– Today, CVS Health announced Symphony, a medical alert
system designed to keep seniors safe and connected at home.
– Symphony consists of a collection of in-home and wearable devices that offer a new at-home experience by connecting a suite of sensors that can monitor for falls, motion, and room temperature while also providing a 24/7 personal emergency response platform for use when needed.
CVS Health, today announced the release of Symphony medical
alert system to help caregivers monitor the safety and well-being of loved
ones, even from afar. This collection of in-home and wearable devices offers a
new at-home experience by connecting a suite of sensors that can monitor for
falls, motion, and room temperature while also providing a 24/7 personal
emergency response platform for use when needed. Symphony is designed to support
the growing number of seniors choosing to maintain an independent lifestyle at
home, as well as those involved in their care.
Spurred in part by COVID, as you may know, an increasing
number of seniors are choosing to “age in place.” But COVID has also
highlighted major challenges in staying connected to loved ones while socially
isolated. Enter Symphony…a collection of in-home and wearable devices that
are now available in approx. 650 CVSH HUBs and online.
Unlike other systems that require a wearable alert device,
Symphony includes a voice-activated Smart Hub that lets seniors call assigned
caregivers or emergency responders hands-free 24/7. Sensors placed around
the house can monitor motion, temperature, and air quality and alert caregivers
of anything out of the ordinary through a free caregiver smartphone app.
Symphony system also provides alerts for falls or other emergencies and can
assist with facilitating care coordination when needed.
Symphony is the latest example of ways in which CVS Health is supporting seniors at home. Organizations like SilverSneakers® are providing virtual exercise classes to help seniors stay active from the comfort of their homes. And Aetna partnered with the companionship benefit company Papa, Inc., to connect Medicare Advantage members with college-age individuals who can provide remote companionship through the telephone. These are in addition to more traditional services, like virtual care, and SDOH resources like grocery delivery, housekeeping, and others.
Designed to fit a family’s specific needs and adapt to a variety of homes, two easy-to-use Symphony device options are available: the Basic Bundle and Essential Bundle. While both systems come equipped with the Smart Hub and a wearable care button, the Essential Bundle also includes motion sensors and a voice-activated Fall Sensor to automatically detect falls in the bathroom, where the majority of accidents occur. Complementary devices are available for both bundles if desired, including additional motion sensors to extend the range of coverage in larger homes, and entry sensors for use on doors, cabinets, or windows.
Pricing starts at $149.99 for the Symphony Basic Bundle and
$249.99 for the Essential Bundle. A monthly service fee is required, although
no long-term contract is needed to activate. Once activated, each Symphony
bundle can help support safety at home as well as in the event of an emergency.
“We’re committed to helping consumers on their path to better health and new consumer health innovations like Symphony can help give caregivers peace of mind as they monitor a loved one’s safety and well-being through a truly differentiated connected health approach,” said Adam Pellegrini, SVP of Enterprise Virtual Care & Consumer Health at CVS Health.
Medicare Advantage enrollment has grown rapidly over the past decade, and Medicare Advantage plans have taken on a larger role in the Medicare program. More than 24 million Medicare beneficiaries (36%) are enrolled in Medicare Advantage plans in 2020. This data analysis provides updated information about Medicare Advantage enrollment trends, premiums, and out-of-pocket limits. It also includes analyses of Medicare Advantage plans’ extra benefits and prior authorization requirements. The analysis also highlights changes pertaining to Medicare Advantage coverage that have occurred in 2020 in response to the COVID-19 crisis.
– Net Health acquires post-acute market analytics platform PointRight to deepen the company’s analytics capabilities, post-acute presence, and support for SNF networks.
Health, a provider of cloud-based software for specialty medical providers
across the continuum of care, today announced that it has acquired PointRight Inc., a leading provider of
analytics and data-driven tools for the post-acute market. The acquisition adds
to Net Health’s expanding investments in analytics capabilities, which include
the recent acquisition of Tissue Analytics in April 2020 and the earlier
acquisition of Focus on Therapeutic Outcomes (FOTO).
Unlock the Power of Advanced Analytics for Post-Acute
Founded in 1995, PointRight provides analytics that shows a 360⁰ view of long-term and post-acute (LTPAC) facility performance and clinical outcomes. Equipped with these insights, LTPAC Provider and Payers can lower rehospitalization rates, improve clinical outcomes, and build and manage high-performing networks. Today, close to 2,400 SNFs use PointRight’s advanced analytics and data-driven decision support tools to further their clinical, financial, and operational objectives.
