today it has
emerged out of stealth and has raised $2.7 million in seed funding backed by Kleiner Perkins, Craft Ventures, and YCombinator, along with other prominent
funds. Pair is an end-to-end operations platform for value-based primary care,
backed by Pair’s own care team. For patients, Pair provides a digital front door
and helps them navigate healthcare.
Automate Primary Care Operations Infrastructure
Founded in 2019 by Neil Batlivala and Cassie Choi, RN after experiencing how critical a high functioning administrative team is to provide high-quality primary care by building out operations together at leading tech-enabled practices of Forward and Circle Medical. The majority of healthcare is local and fragmented, and no solutions were built to enable existing clinics. Pair came out of that need and provides a simple yet comprehensive solution that covers the front, mid, and back-office. Their automation, along with a human-in-the-loop approach provides end-to-end operations of patient outreach, scheduling, e-forms, care gap reports, record requests, referrals, lab coordination, etc., to offload the traditional job functions of the front desk and medical assistants.
“Primary care is systematically and chronically under-resourced. Pair ensures patients receive the very best practices in health care — from annual checkups, follow-ups after hospital discharge, and preventative care screenings,” commented Neil Batlivala, CEO and co-founder of Pair Team. “We not only monitor patient data, but we go further to operationalize it with automation and our care team.”
Pair provides a revenue-sharing model to the share cost of operations with primary care providers. The platform monitors health plan and system data to trigger automated workflows that engage patients to schedule clinically impactful visits, surface care recommendations to clinicians, and manage follow-up care coordination. Their bolt-on model allows them to work as an extension of your care team within existing processes and accelerate quality programs in days, not months. For practices, this drastically improves care quality and visit efficiency. For plans, this aligns day-to-day operations with a total cost of care.
Helping Medicaid Populations Navigate Their Healthcare
Pair helps Medicaid populations navigate their healthcare with follow-ups, preventive cancer screening, and those recommendations on current (and ever-changing) Medicaid requirements. The company starts with existing processes and accelerates quality programs in days, not months.
Despite COVID and patient’s avoidance of medical offices and care, Pair’s wrap-around operations technology and care team tripled the rate of preventative care visits and are on track to increase clinical revenue by 15% by end of the year through quality incentives alone. To date, Pair manages care for thousands of Medicaid patients in southern California and has closed hundreds of care gaps with their remote care team.
Telehealth and virtual care are not brand-new phenomena suddenly cobbled together as a rapid response to the onset of the COVID-19 pandemic, but the average US patient could be forgiven for thinking that it is. Indeed, virtual visits to care providers and remote patient monitoring have been available for quite some time, delivering two key benefits:
– Providing a platform to address cost-efficiencies and accessibility to quality healthcare for the populace at large
– Playing a key role in managing a growing population of chronically ill seniors.
Prior to 2020, however, the rules of reimbursement and implementation for associated telehealth services were difficult to navigate, wildly differing at the state and federal level with a host of regulations further complicating matters. Federal reimbursement policies are centered on Medicare, via the Centers for Medicare and Medicaid Services (CMS) – the single largest payer for seniors and chronically ill patients. Additionally, compliance with the Health Insurance Portability and Accountability Act (HIPAA) dictated rigorous standards for direct and monitoring communications between care providers and patients. Complicating matters further, US states offered a patchwork of individual telehealth laws dictating separate Medicaid policies.
The result was a lack of clarity of how healthcare providers could overcome regulatory and financial reimbursement barriers to implement effective telehealth programs as well as a lack of parity in coverage services and payments for patients. To address this at the federal level, CMS released new guidance in 2020 to relax reimbursement restrictions for providers. Now, we’re at the cusp of a new era of telemedicine where providers could widely offer:
– Virtual office visits that address traditionally in-person services such as primary care, behavioral health, and specialty care (e.g. pulmonary or cardiac health rehabilitation)
– On-demand virtual urgent care to address pressing concerns and urgently needed consultations
– Virtual broader home health services such as remote patient monitoring, outpatient disease management, and various forms of therapy (e.g. physical, speech)
– Tech-enabled home medication administration helping patients receive injectable or consumable medication via monitored self-administration
This is all, of course, dependent upon the mobile technology (e.g. tablets, wearables, etc.) and associated services that telehealth providers will rely upon to make these services happen at parity and scale for their patients. Even more importantly, virtual care programs being scaled up to cover a larger percentage of patients will fall apart if providers don’t have the resources to offer robust support and maintenance options for these devices and services. Quality of virtual care is highly dependent on persistent device and service availability and dependability.
Whether providers have already begun purchasing the mobile devices needed or are still struggling with the choice of what devices and services they need and/or can afford, however, they now face a different quandary: How to stand up these virtual care services at scale in a sustainable way that works within current budget resources and doesn’t pass on ballooning costs to your patients?
One way to make complex mobile technology deployments financially manageable is opting for a mobile device as a service (mDaaS) model which allows you to shift from a CapEx-based spending model to an OpEx spending model for purchasing hardware and allows telehealth providers to bundle or roll up a range of devices, accessories, services, maintenance and support into a single, predictable monthly per-device price. With mobile device technology rapidly evolving, telemedicine providers will need the operational agility to pivot to different solutions and quick technology refreshes as the need arises.
When done with the right third-party partner, it offers the additional advantages of outsourcing end-to-end support and lifecycle management to highly trained agents, who can free up precious IT resources. Most importantly, it creates a level of control over technology and spend that makes standing up virtual care programs convenient and stress-free.
There are many options to consider when expanding telemedicine services rapidly to larger patient bases, whether during disruptive events such as the COVID-19 pandemic or in the years to come. The key to making these services sustainable is finding a financing model that will free up internal resources, offer greater spending flexibility, and offer end-to-end support for your healthcare mobile technology ecosystem.
About Don Godbee Senior Mobile Solutions Architect at Stratix
Don brings a unique perspective to mobility in the Healthcare Vertical with over 25 years of consulting and delivery of critical solutions. Don has delivered various solutions from OEM integration of sensors in medical devices to mobile point of care solutions and services with major EHR software solution providers such as Epic, Cerner, GE Healthcare, Allscripts, and McKesson.
U.S. Representatives Brad Schneider (D-Ill.) and David McKinley (R-W.Va.) introduced the Medicare Sequester COVID Moratorium Act last week.
If passed, the bill would extend the temporary suspension of Medicare sequestration payment reductions, giving home health agencies and other providers more financial flexibility headed into an uncertain 2021.
Since 2014, the U.S. Centers for Medicare & Medicaid Services (CMS) has been cutting Medicare reimbursements to home health providers by 2%, as directly by Congress. Under the law, payments that exceed Medicare’s cap must be returned to CMS.
As part of a larger COVID-19 relief effort, home health providers received a reprieve from sequestration when the CARES Act passed in March. CMS suspended the 2% Medicare sequestration, effectively boosting reimbursement rates during a period some health care experts referred to as a “holiday.”
The provision is soon set to expire at the end of December, but the newly introduced legislation would extend the temporary suspension of Medicare sequestration to an undetermined date.
The aim of the bill is to help providers focus on responding to the COVID-19 emergency instead of financial challenges that may arise during this time.
“At a time when health care workers are on the front lines battling the COVID-19 pandemic, Congress should be doing everything within their power to ease their burden,” Rep. McKinley said in a statement. “America’s health care providers continue to be stretched thin and face serious financial challenges as a result of the economic and public health crisis.”
For many home health agencies, CMS pressing pause on Medicare sequestration payment reductions has ensured that they have the resources to provide care during the public health emergency while staying afloat financially.
If the legislation doesn’t pass, this could mean trouble for providers, Matt Wolfe, a partner at law firm Parker Poe, told Home Health Care News.
“The CARES Act’s temporary suspension of Medicare sequestration payment reductions has allowed home health providers to purchase PPE, train staff, and otherwise invest in keeping patients and staff safe during the pandemic,” Wolfe said. “If this bill does not become law and the sequestration is reinstated, it will be a devastating blow for home health providers at a terrible time.”
With this in mind, the bill has also drawn support from organizations such as the Partnership for Quality Home Healthcare (PQHH).
“The Partnership, alongside the broader home health community and every other provider sector, is supportive of extending the suspension of the 2% sequestration cut for Medicare providers,” Joanne Cunningham, executive director of PQHH, told HHCN. “With COVID cases on the rise, the entire health care system continues to be challenged.”
Suspending the 2% reduction beyond 2020 is “a prudent step” that will provide much-needed support to the entire Medicare provider community and patients, she added.
PQHH is a home health care advocacy organization based in Washington, D.C.
Additionally, the bill has garnered support from organizations including the American Association for Homecare, LeadingAge, the Visiting Nurse Associations of America and the National Association for Home Care & Hospice (NAHC).
“We see an extension of the sequestration moratorium as a high priority for all Medicare providers in order to preserve our very fragile health care system,” NAHC President William A. Dombi told HHCN. “Reducing payments to health care providers, already stressed to a breaking point during the height of the pandemic, will add unnecessary risks to care.”
As if 2020 couldn’t be
any more challenging for healthcare providers, new federal rules on
interoperability and patient access, granting patients direct access to their healthcare
data, begin taking effect this November and continue into 2022. These rules,
while ultimately beneficial to patients, bring an additional level of
operational complexity to many revenue-stressed healthcare organizations.
If anything, the 2020 pandemic has illustrated the vast potential of interoperability. For example, consider the huge increase in 2020 in virtual care visits, projected to be more than 1 billion by year’s end, and with an estimated 90% related to Covid-19. Many of these new virtual health patients will move through different care networks, using different health plans, and seeking remote access to their health records. These are precisely the type of patients’ interoperability is meant to help.
What should healthcare providers be doing now to ensure they’re not only compliant with new interoperability rules, but also applying them as optimally as possible to benefit their patients and organizations? In this article, we review the upcoming rules and suggest five key steps providers can take to ensure their interoperability implementations proceed as smoothly as possible.
What’s Ahead with
After several years of discussion on interoperability standards, the Office of the National Coordinator (ONC) for Healthcare IT and the Centers for Medicare & Medicaid Services (CMS) issued their final rules on interoperability in the spring of 2020. The new rules, covering both health systems and health plans, are intended to ensure that patients can electronically access their healthcare information regardless of health system or type of electronic health records (EHR) and covering all CMS-regulated plan types, including Medicare Advantage, CHIP, and the Federally Facilitated Exchanges.
Starting Nov. 2, 2020, healthcare systems must begin complying with interoperability rules preventing information blocking, which means not interfering with patients’ access to or use of their electronic health information. Providers must also attest they are acting “in good faith” regarding preventing information blocking, with any non-compliance flagged on the National Plan and Provider Enumeration System. By May 1, 2021, hospitals, psychiatric hospitals, and critical access hospitals with an EHR must send notification of their patients’ admission, discharge, and transfer (ADT) events to providers.
Interoperability will replace the current fragmented and error-prone ways of exchanging vital healthcare information. Near-term benefits of interoperability include improved care coordination and patient experience, greater patient safety, and stronger patient privacy and security. Longer-term benefits include higher provider productivity, reduced healthcare costs, and more accurate public health data.
For providers, the good
news about interoperability is that they’ve had years to think about and
implement many of its fundamental tenets, based on their work meeting
meaningful use requirements. That’s borne out in a 2019 HIMSS survey of
healthcare organizations which found nearly 75% of respondents past the
“foundational” level of interoperability – “foundational” defined as allowing
data exchange from one IT
system to another, but without data interpretation.
Five Steps for
While healthcare systems
will achieve significant interoperability gains through technology investments,
they should not consider technology as the ultimate sole key to
interoperability success. If anything, financial and political considerations
may be far more important to your organization’s interoperability success. Here
are five critical non-technology factors to consider:
1. Determine your “master”
All pertinent stakeholders in your organization should be on the same page about your interoperability strategy, resources, and timing. Know up-front that those implementing interoperability may not have previously worked with patient-centric analytics, partners, or departments in your organization. Plan your resources and timing accordingly. Your strategy should focus on the value-add of interoperability internally, such as access to additional data points on your patients, and externally, such as how you describe the upcoming benefits of interoperability to your patients.
2. Convey your vision, expectations
and expected return
An interoperability implementation is
a massive change management initiative, which requires continuous, top-down
leadership and championship, and proper expectation-setting. Communicate where
your organization currently stands regarding its interoperability capabilities,
and where you wish to have it go. Convey how the organization plans to get to
its future desired state. And perhaps most importantly, share the likely return
on investment in this effort. Be as specific as possible. For example, if you
believe interoperability gains will ultimately enable a 5% decrease in your
hospital readmissions, state that.
3. Examine workflows and identify
specific use cases
Every type of ADT event in your
organization, and its corresponding workflows and system interactions, should
be under review. Consider all types of clinical use cases, the types of data to
be exchanged, and those involved in providing patient care. This will help
determine your optimal approach to data-sharing and how your organization can
strategically use the additional data you receive from other health
4. Rigorously prep your data
Standardized data collection and reporting
which produces quality data is the heart and soul of successful
interoperability. Be sure your organization’s data is clean and meaningful, and
will ultimately be understandable and useful to your patients.
5. Think big-picture differentiation
There’s nothing in the ONC and CMS
interoperability rules that says you need to stop at mere rules compliance.
Consider your pursuit of interoperability as a singular opportunity to be a
patient-centric leader in your market. Let everyone relevant know of the
success you’ve achieved.
offers a chance for healthcare systems to achieve multiple operational gains,
when handled well, it is ultimately a patient-centric endeavor. Always keep the
needs and interests of your patients at the core when facilitating access to
their personal health data. It’s the ultimate smart long-term interoperability
Andy Slavitt has spent much of 2020 talking with almost everybody who knows anything about the COVID-19 pandemic — and sharing what he learns in real time, first on Twitter, then on his pandemic podcast, “In the Bubble.”
To do our own podcast episode about what we’ve learned so far and what we might expect next, Slavitt was the person to speak with.
He is a former head of the Centers for Medicare & Medicaid Services during the final years of the Obama administration.
Slavitt shared some of the cost-side realities of vaccines and testing. Then there was an uncomfortable guest-host moment about the characterization of his role as founder of a venture capital firm — before the conversation got back on track and he shared thoughts on the role of profit and health care.
“We’ve created some of the worst excesses, and we’re not getting the basic job done. Health care is not affordable to people,” Slavitt said.
Given the choice, he said, he would pick a health system that covers everybody even if it were a little worse than the current system, versus one that is very expensive and leaves many people without health care.
“I’d be, ‘I’m all over the socialist side,’” he said. “If you asked me, though, what do I think are the ingredients to a successful health care system? I would say it includes innovation.”
“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.
– CommonHealth has connected to 230
health systems in the United States, allowing patients to gather, manage and
share their health and test data, including COVID test and vaccination status. By
the end of this month, CommonHealth will connect to more than 340 health
– CommonHealth extends the health data
portability and interoperability model pioneered by Apple Health to the 55
percent of Americans with Android devices (85 percent globally)
The Commons Project, a nonprofit public trust established to build digital platforms and services for the public good, today announced that the CommonHealth app has now connected to 230 health systems in the United States, allowing patients using those health systems to gather, manage and share personal health information – including COVID test and vaccine status – on Android devices for free. CommonHealth enables broader and more equitable participation in remote consultations with doctors, telemedicine, innovative care models, next-generation health services, and research.
CommonHealth App Development Background
Developed in collaboration with UCSF, Cornell Tech, and Sage Bionetworks with a team of clinicians, public health experts, technologists, scientists and privacy advocates, CommonHealth is operated by The Commons Project. CommonHealth was first deployed at UCSF Health and underwent substantial testing and user experience research in multiple diverse populations in San Francisco. CommonHealth is the first and only platform designed to allow users of the Android operating system to collect and manage their health data on their mobile devices in a similar way that Apple Health Record operates on iOS.
Already integrated with LabCorp, which
operates one of the largest clinical laboratory networks in the world,
CommonHealth allows individuals to store their COVID test results and vaccination
status, in addition to any health record. CommonHealth plans to integrate with
an additional 110 health systems in December, connecting to more than 340
health systems before the year ends.
Earlier this year, the Center for Medicare and Medicaid (CMS) rolled out new patient health record sharing rules that will require hospitals and physician offices to send standardized medical information, such as lab test results, vaccination records, and imaging tests, directly to third-party apps, like CommonHealth, by July 2021.
Why It Matters
“The COVID pandemic has accelerated the need for the safe sharing of health data as medical consultations go online and individuals are required to demonstrate COVID test and vaccination status in order to travel, work, study and undertake other social activities,” said JP Pollak, co-founder and chief architect at The Commons Project. “CommonHealth extends the privacy-centered data portability and interoperability model pioneered by Apple Health to the 55 percent of Americans who have Android devices.”
When doctors know their patients have been to the hospital, they can act fast to provide needed support. Widespread use of hospital event notifications is associated with all kinds of health benefits, including a 10 percent decrease in readmissions for Medicare beneficiaries. These event notifications are one of the simplest, easiest (most-bipartisan!), and most impactful changes we can make to improve patient outcomes in U.S. healthcare.
To this goal, the Centers for Medicare and Medicaid Services (CMS) released new regulations in March that will require hospitals to share event notifications with community providers when a patient is admitted, discharged, or transferred (ADT). Hospitals have to comply by May 2021 if they want to keep getting paid by Medicare and Medicaid.
This policy will improve care, reduce costs, and save lives. It’s also simple and straightforward. CMS explains, “Lack of seamless data exchange in healthcare has historically detracted from patient care, leading to poor health outcomes, and higher costs.” ADT notifications close these gaps and many healthcare organizations have been using them for years, vastly improving care for patients.
Take the Utah Health Information Network (UHIN) which has utilized ADT notifications to reduce costs and readmissions for over a decade. According to the former UHIN President and CEO, Teresa Rivera,
“This level of care coordination quite literally saves both lives and money.” She continues, “This secure and cost-effective method provides the patient’s entire medical team, regardless of where they work, with the important information they need to coordinate care. That coordination is important to reducing readmission rates, and helps health care professionals provide a better experience to patients.”
ADT notifications are a standard set of messages that most electronic health record (EHR) systems can generate with minimal set-up. In fact, in a 2019 letter from the National Association of ACOs in support of CMS’ proposal to require hospitals participating in Medicare and Medicaid to send event notifications, they expressed that new standards efforts are not needed for the successful implementation.
The authors wrote, “In numerous conversations with HIEs, other intermediaries and providers, we were unable to find a single example where a hospital was unable to send an ADT notification today due to lack of standards.”
But you wouldn’t know it if you listened to the misconceptions that are currently being spread to hospitals about this requirement. Here are five myths that I’ve encountered just this month:
Myth 1: The ADT notification policies are strict and difficult to comply with. Not true. CMS listened to feedback that Meaningful Use requirements were too regimented and promoted a “check the box” not “get it done” mentality. CMS purposely worked to keep these ADT requirements broad and non-prescriptive. Hospitals don’t need to comply with any specific technical standard. The CMS regulations released in March are final.
Myth 2: You have to connect to a nationwide network. Wrong. Hospitals can choose from a wide variety of regional and statewide health information exchange (HIE) partners. The policy requires “reasonable effort” to send notifications to providers in your community. An intermediary can be used to comply with the rule as long as it “connects to a wide range of recipients.” Unlike what some nationwide companies are saying, the regulations do not mandate out-of-state alerts.
Myth 3: The policy creates a big technical burden for hospitals. More than 99 percent of hospitals have EHR systems in place today, and most of those can produce standard ADT transactions with relatively minimal effort. While the time to activate ADT notifications varies, it can usually be done in as little as a day by a hospital IT team.
Myth 4: The timing isn’t right. It’s happening too fast. A global pandemic is exactly the moment when we need this kind of data sharing in our communities. With COVID-19, it is even more crucial that care teams are alerted promptly when a patient is seen in the emergency department or discharged from the hospital so that they can reach out and provide support. Regardless, CMS has given an additional six months of enforcement discretion for hospitals, pushing back the deadline to May 2021.
Myth 5: There’s no funding available for this work. Wrong again. In California and several other states, hospitals can take advantage of public funding to connect to regional HIEs that provide ADT notification services. There’s $50 million in funding available just in California.
This new policy is an exciting step forward for patients and providers. It gives primary care and post-acute providers crucial, needed information to improve patient care. Hospitals can meet the requirements with minimal burden using existing technologies. Patients will have a more seamless experience when they are at their most vulnerable.
In healthcare, it’s easy to assume that great impact requires great complexity. But time and again the opposite is true. So let’s bust the myths, get it done, and keep it simple.
About Claudia Williams
Claudia Williams is the CEO of Manifest MedEx. Previously the senior advisor for health technology and innovation at the White House, Claudia helped lead President Obama’s Precision Medicine Initiative. Before joining the White House, Claudia was director of health information exchange at HHS and was director of health policy and public affairs at the Markle Foundation.
The U.S. Centers for Medicare & Medicaid Services (CMS) — along with the Center for Medicare & Medicaid Innovation (CMMI) — is now adding to its direct-contracting portfolio while also shining a light on home care.
CMS announced on Thursday that it’s launching the “Geographic Direct-Contracting Model,” another new, voluntary direct-contracting pathway designed to pay health care providers for the quality of their care and ability to cut costs.
The launch shouldn’t come as a surprise to those who have been listening to CMS Administrator Seema Verma or CMMI Director Brad Smith over the past couple of months. Even with immediate coronavirus-related challenges within the health care system, both underscored the government’s commitment to value-based care during an October virtual presentation.
“The Geographic Direct-Contracting Model is part of the Innovation Center’s suite of Direct-Contracting models and is one of the Center’s largest bets to date on value-based care,” Smith said in a statement from Thursday’s announcement. “The model offers participants enhanced flexibilities and tools to improve care for Medicare beneficiaries across an entire region while giving beneficiaries enhanced benefits and the possibility of lower out-of-pocket costs.”
By initially testing the new direct-contracting model in a small number of geographies, CMS and CMMI will be able to thoughtfully learn how emerging flexibilities are able to impact quality and costs, he added.
Under the model, participants will take upside and downside responsibility for Medicare beneficiaries’ health outcomes, giving them a direct incentive to improve care in their given markets.
Within each geographic region, participants with experience in risk-sharing arrangements and population health will partner with health care providers and community organizations to better coordinate care.
“The need to strengthen the Medicare program by moving to a system that aligns financial incentives to pay for keeping people healthy has long been a priority,” Verma said in a statement. “This model allows participating entities to build integrated relationships with health care providers and invest in population health in a region to better coordinate care, improve quality and lower the cost of care for Medicare beneficiaries in a community.”
Medicare beneficiaries in the model will remain in traditional Medicare, maintaining all of their benefits and coverage rights.
Organizations that participate in the new Geographic Direct-Contracting Model may create “a network of preferred providers, armed with the model’s enhanced flexibilities to provide the right care for beneficiaries at a lower cost,” according to CMS. That will certainly include home-based care businesses, many of which go by the mantra of delivering “the right level of care at the right time.”
Additionally, participants and preferred providers may choose to enter into alternative payment arrangements, including prospective capitation and other value-based arrangements.
In other words, home-based care providers may have a new runway to take off into value-based care.
“Beneficiaries may also receive enhanced benefits, including additional telehealth services, easier access to home care, access to skilled nursing care without having to stay in a hospital for three days, and concurrent hospice and curative care,” CMS noted in its announcement.
The Geographic Direct Contracting Model will have two three-year performance periods.
The first performance period will take applications in 2021 and have a performance period from Jan. 1, 2022, through Dec. 31, 2024. The second performance period will take applications in 2024 and have a performance period from Jan. 1, 2025, through December 31, 2027.
CMMI expects to release a request for applications for the first performance period in January.
The agency has already identified 15 “candidate regions” for the new model, each of which contains between roughly 150,000 to 700,00 Medicare beneficiaries. Those regions include major metropolitan such as Philadelphia and Pittsburgh in the eastern to U.S., to San Diego and Los Angeles in the West.
In its initial announcement, the U.S. Centers for Medicare & Medicaid Services (CMS) went out of its way to clearly state its new hospital-at-home waiver program was not designed for home health agencies.
But that doesn’t mean there isn’t any upside for them, industry insiders say.
Unveiled on Nov. 25, CMS’s new hospital-at-home waiver program gives approved acute care facilities more freedom to provide — and get paid for — medical services in the home setting at a time when in-patient capacity is severely limited.
A record-high 96,039 COVID-19 patients were hospitalized in the U.S. as of Monday night, according to data from the COVID Tracking Project.
“CMS believes that treatment for more than 60 different acute conditions, such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) care, can be treated appropriately and safely in home settings with proper monitoring and treatment protocols,” agency officials noted in their announcement.
At least seven confirmed hospital systems have received hospital-at-home waivers.
While home health agencies have experience caring for patients with these and other complex conditions, they are somewhat restricted from taking ownership of a CMS-approved hospital-at-home program of their own.
“A program does not have to be physically administrated within a hospital, but a hospital must accept responsibility for the program in order to satisfy the Conditions of Participations for this level of patient care,” CMS noted. “Additionally, the program must be integrated within a hospital to a sufficient degree to ensure that rapid escalation of care is seamless.”
That language suggests there may be ample hospital-at-home opportunities for home health agencies that are already housed within larger health systems, though that size of that group continues to shrink. In the late 1990s and early 2000s, many hospitals decided to close their agencies or spin them off as freestanding entities, partly due to reimbursement pressures.
Home health operators with pre-established joint venture relationships with health systems may likewise be well-positioned for the hospital-at-home opportunity, according to Stephens Inc. analyst Scott Fidel.
And that group, in contrast, is rapidly growing.
“Just conceptually, the most logical area that we would think about as being an opportunity here would be around areas where there’s already momentum around JVs,” Fidel told Home Health Care News.
Fidel — a veteran health care analyst who was brought in to lead Stephens’ health care services division in 2018 — described the hospital-at-home waiver news as an “encouraging” common-sense response to ongoing COVID-19 challenges.
“My gut reaction is that this is CMS trying to respond as actively as they can to the impact of COVID,” Fidel said. “I think these are changes to regulatory structures that they can deliver relatively easily to compensate for some of the pressures acute care hospitals are facing.”
Most headlines focus on bed capacity, but many hospitals are dealing with some degree of staffing shortages, too. In fact, a mid-November tally conducted by STAT and the American Hospital Association found that hospitals in at least 25 states were critically short of nurses, doctors and other staff members.
That situation has only grown more dire since then, with Thanksgiving travel and family gatherings projected to cause an even large spike in new infections.
One of the latest White House coronavirus task force reports sent to states included a warning that “the COVID risk to all Americans is at a historic high,” NBC news reported.
“Hospitalizations themselves are now reaching record levels from during the crisis,” said Fidel, who follows the managed care space as well as the post-acute and acute care sectors. “And there just seems to be a lot more pressure on staffing, in particular. I think staffing is the real big story here, frankly.”
With the staffing shortages, hospitals with new CMS waivers may look to enlist home health agencies as they shift patients into the home setting.
Agencies have historically faced their own staffing challenges, but their ability to care for new patients is currently greater than that of hospitals.
Additionally, industry data on patient volume and new admissions suggests home health agencies are hovering around pre-pandemic norms — not record-breaking figures.
“Then connecting into that home health staffing apparatus, to me, it feels like there is still capacity,” Fidel said. “Home health volumes have improved quite markedly in terms of a recovery, but we’re still really just sort of back to pre-COVID levels. It feels like there’s a lot more volume, a lot more capacity that home health agencies can take on at this point.”
Putting ‘meat on the bone’
Apart from getting a piece of hospital-at-home action for staffing support, home health agencies may also eventually see a trickle-down effect as hospitals deliver more services in the home.
“I think the other area that we’ve also gotten some feedback from the companies on, where they see an opportunity, is just around whether this could actually end up supporting or codifying more of an ability for these types of services in the home to actually get reimbursed,” Fidel said.
For now, most agencies are in “wait-and-see mode,” however.
More information on the hospital-at-home waiver program will likely emerge in weeks to come, especially as more hospital systems complete the application process.
“There’s a lot of meat that needs to be put on the bone,” Fidel said. “As I’ve done checks with some of the home health companies about this, that’s the type of feedback that I’m getting from them already. I think everyone is encouraged by the thrust of what CMS is announcing here, but it still does feel quite preliminary.”