SNFs use PointRight to improve the accuracy of their reimbursement and regulatory submissions and to enhance overall performance in readmissions, quality, and outcomes, including more accurate and compliant patient assessments, reduced rehospitalization rates, and optimized care transitions.
More recently, health systems, ACOs, payers, and real estate investment trusts (REIT) have relied on PointRight to provide insight into the health of their SNF networks and to identify areas for improvement.
Acquisition Expands Net Health’s
Market Share in Growing Post-Acute Market
acquisition of PointRight expands Net Health’s position and scale in the
growing post-acute market. Additionally, the acquisition will enable Net
Health’s broad roster of hospital clients to better manage their skilled
nursing facility (SNF) networks and support outcomes measurement and performance
improvement in Medicare Advantage and managed Medicaid programs. As part of the
acquisition, Net Health
plans to fully integrate PointRight staff to accelerate the delivery of new
analytics solutions and expand the availability of PointRight to Net Health’s
customers and markets.
“Through PointRight, Net Health will significantly expand how we support SNFs and their health system, accountable care organization (ACO), payer and REIT partners,” said Josh Pickus, Net Health’s Chief Executive Officer. “It also strengthens our growing analytics capabilities by providing insights into post-acute performance, which enables providers and payers to align around value-based care initiatives.”
Financial details of the acquisition
were not disclosed.
The majority of health care financial leaders view home care as a key area of investment.
That’s according to a recent survey from BDO, a Chicago-based accounting, tax, financial advisory and consulting organization. Released Monday, the survey includes the responses of 100 CFOs at U.S. health care organizations, including home health providers, with revenues ranging from $250 million to $3 billion.
Specifically, 12% of the CFOs surveyed were leaders at home health or hospice organizations.
The COVID-19 virus is among the drivers making home care a priority. One of the impacts of the public health emergency is that it forced many health care organizations to reevaluate their areas of focus and specialties in order to address patient needs.
When looking toward 2021, 59% of surveyed CFOs identified home care as a priority investment.
This finding further suggests that home-based care providers demonstrated their value in delivering care during the past several months. As the U.S. still faces ongoing COVID-19 surges, the demand for home-based care will likely continue to grow.
“The home health setting has seen many significant contributions to the value-based care supply chain,” Steven Shill, partner and national leader of the BDO Center for Healthcare Excellence & Innovation, told Home Health Care News in an email. “I think the pandemic has just served to confirm an already valuable process.”
Aside from home care, 56% of surveyed financial executives identified elder care as a priority investment.
Another 77% of CFOs said they’re looking to fund primary care.
“A significant number of in-home primary care users are the elder population,” Shill said. “As there is a transition to Medicare Advantage, you will see an acceleration of in-home primary care. The reason is that, when a physician, nurse or [physician’s assistant] visits higher-risk patients in their homes, patients are less likely to need emergency room visits, acute care hospitalizations or institutionalization in a [skilled nursing facility] for example. This will likely reduce the overall costs.”
In addition to identifying key investment areas, the survey also touched on emerging trends. From an M&A perspective, for example, 42% of surveyed CFOs said they believe the COVID-19 emergency will cause increased consolidation throughout health care.
In fact, many health care organizations went into the public health emergency with already weakened balance sheets, according to Shill.
Many have been able to stay afloat thanks to the Paycheck Protection Program (PPP) and CARES Act funding, but eventually, those wells will run dry.
“The focus on consumerism, the move towards value-based care and a major drive toward digitization in health care — trends that existed prior to the pandemic — all contributed to consolidation,” Shill said. “Many health care organizations pre-pandemic did not have the resources to address these trends, which in turn caused them to have weakened positions in the marketplace, increasingly inefficient operations and significant losses to patient volumes, all ultimately resulting in them becoming financially weakened and forcing them to either merge, be acquired or shut down.”
Additionally, BDO’s survey found that partnerships will likely take center stage in 2021.
About 31% of surveyed CFOs said they had plans to acquire physician practices. Another 28% said they planned on merging with another organization, with 24% planning to form a joint venture.
In the home-based care space, this move toward partnerships could be a business opportunity for providers.