The Boston-based hospital and digital therapeutics company are rolling out their co-developed remote monitoring solution across the country, which can help hospitals rapidly implement hospital-at-home programs. The announcement comes soon after CMS launched a program enabling health systems to provide hospital-level care at home for more than 60 conditions.
The Centers for Medicare & Medicaid Services (CMS) last week took extraordinary steps toward increasing the U.S. health care system’s capacity by shifting more acute care into the home.
In a Wednesday announcement, CMS unveiled new, comprehensive flexibilities that allow hospitals to provide their services “in locations beyond their existing walls.” To secure those flexibilities, hospitals must apply for a special waiver via an online portal, with experienced hospital-at-home organizations eligible for “an expedited process.”
So far, seven hospital systems have received waivers, including Mount Sinai Health System in New York City, one of the earliest adopters of the hospital-at-home model. In 2018, a team of Mount Sinai researchers led by Dr. Albert Siu found that its hospital-at-home program resulted in shorter lengths of stay, fewer ER visits and stronger clinical outcomes compared to traditional in-patient care.
Despite those and other promising findings, the hospital-at-home idea has been slow to catch on in the U.S. due to reimbursement challenges, at least compared to countries where it’s much more common — Australia, Israel, Spain and elsewhere.
CMS’s new hospital-at-home strategy will likely change that, according to Siu.
“While we were collecting this critical evidence base, we started to work closely with CMS and provide input on the model and how it could be leveraged more broadly and more strategically,” said Siu, who serves as chair emeritus of the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. “We were able to bring hospital-level services into the homes of our patients throughout New York City, but the one obstacle we faced was, how do we pay for this? To facilitate widespread adoption, we needed a mechanism of reimbursement that would capture a larger portion of the Medicare population.”
In part, CMS is backing the hospital-at-home model due to the coronavirus pandemic, which has stretched hospitals dangerously thin. As of Sunday, a record 93,238 patients were hospitalized due to the virus, according to the COVID Tracking Project.
Mount Sinai admitted its 1,000th hospital-at-home patient during the peak of the public health emergency.
In addition to Mount Sinai, the other hospital systems with waivers include Massachusetts General, the Huntsman Cancer Institute, UnityPoint Health, Presbyterian Healthcare Services and Brigham Health Home. Mercy Hospital St. Louis was approved for a waiver on Monday, a CMS spokesperson told Home Health Care News.
More will join that list in days to come, as many have already been working with private hospital-at-home operators — DispatchHealth, Medically Home and Contessa among them — prior to new CMS flexibilities.
Rami Karjian — co-founder and CEO of the Boston-based Medically Home — told HHCN this is a “transformational moment” for high-complexity patients everywhere.
“By decoupling high-acuity patient care from hospital buildings, CMS is enabling hospitals to care for patients in their homes with a model that has been widely shown to deliver better clinical results, higher patient satisfaction and lower costs,” Karjian said in an email.
‘It’s very exciting’
DispatchHealth — the on-demand in-home care provider based in Denver — launched its own hospital-at-home service line in November 2019.
Similar to other models, it has achieved incredible results thus far. Data released by DispatchHealth in October, for example, found that its Advanced Care program saved an average of $6,200 per individual by keeping them away from the traditional hospital setting.
Additionally, hardly any of the high-acuity patients DispatchHealth treat in the home end up back in a brick-and-mortar hospital, according to Dr. Mark Prather, the company’s CEO. In fact, DispatchHealth’s hospital-at-home offering has been “one of the better things” Prather “has ever been involved with as a clinician,” he noted.
Last week’s news from CMS now adds further fuel to the fire.
“It’s very exciting,” Prather told HHCN. “A lot of us have been disciples of home-based care for many years. I think this is another step forward in opening the aperture for care delivery in the home.”
Under CMS’s new flexibilities, developed in tandem with The Hospital at Home Users Group, participating hospitals will need to provide in-person physician evaluation before starting care in the home. On top of that, a registered nurse is required to perform evaluations on each patient — in person or remotely — daily.
While CMS officials mostly touted last week’s move as an effort to boost capacity as hospitals navigate through worsening COVID-19 surges, hospital-at-home programs will likewise help keep complex populations out of acute settings in the first place.
That’s been a focus of DispatchHealth’s model, Prather said.
“Many of the patients we care for are high-medical needs, high-social needs patients,” he said. “They may not have COVID, but they could have a congestive heart failure exacerbation. By keeping them in the home, we are limiting their exposure to COVID.”
Applying for a waiver
Experienced hospitals participating in the hospital-at-home waiver program will be required to submit monitoring data on a monthly basis, according to CMS. Those without experience will be required to submit data on a weekly basis.
While experienced hospitals will be placed into a fast-track waiver process, those new to the hospital-at-home concept will have to go through a “more detailed waiver request” that “emphasizes internal processes that prove capability of treating acute hospital care at home patients with the same level of care as traditional in-patients.”
If a hospital system has multiple hospitals providing acute hospital care at home, each facility will need to request a waiver.
“However, if the services are run by the same group within a health system, CMS understands that each request could appear very similar,” agency officials clarified.
A hospital-at-home program does not have to be physically administered within a hospital, but a hospital must accept responsibility for the program in order to satisfy the Conditions of Participations.
Moreover, the program must be integrated within a hospital to a “sufficient degree” to ensure that rapid escalation of care is seamless.
As hospital-at-home programs become more common, Prather stressed it will be important to develop additional standards to ensure high-quality care.
The CEO said he has high expectations for DispatchHealth’s program, even after the pandemic subsides.
“There are already significant tailwinds to home care delivery,” Prather said. “It’s, frankly, what consumers want, regardless of the pandemic. We’re very encouraged by the movement at CMS, and I do think that it will continue to open doors.”
Over the past several years, it seems as though the home health industry has been inching closer and closer toward the elimination of Medicare’s strict physician-certification policy. Now — thanks to the CARES Act — nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs) are able to certify eligibility for home health.
Home health industry insiders have long been vocal about Medicare’s physician-certification policy — a rule many see as antiquated and overly rigid. Generally, those critics argue the policy created roadblocks that made it more difficult for older adults to gain access to home health care, in turn impacting providers’ bottom lines.
Before the CARES Act, home health services had to be certified — and recertified — by a physician. That process often resulted in heavy delays, especially when physicians were busy.
PAs, in particular, are fairly autonomous in terms of their ability to practice. They are often not in the same location as the physician with whom they collaborate or work with, according to Michael Powe, vice president of reimbursement and professional advocacy at the American Academy of PAs (AAPA).
“For that reason, it’s important for PAs to have the ability to take care of the complete range of services their patients need,” Powe said. “If you’re a PA in a satellite clinic, that might be 25 miles away from the collaborating physician. You don’t want to have to run to that physician to have them sign-off on a certification for home health.”
AAPA is an Alexandria, Virginia-based nonprofit advocacy organization that represents more than 131,000 PAs across the U.S.
When patients aren’t able to get home health care services in a timely manner, those delays drive up costs and result in negative health outcomes.
“They may be in another situation, such as being in a hospital for an extra day or two if can’t get the home health services they need,” Powe said. “That simply runs up the cost of health care for the entire system. If those [home health services] aren’t being provided in a timely manner, then you’re more likely to have a patient who suffers an adverse medical consequence.”
The CARES Act was an attempt to course correct and avoid those issues. It pulled from the April 2019 Home Health Care Planning Improvement Act, which previously sought to give NPs, PAs and CNSs the ability to certify home health permanently.
“It makes it a much more manageable relationship between the home health agency and the attending practitioner for the patient,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “Everything from the original plan of care, to changing orders, to signing the documents on a timely basis in order to then submit and get payment — it really reduces some administrative and care roadblocks.”
Despite federal regulations, there are a number of state-level challenges that stand in the way for NPs, PAs and CNAs.
For example, the scope of practice for NPs is an issue in some states. NPs are divided into two classes: independent practice and collaborative practice with a physician. Less than half of states allow for full, independent practice, according to Dombi.
Meanwhile, most states require PAs to work under the supervision of a physician. PAs are allowed to take on the tasks of ordering care and certifying eligibility, provided that supervisory status exists.
Another issue comes by way of licensure in the states, according to Dombi.
“[About] 35 states have full-blown licensure for home health agencies,” he said. “That licensure generally is fashioned consistent with the Medicare Conditions of Participation (CoPs). While the [CoPs] for Medicare have changed, states have to take the step of changing and updating their own licensure standards to mirror those.”
Another challenge comes from the Medicaid side. There are many states where the Medicaid payment rules need to be updated to allow for a practitioner — and not just a physician — to authorize plans of care and certify eligibility.
Dombi pointed out that the issues surrounding Medicaid payment rules and state CoPs likely have more to do with timing, meaning state governments may just be slow to catch up with federal changes, than a difference of opinion in regard to policy.
On the flip side, Dombi stresses that the scope of practice issues are more serious.
“Some states may never allow non-physician practitioners to have independent practice, and that’s within the state authority to do so,” he said.
As things stand, larger providers that run multi-state operations will have the major task of figuring out the rules and regulations in each state.
“They definitely carry a lot of risks, if they think that a non-physician practitioner can do everything in all of the states,” Dombi said. “Having to manage that on a state-by-state basis creates a burden, of sorts, for them. If you’re in a single state, as a small company, find out what the rules are — and follow them.”
Moving ahead, Dombi believes advocacy will continue to be important to help get state policies to catch up with federal law.
“We’ve worked with many of the state home care associations, which are taking the step to do that,” he said. “Those voices within home health care and the non-physician practitioner community have to step up … and initiate the advocacy to make that happen.”
Overall, 30 states have recently taken temporary or permanent actions to authorize NPs to order home health services. In the last week alone, both California and New Mexico updated their regulations to permanently authorize NPs to order home health services, according to the American Association of Nurse Practitioners (AANP).
Austin, Texas-based AANP is a national advocacy organization that represents the interests of more than 270,000 NPs.
So far, NAHC has worked with state associations in Massachusetts, New York and California, according to Dombi.
Additionally, organizations such as NAHC, AAPA, the American Academy of Home Care Medicine, LeadingAge, Visiting Nurses Association of America and others collaborated on a letter addressed to the National Governors Association, encouraging policymakers to recognize the federal change and provide flexibility.
In an effort to boost value-based care, the U.S. Centers for Medicare & Medicaid Services (CMS) recently announced that it has finalized changes to the Physician Self-Referral Law — often referred to as the Stark Law.
For home health providers, the changes could mean more opportunities for value-based care arrangements moving forward, experts believe.
Broadly, the Stark Law was originally intended to prevent physicians from self-dealing and making compromised medical decisions based on financial incentives.
Under previous rules and regulations, physicians were prohibited from making referrals for “certain designated health services payable by Medicare to an entity with which he or she has a financial relationship.” In some instances, this meant home health providers.
In CMS’s statement announcing the recent change, the agency called the law an “outdated” regulation that “burdened” health care providers during the U.S. health care system’s shift toward quality.
“These reforms under the Stark Law and Anti-Kickback Statutes are historic reforms and come as part of the regulatory sprint to coordinated care that I led over the past few years,” said U.S. Department of Health and Human Services (HHS) Deputy Secretary Eric Hargan. “Too often, ‘sorry, Stark’ or ‘can’t do it, AKS’ have been watchwords in American health care.”
In value-based care arrangements, physicians and other care providers typically form interdisciplinary teams to manage patients as their needs change, sometimes sharing upside and downside risk. Discouraging a physician from referring within that internal team makes little sense.
There has long been an effort to make changes to the law, Matt Wolfe, a partner at law firm Parker Poe, told Home Health Care News.
“Since the enactment of the statute, there have been a whole host of different regulatory efforts to better define and narrow the scope of the law, recognizing that there are a number of times where it would be appropriate for a physician to refer a patient to designated health care services,” Poe said.
Other legal experts echoed those sentiments.
The update to the Stark Law now creates exceptions that make room for innovation and value-based compensation structures, according to Danielle Sloane, a health care attorney at Bass, Berry & Sims.
“For home health agencies that want to participate in value-based arrangements, I think it provides more avenues to work together with hospitals and physician groups — and to share in the savings from any efficiencies,” Sloane said. “[It provides more avenues] to share in the bonuses from a quality perspective.”
Additionally, CMS provided guidance on requirements of the exceptions to the Stark Law and technical compliance requirements.
Still, Sloane warned that despite the flexibility the changes provide, it’s important for home health providers to continue to devote time and energy to compliance. First and foremost, providers must ensure they have appropriate arrangements with physicians.
“There are certainly some flexibilities here for those ‘oops’ scenarios, but I don’t think it changes best practices of making sure you have a contract in place,” she said.
The overall impact of the update will depend on things ranging from existing arrangements with physician practices, health systems and payers, but most providers will be impacted in some way, according to Wolfe.
Similar to Sloane, Wolfe stressed that providers should take inventory of their existing contractual arrangements.
“Even though one of the goals of this regulatory action is to reduce regulatory burdens, I think, in the short run, providers are going to have to put some resources into making sure that their current arrangements comply with the new iteration of the laws and regulations,” he said.
In an effort to increase hospital capacity amid the current COVID-19 surge, the U.S. Centers for Medicare & Medicaid Services (CMS) on Wednesday announced “unprecedented” flexibilities around providing hospital-level care for patients in their homes.
Similar to CMS’s recent allowances surrounding telehealth, the agency’s latest efforts are focused on lifting barriers that could potentially hinder care during the public health emergency, CMS Administrator Seema Verma said in a statement.
Wednesday’s flexibilities aren’t coming out of thin air. Instead, they build off the success and learnings of the nation’s existing hospital-at-home models, pioneered by organizations like Johns Hopkins and Mount Sinai.
“With new areas across the country experiencing significant challenges to the capacity of their health care systems, our job is to make sure that CMS regulations are not standing in the way of patient care for COVID-19 and beyond,” Verma said.
Through CMS’s “Acute Hospital Care At Home program,” eligible hospitals will be granted “unprecedented” and “comprehensive” regulatory flexibilities to treat certain patients in their homes. The agency clarified the new flexibilities are aimed at acute care in the home and very different from “traditional home health services.”
In addition to building new capacity, CMS’s program is also a means to support established hospital-at-home programs, which have mostly had to rely on payment mechanisms outside of the Medicare fee-for-service world. CMS believes that with proper monitoring and treatment, acute conditions such as asthma, congestive heart failure, pneumonia and chronic obstructive pulmonary disease (COPD) can be treated in the home setting.
Wednesday’s move received praise from Dr. Bruce Leff, a hospital-at-home expert and the director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine.
“CMS made a terrific decision in recognizing the value of hospital-at-home care for the public health emergency,” Leff told Home Health Care News in an email. “Hospital-at-home is well proven to provide high-quality hospital-level care in patients’ homes for many acute conditions — and patients and their families love it.”
Similarly, the move drew applause from Contessa, a company that helps organizations provide hospital-level care in the home through its Home Recovery Care model.
“Given the tremendous strain COVID-19 is putting on our health care system, access to home hospital care has never been more important,” Travis Messina, CEO of the company, said in an email. “The teams at CMS and CMMI expertly executed this hospital-driven model. Hospital-level care requires appropriate clinical oversight from hospital leaders.”
Messina added that his team is “thrilled” Mount Sinai Health System, one of Contessa’s partners, was already approved for CMS’s new model due to its extensive experience with the hospital-at-home concept.
Under the program, participating hospitals will be required to implement screening protocols prior to delivering care in the home. Participants will need to screen for both medical and non-medical factors, including working utilities, assessment of physical barriers and screenings for domestic-violence concerns.
Participating hospitals will also need to provide in-person physician evaluation before starting care in the home.
Additionally, a registered nurse is required to perform evaluations on each patient — in person or remotely — daily.
“Acute Hospital Care at Home is for beneficiaries who require acute in-patient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis,” CMS noted.
Wednesday’s announcement from CMS has roots in its Hospitals Without Walls program, which was first established in March. CMS’s Hospitals Without Walls program loosened regulatory restrictions in order to enable hospitals to provide services in other settings.
Over the years, the hospital-at-home model has gained a reputation for providing better outcomes at a lower cost. Despite this, the model has still mostly existed as a niche service line for providers in the U.S.
Recently, the COVID-19 emergency has served as a catalyst for renewed interest in the model.
Currently, Brigham and Women’s Hospital, Huntsman Cancer Institute, Massachusetts General Hospital, Mount Sinai Health System, Presbyterian Healthcare Services and UnityPoint Health are being approved for CMS’s new program.
“We’re at a new level of crisis response with COVID-19, and CMS is leveraging the latest innovations and technology to help health care systems that are facing significant challenges to increase their capacity to make sure patients get the care they need,” Verma’s statement continued.
CMS has finalized changes to the Physician Self-Referral Law, also known as Stark Law. Healthcare law experts say that these changes will generally make it easier for hospitals and physicians to remain in compliance with the statute.
Healthcare can achieve optimum efficiency when patients are at the center of care. When patients have the necessary information to navigate their care journey, they will choose the path to high-quality care at the lowest costs. Cost-sharing and insurance premiums are rising consistently since the last decade for employer plans, which covers nearly half of the country’s population. Plan members are shouldering a part of the healthcare cost burden, so they want to keep it as low as possible. At the same time, they want maximum value for their money with access to quality care.
CMS identified this as an opportunity and issued the Final Interoperability and Patient Access rule. The rule allows patients to access electronic health data through any third-party application of their choice. The rule intends to allow patients to take control of their data and determine who can see which data. It will also make transferring data from provider to provider easier. So that patients can be ensured that their provider is fully aware of their medical history.
The Challenge of Providing Members Access to Healthcare Data
The biggest challenge that health plans will face is to extract data from multiple sources in-house, clean and scrub it, and ensure it is in the appropriate format as required by the Centers for Medicare and Medicaid Services (CMS). Some health plans have been in business for a really long time. Patient data has been accumulating through these years in legacy systems. Providing access to that data through certified third-party applications will require a lot of effort on the part of health plans. The health plans also have to ensure tight authentication standards so that only the people requested by the members have access to their healthcare data.
In addition, there are multiple problems associated with provider data. Incorrect data in the provider database costs close to $3 billion annually. CMS has also issued warnings for inaccurate provider directories, high claim-reprocessing volumes, and substantial encounter-data rejection rates. Payers have been addressing the data issues with short term solutions. But now they have to resolve the provider data problems for good and make health data readily available to the members.
The COVID Crisis Upended The Payer Compliance Initiatives
Payers are in solidarity with providers and patients in this time of crisis. While providers work tirelessly to help an increased number of patients access the required care, payers are providing support through fast track reimbursements and reduced utilization management.
Many health plans are focused on ensuring that their members have access to resources to fight COVID, which is why CMS extended the deadline for the Final Interoperability rule. Utilization patterns are witnessing a significant change. Many members are not receiving scheduled care as some elective surgeries are rescheduled and some provider offices are shut down. There has been a drop in certain kinds of utilization. Conversely, there has been a dramatic surge in telehealth office visits and behavioral health services.
The Road Ahead for Health Plans
Healthcare payers have endured significant claims-based, economic, and operational challenges during the pandemic. While they battle those bottlenecks, they also have to ascertain and prepare for the future and devise ways to ensure that their members have access to quality care.
Health plans will have to try to anticipate what utilization patterns will look like in the future, especially in the next year. Telehealth utilization will not be the same as it was pre-COVID. They will also have to ensure that members have access to care. They will have to reach out to members, especially those who are the most vulnerable. They will have to make sure members are not suffering from social isolation, they are taking their medication and they have access to transportation to get to the doctor.
Provider Alliance for CMS Compliance
CMS is handing over the reins of the care journey to the patients to improve care delivery through the Interoperability rule. Providers will play a key role in enabling access to healthcare data to patients by streamlining data and closing coding gaps. Payers must assist providers with their data needs to ensure compliance with the CMS rules.
As the pandemic ends and CMS comes out with more definitive long term rules and coverages, it is going to be important to ensure that providers are on the same page with payers. Health plans can partner with providers to educate them about the acceptable telehealth codes and what type of services are to be performed using those codes. Providers want to take care of their patients and they want to do it well. They want to leverage technology to ensure patient access to care and ensure their safety, especially for patients who suffer from multiple comorbidities.
About Elizabeth Bierbower
Elizabeth Bierbower is a strategic leader with more than thirty years of executive experience in the health insurance industry. She has experience scaling cost-effective and profitable growth strategies through internal innovation, and a reputation as being one of the industry’s most fiscally responsible and progressive leaders. Bierbower currently serves on the Boards of Iora Health, the American Telemedicine Association, and is on Innovaccer’s Strategic Advisory.
Previously Beth was a member of Humana’s Executive Management Team and held various roles including Segment President, Group and Specialty Benefits, and was an Enterprise Vice President leading Humana’s Product Development and Innovation teams.
The U.S. Centers for Medicare & Medicaid Services (CMS) is moving forward with its plan to retire the old Home Health Compare in favor of a new, multi-setting tool known simply as “Care Compare.”
By Dec. 1, CMS will move away from Home Health Compare, Nursing Home Compare, Hospital Compare and the five similar online tools that help Medicare beneficiaries weigh their care options. CMS has been posting a subset of OASIS-related information on Home Health Compare since 2003, adding a star-ratings component in 2015.
Other compare tools have been around for even longer.
CMS first announced plans to merge all the compare sites into a single service in January. The agency officially launched the streamlined Care Compare in September, giving Medicare providers a few months of transition time before sending the old tools to the digital scrapyard.
“Care Compare provides a single user-friendly interface that patients and caregivers can use to make informed decisions about health care based on cost, quality of care, volume of services and other data,” the agency stated at the time. “With just one click, patients can find information that is easy to understand about doctors, hospitals, nursing homes and other health care services instead of searching through multiple tools.”
Before Care Compare, someone who is planning to have bypass surgery would need to visit Hospital Compare, Nursing Home Compare and Home Health Compare individually to research providers for the different phases of their surgery and rehabilitation. The new system is designed to theoretically avoid that.
The launch of Care Compare is part of the Trump administration’s 2018 eMedicare initiative, a multi-year plan to update the way beneficiaries get information about Medicare.
“Since [September], you’ve had the opportunity to use and familiarize yourself with Care Compare while having the option to use the original compare tools, too,” CMS said in a Nov. 18 alert. “You’ve also been able to share feedback from a survey directly on Care Compare, and we’ve received lots of great feedback so far.”
While CMS is moving away from the eight original compare tools, Medicare beneficiaries and others will still be able to find historic information about health care providers and quality data on Care Compare. Individuals will also still be able to download CMS publicly reported data from the Provider Data Catalog on CMS.gov.
Additionally, fully transitioning to Care Compare does not change how CMS measures quality, the agency noted. Moving forward, officials plan to continue making improvements to Care Compare based on stakeholder and consumer feedback.
For home health providers that have yet to think about the switch to Care Compare, CMS is urging them to start exploring the tool while asking their caregivers, patients and staff to do the same.
CMS also recommended that providers update any links to the eight original care tools on their public-facing websites.
Keith Myers has seen his fair share of change in Washington, D.C.
Since co-founding the business with his wife, Ginger, in 1994, Myers has helped lead LHC Group Inc. (Nasdaq: LHCG) through parts of five presidencies as chairman and CEO. A new administration with Joe Biden in the White House would make that six.
Although President Donald Trump has yet to formally concede due to his team’s ongoing legal challenges to the 2020 election, Myers’ roles at LHC Group and the Partnership for Quality Home Healthcare mean he must plan ahead for all outcomes. Since last year, he’s been working to make sure home health care maintains its rising position, regardless of the political landscape.
Home Health Care News sat down with Myers for an inside look at those policy efforts. In addition to the 2020 election, LHC Group’s top executive also touched on recent COVID-19 vaccine news, emerging post-acute care trends, the future of the Center for Medicare & Medicaid Innovation (CMMI) and more.
Highlights from HHCN’s conversation with Myers are below, edited for length and clarity.
HHCN: Looking back, what have the past four years meant for in-home care?
Myers: I think the data speaks for itself. Pre-COVID, we had a significant, measurable tailwind. Policy has been moving in our direction. I think that was influenced heavily by all the investments we’ve made in data-driven policy work in D.C., especially over the last decade.
When COVID happened, it took those tailwinds and put them on steroids.
We’re already going in the direction of shifting more care into the home. We’ve been able to bring that shift about thanks to the industry’s work, paired with the insights from Dobson DaVanzo & Associates and the others we’ve brought in as objective third parties. These groups have looked at the claims data, proving beyond a shadow of a doubt the efficacy of the home health benefit and our ability to create favorable outcomes at much lower costs.
Apart from demonstrating the value of home health care over the years, the industry has also been able to improve its standing with the U.S. Centers for Medicare & Medicaid Services (CMS). Providers have drastically lowered improper payments, for example.
I think back to the late 90s. There was a group of us — some of the original home health pioneers — who got together and decided to invest in data. We had the courage to invest in data to not only show where the opportunity was, but how we could improve. We looked at who the bad actors were.
Rather than the whole industry being viewed as problematic, we started holding those bad actors accountable. I think we gained a lot of credibility from that.
Those efforts helped CMS hone their skills on what to look at. They’re much more targeted now in their approaches, and I think that’s good for everyone.
Looking ahead, what are some of the things that might change? What could a potential Joe Biden administration mean for LHC Group and other in-home care providers?
Well, historically, Democrats have been more favorable to health care, generally. I think that is still true today. If we’re positioned with reliable data to give us a seat at the table going in, I think that’s important.
At the Partnership for Quality Home Healthcare, we started preparing for this potential outcome last year. LHC Group is represented by former U.S. Senator John Breaux, who is a former board member of ours. He’s still very active. I talk to Senator Breaux every other day.
We reached out and brought in former Senator Blanche Lincoln during the summer. We started orienting her specifically for this potential outcome. She’s at Lincoln Policy Group, as is Tom Scully, a former CMS administrator who also represents the Partnership. Another name is former U.S. Representative Joe Crowley. We’re working with him as well.
We have the right story. We have the right messengers, people who know President-Elect Biden and all the likely players who will be in his administration. I think we’ve positioned ourselves very well.
And we weren’t just planning for this outcome. We had strategies for both potential outcomes.
One of the things Biden has talked about is “Medicare at 60.” What would that mean for the home health industry?
The obvious impact is volume. Volume would be increased.
But I do believe we’re going to have a divided government, so I don’t expect to see anything too big happen. I don’t think we’re going to see anything transformative.
You’ve been in this business a long time. You and your wife, Ginger, started the business from your kitchen table. How disruptive is it when there’s an administration change?
It’s a great feeling to be able to say what I’m about to say — and mean it 100%. Today, I don’t think it’s that big of a deal. That’s because the data and the policy momentum are already on our side.
Back in the 1990s, we didn’t have much of a position. We just had, you know, some people who would support us. For me, that was folks like Senator Breaux and others. We were cobbling together data and support for home-based care, but we didn’t have overwhelming evidence gathered by independent, third-party experts like we do today.
This is going to be my sixth president. I’ve seen all the different political landscapes. I’ve seen a White House controlled by Democrats. I’ve seen Republicans having both the House and Senate. I’ve seen all the different combinations.
In our experience, the highest risk has been when one party controls both the House and Senate, never mind who’s in the White House. But listen, I think we have a favorable landscape right now. Yes, we have some Senate races that still make things very tight. But Democrats in the House are seeing their numbers go the wrong way, so it’s unlikely they’ll do anything way out there.
And Biden is largely considered a moderate, someone who works across the aisle, much like Senator Breaux did.
CMMI has tested out a number of alternative payment models over the past four years. Overall, it has launched 54 since its formation, with officials often citing the Home Health Value-Based Purchasing Model as one of the most successful. How has LHC Group performed under that?
We’ve performed well in the nine initial states where we’ve had the opportunity.
There’s also the Comprehensive Care for Joint Replacement (CJR) model. We’ve done significant work there with Ochsner and had great success. That has informed a lot of our strategies around skilled nursing facility (SNF) diversion and other efforts to move patients downstream.
I would also point to our broader and deeper experience with accountable care organizations (ACOs). We’re very proud of that. We’ve really come a long way with ACOs. I’d say the two biggest levers we’re pulling in that regard are preventative measures and care management on the front end, then, when patients do need care, leveraging home health care to the greatest extent possible.
Would you support a nationwide expansion of the Home Health Value-Based Purchasing Model?
Yes. The details are always important, but given a choice between strict fee-for-service versus some sort of value-based purchasing, we’re always going to take the value-based option.
What do you think a Biden administration would mean for value-based care? Would it be more of the same — or would there be a drastic difference?
I haven’t seen any evidence or indicators where I’d say “drastically different.” I think Democrats tend to lean into provider-based care. They’re not as much in favor of Medicare Advantage as Republican administrations, in my view.
I’m a big believer that providers should have — if not full control — a more meaningful stake in the risk pool. I think some of the CMMI demonstrations support that. You get the best of both worlds when providers have that seat at the table. You get lower costs and quality outcomes.
Earlier this week, Biden’s transition team unveiled members of its COVID-19 task force. It includes Atul Gawande, a former FDA commissioner and several others, but no in-home care experts. What are your thoughts on that?
I think we’ve learned over the years that there are a lot of ways to influence the process without having somebody officially named to a particular position. We know this through our experience with the Medicare Payment Advisory Commission (MedPAC).
I think there are more people favorable to home-based care policy than one might think. But, sure, we’d love to have somebody on the task force who’s directly involved with the home health industry.
If you had to look in your crystal ball right now, what’s one prediction for home health, hospice and personal care moving forward?
I think care in the home, across the board, is going to be the “ask” of patients. It’s also going to be the very first inclination of referral sources.
In the past, home-based care hasn’t been an afterthought, but it wasn’t always at the top of the list. Let’s take SNFs, for example. In the past, if a patient qualified for SNF, then they would typically get referred to SNF. Referral sources would automatically think it was the safest route for them, from a risk perspective.
But now, they see the risks associated with going to an in-patient setting. I’ve seen patients, families and referral sources acknowledging that risk more than ever. They’re saying, “You can be cared for at home, if that’s what you want to do.”
That conversation is happening with discharge planners and referral sources everywhere. It’s happening at a level that we weren’t seeing pre-COVID. I don’t think we’re going to go backwards on that. It’s a new normal.
Pfizer and Moderna came out and said they’re very close on COVID-19 vaccines. Once those are ready to distribute, what role should home health providers play?
Well, it’s almost not fair for me to answer that. Of course I think home health workers should play a role. And we’re all familiar with the phrase “social distancing” now. What better place to bring the vaccine to people than in their homes? Why would you bring everyone to a centralized location for a vaccine?
I think our front-line workers and the people they care for, including the elderly, should also be among the first to receive a vaccine. I’d like to hear arguments against that.
What has you excited about 2021?
There’s a lot to be excited about. Having been in the industry as long as I have been, I don’t know if 20 years ago I really believed I would see the day with this much opportunity.
I couldn’t see it from where we were back then. We were just fighting for survival. To see this opportunity intersect with our preparation as an industry and our ability as individual providers to care for patients downstream, it’s incredible. It’s what dreams are made of.
I couldn’t be more excited for or proud of our industry. It puts some pep in my step and makes me want to keep doing this for a really long time.
The U.S. Centers for Medicare & Medicaid Services (CMS) issued its final 2021 home health payment rule in late October. When it came out, some providers were less than pleased.
On one hand, the Patient-Driven Groupings Model (PDGM) wasn’t substantially altered to balance out its flawed behavioral assumptions. On another, there are also a few “quirks” in the rule that will make 2021 a unique, potentially complicated year.
Overall, the final rule adds an estimated $390 for home health agencies next year, roughly equal to a payment increase of 1.9%. Those figures are less than the $540 million boost and 2.6% increase initially floated in CMS’s proposed rule.
Since the final rule came out, providers have additionally learned more about the fines tied to late Requests for Anticipated Payment (RAPs). Although RAPs are being phased out next year, providers will still be required to submit a “no-pay RAP” within five calendar days of the start of care.
Under the Prospective Payment System (PPS), agencies could receive 50% to 60% of their payment up front. This year, that was lowered to 20% for existing agencies, with new agencies being shut out from RAPs.
In 2021, there will be no payment tied to the RAPs for anybody. Once RAPs are fully phased out in 2022, the Notice of Admission (NOA) will take its place.
“So this was a pretty standard annual update from Medicare, especially if you consider what we went through last year with the transition to PDGM,” Matt McGowan, a consulting manager at McBee Associates, said on a recent webinar. “But we have to go through this kind of awkward transition year with the RAP in 2021, which is a blend between the RAP that you’re used to and what the process will be under the NOA in 2022.”
Wayne, Pennsylvania-based McBee Associates is a health care services and consulting firm that offers financial, operational and clinical help to health care providers across the continuum.
In other words, a RAP fine only comes after the fifth day, but if providers submit on the sixth day, they will be docked one-thirtieth of the payment for each of those five days as well, which comes out to a 20% fine.
That — and other quirks in the final rule — will put a couple of landmines in home health providers’ way in 2021.
For instance, because RAPs are no longer providing payment, but RAP submissions are still required, that changes the entire coding process for providers.
“Now that there’s no money tied to the RAPs, Medicare is telling us that we don’t need to wait until the OASIS and the coding are completed in order to submit the RAP,” McGowan said. “Once you have that order in and the first visits completed, just go ahead and submit the RAP.”
That marks a significant change in agencies’ operational processes and workflow. But there are still certain coding requirements tied to the RAP in 2021.
“Here’s where we get into that awkward transition issue, because the RAPs still need to have a primary diagnosis code on them and the HIPPS code,” McGowan said. “Medicare is not going to be using that primary diagnosis code on the RAP or the HIPPS code for anything, so we can submit a generic primary diagnosis code — like hypertension — on all RAPs.”
So, because the code will be less important up front, agencies can submit a generic HIPPS code like 1AA11 on all RAPs.
But that’s not where the quirkiness ends in the 2021 submission process. After the first visit, RAP submission, ICD-10 coding, OASIS QA and documentation are all completed, there is one more element to pay attention to.
“When you do submit that final claim, it has to have the same HIPPS code that was used on the RAP — the HIPPs code on the RAP and the final claim still needs to match,” McGowan said.
Even though CMS is not using that HIPPs code for anything, that’s a rule that will be carried on in 2021, so it’s imperative that a provider keeps those codes aligned.
Home health providers continue to make serious progress in reducing improper payments under fee-for-service Medicare, the U.S. Centers for Medicare & Medicaid Services (CMS) announced Monday.
Since 2016, improper payments to home health providers have dropped by an estimated $5.9 billion, according to CMS. All improper payments in fee-for-service Medicare are down by an estimated $15 billion compared to four years ago.
“From the beginning, this administration has doubled down on our commitment to protect taxpayer dollars,” CMS Administrator Seema Verma said in a statement. “This year’s continued reduction in Medicare improper payments is a direct result of those actions.”
The government has paid out an estimated $25.74 billion in Medicare fee-for-service improper payments in 2020, with an overall improper payment rate of 6.27%. Last year, the government paid out $28.91 billion in estimated improper payments, with a rate of 7.25%.
Improper payments are occasionally tied to fraud, waste and abuse, but that’s not always the case. Improper payments are often payments that simply did not meet certain regulatory or administrative requirements, perhaps due to unintentional documentation mishaps.
Additionally, improper payments do not necessarily represent expenses that should not have occurred, according to CMS.
CMS attributed to this year’s decrease in improper payments to the ongoing corrective actions it has taken over the years. The agency’s Review Choice Demonstration (RCD) is one example of those actions specific to home healthy care.
“Health care costs are skyrocketing; by 2026, one out of every five tax dollars will be spent on health care,” CMS noted in its Monday announcement. “To constrain unsustainable cost growth, CMS must continue to ensure payments are made according to the rules.”
On top of CMS actions, the home health industry has worked diligently over the past several years to police itself and weed out bad actors. The hard look in the mirror has helped the industry slash its improper payment rate drastically compared to 2015, when it checked in at an astronomical 58.95%.
“The value of home care is well established with proven cost savings, better outcomes and innovations in patient care being demonstrated every day,” Amedisys Inc. CEO and President Paul Kusserow wrote to Home Health Care News in April 2019. “We look forward to working with CMS and others to ensure the rate of improper payments continues to decline.”
Improper payments to skilled nursing facilities (SNFs) are also down in 2020.
Specifically, SNFs saw a $1 billion reduction in estimated improper payments in the last year, according to CMS. The agency said the reduction is largely due to a policy change related to the supporting information for physician certification and recertification for SNF services, as well as CMS’s Targeted Probe and Educate efforts.
Despite a vital need for palliative care in community settings, home-based care providers have been slow to invest in such services. Providers have often cited financial concerns as a roadblock.
Yet those providers that have turned their attention to palliative care frequently see positive returns. TRU Community Care, for example, saw its palliative care segment grow by 103% over the course of nine months, partly due to the implementation of new telehealth tools.
Founded in 1976, Lafayette, Colorado-based TRU Community Care is a Medicare- and Medicaid-certified, nonprofit health care organization. The company’s service lines include home health, hospice, assisted living and palliative care.
At the end of 2019, TRU Community Care began its process of revamping its palliative care program. This meant expanding the programs to include physicians, NPs, RNs, social workers, chaplains and care navigators.
It also meant forming a partnership with Boulder Community Health, which created a strong referral pipeline.
But the secret sauce was adopting remote patient monitoring technology, enabling TRU Community Care to transition from in-person to virtual visits in December, according to Michael McHale, the company’s president and CEO.
“More and more people are living with advanced illness. And now because of COVID-19, people are feeling so isolated from their health care resources,” McHale told Home Health Care News. “I think that our expansion into telemedicine enabled them to have a connection back to the health care community.”
Currently, TRU Community Care serves roughly 820 patients across Boulder, Broomfield, Adams, Jefferson, Denver and Weld counties in Colorado.
Typically, palliative care services provide specialized treatment focused on relieving symptoms, often for patients with serious illnesses.
“When you look at traditional palliative care, obviously providers and social workers going out and making visits, we do it based on acuity, whether that be weekly, monthly or bi-monthly,” Chad Hartmann, director of palliative care at TRU Community Care, told HHCN. “With the remote patient monitoring, it gives us the opportunity to oversee those patients and what’s going on with those patients every single day.”
Since providing palliative care through telehealth, TRU Community Care has completed over 15,000 minutes of virtual visits.
Prior to adding virtual visits, nurses entering patients’ homes were able to complete a maximum of five visits per daily. This number jumped to nine patients daily after adding virtual visits.
The new process allowed TRU Community Care to more easily track and trend patients’ disease progression over time, but it also was an added benefit in responding to the COVID-19 emergency.
“It’s really a mutual desire to limit folks coming into the home and then limiting exposure to COVID-19,” McHale said. “Right now, as in most of the country, Colorado is seeing an uptick in COVID diagnoses. We’re finding that more and more people don’t want someone coming into their home.”
Last year, TRU Community Care participated in a mHealth Impact Lab, University of Colorado study. The study found that TRU Community Care was able to save $40,000 through the use of virtual visits.
Historically, palliative care has not been associated with strong reimbursement, however.
Last month, the National Association for Home Care & Hospice (NAHC) publicly stated the organization’s plans to push for the recognition of palliative care as one of the services provided under the Medicare home health benefit.
TRU Community Care went the telehealth route because of the Centers for Medicare & Medicaid Services (CMS) “Patient Care First (PCF) – Seriously Ill Population (SIP)” demonstration. The payment model, part of the Primary Care First initiative, has yet to publicly announce which providers have been accepted to participate.
Still, the organization saw the program — and use of telehealth — as a way to achieve cost-effectiveness.
“The only way that we could see it make sense is if the majority of our visits were done telephonically,” McHale said. “Once you start putting in travel time, your visit cost increases. You have to pay that nurse or social worker that hourly rate for the time that they’ve traveled to the patient’s home and the cost of care that’s delivered while they’re in the home.”
Looking ahead, TRU Community Care is reaching out to other nonprofits in hopes of forming potential partnerships.
“The infrastructure that we’ve set up potentially could benefit them at a much lower cost and enable them to do more of this supportive service out in the community,” McHale said.
CMS will cover monoclonal antibody treatments for Medicare beneficiaries with Covid-19. Though this is a step forward in increasing access to these treatments, there are still hurdles to its widespread use.
Over the past few months, primarily as a result of the COVID-19 pandemic, telehealth has gone from a “nice-to-have” to a “must-have” for healthcare providers. The surge of COVID-19 patients in the spring, coupled with “stay-at-home” orders in many states, meant that many patients in need of care for chronic conditions and other non-emergent health issues were unable to visit their providers face-to-face.
Telehealth became the emergency solution, aided by relaxation of government regulations and improved reimbursement from health payers, led by the U.S. Centers for Medicare and Medicaid Services (CMS). But then a funny thing happened.
As COVID-19 restrictions eased, many patients and providers found they liked telehealth and wanted to keep it around. Patients liked it because they didn’t have to take hours out of their day to travel to an appointment, go through COVID-19 protocols, wait to be called, wait to see their provider, then travel home again.
Providers liked it because they could work more efficiently and, if they were incorporating remote patient monitoring, obtain a more complete view of their patients’ day-to-day health. Both sides also liked telehealth because, quite frankly, it helped them reduce their risk of contracting a highly contagious virus.
While we are not out of the woods yet – many experts are predicting a fall and winter surge that will make the spring surge look like a warm-up act – there are already discussions about whether telehealth was simply a stopgap measure in a crisis or should be viewed as a standard option for care going forward. In order to make telehealth permanent, however, healthcare organizations will want to know exactly what it can contribute once it’s safe to venture to the office once again.
Advanced analytics can help. They can show what worked, and what didn’t, so providers can make data-driven decisions about where, how, and whether to continue using telehealth. The following are eight ways analytics can contribute to present and future telehealth success.
1. Find the patients for whom telehealth visits offer the greatest benefits. Normally, these will be patients who can be diagnosed or assessed without direct laying-on of hands. They may have a condition such as a rash that can be inspected visually or may be able to use consumer-grade devices to take and report biometric readings. Advanced analytics can help discover them, enabling providers to close care gaps while improving Star ratings and HEDIS scores.
2. Prioritize patients by need. Analytics can help identify patients who are most at-risk of deterioration if they do not follow-up after preventive or elective procedures or are not closely monitored. They can also help providers make the appropriate adjustments to those priorities as patient health changes.
3. Get ready for additional surges. The next surge has already begun, and there are likely to be others before the pandemic is fully behind us. Providers need to have measures in place to keep staff safe and avoid the risk of more lockdowns or other changes that will disrupt their operations. Analytics can help them determine how much to invest in additional telehealth equipment and training to ensure uninterrupted service to their patients.
4. Measure telehealth’s impact on patient outcomes and reimbursement. Telehealth is so new, and the pandemic has caused so many shifts in reimbursement, that it can be difficult to determine exactly what effect it has had on outcomes and revenue. Analytics can uncover which changes have been positive and should be continued, and which should either be discontinued or adjusted to produce better health and/or financial result.
5. Uncover and rectify possible coding errors. As the pandemic took hold in March, CMS launched its “patients over paperwork” initiative. The goal was to ensure providers focused on care rather than worrying about coding accuracy, especially as the path to telehealth opened up. At some point, however, accurate coding will again be required. Analytics can help providers uncover and rectify any coding issues to ensure claims are paid fairly and completely.
6. Enable more effective remote patient monitoring. The presence of a global pandemic doesn’t halt chronic or other conditions affecting patient health. These conditions must continue to be managed to prevent them from deteriorating, which will place more of a health burden on patients while increasing long-term costs. Remote patient monitoring delivers the day-to-day data on these conditions. Analytics use that data to spot trends and update providers on the condition of all those patients, making it easier to ensure successful treatment for all of them.
7. Manage timed events more effectively. Risk-adjustment capture of previously documented conditions, which comes through CMS sweeps, retrospective reviews, and other means, can be disruptive to provider operations. Analytics can take the burden off an already exhausted staff by automating and simplifying the process.
8. Use trend and outcome data to inform the future. There is still much we don’t know about the effectiveness – and cost-effectiveness – of telehealth. This type of forward-looking analysis can be used to deliver policy and regulatory guidance for permanent reimbursement and best practices for telehealth-related visits.
As we continue to battle the global pandemic, telehealth does more each day to demonstrate its value. But what happens when the battle is finally won? Should it go back to the background or become fully integrated into a healthcare organization’s standard offerings?
Advanced analytics can be used to answer these questions and many others, helping providers make the decision that best fits their organization.
About Prasad Dindigal Prasad Dindigal serves as Vice President, Healthcare & Life Sciences, with EXL, a leading operations management and analytics company that helps our clients build and grow sustainable businesses.
Interoperability in healthcare is a national disgrace. After more than three decades of effort, billions of dollars in incentives and investments, State and Federal regulations, and tens of thousands of articles and studies on making all of this work — we are only slightly better off than we were in 2000.
Decades of failed promises and dozens of technical, organizational, behavioral, financial, regulatory, privacy, and business barriers have prevented significant progress and the costs are enormous. The Institute of Medicine and other groups put the national financial impact somewhere between tens and hundreds of billions of dollars annually. Without pervasive and interoperable secure communications, healthcare is missing the productivity gains that every other industry achieved during their internet, mobile, and cloud revolutions.
The Human Toll — On Both Patients and Clinicians
Too many families have a story to tell about the dismay or disaster wrought by missing or incomplete paper medical records, or frustration by the lack of communications between their healthcare providers. In an era where we carry around more computing power in our pockets than what sent Americans to the moon, it is mystifying that we can’t get our doctors digitally communicating.
I am one of the many doctors who are outraged that the promised benefits of Electronic Medical Records (EHRs) and Health Information Exchanges (HIEs) don’t help me understand what the previous doctor did for our mutual patient. These costly systems still often require that I get the ‘bullet’ from another doctor the same way as my mentors did in the 1970s.
This digital friction also has a profoundly negative impact on medical research, clinical trials, analytics, AI, precision medicine, and the rest of health science. The scanned PDF of a fax of a patient’s EKG and a phone call may be enough for me to get the pre-op done, but faxes and phone calls can’t drive computers, predictive engines, multivariate analysis, public health surveillance programs, or real-time alerting needed to truly enable care.
Solving the Surround
Many companies and government initiatives have attempted to solve specific components of interoperability, but this has only led to a piecemeal approach that has thus far been overwhelmed by market forces. Healthcare interoperability needs an innovation strategy that I call “Solving the Surround.” It is one of the least understood and most potent strategies to succeed at disruptive innovation at scale in complex markets.
“Solving the Surround” is about understanding and addressing multiple market barriers in unison. To explain the concept, let’s consider the most recent disruption of the music industry — the success of Apple’s iPod.
The iPod itself did not win the market and drive industry disruption because it was from Apple or due to its great design. Other behemoths like Microsoft and Philips, with huge budgets and marketing machines, built powerful MP3 players without market impact. Apple succeeded because they also ‘solved the surround’ — they identified and addressed numerous other barriers to overcome mass adoption.
Among other contributions, they:
– Made software available for both the PC and Mac
– Delivered an easy (and legal) way for users to “rip” their old CD collection and use the possession of music on a fixed medium that proved legal “ownership”
– Built an online store with a massive library of music
– Allowed users to purchase individual tracks
– Created new artist packaging, distribution, licensing, and payment models
– Addressed legalities and multiple licensing issues
– Designed a way to synchronize and backup music across devices
In other words, Apple broke down most of these barriers all at once to enable the broad adoption of both their device and platform. By “Solving the Surround,” Apple was the one to successfully disrupt the music industry (and make way for their iPhone).
The Revolution that Missed Healthcare
Disruption doesn’t happen in a vacuum. The market needs to be “ready” to replace the old way of doing things or accept a much better model. In the iPod case, the market first required the internet, online payment systems, pervasive home computers, and much more. What Apple did to make the iPod successful wasn’t to build all of the things required for the market to be ready, but they identified and conquered the “surround problems” within their control to accelerate and disrupt the otherwise-ready market.
Together, the PC, internet, and mobile revolutions led to the most significant workforce productivity expansion since WWII. Productivity in nearly all industries soared. The biggest exception was in the healthcare sector, which did not participate in that productivity revolution or did not realize the same rapid improvements. The cost of healthcare continued its inexorable rise, while prices (in constant dollars) leveled off or declined in most other sectors. Healthcare mostly followed IT-centric, local, customized models.
Solving the Surround for Healthcare Interoperability
‘Solving the Surround’ in healthcare means tackling many convoluted and complex challenges.
Here are the nine things that we need to conquer:
1. Simplicity — All of the basics of every other successful technology disruptor are needed for Health communications and Interoperability. Nothing succeeds at a disruption unless it is perceived by the users to be simple, natural, intuitive, and comfortable; very few behavioral or process changes should be required for user adoption.
Simplicity must not be limited to the doctor, nurse, or clerical users. It must extend to the technical implementation of the disruptive system. Ideally, the new would seamlessly complement current systems without a heavy lift. By implication, this means that the disruptive system would embrace technologies, workflows, protocols, and practices that are already in place.
2. Ubiquity — For anything to work at scale, it must also be ubiquitous — meaning it works for all potential players across the US (or global) marketplace. Interoperability means communicating with ease with other systems. Healthcare’s next interoperability disruptor must work for all healthcare staff, organizations, and practices, regardless of their level of technological sophistication. It must tie together systems and vendors who naturally avoid collaboration today, or we are setting ourselves up for failure.
3. Privacy & Security — Healthcare demands best-in-class privacy and security. Compliance with government regulations or industry standards is not enough. Any new disruptive, interoperable communications system should address the needs of different use cases, markets, and users. It must dynamically provide the right user permissions and access and adapt as new needs arise. This rigor protects both patients from unnecessary or illegal sharing of their health records and healthcare organizations in meeting privacy requirements and complying with state and federal laws.
4. Directory — It’s impossible to imagine ubiquitous national communications without a directory. It is a crucial component for a new disruptive system to connect existing technologies and disparate people, organizations, workflows, and use cases. This directory should maintain current locations, personnel, process knowledge, workflows, technologies, keys, addresses, protocols, and individual and organizational preferences. It must be comprehensive at a national level and learn and improve with each communication and incorporate each new user’s preferences at both ends of any communication. Above all, it must be complete and reliable — nothing less than a sub-1% failure rate.
5. Delivery — Via the directory, we know to whom (or to what location) we want to send a notification, message, fetch request or record, but how will it get there? With literally hundreds of different EHR products in use and as many interoperability challenges, it is clear that a disruptive national solution must accommodate multiple technologies depending on sender and recipient capabilities. Until now, the only delivery “technology” that has ensured reliable delivery rates is the mighty fax machine.
With the potential of a large hospital at one end and a remote single-doctor practice at the other, it would be unreasonable to take a one size fits all approach. The system should also serve as a useful “middleman” to help different parties move to the model (in much the same way that ripping CDs or iTunes gave a helping hand to new MP3 owners). Such a delivery “middleman” should automatically adapt communications to each end of the communication’s technology capabilities, needs, and preferences..
6. Embracing Push — To be honest, I think we got complacent in healthcare about how we designed our technologies. Most interoperability attempts are “fetch” oriented, relying on someone pulling data from a big repository such as an EHR portal or an HIE. Then we set up triggers (such as ADTs) to tell someone to get it. These have not worked at scale in 30+ years of trying. Among other reasons, it has been common for even hospitals to be reluctant to participate fully, fearing a competitive disadvantage if they make data available for all of their patients.
My vision for a disruptive and innovative interoperability system reduces the current reliance on fetch. Why not enable reliable, proactive pushing of the right information in a timely fashion on a patient-by-patient basis? The ideal system would be driven by push, but include fetch when needed. Leverage the excellent deployment of the Direct Trust protocol already in place, supplement it with a directory and delivery service, add a new digital “middleman,” and complement it with an excellent fetch capability to fill in any gaps and enable bi-directional flows.
7. Patient Records and Messages — We need both data sharing and messaging in the same system, so we can embrace and effortlessly enable both clinical summaries and notes. There must be no practical limits on the size or types of files that can easily be shared. We need to help people solve problems together and drive everyday workflows. These are all variations of the same problem, and the disruptor needs to solve it all.
8. Compliance — The disruptor must also be compliant with a range of security, privacy, identity, interoperability, data type, API, and many other standards and work within several national data sharing frameworks. Compliance is often showcased through government and vendor certification programs. These programs are designed to ensure that users will be able to meet requirements under incentive programs such as those from CMS/ONC (e.g., Promoting Interoperability) or the forthcoming CMS “Final Rule” Condition of Participation (CoP/PEN), and others. We also must enable incentive programs based on the transition to value-based and quality-based care and other risk-based models.
9. On-Ramp — The iPod has become the mobile phone. We may use one device initially for phone or email, but soon come to love navigation, music, or collaboration tools. As we adopt more features, we see how it adds value we never envisioned before — perhaps because we never dreamed it was possible. The healthcare communications disruptor will deliver an “On-Ramp” that works at both a personal and organizational scale. Organizations need to start with a simple, driving use case, get early and definitive success, then use the same platform to expand to more and more use cases and values — and delight in each of them.
So here we are, decades past the PC revolution, with a combination of industry standards, regulations, clinician and consumer demand, and even tens of billions in EHR incentives. Still, we have neither a ‘killer app’ nor ubiquitous medical communications. As a result, we don’t have the efficiency nor ease-of-use benefits from our EHRs, nor do we have repeatable examples of improved quality or lower errors — and definitively, no evidence for lower costs.
I am confident that we don’t have a market readiness problem. We have more than ample electricity, distributed computing platforms, ubiquitous broadband communications, and consumer and clinician demand. We have robust security, legal, privacy, compliance, data format, interoperability, and related standards to move forward. So, I contend that our biggest innovation inhibitor is our collective misunderstanding about “Solving the Surround.”
Once we do that, we will unleash market disruption and transform healthcare for the next generation of patient care.
About Peter S. Tippett
Dr. Peter Tippett is a physician, scientist, business leader, and technology entrepreneur with extensive risk management and health information technology expertise. One of his early startups created the first commercial antivirus product, Certus (which sold to Symantec and became Norton Antivirus). As a leader in the global information security industry (ICSA Labs, TruSecure, CyberTrust, Information Security Magazine), Tippett developed a range of foundational and widely accepted risk equations and models.
He was a member of the President’s Information Technology Advisory Committee (PITAC) under G.W. Bush, and served with both the Clinton Health Matters and NIH Precision Medicine initiatives. Throughout his career, Tippett has been recognized with numerous awards and recognitions — including E&Y Entrepreneur of the Year, the U.S. Chamber of Commerce “Leadership in Health Care Award”, and was named one of the 25 most influential CTOs by InfoWorld.
Tippett is board certified in internal medicine and has decades of experience in the ER. As a scientist, he created the first synthetic immunoglobulin in the lab of Nobel Laureate Bruce Merrifield at Rockefeller University.
– Today, Sony announced an update to our NUCLeUS medical
imaging platform, which improves support for remote patient observation.
– NUCLeUS has added new functionality and features,
including powerful bi-directional telestration capabilities allowing multiple
remote users to simultaneously annotate, draw or highlight areas of interest in
a live stream video or still image.
announced an update to its vendor-neutral medical imaging platform NUCLeUS. The latest release introduces Remote
Patient Monitoring (observation) functionality with recording functionalities
for use in the operating room (OR), Intensive Care Units (ICU), endoscopy
suites, procedure rooms or anywhere else in the hospital.
The Smart Digital Imaging Platform for Medical Environments
Developed in consultation with leading surgeons and with vendor
neutrality in mind, NUCLeUS guides clinical staff through the planning,
recording and sharing of video, still images and other patient-related data.
Seamlessly linking Sony and third-party devices, applications, video and most
importantly, people, NUCLeUS focuses on hospital staff requirements and use
cases, adding value to imaging workflows.
Bi-Directional Telestration Capabilities
NUCLeUS has added
new functionality and features, including powerful bi-directional telestration
capabilities allowing multiple remote users to simultaneously annotate, draw or
highlight areas of interest in a live stream video or still image. This can be
securely shared with authorized viewers to discuss as a group in real time,
ideally suited for socially distanced environments. Equipped with a full
set of recording functionalities, NUCLeUS is also a valuable tool for
hospitals, outpatient surgery centers and private practices serving a variety
of specialties including Urology, ENT, Obstetrics, Ophthalmic, Plastic surgery,
New NUCLeUS Functionality Features
New functionalities of NUCLeUS include:
presenting video streams from image sources in multiple ORs and ICUs
simultaneously on a single display, thus providing a situational overview of
activity in a tiled or mosaic format.
iPad Streaming function, allowing clinical staff to access images from any modality via
an iPad in virtual real time within the OR, so medical staff can follow the
intervention on their handheld device.
quality 4K conversion, allowing any HD resolution video content to be converted to 4K
using advanced resolution-augmentation algorithms superior to conventional
upscaling, giving a crisp ultra-high resolution view of converted video
Expanded Patient Distraction – helping to reduce patient anxiety through music tracks and
video imagery that can be played in the OR to create a more relaxing and
Time-Out Functionality, featuring checklists that simplify time out of safety
standards at the start, during and end of an operation.
Printing capabilities, allowing hard copies of still images captured by NUCLeUS to be
created inside the OR using an optional UP-DR80MD A4 digital color printer. The
Auto Print function also extends CMS (Content Management System) print
functionality to collect a preconfigured number of stills, printing them
compatibility with the latest Sony PTZ and fixed cameras including HD and 4K
“Sony is committed to developing NUCLeUS to suit the needs of patients and medical staff at all times,” said Theresa Alesso, pro division President, Sony Electronics. “The Remote Patient Monitoring capabilities within NUCLeUS are a primary example of this and were developed to help hospitals manage day-to-day requirements through the COVID-19 pandemic. We are committed to helping hospitals and healthcare providers reinvent their workflows and provide medical staff with the tools they need to continue delivering excellent patient care.”
As every healthcare executive knows, a healthy revenue cycle relies on precise paperwork. That’s why all Medicare providers should be paying close attention to the revised medical necessity form, which will be mandatory starting January 1, 2021. Failure to use the new Advance Beneficiary Notice of Non-coverage (ABN) form could lead to denied claims, financial penalties and a subpar patient experience.
We interviewed Theresa Marshall, senior director of data compliance at Experian Health, about what’s changed and what providers can do to prepare.
What is a medical necessity form?
Medicare only pays for services and procedures considered “medically necessary.” In situations where a procedure isn’t considered medically necessary, providers must issue the patient with an ABN which ultimately transfers financial responsibility to the patient.
Services that could be considered medically unnecessary might include treatment in hospital that could have been provided in a lower-cost setting, screening or therapies that are unrelated to the patient’s symptoms, or hospital stays that exceed a specified length of time. Perhaps a patient is receiving support with personal care from a home health agency – this may not be strictly medically necessary, so the provider might anticipate that it won’t be covered by Medicare. An ABN isn’t required for services that are never covered by Medicare, such as dental care or cosmetic surgery.
What’s changed on the new medical necessity form?
The new form, CMS-R-131, replaces the version released by CMS in June 2017. The main change is the addition of new instructions for Dual Eligible beneficiaries. These are patients who are eligible for both Medicare and Medicaid, and most likely enrolled in the Qualified Medicare Beneficiary Program (QMB), which means Medicaid pays for any Medicare-covered services. Providers must not levy any charges against QMB patients, or they’ll face sanctions. The new instructions specify that in addition to edits that strike through specific language, “dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication.”
How should providers prepare?
Should they chose, providers can start using the new form now. The important thing to remember is that they must have the new form in place by the new year. Any outdated forms after the first of the year will be invalid.
Many providers are still using manual processes which require checking medical necessity rules for both Medicare and commercial payers via the CMS website, then calculating and preparing the required paperwork themselves. This can be time-consuming and vulnerable to errors, which also results in denied claims and extra days in accounts receivable (A/R) – not to mention the extra stress it causes for patients.
A time-saving alternative is an automated tool such as Experian Health’s Medical Necessity. With automation, you can validate clinical orders against payer rules quickly and accurately, for cleaner claims the first time around. Medical Necessity integrates seamlessly with multiple electronic medical records (EMR), scheduling and registration systems, to run automatic checks for medical necessity, frequency and duplication. With up to half of denied claims occurring early in the revenue cycle, any actions to minimize errors and delays during registration could bring big financial benefits.
Medical Necessity from Experian Health will include an automatic check of a Medicare beneficiary’s QMB status ahead of the January 2021 deadline, so the electronic ABN can be updated immediately, ready for the patient’s signature.
Could this improve the patient experience?
Yes, definitely. In addition to reducing manual processes, preventing denied claims and protecting against lost revenue and financial sanctions, automating medical necessity checks also creates a much less stressful experience for patients. For individuals who are financially vulnerable, any lack of clarity about their medical bills can be a huge source of worry. But when providers can quickly identify patients who shouldn’t be charged, the billing experience is a much smoother ride.
Medical Necessity is just one of the many ways that Experian is working to reduce the burden on hospital resources, improve patient experiences, and ensure that hospitals are fully compensated for the care they provide. Find out how we can help your organization get your paperwork in order in time for the new ABN requirements in January 2021, so you can offer a better patient experience and reduce claim denials at the same time.
With the Trump administration announcing two days before Election Day that Georgia’s healthcare.gov website will no longer provide options for residents shopping for plans starting in 2022, consumers will need to rely on private brokers, insurance companies, agents and commercial websites.
Republican Georgia Gov. Brian Kemp, who pushed the plan, argued that this would give private entities an opening to aggressively advertise and compete for consumers and increase the number of plans sold for 2023.
The plan, which generated overwhelming opposition and almost no support during the public comment period, has been greeted warily as a test of how radically states can alter the rules of the Affordable Care Act under the Trump administration. Skeptics say Georgia’s plan would resurrect the chaotic and murky marketplace that existed before the ACA was passed, in which individual brokers would push the policies that paid the biggest commissions, even if they didn’t have the best price or offered coverage with major loopholes.
“The payoff doesn’t strike me as being there,” said Joseph Antos, a health care expert at the American Enterprise Institute, a right-leaning think tank in Washington, D.C. “I’m sure people in Georgia, just like everyone else, have had the federal website URL [healthcare.gov] pumped into their heads. The people who would be newly interested in exchange coverage are clearly not going to know where to go.”
The timing of the announcement is notable, coming on the eve of a national election in which President Donald Trump and Republicans have been on the defensive about their efforts to unravel the Affordable Care Act. Georgia has also been targeted in recent weeks by the campaign of Democratic presidential nominee Joe Biden, who visited the state last week.
It also comes just as the 2021 open enrollment period has gotten underway. The federal exemption, known as a 1332 waiver, is expected to face legal challenges, because the ACA permits states to try out different methods only if they lead to at least the same number of people getting insurance.
The number of Georgians purchasing health insurance through the federal marketplaces has declined during the Trump administration.
The Kemp administration predicts the change will increase enrollment by 6.8% for plans starting in 2023. If successful, that would partially reverse the coverage losses that have occurred under Trump. Enrollment dropped from 587,845 in 2016 to 458,437 in 2019, although it climbed a bit to 463,910 this year. Georgia’s overall drop of 21% was twice the national average decline, according to KFF data. (KHN is an editorially independent program of KFF.)
Laura Colbert, executive director at Georgians for a Healthy Future, a nonprofit advocacy group, said the enrollment decline in Georgia plans was due to increases in premiums and cuts in outreach efforts. Since Trump took office, enrollment has decreased in 39 states.
In her approval letter, Seema Verma, administrator of the federal Centers for Medicare & Medicaid Services, said the enrollment outreach set up by the Obama administration, known as the Navigator program, “has simply had limited impact on reducing the overall uninsured rate in Georgia, suggesting there may be a more effective way to reach and engage consumers. In fact, one of the key criticisms of HealthCare.gov and the implementation of the Navigator program is that it has squeezed local agents and brokers out of the market with government-funded competition.”
But there has been almost no public support for the plan, even among people within Georgia’s insurance and brokerage industries. Seventy-two of 75 organizations submitting formal comments opposed the change, and 1,746 of 1,751 individual letters favored the unified format of healthcare.gov, where all plans are listed and can be compared on price and other factors.
“Even though I was educated at an elite university, it is still difficult to be certain I am choosing the best option for my situation,” one commentator wrote. “I am certain that the proposal to force me off the exchange and into the hands of for-profit insurers or brokers will benefit them and not me.”
Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, said Georgia’s proposal says “over and over there will be new options and new competition, but brokers already exist. The waiver doesn’t enable new options; it just takes away healthcare.gov.”
Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities, said that for people too poor to afford private plans, healthcare.gov has been an effective way to redirect consumers to state Medicaid programs. Private brokers, she said, have no such incentive to help them access public coverage. “These are thousands of people who could be lost along the way,” Straw said.
Brokers get paid more to sell short-term plans that do not have to offer as many benefits as ACA-complaint plans: on average $8.42 per member each month for the short-term plans versus $6.88 for the ACA plans, according to Georgia’s calculations. Georgia officials said that was too small a difference to “drastically” change broker behavior.
The U.S. Centers for Medicare & Medicaid Services (CMS) on Monday touted several tools designed to help states rebalance their long-term care ecosystem toward home- and community-based services.
The development is the latest in a series of CMS efforts aimed at strengthening home- and community-based services amid the COVID-19 pandemic, with the ultimate goal of decreasing America’s reliance on nursing home care.
“The COVID-19 crisis has shone a harsh light on the human costs of a long-term care system that relies too heavily on institutional services like nursing homes,” CMS Administrator Seema Verma said in a statement included in Monday’s announcement. “Too often, they are seen as the default option, even for those who may not require round-the-clock care.”
Broadly, Monday’s “toolkit” offers examples of innovative state models and best practices to rebalance long-term services and supports programs toward in-home care. Examples largely focus on Medicaid, the primary funder of long-term services and supports nationally.
One specific example highlighted in the toolkit is Pennsylvania’s managed care policy that requires plans to implement a home care workforce innovation component within their programs, utilizing person-centered planning principles to improve the recruitment, retention and skills of direct care workers.
Another is Vermont’s Medicaid section 1115 demonstration to increase access to home- and community-based services for adults at risk for nursing home admission who may not be eligible for Medicaid and who do not meet level-of-care criteria for a nursing home.
“While nursing homes will always be an important part of a complete care continuum, many elderly individuals and their families should have access to a more robust set of home care and community-based care options,” Verma’s statement continued.
In FY 2018, 79% of total Medicaid long-term care spending for individuals with intellectual and developmental disabilities (I/DD) was tied to home- and community-based services. Nearly half of long-term care spending for individuals with mental health and substance use disorders was tied to home-base care.
Meanwhile, just 33% of long-term care spending for older adults and individuals with physical disabilities was tied to home- and community-based services in FY 2018.
Contextually, CMS issued its toolkit on the same day The American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) released a report revealing that new COVID-19 cases are increasing in nursing homes in the U.S., mostly due to the community spread among the general population.
Weekly new COVID-19 cases in the general population rose by 61% to 391,527 new cases the week of Oct. 18, according to data from Johns Hopkins University.
A correlating uptick in new cases in nursing homes occurred when cases in the surrounding community started rising back in mid-September.
“As we feared, the sheer volume of rising cases in communities across the U.S., combined with the asymptomatic and pre-symptomatic spread of this virus, has unfortunately led to an increase in new COVID cases in nursing homes.” Mark Parkinson, president and CEO of AHCA and NCAL, said in a press release. “It is incredibly frustrating as we had made tremendous progress to reduce COVID rates in nursing homes after the spike this summer in Sun Belt states. If everybody would wear a mask and social distance to reduce the level of COVID in the community, we know we would dramatically reduce these rates in long term care facilities.”
Nearly half the nation’s hospitals, many of which are still wrestling with the financial fallout of the unexpected coronavirus, will get lower payments for all Medicare patients because of their history of readmitting patients, federal records show.
The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between July 2016 and June 2019, so the flood of coronavirus patients that have swamped hospitals this year were not included.
The Centers for Medicare & Medicaid Services announced in September it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.
For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.
Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.
The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.
“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”
The penalties are based on readmissions of Medicare patients who initially came to the hospital with diagnoses of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.
A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.
The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.
Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.
“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”
The U.S. Centers for Medicare & Medicaid Services (CMS) released its final home health payment rule for CY 2021 on Thursday, with essentially no changes to the Patient-Driven Groupings Model (PDGM) or its controversial behavioral adjustment.
In addition to doubling down on PDGM, boosting the home health base payment rate by 1.9% and making minor adjustments to the Home Health Value-Based Purchasing Model, CMS also clarified its new policy on Requests for Anticipated Payment (RAPs) for next year and beyond.
Home health agencies likely won’t be happy with the fine print.
In its 2020 rulemaking, CMS announced it was moving forward with a plan to fully eliminate RAPs — or home health-prepayments that provide a chunk of an episode’s anticipated payment at the beginning of care — by 2021. In place of RAPs, the agency explained it will instead require agencies to submit a one-time Notice of Admission (NOA) starting in 2022.
Although NOAs kick in for 2022, 2021 would be a transition year, with agencies still required to submit a watered-down RAP for billing purposes.
“With the removal of the upfront-RAP payment for CY 2021, we relaxed the required information for submitting the RAP for CY 2021 and stated that the information required for submitting an NOA for CYs 2022 and subsequent years would mirror that of the RAP in CY 2021,” CMS wrote in Thursday’s final rule. “Starting in CY 2022, [agencies] will submit a one-time NOA that establishes the home health period of care and covers all contiguous 30-day periods of care until the individual is discharged from Medicare home health services.”
While the elimination of pre-payments is already incredibly impactful, especially for smaller, cash-strapped home health agencies, CMS’s new policies also come with a built-in penalty for late submissions.
The RAP in 2021 and the one-time NOA starting in 2022 must both be submitted within five calendar days from the start of care. If agencies fail to do so, they’re subject to a one-thirtieth reduction to the wage and case-mix adjusted 30-day period payment amount for each day from the start of care date until the date agencies submit their RAP or NOA.
In other words, home health agencies will be hit with a 3% fine for each day they’re late filing their paperwork.
The fine print
A 3% fine for each late day to file a RAP or NOA doesn’t seem too bad at first glance. But that 3% fine turns into a 20% penalty very quickly.
After issuing its proposed rule in June, CMS received multiple comments from industry stakeholders asking when the non-timely payment reduction actually begins.
“A commenter requested clarification on the methodology used to calculate the non-timely submission payment reduction,” CMS stated in its 2021 final rule. “This commenter asked whether the reduction begins on Day 1 or Day 6.”
For purposes of determining if a “no-pay” RAP is timely-filed, the no-pay RAP must be submitted within five calendar days after the start of each 30-day period of care. For example, if the start of care for the first 30-day period is Jan. 1, then the no-pay RAP would be considered timely-filed if it is submitted on or before Jan. 6, the agency clarified.
What’s that mean? Well, in the event that the no-pay RAP is not timely-filed, CMS will calculate the one-thirtieth penalty from the first day of that 30-day period. So in the previous example, the penalty calculation would begin on Jan. 1 — and not on Jan. 7, the first day after an agency misses its deadline.
Translation: If an agency submits its no-pay RAP one day late, the result would be a 20% reduction to its 30-day payment amount.
“That will take these small agencies out,” McBee Associates President Mike Dordick told HHCN in July 2019.
A possible 20% penalty on top of that just adds insult to injury.
Cheating on your taxes
The RAPs penalty is an important detail from CMS’s final payment rule for next year, but the main takeaway is still the agency’s decision to stick to PDGM’s behavioral adjustment — effectively a 4.36% cut if left unmitigated.
Industry stakeholders were hoping CMS would reconsider the adjustment after emerging data suggested it’s inherently flawed but exacerbated due to the COVID-19 pandemic. The adjustment has proven difficult for many agencies, particularly when paired with astronomical personal protective equipment (PPE) costs and other factors.
“Our members have been working hard throughout this health care crisis to serve older adults in need of home health care, while at the same time shouldering significant pandemic-related expenses for PPE, staffing and other needs,” Katie Smith Sloan, president and CEO of LeadingAge, told HHCN in an email. “They’ve cared for older adults both in person and via telehealth, despite shortcomings in Medicare reimbursement policies that keep providers from being paid for delivering telehealth services.”
Those facts, coupled with CMS’s decision to not address faulty behavior assumption adjustments in its rule for CY 2021, put home health agencies in “an untenable position,” she added.
In addition to her role at the Washington, D.C.-based aging services industry association LeadingAge, Smith Sloan also serves as acting president and CEO of ElevatingHOME and the Visiting Nurse Associations of America.
In part, PDGM’s behavioral adjustment was based on CMS assuming home health agencies would do everything possible to lower Low Utilization Payment Adjustment (LUPA) rates while always “upcoding” to the highest-paying primary diagnoses.
Intrepid USA CEO John Kunysz told HHCN that line of thinking was wrong from the start.
“Maintaining the behavioral adjustment is akin to the government saying, ‘We believe you are going to cheat on your taxes, so we are disallowing a percentage of your deductions,’” Kunysz said in an email. “We operate in a highly regulated environment. The incentives to provide appropriate care far outweigh any temptation to try and game the system.”
Dallas-based Intrepid USA is a home health, hospice and home care provider with operations in more than a dozen states. In 2019, the company cared for more than 22,000 patients under its home health service line.
The final rule adds an estimated $390 million home health payment boost for agencies in 2021, or an aggregate increase of 1.9%. That estimate is less than the $540 million boost and 2.6% increase originally outlined in CMS’s proposed rule.
The increase reflects the effects of the 2% home health payment update percentage and a 0.1% decrease in payments due to reductions in the rural add-on percentages mandated by the Bipartisan Budget Act of 2018 for 2021, the agency noted. The rule also updates the home health wage index, limiting any decreases in a geographic area’s wage index value to no more than 5% next year.
On one hand, the rule brings a semblance of stability to the home health industry by not making any major changes to the Patient-Driven Groupings Model (PDGM). At the same time, by keeping the status quo, CMS also keeps in place the widely controversial behavioral adjustment built into PDGM.
Home health advocates had been pushing for CMS to reconsider PDGM’s behavioral adjustment for months, especially after an independent analysis found the overhaul lowered home health spending by a projected 21.6% in 2020. William A. Dombi, president of the National Association for Home Care & Hospice (NAHC), expressed disappointment on that point in an email to the organization’s members.
“We are disappointed that CMS put off consideration of dropping the behavioral adjustment to payment rates based on its view that it needs a full year of data before it can act,” Dombi wrote. “We believe sufficient information is available to recognize that the behavioral changes assumed have not occurred. We will continue to work to get a mid-year rate change to reflect the absence of the rate behavior that CMS assumed.”
This is a developing story. Please check back shortly for additional updates.
President Donald Trump entered office seeking a massive overhaul of the Medicaid program, which had just experienced the biggest growth spurt in its 50-year history.
His administration supported repealing the Affordable Care Act’s Medicaid expansion, which has added millions of adults to the federal-state health program for lower-income Americans. He also wanted states to require certain enrollees to work. He sought to discontinue the open-ended federal funding that keeps pace with rising Medicaid enrollment and costs.
He has achieved none of these ambitious goals.
Although Congress and the courts blocked a Medicaid overhaul, the Trump administration has left its mark on the nation’s largest government-run health program as it has sought to make states more responsible for assessing its impact and improving the health of enrollees.
One notable achievement: The Trump administration pushed some states to be more aggressive in weeding out ineligible recipients — an initiative that led to a drop in enrollment of children in several states, including Missouri and Tennessee. About half of those enrolled in Medicaid are children.
A recent report from the Georgetown University Center for Children and Families found that the number of uninsured children rose by more than 700,000 to 4.4 million from 2017 through 2019. The increase of uncovered children stands out since uninsured rates typically drop during periods of economic growth, such as the one occurring from 2017 to 2019.
Advocates for the poor say the administration’s efforts contributed to an increase in the number of uninsured children, after years of decline. “The administration has not succeeded on any of its goals in any meaningful way,” said Joan Alker, executive director of the Georgetown center. “But they still have inflicted some damaging changes to the program.”
“The administration has not prioritized the health of children,” said Bruce Lesley, president of the child advocacy group First Focus on Children.
Alker attributes the rise in uninsured children to federal officials’ decision to slash outreach funding for the Obamacare insurance exchanges — through which families eligible for Medicaid are often identified — and the administration’s focus on the “public charge” rule. That provision allows the federal government to more easily deny permanent residency status, popularly known as green cards, or entry visas to applicants who use — or are deemed likely to use — publicly funded programs such as food stamps, housing assistance and Medicaid.
Medicaid officials said the increase is partly due to loss of health coverage by middle-income families who are not eligible for Medicaid. They say those families don’t qualify for government subsidies for the ACA’s marketplace plans and were forced to drop their plans because of high premiums.
But Alker said federal data suggests that families who have incomes over the 400% federal poverty level eligibility limit for subsidies (about $87,000 for a family of three) saw a slower rate of increase in the number of uninsured children as opposed to lower-income kids.
A spokesperson for the federal government’s Centers for Medicare & Medicaid Services said the agency was “committed to ensuring that eligible children are enrolled and retained in coverage” and it spent $48 million in grants for outreach and enrollment effort last year.
The Trump administration opposes the ACA’s expansion of Medicaid, which provided billions in federal dollars to cover nondisabled, low-income adults. Yet seven states adopted the expansion during the past three years, including Republican-controlled Utah, Idaho, Oklahoma, Nebraska and Missouri.
Despite the aim to shrink the program, about 75 million people were enrolled in Medicaid in June 2020 — roughly the same number as in January 2017, when Trump took office.
One reason is that Medicaid enrollment soared this year following the COVID-19 outbreak as unemployment spiked to historic highs and federal stimulus money forbid states to drop anyone unless they moved out of state.
But that is far from the administration’s goal of “ushering in a new day” for Medicaid, as CMS Administrator Seema Verma said when she laid out her bold vision in a 2017 speech.
Verma acknowledged she was stepping into a hornet’s nest of entrenched stakeholders and interest groups.
“I would like to invite everybody here today who have fought the political healthcare battles over the last decade to take a deep breath, exhale and agree to reset as a group,” she said.
They didn’t. The administration’s major Medicaid changes were met with opposition from hospitals, doctors and patient advocacy groups, who feared the efforts would lead to cuts in funding or add obstacles for enrollees seeking care.
Officials spent two years seeking to allow states to require enrollees to work or volunteer as a condition for enrollment. They approved proposals from 10 states, but only Arkansas implemented the new requirement before a federal judge ruled it illegal. Arkansas’ brief experience resulted in more than 18,000 adults losing coverage.
After losing in federal district and appeals courts, the Trump administration has appealed to the Supreme Court, which will decide later this year whether to take the case.
The push for work requirements and other changes have altered the culture of Medicaid so that officials are more intent on keeping people out of the program instead of welcoming more in, said Lesley, of First Focus.
Before the pandemic, he said, the administration allowed states to add hurdles for families to get enrolled and stay enrolled, such as requiring them to more frequently recertify their income eligibility.
Aaron Yelowitz, a professor of economics at the University of Kentucky, said one of the Trump administration’s biggest impacts on Medicaid was prodding states to be more active in making sure they were covering only people who met the states’ eligibility rules. He noted the ACA gave states incentives to enroll newly eligible adults over traditional groups such as children and the disabled because the federal government paid a higher share of the cost.
Seeking Flexibility for States
The administration — as well as Republicans in Congress — favored a fundamental change in how Medicaid is funded. But Congress failed to move the program to a “block grant” approach, which would have given states a set annual amount — rather than the current system that provides funding determined by how many people qualify for the program and health costs. The GOP proposal also would have allowed states more flexibility in running the operations.
Critics predicted a block grant would have cut billions in state funding and led to cuts in services and eligibility.
Once the legislative proposal was dead, the administration sought to enact the strategy via its authority to test changes in payment methods. Only one state applied — Oklahoma — and it dropped its application this year after voters passed a Medicaid expansion ballot initiative.
Verma promised to give states more flexibility in running their programs in other ways, while also holding them more accountable for care to Medicaid enrollees. CMS has approved dozens of Medicaid waivers since 2017, including allowing states to be more innovative in helping enrollees with substance abuse or addiction problems and serious mental illness. It granted more than 30 states waivers to enhance treatment options.
With Medicaid paying for more than half of all births in the United States, Verma also sought to improve oversight of prenatal and early childhood services.
While CMS has started a scorecard to track Medicaid outcomes, the data is missing for several states or outdated on several measures. For example, the low-birthweight measure is missing data from more than 20 states and no data is listed on children born with an addiction.
CMS officials said they are working to provide more updated information on its report card.
Changes implemented by the administration, officials added, have elicited more timely data from states, allowing them to spot problems quicker. For example, in September, CMS determined that many children were delayed from March through May in seeing a doctor and getting important vaccines as the pandemic took hold. CMS pushed states and health providers to remedy the problem but did not offer specific help.
Asked during a recent phone briefing with reporters about Medicaid’s legacy under her stewardship, Verma didn’t mention the expansion, work requirements or efforts to turn Medicaid into a block grant program for states.
“We have aimed to try to ensure the program is sustainable for generations to come and ensure better outcomes for those it serves,” she said.
CMS’ interim rule states that Medicare will cover Covid-19 vaccines approved by the FDA, including those receiving emergency use authorization, in a reversal from its usual policy. The vaccine will be made available at no cost to Medicare beneficiaries.
In response to ongoing opposition from both lawmakers and providers, the Department of Health and Human Services (HHS) recently announced it has made changes to its rules surrounding COVID-19 relief funding.
The department’s amended rules now allow providers to use Provider Relief Fund (PRF) money toward lost revenue that’s potentially unrelated to COVID-19.
“After reimbursing health care-related expenses attributable to coronavirus that were unreimbursed by other sources, providers may use remaining PRF funds to cover any lost revenue, measured as a negative change in year-over-year actual revenue from patient care related sources,” HHS said in a recent statement.
Before the recent update, HHS placed a stricter stipulation on what would eventually amount to $175 billion of funds provided through the CARES Act stimulus package. This was to prevent providers from becoming more profitable in 2020 than 2019 by improperly using federal funds for financial gain instead of an operational lifeline.
While the PRF program was “well-intentioned,” it has been mired with challenges associated with conflicting and unclear guidance along the way, Matt Wolfe, a partner at law firm Parker Poe, told Home Health Care News.
“In September, when HHS put out guidance that seemed to limit or restrict these provider relief funds, there was understandably a significant amount of pushback by providers and members of Congress,” Wolfe said. “When [HHS] created this program under the CARES Act, they were really trying to make sure that health care providers of all stripes were able to respond to the public health emergency and keep their doors open.”
Since its formation, the PRF has accomplished its goal of keeping home health agencies and other afloat, Wolfe believes. Still, over the past couple of months, there had been growing concern that HHS was becoming more restrictive than what Congress originally intended.
“You’re putting providers in this difficult situation of saying, ‘Well, I needed this money because it’s what allowed me to make it through this unprecedented challenge,’” he said. “At the same time, they’re wondering, ‘If I retain the funds and don’t pay them back, am I going to have some potentially large obligation down the road?’”
HHS’s amendment to the reporting requirements is key because it clarifies whether providers should hang on to the funds.
While certainly an improvement for home health agencies, and “a step in the right direction,” there’s still work that needs to be done to accomplish the Congressional intent of the program, according to Wolfe.
“For example, it allows a provider to be able to show lost revenue attributable to the coronavirus, essentially by looking at 2019 patient-related revenue compared to 2020 patient-related revenue,” he said. “Depending on your operations in 2019, you may have had an acquisition or some other type of growth at the beginning part of 2020. You may have actually still lost revenue that isn’t dissipated revenue in 2020, but that simplistic comparison of 2019 to 2020 may not actually show that.”
As more providers retain funds, the industry will likely also see an increase in federal oversight.
Since providers are dealing with federal dollars, there’s the possibility of False Claims Act liability, according to Wolfe.
Moving forward, it will be critical for providers to receive clarity in order to continue to make informed business decisions.
“There’s a lot still to be determined in terms of how you’re going to comply with these reporting requirements,” Wolfe said. “Some of the decisions about how to report are going to influence how you spend the money. It’s really critical that HHS provides that clarity so that providers can make decisions about how to utilize these funds if they haven’t already.”
The HHS to loosen the Provider Relief Fund rules marks the second significant relaxation of rules around federal support for health care providers in recent weeks.
The Centers for Medicare & Medicaid Services (CMS) also extended repayment terms for its Medicare Accelerated and Advance Payment Program earlier this month.
The Centers for Medicare and Medicaid Innovation (CMMI) created the Direct Contracting Model to expand opportunities for more diverse providers and healthcare organizations to participate in value-based care arrangements for Medicare fee-for-service (FFS) beneficiaries.
The goal of the new model is to create the next generation of risk-sharing arrangements to improve outcomes for patients, lower costs, and ensure high-quality care. In developing the Direct Contracting model and associated payment options, CMMI decided to build on lessons learned from accountable care initiatives, in particular, the Next-Generation ACO (NGACO) Model, as well as Medicare Advantage and other innovative private payers. The new model specifically aims to attract providers new to Medicare FFS and Innovation Center models: “the payment model options appeal to a broad range of physician practices and other organizations because they are expected to reduce burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from organizations that have not typically participated in Medicare FFS or CMS Innovation Center models.”
High risk equals high reward for the new Direct Contracting Entities (DCE). The payment model options that participants can choose from aim to (1) increase risk-sharing arrangements through capitated and partially capitated population-based payments, (2) include providers and organization new to Medicare FFS, (3) increase access and empower beneficiaries in their care, and (4) decrease provider burden by emphasizing only core quality metrics and making certain care delivery waivers available. Importantly, the model offers options for new entrant DCEs, meaning DCEs that have no or limited experience with Medicare FFS beneficiaries and associated Medicare risk-based contracts, as well as high needs DCEs that will focus specifically on high cost, high acuity beneficiaries.
The Direct Contracting model begins with an optional six-month implementation period on October 1, 2020, which is intended to support organizations that need additional time to align beneficiaries and optimize their care coordination and management functions. In light of COVID-19’s overwhelming impact on healthcare this year, CMMI announced the first Direct Contracting Model performance year will start April 1, 2021—a three-month delay from the original start date, with five performance years to follow. The second cohort of Direct Contracting participants will begin in January 2022.
The Innovation Center will initially test two risk-sharing options:
Professional – includes a 50% shared savings/shared losses provisions and Primary Care Capitation, a capitated, risk-adjusted monthly payment for enhanced primary care services that’s equal to seven percent of the total cost of care benchmark for enhanced primary care services
Global – is 100% full risk option with either Primary Care Capitation or Total Care Capitation, which is a capitated, risk-adjusted monthly payment for all services provided by Direct Contracting Participants and preferred providers.
CMS may test a third option, the Geographic Option, in the future, which would also be a 100% risk arrangement offering an opportunity for participants to assume the total cost of care risk for Medicare FFS beneficiaries in a defined region.
Achieving Success in the Direct Contracting Model:
Similar to existing accountable care models, critical elements to achieve success in the Direct Contracting model include a focus on workflows, systems, and partnerships that support care coordination activities, including connections to needed healthcare and wrap-around services, as well as supporting providers in attaining quality benchmarks while managing overall utilization. Underlying these capabilities is access to real-time actionable information to drive timely interventions and coordination activities.
Real-time information through admission, discharge, and transfer (ADT) event notifications for Emergency Department, hospital, or post-acute encounters enable care coordination teams to deploy workflows and resources to more easily and quickly support patients. Knowing when and where patients are receiving care and understanding the clinical context for their care allows providers and care teams to more seamlessly work together to provide the right care at the right time without unnecessary or duplicative interventions. It also allows care teams to identify patients at high risk for complications, including readmissions and can prompt time-sensitive outreach and connection to additional resources.
Having access to real-time information can not only improve patient outcomes and quality but will also help to maximize payment incentives for Direct Contracting participants. Coordinated care consistently leads to shorter lengths of stay, which not only has positive quality implications for patients but also financial benefits for Direct Contracting Entities.
In addition, healthcare organizations can use real-time information to continuously strengthen and refine care network partnerships and collaborations.
To effectively manage Medicare FFS patients within the Direct Contracting Model, participants will need to coordinate with other providers across care settings and deploy timely interventions that support patients’ health and well-being. Real-time information, through ADT data, will provide participants with a new level of clinical intelligence to successfully prioritize and deploy care coordination services and ensure seamless transitions of care for patients while also creating optimal opportunities to achieve shared savings.
About Vanessa Kuhn, Ph.D
Vanessa Kuhn, Ph.D., is the Director of Policy at PatientPing, a care collaboration platform that provides real-time visibility into patient care events across the continuum. PatinetPing works with hospitals, post-acutes, health plans, ACO’s and beyond, the platform connects providers across the nation to improve patient and organizational outcomes.
The COVID-19 virus is ravaging the planet at a scale not seen since the infamous Spanish Flu of the early 1900s, inflicting immense devastation as the U.S. loses more than 200,000 lives and counting. According to CDC statistics, 94% of patient mortalities associated with COVID-19 were simultaneously suffering from preexisting conditions, leaving a mere 6% of victims with COVID-19 as their sole cause of death. However, while immediate prospects for a mass vaccine might not be until 2021, there is some hope among rural hospital health information technology consultants where the pandemic has hit the hardest.
The fact that four in ten U.S. adults have two or more chronic conditions indicates that our most vulnerable members of the population are also the ones at the greatest risk of succumbing to the pandemic. From consultants laboring alongside healthcare administrators and providers, all must pay close attention to patients harboring 1 of 13 chronic conditions believed to play major roles in COVID-19 mortality, particularly chronic kidney disease, hypertension, diabetes, and COPD.
Vulnerable rural populations must be supervised due to their unique challenges. The CDC indicates 80% of older adults in remote regions have at least one chronic disease with 77% having at least two chronic diseases, significantly increasing COVID-19 mortality rates compared to their urban counterparts.
Health behaviors also play a role in rural patients who have decreased access to healthy food and physical activity while simultaneously suffering high incidences of smoking. These lifestyle choices compound with one another, leading to increased obesity, hypertension, and many other chronic illnesses. Overall, rural patients that fall ill to COVID-19 are more likely to suffer worsened prognosis compared to urban hubs, a problem only bolstered by their inability to properly access healthcare.
Virus Helping Push New Technologies
COVID-19 has shown the cracks in the U.S. healthcare technology system that must be addressed for the future. As the pandemic unfolds, it’s worth noting that not all lasting effects will be negative. Just as the adoption of the Affordable Care Act a decade ago spurred healthcare organizations to digitize their records, the COVID-19 pandemic is accelerating overdue technological shifts crucial to providing better care.
Perhaps the most prominent change has been the widespread adoption of telehealth services and technologies that connect patients with both urgent and preventive care without their having to leave home. Perhaps the most prominent change has been the widespread adoption of telehealth services and technologies that use video to connect patients with both urgent and preventive care without their having to leave home.
Even if COVID-19 were to fade away on its own, the next pandemic may not. Furthermore, seasonal influenza serves as a reminder that healthcare is not a skirmish, but a prolonged war against disease. Rather than doom future generations to suffer the same plight our generation has with the pandemic, now is the time to develop innovative IT strategies that focus on protecting our most vulnerable citizens by leveraging existing healthcare initiatives to focus on proactive responses instead of reactive responses.
On the Right Road
While some of the most vulnerable people are the elderly, rural residents, and the poor, the good news for them is that CMS has long advocated the use of preventive care initiatives such as Chronic Care Management (CCM) and Remote Physiologic Monitoring (RPM) to track these geriatric patients. To encourage innovation in this sector, CMS preventive care initiatives provide generous financial incentives to healthcare providers willing to shift from conventional reactive care strategies to a more proactive approach focused on prevention and protection. This should attract rural hospital CEOs who have been struggling even more than usual because of the virus.
These factors led to the creation of numerous patient CCM programs, allowing healthcare executives and providers to remotely track the health status of geriatric patients suffering from numerous chronic conditions. The tracking is at a rate and scope unseen previously through the use of electronic media. Interestingly enough, the patients already being monitored by CCM programs overlap heavily with populations susceptible to COVID-19. To adapt existing infrastructure for the COVID-19 pandemic is a relatively simple task for hospital CIOs.
As noted earlier, one growing CCM program that could be retrofitted to deal with the COVID-19 pandemic are the use of telehealth services in rural locations. Prior to the pandemic, telehealth services were one of the many strategies advocated by the CDC to address the overtaxed healthcare systems found in rural locations.
Better Access, Funding and User Experience for Telehealth
Today, telehealth is about creating digital touchpoints when no other contact is possible or safe. It offers the potential to expand care to people in remote areas who might have limited or nonexistent access, and it could let other health workers handle patient screening and post-care follow-up when a local facility is overwhelmed. As a study published last year in The American Journal of Emergency Medicineaffirms, virtual care can cut the cost of healthcare delivery and relieve strain on busy clinicians.
Telehealth has also gotten a boost from the $2 trillion CARES Act stimulus fund, which provides $130 billion to healthcare organizations fighting the pandemic. The effort also makes it easier for providers to bill for remote services.
The reason for the CDC and hospital administrators’ interest in telehealth was that telehealth meetings could outright remove the need for patients to travel and allow healthcare providers to monitor patients at a fraction of the time. By simply coupling existing telehealth services with CMS preventive care initiatives focused on COVID-19, rural healthcare providers could detect early warning signs of COVID-19.
Integration Key to Preemptive Detection
This integration at a faster and far greater scale could mean much greater preemptive virus detection through routine telehealth meetings. The effect of telehealth would be twofold on hospitals serving rural and urban health communities. It could slow the spread of COVID-19 to a crawl due to decreased patient travel and improved patient prognosis through early and intensive treatment for vulnerable populations with two or more chronic health conditions.
This integrated combination would shift standard reactive care to patient infections to a new monitoring methodology that proactively seeks out infected patients and rapidly administers treatment to those most at risk of mortality. This new combination of preventive care and telehealth services would not only improve patient and community health but would relieve the financial burden incurred from the pandemic due to the existing CMS initiatives subsidizing such undertakings.
In conclusion, preventative care targeting patients with pre-conditions in rural locations are severely lacking in the context of the COVID-19 pandemic. By leveraging CMS preventive care initiatives along with telehealth services, healthcare providers can achieve the following core objectives.
First, there are financial incentives with preventive care services that will relieve the burden on healthcare systems. Second, COVID-19 vulnerable populations will receive the attention and focus from healthcare providers that they deserve to slow the spread through the use of early detection systems and alerts to their primary health provider. Third, by combining with telehealth service, healthcare providers can efficiently and effectively reach out to rural populations that were once inaccessible to standard healthcare practices.
The COVID-19 pandemic has forever changed patient expectations for healthcare delivery, including offered services and health office operations. Although health systems have remained dynamic in adopting telehealth capabilities, their long-term capital, like real estate and supply chain management (SCM) protocols, have not adapted to match these expectations. Health systems must be aware of current trends in both areas to inform their future decisions.
Divesting in healthcare real estate is also key to reducing unnecessary costs to a health system, especially if optimal use of these spaces is already lacking. The overwhelming costs of ownership and management lock money away in underutilized and obsolete real estate spaces. Divesting provides more capital liquidity, and frees capital to go towards investment in telehealth, diagnostic technology, and emerging specialties, assets that go towards increasing patient and workforce engagement and satisfaction. In addition, eliminating unused real estate assets allows freedom from liabilities and human capital investments, like facility maintenance and upkeep, not to mention the increased frequency of deep cleaning necessary in the post-COVID-19 bi-lateral operations era.
Further, years of mergers and acquisitions in the healthcare industry have left many health systems with the unwanted result of increases in real estate assets. This has led to increased consolidation of these assets, a trend that has been exacerbated by the pandemic pressure on health system funds. Future consolidation and reevaluation of assets should be informed by trends in patient expectations as well as trends in the market.
Here are five emerging trends driving the future of healthcare real estate and assets. Each encourages divestment out of health system real estate ventures or restructuring of existing spaces in order to better cater to forever changed patient expectations.
1. Rise of Telehealth
According to the Department of Health & Human Services, telehealth use is up around 50% in primary care settings since the beginning of the public health emergency and is projected to remain high in the time following. Most recently, in-person visits have increased and as a result, telehealth visits have declined due to the state’s reopening, and thereby some critics posit that this trend may not continue. However, that could not be further from the truth.
Moving forward, despite health system fear regarding long-term reimbursement may be lacking from federal, state, and commercial health plan payers for virtual care delivery, leveraging telehealth to augment traditional healthcare delivery will become a necessity because consumers will demand it and physicians in some studies have shown satisfaction with their video visit platforms. This will no doubt have an impact on office layout and services.
2. Convenience of Outpatient Services
Motivated in part by telehealth utilization, patients seek convenience and accessibility in their healthcare now more than ever. Health system expansion may therefore mean satellite offices in high traffic areas to cater to the patient’s need for accessibility, marking a movement away from the traditional, centralized hospital campuses.
3. Value-Based Care Transitions
As legislation and CMS regulation moves more towards a value-based care system, trends show a natural move towards lower-cost facilities that provide preventive care. These could also contribute to continued trends to more off-campus real estate and planning for alternative care delivery options, for example, mobile vans reaching more vulnerable, at-risk populations for care such as life-saving vaccinations.
4. Pandemic Precautions
Bilateral operations are likely to be maintained for some time even after more normal operations return, and healthcare real estate, especially with consolidation, will need to accommodate this precaution, and others like it in all locations.
New diagnostic and testing tools are constantly being released, forcing health systems to reevaluate their current assets and make room for new ones which contributes to wasted space. Furthermore, remote monitoring apps will continue to proliferate in the market and become more affordable and accessible to consumers while advancing interoperability standards and federal information blocking requirements will allow information to flow more freely.
Strategies to Optimize Healthcare Real Estate & Strategy
In order to unlock money trapped in assets, health systems should look to make their assets work better in response to current trends and patient expectations. To accommodate patient demands and changes to health industry regulation and reimbursement, it makes sense to ensure efficient use of all facilities and optimize real estate and assets using the following strategies:
– Divest underutilized assets of any kind: Begin with real estate and move smaller to reduce unneeded capital investment.
– Remove or reduce administrative spaces: Transition non-clinical workforces to partial or complete work from home status, including finance, legal, marketing, revenue cycle, and other back-office functions. Shared space or “hotel” workspaces are popular.
– Reconfigure medical office or temporary care buildings: As these are often empty several days a week, they must be consolidated.
– Get out of expensive leases for care that can be given remotely or in lower-cost options or by strategic partners: Take full advantage of telehealth capabilities and eliminate offices that have become obsolete.
– Integrate telehealth into real estate only where it makes sense: Telehealth is more applicable to some services and care modalities than others. Offices should reconfigure to meet these novel needs where necessary, even if it means forgoing leases for the near term.
– Assess other expensive assets: Appraise assets like storage and diagnostic tools. Those not supportive of the new post-COVID-19 care model or prioritized service lines and are otherwise not producing revenues should be sold or outsourced to strategic partners.
– Diversify with off-campus offices: Provide convenient access to outpatient care and new outpatient procedures by investing in outpatient medical offices in high foot traffic locations.
– Create space for services in high demand: Services like preventive care and behavioral health should be given physical or virtual space in the system to cater to patient needs.
About Moha Desai
Moha Desai is a Principal of Healthcare Strategy and Transformation where she focuses on driving forward strategic, planning, financial, revenue cycle, operational improvement, and patient engagement healthcare projects for providers, federal government health agencies, and various firms requiring growth, business development, and project implementation and management. She has previously served in leadership roles at Partners HealthCare, Deloitte Consulting, Bearing Point, etc. Moha received her B.A. in Economics and her M.B.A. at Yale University.
While there are encouraging signs of reimbursement falling in step with the move towards a more value-based healthcare system, what is needed now to further encourage healthcare innovators is to properly rationalize approval processes imposed by the FDA and CMS.
After Nebraskans cast their vote for Medicaid expansion in 2018, the state is finally expanding coverage to more residents. As part of the state’s rollout, it split its expanded Medicaid plans into two tiers, with work and other requirements to access dental and vision coverage.
As home health and home care operators move toward the ninth month of the COVID-19 pandemic, it’s important to take stock of what has been accomplished from a policy perspective. Many of 2020’s regulatory changes will be fleeting, but others will shape the future of post-acute care for years to come.
That was the message delivered Monday by National Association for Home Care & Hospice (NAHC) President William A. Dombi during the nonprofit advocacy organization’s annual conference. In addition to providing a regulatory recap, Dombi hinted at new Medicare benefits on the horizon and explained how the value of home-based care is at an all-time high.
“There has been an increased awareness of the breadth and depth of care at home, and this will have a long-standing impact on policy and politics as well,” he said. “There has been an absolute, exponential increase in respect for what you do in the home care setting. We took the stresses of the pandemic head-on and proved that care in the home is not only essential but [the best option].”
During Monday’s Washington update, Dombi revealed that 67% of in-home care providers are serving COVID-19-positive patients.
To support them in delivering that care, providers have been able to lean on a variety of lifelines, including funds from the CARES Act Provider Relief Fund and the Paycheck Protection Program (PPP). Providers have also received essential-worker classification and greater telehealth flexibilities.
Additionally, the U.S. Centers for Medicare & Medicaid Services (CMS) has recognized that virtually the entire Medicare population meets homebound status requirements.
“When you’re Medicare eligible, over the age of 65 or on disability, and you need health care services, you have a compromised condition to put you at even greater risk of fatality,” Dombi said. “CMS agreed with our position on this and issued interpretive guidance indicating that individuals who need to leave the home for services, it is medically contraindicated, thereby meeting the homebound standard.”
During the public health emergency, CMS also paused claims audits and the Review Choice Demonstration (RCD), a regulatory initiative designed to reduce improper billing in home health care. That has since been restarted, with temporary administrative flexibilities.
COVID-19 testing, non-physician certification
At the end of September, the U.S. Department of Health & Human Services (HHS) announced that home health and hospice agencies would receive 10 million rapid COVID-19 tests from a federal inventory of about 150 million. Dombi likewise touted that as a win.
In the first week of distribution alone, he noted, about 160,000 tests were distributed to home health and hospice agencies.
“The fact that HHS recognized that home care was an essential part of health care services and made us part of that allocation in itself is a notable success,” Dombi said. “Just being recognized, not being considered some stepchild in health care.”
Among the other topics he touched on during his Washington update, NAHC’s president highlighted excitement around non-physician certification, something the home health industry had been working toward for years.
Senator Susan Collins (R-Maine) first introduced legislation that pushed for this change in 2007.
“We found ourselves in the middle of discussions, negotiations and advocacy with the CARES Act, and Senator Collins said, ‘I think this is our chance to get it done.’ [She] was able to convince the Senate that now is the time to allow non-physician practitioners to have equal status with physicians, to the extent that the state law allows it within the Medicare home health benefit,” Dombi said.
New Medicare benefits
Despite making major inroads across various fronts, there are still a number of measures that need to be taken.
For one, providers are still on the lookout for the next coronavirus-related stimulus package, which was originally expected before the July 4th Congressional recess, then again before the August recess.
“This is a back and forth that’s happening between the House and the Senate, between Republicans and Democrats,” Dombi said. “We’re still looking to see if we can have something before they go on recess in October, but we’re planning also for a lame-duck session on it.”
As far as what providers hoped to see in the next package, the list includes continued funding for the Provider Relief Fund, plus expanded funding for Medicaid home- and community-based services. The list also includes premium pay for front-line workers and litigation immunity.
Another area of focus for NAHC is palliative care. The organization is moving to get revisions in the Medicare coverage manual under home health care to fully recognize palliative care as one of the services provided as part of the existing benefit.
“We don’t think we need Congressional action to get there,” Dombi said. “Some of you — maybe many of you — are already doing things that would qualify as skilled palliative care under the benefit and getting Medicare to pay for it.”
Home health providers can also expect to see the 2021 payment rule finalized before the end of October or during the first few days of November. NAHC is calling on CMS to roll back the 4.36% behavioral adjustment in the Patient Driven Groupings Model (PDGM) ahead of the announcement of the final rule.
“It’s not just because we are in this unprecedented year of COVID-19,” Dombi said. “CMS projected a decrease in [Low Utilization Payment Adjustments], as they thought home health agencies would try to maximize 30-day episodic reimbursement. We have seen just the opposite of that, partially influenced, of course, by COVID-19.”
Additionally, NAHC is pushing for the creation of a new benefit that will allow for a skilled nursing facility (SNF) level of care at home.
“We have designed a [SNF-at-home] benefit to give individuals on the Medicare program the option of going home with expanded services,” Dombi said. “We think the design will work to be a win for the Medicare program as well. It’s been proven that you can provide less costly and high-quality care at home.”
Medicare doesn’t currently cover drugs approved under emergency use designations. But CMS Administrator Seema Verma said the agency was coming up with a plan to make sure Medicare beneficiaries were covered once a coronavirus vaccine is developed.
The Center for Medicare & Medicaid Innovation (CMMI) is in need of a “course correction,” top U.S. health care officials believe.
And part of that may include a national expansion of the Home Health Value-Based Purchasing Model.
Created under the Affordable Care Act, CMMI — also known as the CMS Innovation Center — supports the development and testing of innovative health care payment models. Since its formation, CMMI has developed at least 54 payment models, including the Home Health Value-Based Purchasing Model.
As U.S. health care costs continue to rise, CMMI’s work has grown increasingly important, especially around value-based care, according to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma. National health care spending is expected to grow at an average annual rate of 5.4% from 2019 to 2028, outpacing the gross domestic product’s average annual growth rate of 4.3%.
But of those 54 payment models, only a handful appear to be working.
In fact, just five have shown statistically significant savings.
“In 2019 alone, over 450,000 providers participated [in those models], serving over 26 million patients,” Verma noted. “But more recently, the evaluation data for the early models have been completed. And unfortunately, the results are deeply concerning.”
Verma addressed CMMI’s progress and the future of value-based care on Tuesday during a virtual event hosted by CMS’s Health Care Payment Learning & Action Network (LAN). Verma was joined by Brad Smith, who co-founded and served as CEO of home-based palliative care provider Aspire Health before being named CMMI’s director in January.
“The Center stands in need of a course correction in model design and portfolio selection, if value-based care is to advance,” Verma said.
Providers ‘must have skin in the game’
Shifting the U.S. health care system toward value-based care is one of CMS’s many priorities, Verma remarked during the virtual event. In addition to payment, value-based care also means providing pricing transparency, strengthening interoperability and minimizing paperwork burden for providers.
When it comes to establishing more successful value-based payment models, CMMI needs to prioritize two pillars, Verma said.
First, it must step back from voluntary models “designed with an abundance of financial carrots to attract participation.”
“Models must incorporate design elements that require participants to have skin in the game,” Verma said. “Models where providers have downside risks have actually performed better.”
Secondly, CMMI needs to do a better job of developing effective, meaningful benchmarks to measure the success of value-based payment models.
Smith echoed that idea, pointing out that CMS and CMMI have been too generous or lenient in judging how new payment mechanisms are performing.
“CMMI has learned a tremendous amount over the past 10 years about value-based care arrangements, and we are grateful for the tremendous participation we have had to date in our models,” Smith said at the LAN event. “As we move into the next phase of the Innovation Center, we believe we must push even harder to move more providers into value-based care payment arrangements.”
Expanding the Value-Based Purchasing Model
While most of Tuesday’s remarks took a hard look at what CMMI has accomplished thus far, both Verma and Smith did point out several positives.
Smith, for instance, called out the Home Health Value-Based Purchasing Model as one of the Innovation Center’s most successful efforts.
Implemented in 2016, the Value-Based Purchasing Model was designed to pay home health providers in nine states based on outcomes and the value of services delivered. This year was the sixth year of CMMI testing out the model, exposing home health providers to 6% upside or downside risk based on their performance.
Home health providers in participating states have mostly supported the value-base model, with many calling for a national expansion beyond the current states of Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee and Washington.
CMMI hasn’t hinted it has any plans to do so — until now.
“As we look at our portfolio, we have other models that we believe may be able to expand in the coming years,” Smith said. “For example, our Home Health Value-Based Purchasing Model has shown significant cost savings and improvement on key quality metrics. It’s one of the examples of the models that we’re looking at to think about if we could expand it nationally in the next year or so.”
Besides the Value-Based Purchasing Model, Verma and Smith likewise pointed to the relatively new Primary Cares Initiative and the related direct-contracting model as impactful value-based care efforts.
“Last year, we announced the CMS Primary Cares Initiative, featuring the direct contracting model, which has the potential to drive quality and value across the entire system in a way that we’ve never seen before,” Verma said. “Going forward, we believe direct contracting can take an exciting new step with a geographic option, in which a set of entities would take on full risk for all eligible Medicare beneficiaries in a certain region.”
Healthcare providers won’t have to start paying back Medicare advance loans until a year after they were issued. Under the original timeline, hospitals were supposed to start paying back the loans in August.
Now that the dust has settled on the Patient-Driven Groupings Model (PDGM), some have returned their attention toward the idea of another major reimbursement overhaul: a unified post-acute payment system.
There had been mounting momentum behind a unified payment model for post-acute care providers headed into 2020. The ongoing COVID-19 emergency has derailed a lot of that momentum, but conversations are starting to pick up again.
Generally, the post-acute care landscape includes skilled nursing facilities (SNFs), in-patient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs) and, of course, home health providers.
Currently, these providers operate under setting-specific Medicare reimbursement mechanisms, such as PDGM in the home health care and the Patient-Driven Payment Model (PDPM) in the SNF space. A unified model would eliminate this separation, creating one payment system for all post-acute providers.
It’s an idea that was originally born out of the IMPACT Act, which was passed in 2014.
“The idea was to flatten payment across the four post-acute care settings,” David Grabowski, a health care policy professor at Harvard Medical School, told Home Health Care News. “Rather than paying different payment rates for four different sets of services, it was an idea that the Medicare program could level the playing field and pay a common rate for patients who might be discharged to any of those four settings.”
A key benefit of having one post-acute reimbursement system would be having payment tied to a patient’s condition rather than setting, according to Grabowski.
“Currently, we have these distortions where we have individuals that probably could be cared for in lower-intensity settings, [but they’re] unfortunately being discharged to institutional settings or going to an LTCH when they could be at a SNF, or getting discharged to a SNF when they could be at a home health agency,” he said.
As envisioned by the IMPACT Act, there is also a greater emphasis on outcomes as a driver of reimbursement under a unified post-acute payment system, Lisa Grabert, a research professor at Marquette and Georgetown universities, told HHCN.
“It required that all of the data that’s reported to CMS across the four different settings be done in a consistent manner,” Grabert said. “You could potentially make comparisons across the settings.”
Making sense of an ‘anomaly of a year’
Despite perceived benefits, there are a number of potential difficulties in creating a unified post-acute payment model.
“Unifying payment also means unifying regulation,” Grabowski said. “It also means unifying quality measurement across the four settings, and it’s not clear to me that some of the rules that we’ve had in place work very well.”
For example, in the SNF world, the three-day rule requires an individual to have been admitted to the hospital on an in-patient basis no fewer than three consecutive days in order to qualify for fee-for-service reimbursement in a SNF.
Grabowski questioned how a rule such as this one would persist under a new model, especially in relation to home health care, where a number of individuals are receiving services without prior hospitalization. He pointed out that exceptions will have to be made in order to proceed.
There is also the COVID-19 emergency to consider.
In some ways, the public health emergency shifts post-acute care toward a universal payment model, according to Grabowski and Grabert. In other ways, it pushes the segment further away from it.
It’s important to remember that 2020 is an anomaly of a year in terms of the services that the Medicare program has delivered in the four settings of post-acute care. It would be difficult to use information gleaned from this year as the baseline to form the new model, according to Grabert.
Additionally, the comprehensive payment reforms in both the home health and SNF settings may further contribute to these difficulties.
“Those two factors coupled on top of each other mean that it’s really difficult to figure out what were new changes and phenomenons of the new payment system, versus just changes and phenomena associated with the pandemic,” Grabert said. “Those two stacked on top of each other may mean that it will be several years before CMS can figure out if they have accurate enough data to move to that unified payment system.”
Support for a unified model
On the other hand, the spotlight that has been placed on nursing homes throughout the public health emergency may play a role in pushing a unified post-acute payment model.
At the beginning of the month, the Medicare Payment Advisory Commission (MedPAC) had its first meeting of the year and released new data that revealed 80% of COVID-19 deaths are in the Medicare population, and over 40% of deaths are among residents of nursing homes and assisted living facilities.
Many policymakers, in addition to the media, have zeroed in the nursing home space because of this. The public perception of the nursing home industry, as a result of the public health emergency, may be strong enough to give CMS the political cover it needs to use its unified payment authority to implement a big policy change for nursing homes without any legislative barriers, according to Grabert.
“Given that skilled nursing facilities make up nearly half of the overall annual spend in the Medicare post-acute baseline, policymakers may be tempted to take advantage of the unified [post-acute care] model as a policy tool to address SNF, and possibly broader, reform,” she said. “Though actually implementing unified payment may need additional Congressional action, the mechanics to actually develop payment reform and release a detailed plan need no further Congressional action — a tremendous amount of authority already exists within the executive branch.”
If the Trump administration is reelected, it’s likely officials will be looking at looming fiscal pressures. The concept of a unified payment system has been on its radar in the past as a cost-savings tool
In February, the Trump administration released its proposed budget for the fiscal year 2021, which projected that a unified post-acute care payment model would save $101.5 billion from 2021 to 2030.
Even if a new administration is elected, this could still remain a factor.
“If the Biden administration comes into power, they may be looking again at this post-acute care space and the idea of unified payments as a [way] to get some savings out of the Medicare program,” Grabert said.
As of now, CMS has only affirmed its intentions of following the Congressional mandate, according to Grabert.
“There’s nothing really significant, I would say, coming out of CMS on this topic, aside from the fact that they take the current Congressional mandate of coming up with this unified prototype seriously, and they plan on issuing a report to Congress on time, as is required under current law of the IMPACT Act,” she said.
Congress has also begun to posture that it would like the agency to do some oversight and report to them on how the implementation has been going and possibly slow things down on the timeline.
“The evidence of that is a recent letter that came out from [Senators Pat Toomey (R-Pa.) and Michael Bennet (D-Colo.)] to CMS on the IMPACT Act timeline,” Grabert said. “There’s this Senate letter requesting some oversight of how CMS has implemented the underlying law, and certainly suggest that a delay should be considered at this time due to the pandemic and comprehensive home health and SNF payment reform.”
– Humana Inc. and Fresenius Medical Care North America
(FMCNA) today announced an agreement to broaden their collaboration toward
improving the health of eligible Humana Medicare Advantage members
agreement between Humana and Fresenius Medical Care North America goes into
effect Jan. 1, 2021.
Humana Inc. and leading renal care company Fresenius Medical Care North America (FMCNA) announced an agreement to broaden their collaboration toward improving the health of eligible Humana Medicare Advantage and commercial members with chronic kidney disease (CKD) and end-stage renal disease (ESRD) through more coordinated, holistic care.
The expanded partnership is in keeping with the goals
outlined in the 21st Century Cures Act, which enables people with ESRD to
enroll in Medicare Advantage Plans, and with federal initiatives that call for earlier diagnosis and
treatment of kidney disease; a reduction in the number of Americans developing
ESRD; and support for patient treatment options such as home dialysis or kidney
transplant as applicable.
The agreement between
Humana and Fresenius Medical Care North America goes into effect Jan. 1, 2021,
and encompasses the following:
Expanded Availability of Care Coordination Services:
FMCNA currently provides specialized care coordination services for Humana
members with CKD in three states: Iowa, Kentucky, and North Carolina. The
agreement expands the availability of these services to eligible Humana members
in an additional 39 states, with the goals of improving quality of life and
health outcomes, increasing access to care and minimizing care gaps, slowing
disease progression and lowering hospitalization rates, and reducing the cost
FMCNA’s care coordination services include early detection of CKD to slow
disease progression; medication reviews and regimen adherence guidance;
behavioral health screenings; nutritional counseling; strategies for managing
multiple comorbidities; education about – and support for – home dialysis
treatment when applicable and beneficial to the patient; transplant education;
and palliative care.
FMCNA partners with InterWell Health, a physician-led population health
management company working to improve clinical outcomes and lower medical costs
through its network of over 1,100 nephrologists across the country.
Transitional Care Units: These units are
designed to help people recently diagnosed with kidney failure learn about
treatment options available to them – including transplant and home dialysis –
and be more empowered in managing their own care. Transitional Care Units may be either a space within a
dialysis center or a standalone facility, offering comprehensive, hands-on
education from dedicated staff that is individualized for each patient. This
includes the importance of renal nutrition, medication adherence, and vascular
access care; assisting patients transitioning between modalities (e.g., from
in-center dialysis to home dialysis); and supporting individuals returning to
dialysis from transplant. The agreement is intended to locate Transitional Care
Units in select areas where Humana has significant Medicare Advantage
Value-Based Agreement: The expanded
collaboration also improves upon the parties’ existing clinic network contract,
which provides eligible Humana Medicare Advantage and commercial members with
ESRD access to dialysis at more than 2,600 centers of Fresenius Kidney Care, the dialysis services division of
Fresenius Medical Care North America. By implementing a value-based payment
model for in-center and home dialysis services and at Transitional Care Units,
as well as for CKD care coordination services, compensation will be based on
meeting agreed-upon quality improvement and patient outcome goals, and reducing
overall costs to the system.
Individuals with CKD have kidneys that do not filter blood
properly, which causes waste and fluid levels that can be dangerously high. CKD
and ESRD affect a wide spectrum of the population but the degree of impact is
not uniform. For example, kidney failure rates among Black Americans are about
three times that of white Americans. In total, approximately 15% of American
adults, or about 37 million people, have CKD, but many are unaware of their
condition. CKD management is complex, and failure to appropriately manage the
condition may cause considerable symptoms and worsening health outcomes,
This agreement represents an evolution of our work with
Humana and leverages our over 10 years of industry leadership in value-based
care,” said Bill Valle, Fresenius Medical Care North America’s Chief Executive
Officer. “Our scale, integrated nephrology network, and standardized clinical
interventions and protocols uniquely position us to predictably and
consistently improve health outcomes and reduce overall costs. We welcome this
opportunity to offer more coordinated, holistic care to Humana’s members, with
a keen focus on education, comorbidity management, early detection, and
treatment options, including home dialysis. This approach also helps eliminate
barriers to keep renal disease treatment uninterrupted for at-risk
– Innovaccer unveils new risk adjustment solution to help providers better segment their population to refine the risk scoring process and improve coding accuracy and efficiency, thereby improving performance on risk-based contracts.
– The solution utilizes Artificial Intelligence (AI) and
Natural Language Processing (NLP) to make risk predictions.
Innovaccer, Inc., a
technology company, has launched its Risk Adjustment
Solution. Leveraging Innovaccer’s industry-leading, FHIR-enabled Data
Activation Platform, providers can better segment their population to refine
the risk scoring process and improve coding accuracy and efficiency, thereby
improving performance on risk-based contracts. The solution utilizes Artificial Intelligence
(AI) and Natural Language Processing (NLP) to make risk predictions. By
improving care management workflows, Innovaccer works to help all members of
the health team care as one.
Addressing End-to-End Risk Adjustment
Innovaccer’s solution is designed to address end-to-end risk
adjustment needs by allowing providers to use actionable insights on dropped
codes and suspected codes across various risk models. The solution works with
the Centers of Medicare & Medicaid hierarchical condition categories
(CMS-HCC), Department of Health and Human Services hierarchical condition
categories (HHS-HCC), and the Chronic Illness and Disability Payment System
(CDPS), helping providers improve coding accuracy.
Segment Patient Population Based on Risk Scores
Providers can identify codes that can be integrated into the EHR using simple
steps through advanced risk adjustment analytics. Innovaccer’s platform can
also segment the patient population based on risk scores available through
historical data and provide dashboards to identify details related to Risk
Adjustment Factor (RAF) and risk capture trends. Providing curated insights to
risk coders prevents them from having to switch between multiple screens,
reducing the time spent on coding processes.
“Innovaccer’s Risk Adjustment Solution caters to all risk management needs through one seamless platform. It is AI and NLP ready, and by leveraging the platform’s smarter workflows and actionable insights, providers can decrease time spent on risk-related coding by up to 40%. The solution helps providers to refine the risk scoring process and improve coding accuracy and efficiency for improved performance on risk-based contracts,” says Abhinav Shashank, CEO at Innovaccer.
Since COVID-19 emerged as a major health threat, virtual care has taken off. As many as 46% of patients reported in late April that they had used telehealth to replace a canceled healthcare visit in 2020, while 48% of physicians said they had started using telehealth to treat patients.
While a shift in care models was necessary to address business continuity amid the pandemic, these trends also represent positive movements as a growing body of evidence supports the real-life benefits of telehealth. Remote models of care are connected to safe and effective consultations across many use cases, low exposure to viruses, and much-needed access to care.
Yet the fact that physician adoption isn’t higher suggests two things:
1) Physicians may be taking a ‘wait and see’ approach in the hopes that patients will want to return to in-person care as economies reopen; or
2) Some physicians haven’t yet figured out their long-term telehealth strategy. In truth, many providers are treating telehealth as a “stop-gap” — or temporary — solution until life returns to normal.
But given the increasingly positive data around telehealth as a safe alternative to in-person care, as well as its track record in successfully treating patients, it’s time for providers to reframe their thinking. In the future, practices will need a healthcare strategy that balances virtual with in-person care.
As recently as ten years ago, telehealth reimbursement was largely limited to patients in rural areas, as payers didn’t yet see the value of compensating doctors for virtual encounters.
Today, most payers and providers recognize the value of telehealth on some level amid rising demand for services and severe professional shortages. In particular, remote care models have proven their worth during the pandemic as an effective means of preventing the spread of disease. Greater acceptance of telehealth is further demonstrated by the recent decision to relax HIPAA requirements by HHS’ Office of Civil Rights (OCR), allowing more providers and patients to virtually connect through FaceTime, Zoom, or other two-way communications systems during the current pandemic.
This is an important first step, although many providers remain resistant to change for a variety of valid reasons. Some of these include discomfort with remote care models, reimbursement concerns, and the cost of deploying telehealth.
Performing medicine in a way that doesn’t align with one’s training feels unnatural, and some providers have said that virtual encounters feel less personal. The fact is that most clinicians weren’t trained to diagnose patients remotely or engage over a screen and are simply hesitant to embrace this approach to care.
Also, providers may have trepidation about not getting paid. While CMS and private payers have expanded coverage, multiple healthcare providers have reported that bills are being delayed or only partially paid by health plans.
With limited insight into the potential return on that investment, concerns over the cost of implementing telehealth are also reasonable. A physician who is consulting with patients remotely through FaceTime, for example, might wonder if the investment in a more secure, robust telehealth platform will make sense in 12 months, should a COVID-19 vaccine materialize.
Yet by not adopting a more permanent telehealth solution, providers may be hurting themselves down the road. Patients increasingly believe virtual care is highly effective, and some even prefer it. According to a SYKES consumer survey administered in March, 60% of 1,441 respondents said the COVID pandemic has increased their willingness to try telehealth.
Also, while HHS has relaxed HIPAA enforcement at the moment, there’s no indication this will continue. Healthcare organizations will need to ensure that the platform or program they’re using is designed to keep protected health information (PHI) safe.
Investing in the Future
Given the upward trajectory of telehealth, it benefits providers to thoughtfully invest in the right strategies and solutions now to extract the greatest value and return on investment down the road. Here are four steps to take, when shifting to a long-term telehealth strategy:
– Identify needs. Many primary-care practices may have seen a bump in interest in telehealth due to COVID-19, while specialty practices may see increases stay steady, even when fears of the coronavirus fade. When planning long-term, put patient needs first: In what ways can telehealth improve care delivery, going forward? Look at data, such as virtual-visit utilization patterns, to see where there are opportunities to grow telemedicine (e.g., expanding chronic care management) based on needs.
– Consider workflows. The ideal telehealth program doesn’t interrupt clinical workflows – it enhances them. If you’re using a ‘stop-gap’ video conferencing solution to provide telemedicine, is it easy to integrate practice notes with your EHR? Or, do you have to take extra steps to document patient encounters for clinical and billing departments?
–Seek supportive partners. You can use any number of technology platforms to conduct telemedicine encounters, but not all platforms are created equal. When looking at implementing a telehealth platform, consider not only ease of use, and interoperability, but also what a particular vendor is offering: How well the telehealth platform in question can accommodate the needs of a particular specialty? What are existing clients are saying about things like training, vendor support, and the patient experience?
– Proactively engage. Your patients have most likely heard of telehealth, but they may not realize that telehealth is multifaceted and can be used to diagnose conditions such as skin disorders or allergies and can be just as effective as in-person visits. Educating patients about telehealth’s benefits, and making it easy for them to try telehealth, is essential to success.
Expanding telehealth’s role in the medical practice benefits everyone, from physicians to patients to payers. Moving past the “stop-gap” mentality now will reap greater benefits in the future, regardless of whether we’re in the midst of a pandemic, or simply trying to provide excellent care on a day-to-day basis.
About Roland Therriault
is the President and Executive Vice President of Sales at InSync Healthcare Solutions, a provider
of integrated EHR and practice management software, revenue cycle management
services and medical transcription to thousands of healthcare professionals
throughout the United States. Roland Therriault manages all operations of the
company, driving its go-to-market strategy and overseeing all sales activities.
His experience in healthcare and technology includes more than 20 years of
direct and channel sales, strategic planning and business development. Prior to
joining InSync, Roland served as Vice President of Sales for MD On-Line, a
provider of acute and ambulatory clinical and practice management solutions.
In passing a bipartisan funding bill last week to avoid a possible government shutdown, the U.S. Senate officially restructured and relaxed repayment terms for the Medicare loans taken out by home health providers in spring.
President Donald Trump signed the funding bill into law on Wednesday, just two days before being flown to Walter Reed Hospital due to COVID-19-related health concerns.
The continuing resolution funds the government through Dec. 11. As it pertains to Medicare loans, it creates new deadlines for home health providers, skilled nursing facilities (SNFs) and others to repay any advance and accelerated payments received in 2020.
Overseen by the U.S. Centers for Medicare & Medicaid Services (CMS), advance and accelerated payments are meant to keep Medicare-reimbursed health care organizations afloat during turbulent times. Since the start of the COVID-19 emergency, CMS has disbursed more than $100 billion in such loans.
“Medicare accelerated and advanced payments have been a lifeline to many hospitals and health systems in the fight against this historic pandemic, allowing them to continue to deliver the care that their patients and communities depend on,” American Hospital Association President and CEO Rick Pollack said in a statement.
Under normal conditions, Medicare providers were supposed to begin paying back their loans on Aug. 1 — or risk CMS withholding reimbursement for any unpaid debts. August came and went, however, without CMS garnishing any payments.
The recently finalized funding bill now gives hospitals one year before Medicare can claim their payments to repay the loans. Other Medicare providers will have up to 210 days.
Providers will have 29 months since their first payment to fully repay the loan; they previously only had one year under the original deadline. Additionally, the measure lowers the interest rate on outstanding payments from 10.25% to 4% .
Industry advocates and trade associations have tried to get accelerated payments forgiven entirely, but that was never really an option, Waltz previously noted.
“Medicare can’t just access more money or do whatever Congress does to pay for the federal debt,” she said. “It’s very specific to the trust funds, so the idea of a forgiveness wasn’t realistic.”
Twenty years ago, technology consultants started advising CIOs to build less. That’s when the movement towards Commercial Off the Shelf (COTS) began.
Today, there are many shops, especially those in small and medium-sized organizations, with few programmers who build new applications from scratch.
Yes, they have programmers who configure, script, and integrate various applications but very little is built. For the provider community, we have a habit of either sourcing our needs from our Electronic Health Records (EHR) application vendor or buying a “best of breed” application from a niche vendor.
Moving to Software as a Service (SaaS) has even reduced the dread of upgrades. No doubt buying commercial software has enabled all of us to have access to better solutions and in some cases, may have reduced the ongoing run rate. Still, it means technology costs have gone up and a lot of our technology goals have not been achieved.
For example, interoperability remains a point to point problem. ONC and CMS are still pushing to remove barriers to interoperability and have mandated data exchange with penalties.
CIOs are struggling with the realities of constraint budgets where new programs are starving while dollars go to pay maintenance, integration costs associated with prior purchases (e.g. tech debt).
Then, in a year of the normal pull-and-tug between maintaining current and delivering new systems, COVID-19 arrived and our planning fell short. Technology teams were challenged as never before. They suddenly needed to:
– Enable teams to work from home – even teams who have never worked remotely.
– Stand up telehealth solutions in days – not months.
– Find a good external data source with statistics to integrate and then discover a newer, better source days later.
– Provide real-time updates on the availability of hospital rooms to leadership.
– Provide rapidly evolving guidance to patients on admissions changes, new requirements for entrance to facilities reduced access to admitted patients.
– Be a trusted, consistent source of guidance to reduce the spread of the disease.
This was all new, unplanned work. Work that took resources from other budget areas and other teams. Work that didn’t always meet our aim for better patient care or patient experience.
For example, we saw some providers advertising the availability of telehealth services but requiring a patient to call their primary care doctor to schedule instead of requesting an appointment online. Then due to staff shortages, the patient would land in voice mail, further delaying access to care.
Patients needing tests have been told to get an order from their physician. The truth is telehealth isn’t integrated and isn’t part of our daily processes.
The story here is the emergence of an unsung hero you can’t find on the nightly news: our IT Teams. We need to arm this group of heroes with better tools. Tools where delivery of new programs, updates to existing processes and integrating new data from external sources can be done in days, not months.
Did your clients link to external data sources such as John Hopkins? Did they need to enable test sources from new partners? Did they need to build new mobile applications to integrate workstations in parking lots and third-party locations?
New approach – Low-Code
Today’s challenges require a new approach that is “low-code.” Low-code is shorthand for an application development environment that is primarily visual and uses simple declarative statements to create applications. The primary goal of low-code is to accelerate program delivery.
This is surely a goal for every healthcare technology team. As enterprise clients embrace low-code, they can ensure readiness by putting these building blocks in place so clients can realize the promised value:
– Authentication Management through APIs (OAuth)
– Standardized access through APIs
– Management and Monitoring
In preparation for the adoption of a low-code application platform (LCAP), it is essential to assess the adoption of authentication best practices.
The technology landscape now spans on-prem, private cloud, and public cloud solutions requiring a standardized, tokenized approach to authentication. Without this, security processes will inevitably fall short of the CISO’s goals or will require additional manpower to monitor and maintain.
OAuth is the building block
Given the number of vendors, environments, and the velocity of human interactions (non-employee clinicians, temporary resources of all types, patients, etc.), OAuth is the building block for scalable secure authentication. OAuth is a delegated authentication framework that replaces the need to send credentials in program calls (APIs).
It has been required by CMS for the interoperability rule as a foundation for data sharing. If you haven’t, invest in a centralized identity management system and move to use OAuth to authenticate service and access requests. Standardizing authentication is foundational. Do it before selecting a low-code vendor.
LCAP platforms deliver a variety of methods to access data from other applications. Typical integration patterns include files, database calls (ODBC, JDBC, etc.), and scripting.
Now is the time to adopt API-First and design thinking. Stop building point-to-point integrations – the velocity of LCAP will result in a proliferation of connection methods if interfaces are not standardized.
Using APIs – fast delivery
Using APIs will enable faster delivery and better performance. Providing a set of standardized interfaces that meet the needs of consumers (a fundamental goal of API-First) will reduce test time, production breakage, and upgrade complexity. Don’t wait.
Doing APIs right requires a culture shift – slapping an API on an enterprise application is not the goal. Delivering APIs that drive consumption and adoption by citizen developers and go-to-market programs will power user experiences that truly do more with less.
Management and monitoring
Last but not least is the management and monitoring of your new agile applications, especially the application interactions with your core enterprise applications and external integrations. We have all seen it, a new program or upgrade is delivered, and performance slows to a crawl.
Monitoring and metering access (limited access to X number of calls per time period) is essential to proactively prevent coding errors and shield your client from bad actors. Knowing who is accessing what, and how the load varies, is necessary to achieve the goals of delivery velocity and efficient use of resources.
API Management vendor leaders include policy engines, management, and embedded analytics in their gateways to protect and scale service integrations.
Better, faster, cheaper is our mantra (once again, some of us mutter under our breaths). Adopting low-code will accelerate delivery and help us meet the demands of the new normal.
LCAP demands standardized authentication, application program interfaces (APIs), and secure, monitoring gateways to accelerate adoption while protecting and securing enterprise resources.
About Ruby Raley
Ruby Raley is VP of Healthcare and Life Sciences at Axway. Axway empowers customers to compete and thrive in dynamic marketplaces using hybrid integration solutions to better connect their people, systems, businesses, and digital ecosystems. More than 11,000 organizations in 100 countries rely on Axway to solve their data integration challenges.
In August, the Partnership for Quality Home Healthcare (PQHH) unveiled a first-of-its kind, comprehensive analysis of the Patient-Driven Groupings Model (PDGM).
Among its findings, the analysis — conducted by health economics and policy consulting firm Dobson DaVanzo & Associates — highlighted how government spending on home health care is 21.6% lower than what the U.S. Centers for Medicare & Medicaid Services (CMS) projected going into 2020. The cause of that discrepancy: PDGM’s behavioral adjustment, which the home health industry has largely opposed since early drafts of the payment overhaul.
It appears the analysis has done its job in attracting attention to PDGM’s potential flaws.
U.S. Representative Vern Buchanan, a Republican from Florida, has sent a letter to CMS Administrator Seema Verma voicing his concerns about PDGM. Buchanan had previously co-sponsored legislation that, if passed, would have restricted CMS from making assumption-based rate reductions rooted in what it believes providers may or may not do.
The Dobson DaVanzo & Associates analysis showing a drop in home health spending was based on Medicare claims data from the first four months of PDGM. In his letter, Buchanan notes that many of the factors contributing to the spending decrease have continued since.
The Bipartisan Budget Act of 2018 requires PDGM to be budget neutral.
“With these current trends continuing, Medicare home health spending will be well short of the required budget-neutral level, as outlined by Congress,” Buchanan stated.
Specifically, home health spending is down because at least two of the three PDGM assumptions made by CMS have not played out.
According to the Dobson DaVanzo & Associates analysis, home health agencies aren’t “upcoding” by choosing the primary-diagnosis code tied to the most reimbursement dollars.
Additionally, agencies have been hit with far more Low Utilization Payment Adjustments (LUPAs) than CMS projected.
In the first four months of the year when home health agencies were adjusting to PDGM, the national LUPA rate was 24.4% — with an all-time high of 28.7% in March.
Citing the uncertainty of the COVID-19 pandemic, CMS released its 2021 proposed home health payment rule in June with basically no changes to PDGM’s framework. The agency normally releases its final payment rule for the upcoming year at the end of October.
“I urge CMS to carefully consider the data submitted by commenters and to re-evaluate the assumptions used as the basis of the 4.36% rate reduction made in last year’s rule and proposed again for 2021,” Rep. Buchanan added. “CMS should take a data-based approach to its 2021 rulemaking responsibilities and move away from earlier theoretical assumptions and projections in favor of relying on actual provider experience.”
Senators Susan Collins (R-Maine) and Debbie Stabenow (D-Mich.) have also previously taken aim at PDGM’s built-in behavioral adjustment. Rep. Terri Sewell (D-Ala.) has joined Buchanan on the House side.
A Washington, D.C.-based home health advocacy organization, PQHH was quick to praise Buchanan for his continued support of the industry.
“The Partnership thanks Congressman Buchanan for his leadership on this issue and continued support of issues impacting the delivery of Medicare home health to American seniors,” Joanne Cunningham, the organization’s executive director, said in a statement. “Congressman Buchanan is a long-standing supporter of the home health community, and we echo his request that CMS discard any previous theoretical assumptions and projections of providers’ behavioral response to PDGM, and remove the -4.36% behavioral adjustment for CY 2021.”
The COVID-19 pandemic is not just a medical crisis. Since the highly contagious disease hit American shores in early 2020, the virus has dramatically changed all sectors of society, negatively impacting everything from food supply chains and sporting events to the nation’s mental and behavioral health.
For some people, work-from-home plans and limited access to entertainment are manageable obstacles. For others, the shuttered schools, lost wages, and social isolation spell disaster – especially for individuals already living with socioeconomic challenges.
The social determinants of health have always been important for understanding why some populations are more susceptible to increased rates of chronic conditions, reduced healthcare access, and shorter lifespans. COVID-19 is throwing the issue into high relief.
Now more than ever, healthcare providers need to gain full visibility into their populations and the non-clinical challenges they face in order to help individuals maintain their health and keep their communities as safe as possible during the ongoing pandemic.
Exploring correlations between socioeconomic circumstances and COVID-19 vulnerability
Clinicians and researchers have worked quickly to identify patterns in the spread of COVID-19. Early results have emphasized the danger posed by advanced age and preexisting chronic conditions such as obesity, diabetes, and heart disease.
Further, data from the Johns Hopkins University and American Community Survey indicates that the infection rate in predominantly black counties is three times higher than in mostly white counties. The death rate is six-fold higher.
Data from the Centers for Medicare and Medicaid Services (CMS) confirms the trend: black Medicare beneficiaries are hospitalized at a rate of 465 per 100,000 compared to just 123 per 100,000 white beneficiaries. Hispanic Medicare beneficiaries had 258 hospitalizations per 100,000, more than double the white population’s hospitalization rate.
Researchers suggest that the social determinants of health may be largely responsible for these disconnects in infection and mortality rates. Racial, ethnic, and economic factors are strongly correlated with increased health concerns, including longstanding disparities in access to care, higher rates of underlying chronic conditions, and differences in health literacy and patient education.
Leveraging data-driven tools to identify vulnerable patients
Healthcare providers will need to take a proactive role in identifying which of their patients may be at enhanced risk of contracting the virus and experiencing worse outcomes from the disease.
They will also need to ensure that person gets adequate treatment and participate in contact tracing efforts after a positive test. Lastly, providers will have to ensure their public health reporting data is accurate to inform local and regional efforts to contain the disease.
The process begins by developing confidence in the identity of each individual under the provider’s care. Healthcare organizations often struggle with unifying multiple electronic health record (EHR) systems and other health IT infrastructure, resulting in medical records that are incomplete, inaccurately duplicated, or incorrectly merged.
Access to current and complete medical histories is key for highlighting at-risk patients. An enterprise master patient index (EMPI) can provide the underlying technical foundation for initiating this type of population health management.
EMPIs help organizations create and manage reliable unique patient identifiers to ensure that records are always associated with the correct individual as they move throughout the healthcare system.
When paired with claims data feeds, health information exchange (HIE) results, and interoperability connections with other healthcare partners, EMPIs can bring a patient’s complete healthcare status into focus.
This approach ensures that providers stay informed about past and present clinical issues and service utilization rates. It can also support a deeper dive into the social determinants of health.
Combining EHR data with standardized data about socioeconomic needs can help providers develop more comprehensive and detailed portraits about their patients’ holistic health status.
By including this information in EHRs and population health management tools, providers can develop condition-specific registries to guide outreach activities. Providers can deploy improved care management strategies, close gaps in care, and connect individuals with the resources they need to stay healthy.
Healthcare organizations can acquire socio-economic data about their communities in a variety of ways, including integrating public data sources into their population health management tools and collecting individualized data using standardized questionnaires.
Once providers start to understand their patients’ non-clinical challenges, including the ability to avoid situations that may expose them to COVID-19, they can begin to prioritize patients for outreach and develop personalized care plans.
Conducting effective outreach and interventions for high-needs patients
COVID-19 has taken a staggering economic toll on many families, including those who may have been financially secure before the pandemic. Routine healthcare, prescription medications, and even some urgent healthcare needs are often the first to fall by the wayside when finances get tight.
Healthcare providers have gotten creative about staying connected to patients through telehealth, drive-in consults, and other contactless strategies. But they must also ensure that their vulnerable patients are aware of these options – and that they are taking advantage of them.
Contacting a large number of patients can be challenging since phone numbers, emails, and home addresses change frequently and are prone to data entry errors during intake. Organizations with EMPIs can leverage their tools to ensure contact information is up to date, accurate, and associated with the correct individual.
Care managers should prioritize outreach to patients with complex medical histories and known clinical risks for vulnerability to COVID-19. These conversations are a prime opportunity to collect social determinants of health information or refresh existing data profiles.
Looking to the future of healthcare in a COVID-19 world
Combining technology-driven strategies with targeted outreach will be essential for healthcare organizations aiming to provide holistic support for their populations during – and after – the COVID-19 pandemic.
By developing certainty about patient identities and synthesizing that information with data about the social determinants of health, providers can efficiently and effectively connect with their patients to offer much-needed resources.
Taking a proactive approach to addressing the social determinants of health during the outbreak will help providers maintain relationships with high-needs patients while building new connections with those facing unanticipated challenges.
With a combination of population health management strategies and innovative technology tools, healthcare providers and public health officials can begin to view the social determinants of health as a fundamental component of the fight against COVID-19.
Andy Aroditis, is CEO of NextGate, the global leader in healthcare enterprise identification.
New rules by the Center for Medicare and Medicaid Services would penalize hospitals and laboratories that report Covid-19 data. Hospitals would be required to report the number of confirmed or suspected Covid-19 patient, occupied beds, and availability of ventilators and other critical supplies.
For decades, home health agencies have learned to operate — and often thrive — in the midst of massive change.
But since the start of 2019, that change has felt overwhelming for some agency owners, particularly those who run mom-and-pop businesses with razor-thin margins. Above all, perhaps, the decision by the Centers for Medicare & Medicaid Services (CMS) to eliminate home health pre-payments — or Requests for Anticipated Payment (RAPs) — has been most difficult to manage.
CMS finalized its plan to phase out RAPs in its 2020 home health payment rule, outlined in October 2020. Under the plan, CMS started reducing pre-payment levels for existing agencies this year, with the goal of eliminating them by 2021.
New home health agencies were blocked from RAPs entirely in 2020.
In this latest installment of the Confessions series, HHCN spoke with a home health agency owner who sounded off on cash flow challenges — and how it sometimes feels like CMS is pushing agencies like his out of business. The subject of this interview — a registered nurse and long-time home health executive who launched his own agency in 2019 — is kept anonymous so he can speak without fear of retribution.
During the interview, the source also discussed his agency’s experience during the COVID-19 pandemic, in addition to his personal experience battling the virus as somebody who tested positive.
The home health agency owner’s responses are below, edited for length and clarity.
HHCN: To start off, how has your agency handled the transition to the Patient-Driven Groupings Model (PDGM)?
Agency owner: PDGM has been a positive for our operations. If you still look at an episode as a 60-day episode, our average revenue per episode has actually gone up.
The big challenge has been Low Utilization Payment Adjustments (LUPAs). LUPAs were always something we kept an eye on, but you really have to keep an eye on them now, particularly during the second 30-day portion of an episode of care. We’ve gone to using a lot more PRN visits in an effort to address LUPAs during the second 30-day period.
How have you handled cash flow during the transition to PDGM?
As far as reimbursement and cash flow goes, we got our actual Medicare certification in January 2019. We missed being eligible for RAPs by 18 days or so. That’s been difficult. In the best-case scenario, we can get money in 45 days of care. In a realistic scenario, that runs closer to about 60. So, we’re covering a full episode of payment for all the people we care for. For an agency like us — one that’s looking to grow but not a huge corporate agency — not being able to get those up-front funds makes cash flow a challenge.
What positives do you see in PDGM?
You won’t hear me say this a lot, but I think most of the changes CMS and Medicare made were appropriate and long overdue.
I think CMS is putting an emphasis on chronic care. It’s putting an emphasis on skilled nursing, taking the emphasis off of rehab and the acute treatment of a condition or illness. I think for what CMS is trying to accomplish in decreasing overall Medicare costs, PDGM is going to end up showing positive results.
Your home health agency is in the Sunbelt region, which has been hit hard by the coronavirus recently. How are you and your staff holding up?
We’re doing OK. Keep in mind, we’re not in an extremely populated area. Out of a county population of about 200,000, I think we’re still at less than 3,000 overall cases. I actually had it.
You tested positive for the COVID-19 virus?
Yes. I had it. One of my nurses had it, too. We recovered from that, then came back to work.
COVID-19 has definitely had an impact on our home health referrals. I think that’s mostly because people are being cautious, not wanting home health services because they’re nervous about having people in their house. I think I read this in an HHCN story, but people need to understand that home health agencies are the firemen — and not the fire. I couldn’t agree with that more.
Patients get very nervous, but when we go into a home, we’re making sure that we’re not bringing COVID-19 to them. We also make sure we’re not taking it out. We have had a fair number of COVID-19 patients or testing-pending patients. I don’t think we have had any that have passed away, so that’s good.
I had no idea that you had the COVID-19 virus. What was the experience like? How are you feeling now?
It was interesting. I think the strangest thing for me was the loss of taste and smell. You don’t really realize how much you use those senses until you don’t have them anymore. It was so odd. I could take cologne, spray it on my arm, see it on my arm wet, smell it — and then smell absolutely nothing. That’s how I first realized I had it. I felt sick probably for four or five days, with body aches that were bad enough where I had to push myself using my arms to roll over in bed. But probably by the fifth day, I started feeling back to normal.
It’s been about two-and-a-half months now since I had it. The biggest issue since has been fatigue. Even after I felt “normal,” my endurance was way, way down. The nurse who got it around the same time as me had more flu-like symptoms, where she had a mild cough and fever of 102 degrees.
I never had a temperature higher than 99.7 degrees. With her, too, her experience lasted for pretty much a whole two weeks, whereas mine was pretty much done and over after five. It was an interesting disease process. We caught it very quickly in the office, so both of us quarantined very quickly.
As somebody operating a home health business as we talk here on Aug. 21, what are currently your biggest challenges?
Staffing is always a challenge, particularly because we operate in an underserved area. But I am very blessed right now; I have one of the best crews that I’ve probably ever had in my whole career.
Cash flow is by far the biggest challenge. Sometimes, it feels like CMS is trying to put agencies like mine out of business. Sometimes, it seems like CMS and regulators want to leave the big corporate agencies as the only ones they have to deal with.
I’ve been saying that for 10 years, but some of the latest plans and initiatives really drive that home. I’m mainly talking about getting rid of RAPs. I mean, the only agencies that can sustain that are those that have large cash reserves.
What’s the downside to consolidation, in your view?
I think you lose innovation. I think a lot of the home health innovation comes from the mom-and-pop shops that have had to be creative. Just look at us — I’ve always had a different take on home health care. What the regulators are saying and doing now, I’ve always felt that way. Since the late 80s, I’ve had chronic illness programs. I think that’s why PDGM — and the actual reimbursement amounts we’re seeing — did not affect my operations as much as other people who were very focused on patients with acute issues.
When it comes to cash flow during the public health emergency, there were a couple of lifelines out there for for agencies. Did you apply for any advance or accelerated payments from CMS, for example?
We absolutely did.
Now, I think where that falls very short is the repayment component. Basically, CMS is going to keep everything you bill. So the advance and accelerated payments were helpful, but that’s a very short lifeline, I guess I would say. If at the end of the two months or the three months, CMS plans on keeping 100% of anything I bill until I’m paid up, that’s kind of a wash. All I did was push back my pain point, right? It’s a net zero.
What about the Paycheck Protection Program (PPP)? Did you apply for a PPP loan?
How has that helped? How have you used those funds?
To me, that was the key lifeline, to be honest with you. We saw no issue using PPP as long as we used it in “the buckets” that the government mandated PPP be used in. We should qualify for forgiveness on that. We used the program to help with payroll. I was still hiring staff when other agencies around us were laying their staff off. We needed those workers to take care of our patients. Looking ahead, I’m still planning for growth, so I didn’t want to lose anybody.
I have some things happening in my business where I think there’s going to be a fair amount of growth. On PPP, I think forgiveness is the right way to go. We were able to keep contributing to the economy. We didn’t get rid of our people. The work kept going. I think that program was great.
Did you request a loan in the under $150,000 category or the above-$150,000 category?
It was actually $150,000 exactly. I think when I looked last, it was considered a “small loan.”
It was a no-brainer and a good business decision to use PPP. The important thing is to keep funds siloed, only using them for certain expenses.
This has been one of the challenges we’ve been hearing pretty frequently: Does your agency provide care inside of long-term care facilities or assisted-living communities? If so, were you shut out from those at all?
We have patients who are in assisted living, for sure. At the beginning of COVID-19, they pretty much kicked us out. We are seeing those assisted-living facilities ease up now.
They’re not as ready to send us referrals as they used to be, though. So it still hurts from that standpoint, but they are allowing us back in. The other interesting pain point that’s related to facilities: I had some employees who were per diem employees who also worked at a skilled nursing facility (SNF) full time. They worked for me on a per diem basis. After COVID-19 hit, a lot of those individuals working in SNFs were no longer allowed to work for us. I lost a fair amount of skilled staff overnight. Within the last week, some of those people have been told they can resume whatever they were doing outside of their full time job.
But for two or three months, we basically had to stop doing occupational therapy (OT). It’s a high utilization-low resource area that I’m in, so there aren’t a lot of OTs around. There’s a lot of sharing. When they locked SNFs down, we essentially had to stop taking any patients that required OT because my occupational therapist got locked down in her primary job.
What about virtual visits or telehealth? Is that something that you’ve turned to during the public health emergency?
We definitely did turn to telehealth at the beginning, when everyone was trying to get their feet on the ground. Don’t get me wrong — I think virtual visits and telehealth visits should be a part of home health if officials really want to limit COVID-19 exposure. Telehealth and virtual visits are also great when it comes to keeping people on service and managing chronic illness. At the very least, virtual visits can help you determine if an in-person visit is needed.
But based on our experience and from talking to other people in home health, there’s just no motivation for doing them. In some cases, they actually hurt you in home health. We did them on certain types of patients, but we had to make sure that by doing them, it didn’t drop us into a LUPA.
Do you have any concerns about being able to stay in business or are you feeling pretty good about where you are at?
I have no intention of staying a mom-and-pop agency. We’re at an acquisition moment ourselves. We’re also talking with accountable care organizations (ACOs) about doing joint ventures or mergers. I’m very plugged into the ACO landscape. I think they are the future of Medicare.
In order for home health providers to see reimbursement success, they need to be able to separate myths from facts when it comes to the Patient-Driven Groupings Model (PDGM).
But one specific point of confusion has been primary diagnosis clinical groups.
“There are a lot of rumors and myths floating around out there,” Robbi D. Funderburk James, coding and OASIS manager at BlackTree Healthcare Consulting, said during a Tuesday webinar. “I see a lot of times that we are interacting with our coders, our physicians and maybe causing frustrations all the way around.”
Overall, there are 12 primary diagnosis clinical groups under PDGM.
One popular myth is that all unspecified codes are unacceptable PDGM primary codes. On the contrary, there are many unspecified codes that are acceptable to bill as PDGM primary and fall into a clinical diagnosis group.
Some examples of this are CHF unspecified, AFib unspecified and COPD unspecified.
“What is true about unacceptable codes under PDGM is that if you have an unspecified anatomical location on the body or unspecified laterality. Those codes will typically not bill under PDGM,” James said. “What CMS is saying is that if we have an arm fracture, in order to appropriately treat this, we would need to know whether the fracture is the right arm or left. CMS requires the physician to state that. It can’t be clinician observed.”
Another myth that has gained traction is that all R codes, more commonly known as symptom codes, are unacceptable primary codes.
Unlike the last myth, this one is mostly true with one exception, according to James.
“The exception to that is the R.13.1 Dysphagia codes,” she said. “In our final rule in 2020, CMS agreed with those in our industry who spoke up and said [that] we must treat dysphagia and we can’t always wait for there to be a confirmed etiology. We need to be able to do that in a timely fashion to prevent subsequent harm to the patient.”
Another myth that frequently pops up has to do with codes that are unacceptable as primary diagnoses also being unacceptable as co-morbidity diagnoses. In actuality, codes that are unacceptable as primary are acceptable co-morbidity codes.
Still, James urges providers to seek greater specificity from physicians when the circumstances call for it.
“This doesn’t mean that in some instances, we shouldn’t take the time to query our physicians to get more specificity and laterality,” she said. “We definitely want to do those things when it is appropriate and necessary, but if you are unable to, it’s not going to hold your claim up.”
Moving forward, there are a number of measures providers can take to make sure they are getting into the appropriate PDGM primary categories, including building a strong referral and intake department.
“It’s all going to start with your referral team and intake team at your agency level,” James said. “We want to make sure that our referral team has good relationships with our referral sources, and that they take the opportunities to educate their referral sources and the providers on what it is we’re going to need as home health agencies to bill under PDGM.”
Knowing when it is and isn’t necessary to query — and training clinical staff to know, too — is also key.
“There are going to be times when we’re going to need field clinicians to follow up on diagnoses, especially those instances where they find a diagnosis in the home that wasn’t mentioned anywhere on the intake and referral paperwork,” James said.
Unlike the past couple of years, the latest proposed payment rule included relatively minor changes and rate adjustments for the year ahead. In light of the mild proposal, CMS only received 161 comments from home health stakeholders.
When initially releasing its proposal, agency officials suggested that CMS did want to make any drastic overhauls due to the ongoing transition to the Patient-Driven Groupings Model (PDGM) and the disruption caused by the COVID-19 virus.
The 2021 proposed payment rule included increasing Medicare payments to home health agencies by 2.6%, a bump worth an estimated $540 million. Comparatively, the 2020 proposed rule included an increase of 1.3%.
The proposed rule also made certain telehealth requirements granted during the public health emergency permanent, such as the face-to-face requirement for home health. It also created new Medicare enrollment policies for qualified home infusion therapy suppliers and updated the home infusion payment rates.
The National Association for Home Care & Hospice (NAHC) was among the group of 161 commenters that made its feelings known. While CMS has yet to publicly release all of the comments, the Washington, D.C.-based advocacy organization shared a copy of its comments with Home Health Care News.
In its comments to CMS, NAHC first addressed the payment systems in place for home health agencies — and why they are, at times, inadequate for an industry dealing with COVID-19 head on. Specifically, NAHC urged CMS to establish a process that would modify home health agency payment systems and rates during a public health emergency.
More than half of all home health agencies have now treated COVID-19-positive patients in 2020, according to NAHC data. And while the hospitals and skilled nursing facilities (SNFs) have seen adjustments made to their payment models and amounts, home health agencies have not.
“Instead, the COVID-19 patients have had to be fit into a payment model that had no such comparable patients in its foundational database,” NAHC wrote in its comments to CMS.
The comments were listed in a letter signed by NAHC President William A. Dombi, along with Mary C. Carr, vice president of regulatory affairs. Katie Wehri, the director of regulatory affairs, also signed.
CMS left home health agencies out of similar relief elsewhere. Hospitals, for instance, can now provide reimbursable virtual care for patients inside their home. Home health agencies are still unable to do so.
“CMS should develop a model for claims reporting and payment for home health visits provided by telecommunication,” NAHC wrote.
NAHC also asked for clarification on audio-only technology and believes it should be included in the permitted telecommunication technologies umbrella moving forward.
Allowing providers to be reimbursed for telehealth visits in place of in-person visits would reduce person-to-person contact, which would also decrease the amount of PPE each agency would need — a pain point for providers since COVID-19 hit the U.S.
PPE, on average, was costing each agency $11.50 per visit and increased 30-day costs by over $100 — approximately 5% of base payment rates, according to NAHC.
That 5% mark is troublesome because the Provider Relief Fund, which derived from the CARES Act, only covered 2%, on average.
“If CMS had included a process for mid-year adjustments for unexpected cost increases, stabilization of home health care access would be more readily achievable,” NAHC wrote.
NAHC recommends that CMS include a PPE cost add-on to the 2020 payment episodic and per-visit payment rates.
Moving forward with PDGM
The rate of Low Utilization Payment Adjustments (LUPAs) in 2020 is likely to be far different from what CMS originally expected.
“While the available data to date obviously does not represent a full year of experiences under PDGM, it is equally obvious that the existing data shows a massive increase in LUPA episodes in clear contrast to the decline assumed by CMS,” NAHC pointed out.
Data suggests LUPA rates are 2 to 3 times what was expected out of agencies in 2020, according to NAHC.
Still, overall, NAHC agrees with CMS’s decision to stand pat on PDGM and its continued application in home health, despite the pandemic.
At this point, it is too hard to know whether the payment model is working as planned, given the effects of the COVID-19 crisis and it still being a relatively new model.
NAHC did have one particular recommended change to PDGM, however.
“One exception is that CMS should restore the use of symptom codes as a patient diagnosis. Practitioners continue to use these codes in patient referrals and care planning for home health patients,” NAHC wrote. “Given that other reimbursement systems in Medicare accept these codes, CMS should incorporate these codes into the existing model with later refinements where needed.”
U.S. Senator Kirsten Gillibrand (D-NY) is asking the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to ensure that in-home care providers have access to essential resources amid the coronavirus.
Throughout the public health emergency, home health and home care providers have been vocal about the challenges they’ve faced acquiring personal protective equipment (PPE), as well as the need for federal payment barriers to be lifted.
Gillibrand — alongside Senators Bob Casey (D.Pa), Tina Smith (D.Mn), Elizabeth Warren (D.Ma), and Richard Blumenthal (D.Ct) — penned a letter to HHS and CMS asking them to address those ongoing concerns and others.
Overall, the letter has drawn support from the industry, with Visiting Nurse Service of New York (VNSNY), American Network of Community Options and Resources (ANCOR) and Home Care Association of New York State (HCA-NYS) giving the authors praise.
“To keep our frontline staff safe and our homebound patients healthy, we must have appropriate policies and financial support,” VNSNY President and CEO Marki Flannery said in a statement. “That means reimbursing home health providers for vital services delivered through telehealth, sufficient Medicare and Medicaid funding for care in the home, and priority access to personal protective equipment.”
In the letter, Gillibrand details the struggles that providers continue to face when it comes to securing and maintaining adequate supplies of PPE. She urges HHS and CMS to grant in-home care providers priority access to PPE.
“In some jurisdictions, home care and hospice were not even recognized by emergency management and public health authorities as essential care settings where PPE was vital for care access, health safety and protection,” Gillibrand wrote in the letter. “HHS and CMS must establish home care and hospice essential personnel status for PPE and other prioritization in emergency response, and direct state and local public health jurisdictions to follow.”
The letter also addresses the need for additional flexibilities in telehealth waivers for Medicare home health providers, namely ones that allow home health providers to be paid for providing virtual visits. While CMS has been active when it comes to granting telehealth payment waivers to many Medicare providers, home health has been left out.
“Efforts have fallen short in regards to home health,” Gillibrand wrote. “Under current law, CMS allows [home health agencies] to provide telehealth to those under their care, but they will not reimburse HHAs for those services as ‘virtual visits.’”
Reimbursement for telehealth would allow home health providers to increase telehealth services while lowering the risk of spreading of COVID-19. An increased use of telehealth services would also help them preserve PPE.
Gillibrand acknowledged that the current payment model for home health may complicate telehealth reimbursement and that some services, such as wound or catheter care, should always be provided in person. Still, she argued it’s “imperative” for CMS and HHS to come up with some sort of payment solution to help home health agencies get home health reimbursement.
Additionally, the letter calls for support of Medicaid long-term care providers delivering services in home and community settings, which have become crucial when it comes to reducing the spread of infection and caring for vulnerable populations, according to Gillibrand.
“Some states have asked for and received waivers that enable states to stabilize [home- and community- based services (HCBS)] providers,” She wrote. “However, state Medicaid budgets are stretched thin, and the waivers only allow retainer payments to [home health agencies]/HCBS providers and employees for thirty days. The federal government must provide adequate resources for these service providers and the workers they employ.”
The U.S. Centers for Medicare & Medicaid Services (CMS) announced Friday it will not resume a full-blown resumption of the Review Choice Demonstration (RCD) for home health agencies in participating states later this month.
Instead, CMS is “phasing in” RCD for agencies in North Carolina and Florida. Agencies in Illinois, Ohio and Texas will be granted flexibilities as well, according to CMS, which cited the current public health emergency as the reason for the newly announced RCD relief.
Despite ongoing operational challenges associated with the COVID-19 virus, CMS officials originally said in early July that the home health industry would once again be subject to RCD demands beginning Aug. 3. Broadly, RCD is a regulatory initiative meant to reduce improper billing by providers by requiring them to undergo pre-claim review, pre-payment review or post-payment review, among other options.
“Given the importance of review activities to CMS’s program integrity efforts, CMS will discontinue exercising enforcement discretion for [RCD] … regardless of the status of the public health emergency,” officials wrote in their July update.
But over the past few weeks, industry stakeholders were able to meet with several key officials from the agency’s Office of the Administrator and Center for Program Integrity, Tim Rogers, president and CEO of the Association for Home & Hospice Care of North Carolina, told Home Health Care News in an email.
Ultimately, those stakeholders — a combination of providers, state associations, the National Association for Home Care & Hospice (NAHC) and the Partnership for Quality Home Healthcare (PQHH) — were able to get their point across, Rogers noted.
“We detailed every scenario we we could regarding hardships and RCD,” Rogers said. “[This is] a great example of when state associations and their members push hard on advocacy, with strong support from our national associations like NAHC and PQHH.”
Specifically, for North Carolina and Florida, agencies may submit pre-claim review requests for billing periods beginning Aug. 31.
Claims that go through pre-claim review and are submitted with a valid UTN will be excluded from further medical review. Claims submitted without going through the pre-claim review process will process as normal and will not be subject to a 25% payment reduction.
Moving forward, claims may be subject to post-payment review in the future through the normal medical review process, according to CMS.
On their end, providers who have already made a choice selection do not need to take any further action if they choose not to participate in RCD at this time.
CMS will reassess the “phased-in approach” in 60 days.
“Providers may choose to send in a handful of claims through the RCD platform to get their feet wet,” said Rogers, who also serves as chair for The Council of State Home Care & Hospice Associations and has a leadership role at the South Carolina Home Care & Hospice Association. “This will enable them to be confident and comfortable when RCD is required.”
Matt Wolfe, a partner at law firm Parker Poe, described CMS’s announcement as “an important” and “helpful” recognition of the need for home health providers to focus on quality clinical care and serving their communities during the COVID-19 spikes sweeping parts of the nation.
“The voluntary option also allows home health agencies to trial the pre-claim review process without putting their cash flow and operations fully at risk,” Wolfe told HHCN in an email. “I am hopeful that CMS will use this approach as a model moving forward for overseeing providers in a thoughtful and measured manner.”
While agencies in Illinois, Ohio and Texas aren’t afforded as many RCD flexibilities, they will likewise see some regulatory relief.
Cycle 2 in Illinois and Cycle 1 in Texas will end on Sept. 30. Affirmation and claim approval rates will be calculated based on review decisions made between Feb. 1 and Sept. 30 for Illinois providers, and between March 2 and Sept. 30 for Texas providers.
Cycle 2 in Ohio will begin on Aug. 31, as CMS previously noted.
Claims submitted under Choice 1 without going through the pre-claim review process will not be subject to a 25% payment reduction until further notice, but will be subject to pre-payment review.
“We consider this to be a victory,” Rogers said. “A very flexible situation for our providers, in fact, and a recognition of the serious nature of … this pandemic and the role home health caregivers are playing in the care continuum in North Carolina and Florida now, which was one of my stresses to CMS.”
In designing the Patient-Driven Groupings Model (PDGM), officials from the U.S. Centers for Medicare & Medicaid Services (CMS) made a handful of assumptions about how Medicare-certified home health operators would respond once the overhaul went live.
Among those assumptions, CMS believed home health agencies would automatically “upcode,” or pick the primary diagnosis code tied to the highest level of reimbursement. The agency likewise believed agencies would do everything possible to reduce their Low Utilization Payment Adjustment (LUPA) rates compared to years past.
So far, those pre-PDGM assumptions appear to be somewhat inaccurate, metrics from Dallas-based software and analytics company Homecare Homebase (HCHB) suggest.
“What CMS thought was going to happen in 2020 is not what’s happening as it relates to LUPA and upcoding behavior,” one home health executive told Home Health Care News.
Each year, HCHB releases an updated analytics tool that helps its agency customers accurately identify how any given proposed payment rule will impact them in the upcoming year. This year, HCHB did so shortly after CMS released its 2021 proposed payment rule on July 25.
Unlike previous years, however, this year’s impact tool from HCHB gave home health operators the ability to see how their “actual behavior” compared to CMS’s assumptions, which the industry has largely disagreed with since the very early days of PDGM.
In particular, CMS missed the mark on upcoding, HCHB customer data suggests. For more insight, HHCN connected with executives from two HCHB customers, granting them anonymity in exchange for transparency into their operations.
“CMS assumed that when there was a higher reimbursing code within the stack of primary and secondary codes, that providers would always choose that higher reimbursing code,” the same home health executive said. “The industry was very much against that from Day 1. We just did not believe that would occur — and that’s exactly what we’re seeing in the data.”
Generally, HCHB’s impact tool showed that the executive’s organization coded similarly to how it did in the past. Typically, reimbursement rates are not factoring into clinical decision-making.
“Our clinicians would tell you that we’re doing what’s most appropriate, selecting the appropriate code as the primary reason for a person receiving home health [services],” the executive said.
The second home health executive told HHCN that his organization’s clinical group behavior had no behavior change 78.2% of the time. In other words, the home health organization was coding how it normally would in nearly eight out of 10 instances.
When there has been a change, 10.3% of the time it’s actually been to a lower-paying code. The organization “upcoded” just 11.5% of the time, HCHB’s impact tool shows.
“We’re obviously going to code based on the clinical and diagnostic information relative to what the hospital provides us, factoring in what the physician’s opinion is and also our own clinical assessment,” the second executive said. “Where there has been a change, it’s been incidental. You’re never going to code the exact same way, year-over-year.”
Many other HCHB customers have pointed out similar trends.
CMS has also been off when it comes to LUPAs, at least for the first executive.
Broadly, LUPAs are standardized per-visit payments for episodes of care that have a low number of overall visits. Since the start of the COVID-19 emergency, many home health agencies have seen their LUPA rates increase — not decrease, as CMS expected going into 2020 — because of patients refusing visits.
In a National Association for Home Care & Hospice (NAHC) survey conducted in May and June, 47% of home health respondents said their agency saw at least a doubling of LUPAs due to the COVID-19 virus.
At his organization, the second home health executive said CMS’s assumptions around LUPAs were fairly accurate, however. CMS expected agencies to lower their LUPA rates by about 33% in 2020, and his agency was able to trim them by 34.2% compared to the previous standard.
“It seems that the industry as a whole, with regard to the COVID pandemic, saw LUPA rates increase,” he said. “We did not see that. Throughout the COVID pandemic, we saw our LUPA rates continue to come down.”
Apart from LUPAs and upcoding, CMS also assumed that home health agencies would utilize PDGM’s co-morbidity adjustment.
In addition to comparing actual behavior to CMS’s assumptions, this year’s impact tool from HCHB gives home health operators the option of using 2019 data to plan for 2021. Many agency leaders see 2020 as an outlier due to the public health emergency.
“We’re looking more at 2019,” the first executive said. “The noise created by COVID is enormous.”
We need to keep in mind three key elements to successfully implement the final interoperability rules from CMS that require private payers to provide longitudinal claims data to members as well as the use of open APIs so a range of third-party applications can be built.
Hospitals improperly coding for post-discharge services contribute to hundreds of millions of dollars in Medicare overpayments. And the majority of incorrect payments are often related to home health services.
The purpose of the OIG audit was to determine if payments met the standards of Medicare’s post-acute care transfer policy. As part of the audit, OIG examined almost 90,000 in-patient claims filed in fiscal years 2016 and 2017, totaling $948 million.
Auditors took a sample of 150 claims and found that Medicare only paid three correctly. Meanwhile, 147 incorrectly paid claims received $722,288 in overpayments.
Overall, that means Medicare may have incorrectly paid $267 million for hospital services over a two-year period, according to OIG. About $218 million of that amount was related to the improper coding of a discharge directly to home, audit found.
“Medicare improperly paid most in-patient claims subject to the transfer policy when beneficiaries resumed home health services within three days of discharge but the hospitals failed to code the in-patient claim as a discharge to home with home health services or when the hospitals applied condition codes 42 (home health not related to in-patient stay) or 43 (home health not within three days of discharge),” OIG auditors noted.
In order to address Medicare overpayments, OIG recommends that the Centers for Medicare & Medicaid Services (CMS) reprocess the claims to recover some of the funds from hospitals that were disbursed within the past four years.
Among other things, OIG also recommended that CMS “correct its related system edits, improve its provider education related to the Medicare transfer policy and use data analytics to identify hospitals disproportionally using condition code 42.”
Additionally, OIG recommends that CMS should reduce the need for “clinical judgment” with claims under the post-acute-care transfer policy.
One way to achieve this would be to consider all home health services within three days of discharge to be related to in-patient hospital services, according to the report. Doing so would have saved an estimated $46.6 million during the review period.
In response to OIG recommendations, CMS stated it will require its Medicare contractors to recover the identified overpayments, reprocess the remaining in-patient claims and review a sample of the remaining in-patient claims.
In addition, CMS has modified its Common Working File (CWF) system for verification, validation and payment authorization.
CMS has also made efforts to educate health care providers on proper billing.
“CMS educates health care providers on appropriate Medicare billing through various channels, including the Medicare Learning Network, weekly electronic newsletters and quarterly compliance newsletters,” CMS Administrator Seema Verma said in a statement to OIG. “For example, CMS published an informational booklet in February 2019 regarding the acute care hospital in-patient prospective payment system, which included information on the transfer policy and related payment adjustments.”
CMS disagreed with OIG’s suggestion related to reducing the need for clinical judgment.
In the late 1940s, the United Kingdom was busily reassembling country and what remained of the empire in the aftermath of World War II. Among many revelations, the war had convinced Britain’s leaders of the need to provide healthcare for all in the event of calamity upending the basic functions of a civilized society. With that, the UK’s National Health Service (NHS) was born.
In 2020, all perspectives about quality and the time it takes to see a provider aside, the NHS remains quite popular among UK citizens and is an enduring source of national pride.
With the United States in the midst of its own upheaval, it’s for a related question: Might the current COVID-19 situation give rise to significant changes to the American healthcare system?
Virtually no one thinks the correct answer is ‘No.’ Things will change. The question is how and to what extent. The healthcare system in place in the United States now is dramatically more complex than that in use by Britons after WW II. There are so many moving parts, so many things that can break.
So, in which aspects of the current American healthcare system are we likely to see changes after COVID-19 is dealt with?
Telehealth: Someone always benefits in a catastrophe. In this case, that someone may be Zoom shareholders.
From 10 million daily users in December, Zoom rocketed to 200 million in March and nearly 300 million a month later. Much of that was healthcare related.
Of course, Zoom is not the only direct beneficiary of coronavirus as venerable meeting platforms like WebEx and Skype, among others, have also experienced dramatic growth.
Hospitals and health systems were incrementally implementing telehealth services prior to the coronavirus outbreak, but there was no sense of urgency that accompanies a rapidly spreading virus. Since then, the federal government, states and insurance companies have allocated funds and rewritten regulation to expand the use of telehealth.
But there are more telehealth related-issues to address, some of which have thorns. Service and payment parity across insurance companies is an issue. If telehealth is going to be a regular component of healthcare, technology gaps will have to be addressed, especially in rural areas.
This is something the federal government recognizes. The White House recently drafted an executive order oriented around improving rural health by expanding technology access, developing new payment models and reducing regulatory burdens. The EO tasks the secretaries of health and human services and agriculture to work with the Federal Communications Commission to “develop and implement a strategy to improve rural health by improving the physical and communications healthcare infrastructure available to rural Americans.” But until Congress gets involved and provides funding for something like this, it will probably never get out of the proposal phase.
In fact, there are enough concerns—parity, technology gaps, added costs—associated with telehealth to wonder if it will endure after coronavirus is in the rear view. Enough about telehealth benefits both providers and patients for it to stick and proliferate, but that could also be said about any number of healthcare initiatives that seem to languish for lack of coordination and political will.
Health Insurance: This is where the NHS analogy is the most relevant. Many millions of workers are furloughed or simply laid off with the impact of COVID-19 on frontline jobs like restaurant worker, massage therapist and barista. Those who had insurance through work may not have it anymore, leaving them doubly vulnerable—no coverage, no income—to illness or accident.
Mass unemployment episodes reveal, each time, the weakness in the patchwork employment-based healthcare insurance system we’ve sort of made peace with for decades. Sure, Medicaid exists to fill the gaps, but it may make sense to render Medicaid unnecessary, especially since its value is questionable in particular states.
“You notice the number of band-aids that Congress is having to apply to help people who have lost their jobs,” said former CMS Administrator Don Berwick, MD. “What we have now is a whole series of band-aids and special measures. What if instead, we just had universal health insurance?”
What if, indeed. Will COVID-19 be the straw that burns the bridge of employer-based health insurance, to mangle a metaphor? That may depend on how long the pandemic lasts, who is president sometime after November 3 and how much damage is done to the national fabric before economy and society start a process of repair.
Payment Models: For years now, hospitals have been in the middle of slow shift from fee-for-service care to value-based care and alternative payment models. That transition didn’t happen quickly enough to prevent most hospitals from falling into a financial chasm. If elective procedures are a big part of revenue, it follows that revenue will fall if those procedures disappear.
To be fair, the hit to hospital finances has been catastrophic enough—more than $200 billion in losses over four months, according to the American Hospital Association—that federal government support would have been necessary even if a full pay-for-quality model had been in place.
But the pandemic spotlights the downside of treating essential services like healthcare as though they are mere services one selects or rejects. And it exposes the folly of not making sure everyone has insurance coverage (a payer) when the individual costs for COVID-19-related hospital admission can range from $20,000 to $88,000.
End-of-Life Care: According to one analysis, 42 percent of COVID-19 deaths have occurred in nursing homes or assisted living facilities. The families of those unfortunate souls who’ve died while in a facility have generally endured the agony of saying goodbye outside a window or over a video link. It’s hard to believe, after COVID-19, that the assisted living industry will continue as before.
“The crisis surely will lead nursing home administrators to reconsider the way patients are cared for,” says Modern Healthcare. “Among the ideas Harvard’s [Professor David] Grabowski believes will get a longer look in the wake of the pandemic are using telemedicine services, creating specialized Medicare Advantage plans for the homes and pursuing smaller settings.”
Perhaps. And perhaps a son or daughter that remembers coronavirus will simply choose not to risk everything by putting their parent in a home. Could enough of them make such a decision that the industry contracts? Is forced to take quality care more seriously? Attracts more serious federal regulation?
As the deaths mount, it’s hard not to give every option serious consideration.
Supply Chain: These days we’re bickering in public and on social media (looking at you, maskless Karen throwing food in Trader Joes) about whether or not masks should be mandated. Look back with me to February, however, and you’ll fondly recall concerns about there being enough masks at all.
Back then we learned that the United States had exactly one mask manufacturer, and that all other masks are sourced from overseas. That it takes longer to get stuff from China than from Amarillo creates obvious potential problems when a crisis hits, but it also pits hospitals and government entities against one another and guarantees that the winner will pay more for supplies than they would in less-critical times.
It also creates weird, unnecessary scenarios that could be avoided using coordination and leadership. The governor of Maryland, for example, used his wife’s connections to South Korea (her country of birth) to secure 500,000 coronavirus tests, which he then put in an undisclosed location and protected using national guard troops.
What’s the remedy?
Modern Healthcare has called for a national supply chain czar, which in other times may have just been the head of FEMA. The suggestion, however, highlights the need for a coordinated central clearing house where supplies can be ordered, managed and dispersed based on need.
Individual hospitals, clinics and health systems can also help themselves by using a robust supply chain software system that keeps track in real time of available supplies, covers all ordering systems and methodologies, and reacts swiftly to certain thresholds.
The uniquely unfortunate aspect of the American political system among western democracies is that, for the most part, it responds to the demands of special interests. Think about your local representative. Chances are good the shouts of specific business interests are ringing in his or her hears so loudly that little else is audible.
As such, there is a significant danger that the American healthcare system will return, post-COVID-19, to the same dynamic it had when the virus arrived, which will be unfortunate. What we need post-pandemic is not necessarily specific changes to hospitals, clinics, insurance companies, etc., though they could be part of an overall solution. What will be necessary is an examination of where every aspect of the healthcare system overall, inasmuch as there is one, didn’t do its job.
Disasters are social sodium pentothal that, while active, force groups of people to take an honest look at their failures. Once the disaster is passed, however, there is a danger that Upton Sinclair’s maxim—“It is difficult to get a man to understand something when his salary depends upon his not understanding it”—will rule the day.
No one hopes for more dramatic damage to the American economy and social fabric, but the irony is that necessary change sometimes only comes when reality is undeniable, as in a shellshocked Britain instituting the NHS. If COVID-19 doesn’t shock us sufficiently into making substantial changes to the healthcare system, it’s a pretty safe bet the same disaster will occur again.
Several federal agencies, including the Centers for Medicare and Medicaid Services, have indicated their interest in expanding telehealth coverage after the federal emergency period ends. But to do that, they’ll need the help of states and Congress.
The executive order would call on the Department of Health and Human Services to develop a new pilot payment model for rural hospitals, and would set up a task force to improve broadband infrastructure in rural communities.
As home health leaders look to the future, the lessons learned from the COVID-19 emergency will likely continue to shape their efforts for years to come.
In terms of business planning, it will likely be a long while before there’s a return to a world where the coronavirus isn’t the central driver of health care strategy, outcomes and cost.
“We realize the current situation is not really going away anytime soon,” Mary Gibbons Myers, president and CEO of Johns Hopkins Home Care Group Inc., said Wednesday. “We’ll continue to be flexible, creative and resilient.”
Myers made her comments at the National Association for Home Care & Hospice’s 2020 Financial Management Conference, which was held virtually due to the COVID-19 emergency.
For Baltimore, Maryland-based Johns Hopkins Home Care Group, utilizing lessons learned from the public health emergency and understanding how it fits into the company’s business model moving forward has been crucial.
“For example, prior to the pandemic, we were preparing for a huge expansion of our facilities,” Myers said. “What we realized is that we really did not need as much space as we thought. We moved that mindset from expansion to contraction and making sure our employees have the optimal experience for the non-patient-facing to be able to do that remotely.”
The COVID-19 emergency also served as a catalyst for innovation for Johns Hopkins Home Care Group, according to Myers.
“In a matter of weeks, we expanded our remote patient monitoring program exponentially to meet the needs of our health system by monitoring COVID-positive patients,” she said. “We are actively discussing strategies to further remote patient monitoring over the years to come with or without COVID.”
Johns Hopkins Home Care Group falls under the larger umbrella of Johns Hopkins Health System’s Home & Community-Based Services division, which includes four Medicare-certified home health agencies, two private-duty companies, a large home medical equipment company, 10 outpatient specialty pharmacies and three alternative care infusion sites.
Similar to Johns Hopkins Home Care Group, Always Best Care Inc. has also scaled back in terms of office space, in relation to the COVID-19 emergency.
Roseville, California-based Always Best Care is a home care franchise company that operates across 209 territories in 30 states.
As part of its COVID-19 strategy, Always Best Care has placed a greater emphasis on infection control — something that will play a larger role for all in-home care providers in 2020 and beyond, according to Sheila Davis, the company’s senior executive vice president of operations.
“One thing that we have learned within our businesses is that you have to be mindful of — and protective of — not only the clients but also of your employees as well,” Davis said at the Financial Management Conference.
While infection control has always been a major aspect of home health, the public health emergency has pushed this to center stage on the non-medical home care side as well.
Additionally, amid the COVID-19 emergency, there have been a number of regulatory exceptions, waivers and other changes.
For Kindred at Home, the Centers for Medicare & Medicaid Services (CMS) and its move to broaden the definition of “homebound” under home health rules has been critical, according to David Causby, the company’s president and CEO. CMS’s goal in the expanded definition was to expand access to home health services, especially to populations at heightened risk for contracting COVID-19.
“This is something the home health industry has been pushing for an extended period of time,” Causby said at the Financial Management Conference. “I think with COVID and … the homebound status relief, we’re really starting to see some real qualitative outcomes, in regards to being able to treat seniors in their home.”
Atlanta-based Kindred at Home provides home health, personal care and community care services in almost 800 locations across 40 states. The provider organization also offers hospice care, palliative care, skilled nursing services, social services and therapy services.
Ranked at the largest home health provider in the country in 2019 by LexisNexis, Kindred at Home operates under the umbrella of Humana Inc. (NYSE: HUM)
Like many providers, Kindred at Home has leaned on telehealth use during the COVID-19 emergency. But Causby believes more relief around telehealth use for home health care is needed.
“While there’s no reimbursement associated with that today, we believe continuing to demonstrate the outcomes and the value of this will be something that, hopefully, CMS will take a look at in the long run,” he said.
Aside from lessons learned, the three Financial Management Conference panelists shared a sneak peek of what they will be prioritizing in their companies’ annual budgets for 2022.
One common theme among the home health leaders — technology.
Kindred at Home’s focus will also be on redesigning the company’s clinical innovative programs.
“We will be focusing on building out new clinical design programs that will have a lot of the technology associated with it,” Causby said. “We’re already starting to look at how we would redesign those clinical innovative programs to possibly care for seniors over a much longer period of time. The ability for these patients not to have to end up back in the ER or an acute setting will change how clinicians think about being task-oriented.”
On the vendor side, all of this means budgeting for more growth.
“As a technology provider, we are budgeting for even more growth next year,” John Olajide, founder and CEO of Axxess Technology Solutions, said at the event. “We’re continuing to hire as our business grows rapidly, not just in the U.S. but globally as well. We’re also continuing our strategic partnerships around expanding all our interoperability solutions to ensuring that our clients are positioned for success long term.”
Additionally, John Hopkins Home Care Group has plans to invest heavily in skilled-nursing-at-home models and hospital-at-home models.
– W2O announced today the acquisition of Discern Health, a leading healthcare consultancy based in Washington, DC, and Baltimore, to strengthen its strategic capabilities in assisting clients with critical healthcare policy trends and value-based reimbursement models.
– Discern Health brings experts with decades of experience in quality, health care measurement, and payment models to W2O’s analytics-driven, technology-enabled marketing and communications solutions. Leaders from Discern come from companies and organizations like the Centers for Medicare & Medicaid Services (CMS), National Quality Forum (NQF), and the National Committee for Quality Assurance (NCQA).
W2O, the leading independent provider of analytics-driven, technology-enabled marketing, and communications solutions to the healthcare sector, today announced the acquisition of Discern Health. This health economics and outcomes research (HEOR) consulting firm provides strategic direction and policy solutions to life sciences companies, government and nonprofit agencies, and health insurers. Financial details of the acquisition were not disclosed.
Discern Health Background/Capabilities
Discern Health counsels leading healthcare organizations on
the performance measures and innovative payment models that shape the market
for their products and services. Discern Health also works closely with
organizations to strengthen and quantify clinical and real-world evidence
strategies that inform ongoing market access and commercialization initiatives.
Discern Health’s staff previously held roles within leading organizations
including the Centers for Medicare & Medicaid Services (CMS), the National Quality
Forum (NQF), and the National Committee for Quality Assurance (NCQA). Discern
has offices in Baltimore and Washington, D.C., further expanding W2O’s presence
with now nearly 100 people dedicated to these increasingly important health
care is a key driver of health system change,” said Guy D’Andrea, Founder
and Managing Partner of Discern Health. “To be successful, health care
companies need to integrate value-based strategy into each level of their
organization and each stage of product development.”
Today’s announcements marks the sixth acquisition W2O has
completed since the company announced its partnership with New Mountain Capital
just over a year ago. W2O’s approach to growth is to add experts and
capabilities that its clients recommend. This approach continues to strengthen
W2O’s offerings and positions the company as a go-to partner of choice to help
clients accelerate clinical trials, achieve commercial success, and navigate
and engage all their stakeholders in an increasingly virtual, social and
digital post-COVID-19 pandemic reality.
Why It Matters
“Value-based metrics, the continued need for real-world data integration, and the changing landscape of federal, state and international health policy in the face of the COVID-19 crisis are impacting healthcare faster than ever before,” said Rita Glaze, Practice Leader, Commercial Strategy and Market Access at W2O. “Our clients need ongoing evidence-generation strategies that mirror the market dynamics they are facing, along with up-to-the-minute insights and counsel. This information is vital to guide policy positions and commercial decisions that will unlock maximum value for their products, solutions and services. With Discern Health as part of our organization, we will continue to raise the quality and depth of our data and analytics offering, to ensure it stands up to the scrutiny of peer and government review. We will truly be #BetterTogether.”
The Discern team will operate under W2O’s single, integrated
profit and loss (P&L) operation, with access to all of W2O’s proprietary
data models and tools as well as its 1,400 person strong multidisciplinary team
– including data analysts, scientific strategists, branding experts,
communications specialists and creatives – to build unfair advantage for
clients and their brands. Additionally, the Discern leadership team will remain
Reversing a three-year decline, the number of people covered by Medicaid nationwide rose markedly this spring as the impact of the recession caused by the outbreak of COVID-19 began to take hold.
Yet, the growth in participation in the state-federal health insurance program for low-income people was less than many analysts predicted. One possible factor tempering enrollment: People with concerns about catching the coronavirus avoided seeking care and figured they didn’t need the coverage.
Program sign-ups are widely expected to accelerate through the summer, reflecting the higher number of unemployed. As people lose their jobs, many often are left without workplace coverage or the money to buy insurance on their own.
Medicaid enrollment was 72.3 million in April, up from 71.5 million in March and 71 million in February, according to the latest enrollment figures released last week by the Centers for Medicare & Medicaid Services. The increase in March was the first enrollment uptick since March 2017.
About half of the people enrolled in Medicaid are children.
The increases varied widely around the country. Kentucky had the largest jump at nearly 7% from March to April. In addition, enrollment rose to 1.4 million in April from 1.2 million in February, according to the CMS data. That has continued, and today it’s up to 1.5 million, state officials said in an interview.
Kentucky has an aggressive outreach strategy using email or phone calls to contact thousands of residents who applied for state unemployment insurance, designed to make sure they know about Medicaid. “It’s been very effective, and in the past few weeks we’ve been enrolling 8,000 to 10,000 people a week,” said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services, which oversees Medicaid.
The Bluegrass State has also made enrollment easier by developing a one-page online form instead of having people fill out a 20-page application, he added.
“This is the right thing to do to help people get signed up for health care coverage and it supports the health industry in our state,” Friedlander said. “The health industry would collapse without Medicaid.”
Joan Alker, executive director of the Center for Children and Families at Georgetown University in Washington, D.C., said she expects Medicaid enrollment to keep rising this summer. “Given that there are no signs that the virus is coming under control anytime soon, job losses will become more permanent, and more folks will become eligible for Medicaid over time,” she said.
One reason Medicaid numbers have not grown faster, she suggested, is because people have more immediate needs than securing health coverage, especially if they are feeling well.
Many people are worried about getting unemployment insurance or getting evicted from their home, she noted. “That’s combined with the fact that many people are reluctant to go to their doctor because of safety concerns,” she said. “And, as a consequence, applying for Medicaid may not be at the top of their list.”
Chris Pope, a senior fellow at the Manhattan Institute for Policy Research, a conservative think tank, said the slower-than-expected growth in Medicaid could signal that people who were laid off had coverage through a spouse or a parent.
In addition, he said, “many jobs that went away did not offer health insurance,” citing millions of service-sector positions in industries such as hotels and restaurants that have been lost.
Beyond the surge in unemployment, Medicaid rolls have risen because states cannot discontinue coverage to people enrolled as of March 18, 2020, as a condition of receiving higher federal Medicaid funding included in a coronavirus relief package passed by Congress.
Medicaid is a countercyclical program, meaning enrollment typically rises during an economic downturn. But that forces states to face the fiscal challenge of paying for their share of the program even as tax revenue dries up.
An exception to this rule was the jump in enrollment starting in 2014 when the Affordable Care Act allowed states to expand Medicaid to cover everyone with incomes below 138% of the federal poverty level, or about $17,609 for an individual this year.
Enrollment soared by about 15 million people from 2014 to 2017, peaking at about 75 million as nearly three dozen states expanded the program. Since then, a strong economy and steadily declining unemployment levels led to a drop in Medicaid rolls until April.
Nevada and Oklahoma posted nearly 4% enrollment growth rates between March and April’s data.
Florida’s Medicaid numbers jumped to 3.7 million in April from 3.6 million in March, nearly a 2.5% increase, the CMS data showed. Since then, Florida data shows enrollment has topped 4.1 million.
The Trump administration has been criticized by consumer advocates for not establishing a national campaign to promote Medicaid during the economic downturn and health crisis.
One indicator that Medicaid enrollment is still going up is the growing number of recipients in managed care plans in 16 states that reported data from March to May. Those plans have increased by a total of nearly 4%, according to a KFF report. (KHN is an editorially independent program of KFF.) Most states have shifted many of their Medicaid enrollees into these private health plans.
KFF estimated that nearly 13 million people who became uninsured after losing their jobs in March are eligible for Medicaid.
Robin Rudowitz, a KFF vice president, said there is typically a lag time of weeks or months before people who have lost their jobs and health coverage seek to enroll in Medicaid. The impact on Medicaid enrollment also lasts well after the immediate effect of a downturn, she said.
Federal watchdogs are once again setting their sights on perceived improper billing practices by home health agencies.
In an audit report published last week, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) found that stronger oversight of Low Utilization Payment Adjustments (LUPAs) in home health care could have saved the government roughly $192 million in fiscal year 2017.
Instead, the Centers for Medicare & Medicaid Services (CMS) and the Medicare administrative contractors (MACs) it worked with allowed some agencies to shirk LUPA thresholds, receiving full reimbursement when they should have received a lesser, standardized per visit payment, according to OIG investigators.
To conduct its audit, OIG’s team looked at $1.25 billion in Medicare payments to home health agencies in 2017. It then selected a stratified, random sample of claims from 120 agencies that delivered just enough visits to avoid triggering a LUPA.
OIG’s audit occurred when the old Prospective Payment System (PPS) was in place. Under that now outdated payment methodology, a home health agency triggered a LUPA if it delivered four or fewer visits during an episode of care.
For any agency, being hit with a LUPA claim could mean hundreds or even thousands of dollars less in Medicare reimbursement.
“Because of the large payment increase starting with the fifth visit, [home health agencies] have an incentive to improperly bill claims with visits slightly above the LUPA threshold,” investigators wrote in their report.
That remains true under the new Patient-Driven Groupings Model (PDGM), which created a more complex framework for how LUPAs are handled.
While the old PPS included a universal threshold of “four or fewer visits,” PDGM moves the LUPA goalposts around depending on patient characteristics, referral sources and a variety of other factors. Today, every one of PDGM’s 432 case-mix groups has its own LUPA threshold, ranging from two to six visits.
Despite the change in payment methodology, OIG believes its findings that home health agencies are improper billing to avoid LUPAs would likely remain true under PDGM.
“The majority of the claims in our sample that did not comply with Medicare requirements under the previous PPS methodology would also have not complied with those requirements under the new methodology,” investigators observed.
OIG’s random sample of 120 claims all included five, six or seven visits in a payment episode — the bare minimum needed to avoid a LUPA in 2017. To determine whether those extra visits were actually needed, OIG enlisted an independent medical-review contractor to look at medical necessity and coding requirements.
Of the 120 sampled claims, 91 complied with Medicare requirements, meaning a full episodic payment was warranted.
But another 25 claims did not comply with requirements, according to the medical-review contractor. The remaining four claims did not have documentation available to make a compliance determination.
In one example, a home health agency was paid $3,131 for an episode of care that included seven visits. However, five of the seven visits did not meet Medicare requirements, meaning the agency should have been hit with a LUPA and only paid $389.
Delivering services to beneficiaries “who were not confined to the home” was the most common reason for agencies not meeting Medicare requirements, OIG investigators found.
In part, the alleged improper payments occurred because the MACs CMS worked with in 2017 did not aggressively look into home health agencies that delivered just enough visits to avoid a LUPA.
One MAC that did conduct reviews was instructed by CMS to instead focus on the Targeted Probe and Educate (TPE) program.
Moving forward, OIG recommends that CMS first direct MACs to recover all perceived overpayments made to home health agencies in its sampled claims — $41,613 in total. Additionally, OIG believes CMS should require all MACs to perform data analysis and risk assessments of claims with visits slightly above the applicable LUPA threshold and target these claims for further review.
More generally, MACs should also start educating home health agencies on properly billing for home health services with visits slightly above the applicable LUPA threshold.
CMS concurred with those recommendations.
Red flags and contradictions
There are multiple red flags and apparent contradictions within OIG’s LUPA report.
On a basic level, the OIG report does not take into consideration CMS’s messaging on LUPAs during the transition to PDGM.
In putting the payment overhaul together, CMS anticipated that home health agencies would do everything possible to “upcode” and avoid LUPAs whenever possible, for instance.
“CMS is almost giving people a license to add visits and code upwards — and that’s not conduct that should be encouraged,” National Association for Home Care & Hospice President William A. Dombi previously told Home Health Care News. “I think the message has been pretty clear to agencies.”
Moreover, a major issue OIG had in its audit was the “homebound requirement” in home health care — or the stipulation that home health patients need to be stuck at home and unable to leave unassisted to be eligible for service. For years, home health insiders viewed that homebound requirement as inherently flawed, hurting patients and providers alike by diminishing access to care.
Maine Senator Susan, a Republican, is among those who have criticized the homebound requirement.
“Right now under Medicare, the definition of homebound is extremely strict,” Collins told HHCN in March 2019. “It says that the patient cannot leave home without — I believe the phrase is — a considerable and taxing effort. There are other beneficiaries who could benefit from home health care if we did not apply such an onerous restriction.”
– Sharecare acquires WhiteHatAI to provide health plan
and provider clients with additional capabilities to ensure healthcare payment
– WhiteHatAI’s ability to detect erroneous claims before
they are paid will help Sharecare’s health plan partners reduce costs
associated with FWA.
– Sharecare will integrate WhiteHatAI’s capabilities to
foster deeper engagement by enabling patients to both verify recent medical
procedures and report satisfaction.
digital health company that helps people manage all their health in one
place, today announced its acquisition
of WhiteHatAI, an innovator
intelligence (AI) healthcare payment integrity applications. WhiteHatAI
marks Sharecare’s 16th acquisition; financial terms of the
deal were not disclosed.
WhiteHateAI Acquisition Benefits for Sharecare
Over the last several years, Sharecare
has introduced a range of capabilities and services to
support payers’ and providers’ workflows –
including digital clinical data solutions and medical
records management; quality, performance and risk-adjustment tools; and
billing contract compliance. Given traditional retrospective systems
fail to recover 99% of erroneously paid medical claims, WhiteHatAI’s
ability to detect erroneous claims before they are paid will help
Sharecare’s health plan partners reduce costs associated with FWA.
Additionally, these capabilities better position Sharecare’s provider
clients to succeed in value-based environments by enabling more timely
payments and fewer claim denials – resulting in cash flow generation
and better revenue
Impact of FWA in Healthcare
“Fraud, waste and abuse in our healthcare system is already a $900 billion problem, which – prior to the pandemic – was expected to increase 6.5% annually through 2024; but given the necessity to fast-track claims in the face of COVID-19, this challenge is likely to grow even bigger, faster,” said Jeff Arnold, founder, chairman and CEO of Sharecare. “By acquiring WhiteHatAI and integrating their suite of AI-driven capabilities across our portfolio, we are bringing industry leading innovation to our payer and provider client partners that will help them not simply detect FWA but do so before it occurs, thus increasing efficiency and accuracy throughout healthcare organizations.”
WhiteHatAI Integration with Sharecare App
WhiteHatAI’s proprietary AI-driven platform also will
empower providers to extract unstructured clinical data from medical
charts – which can contain meaningful insights not available in the
structured record – and enable the identification and calculation of
CMS quality measures. Additionally, as the digital health company partners with physician practices to help
patients manage their own health day-to-day between office
visits with the Sharecare app, it will integrate WhiteHatAI’s
capabilities to foster deeper engagement by enabling patients to both
verify recent medical procedures and report satisfaction. Sharecare
can then message users based on the treatment or care plan addressed during the
medical visit, thereby improving outcomes and lowering the cost curve.
“Sharecare has a track record of innovation and collaboration unlike any other digital health company, and we are excited to merge our expertise in AI and healthcare payment integrity with their ability to convene, rally and engage people, providers and payers in improving health and well-being,” said Pete Ransome, CEO of WhiteHatAI. “Joining the Sharecare family enables us to capitalize on our ability to combat the prolific and fast-growing problem of fraud, waste, and abuse in healthcare, which will save millions of dollars for our collective clients and, ultimately, advance patient care and satisfaction.”
When the U.S. Centers for Medicare & Medicaid Services (CMS) announced that the Review Choice Demonstration (RCD) would resume for participating states in August, home-based care providers and advocates were up in arms over the decision.
But as the resumption date approaches, industry advocates are making a last-ditch effort to get CMS’s attention and persuade regulators to reconsider the move.
“I think it’s one of the most heartless, callous and hypocritical decisions that CMS could make at this time,” Tim Rogers, the president and CEO of the Association for Home & Hospice Care of North Carolina, told Home Health Care News.
RCD states include Illinois, Ohio, Texas, North Carolina and Florida. The latter two are just being introduced to the improper billing initiative.
In part, the resumption of RCD is so brutal due to recent developments in the battle against the coronavirus. Both Florida and North Carolina have rising COVID-19 case trends,