“The home health sector has historically been heavily fragmented, often lacking professional leadership and appropriate levels of capital investment,” Shill said. “That is why, in the few years prior to the pandemic, it was getting a lot of attention from private equity. As institutional health care continues focusing on value-based care and overlaying it with the impact of the pandemic, it would seem that this type of partnership will likely see an acceleration.”
BDO’s survey was conducted by Rabin Research Company, an independent marketing research firm.
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.”
The health system and payer will coordinate care for eligible Medicare Advantage patients through the ACO, with the aim of improving health outcomes and reducing costs. The ACO expands a long-standing relationship between the two entities.
In this brief, we analyze third quarter data from 2018 to 2020 to examine how insurance markets performed financially through the end of September. Average margins remained relatively high compared to the same point in recent years, suggesting many insurers remained profitable even as non-COVID-related care returned in the summer and fall.
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.
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
As mission-driven organizations, SCAN Group and SCAN Health Plan have leaned into trying to solve some of health care’s biggest problems. In particular, keeping seniors independent and healthy at home has been a major area of focus.
SCAN Group is a nonprofit organization focused on helping older adults age in place. Founded in 1977, Long Beach, California-based SCAN Health Plan is one of the nation’s largest not-for-profit Medicare Advantage plans, serving more than 200,000 members.
In June, Dr. Sachin Jain took the helm as CEO and president of SCAN Group. When coming on board, Jain — who previously served as CEO of Aspire Health and CareMore Health — saw an opportunity to take on problems that other organizations in its position may not attempt to tackle.
“I had a tremendous experience leading Aspire and CareMore but felt like I could do more for the U.S. health care system writ large from a platform like SCAN, which is very ambitious in its bones,” Jain told Home Health Care News.
As of late, SCAN Group has zeroed in on addressing the “digital divide” through its HEALHtech benefit.
In light of the COVID-19 emergency, telehealth has emerged as a critical means of delivering care services. Home health providers, for example, have embraced virtual care more than ever before.
Despite telehealth’s role in providing safe care delivery during the pandemic, SCAN Group noticed that, for some seniors, a lack of comfort with digital technologies became a barrier to receiving these services.
“We recognize the need,” Josh Goode, CIO of SCAN Health Plan, told HHCN. “Our seniors were being forced into this digital world, and there is a digital literacy gap. We see a lot of older adults who are, what I would consider, tech-savvy, but there is still a pretty sizable population that is struggling in a digital world.”
SCAN Group’s HEALHtech benefit offers its members free tech support. This can include things like setting up email accounts or installing video conference technologies.
As part of the benefit, the organization also helps older adults learn to navigate their providers’ online health systems.
The benefit has its origins in a technology support line SCAN Group set up for its members after the onset of the COVID-19 emergency.
“We did a pilot where we would triage the calls of those members that were needing support, accessing a telehealth visit or anything else — from a digital standpoint — to help enable them getting care in the home,” Goode said. “We would support them, and it’s been wildly successful.”
The benefit is still in the pilot phase but will officially be available in 2021.
The current embrace of telehealth during the COVID-19 emergency will be the new normal moving forward. That’s because 2020 has allowed providers to become more comfortable with this form of care delivery, according to Jain.
“I think it’s a little bit of an unknown, in terms of what form or fashion, or how widely adopted it will be, but I think [telehealth] is here to stay,” he said. “Obviously, reimbursement plays into this. We’ll see what happens in the long run, but … everybody recognizes the need to deliver care in the home and break down those barriers to access. People are recognizing how effective telehealth can be.”
Looking ahead, SCAN Group will continue to make home-based care a priority.
“We believe that the home is where most people want to stay,” Jain said. “We believe that bad things happen to seniors when they actually step out of their homes to access care. They are exposed to hospital-acquired infections. The orientation of SCAN has always been around [keeping] people in the home.”
To this end, the organization is in the process of launching a home-based geriatric primary care medical group that will include hospital-at-home and primary care services.
“We believe that geriatrics is a medical specialty whose time has really come,” Jain said. “Historically, geriatrics has been something that has been made available to seniors after they’ve had a primary care relationship with someone for a while And as a result, very few patients actually transition in their older age from primary care to geriatric care.”
SCAN Group also has plans to enter the palliative care space. Additionally, the organization is focused on building innovative solutions to address homeless seniors.
The public comment period has just closed for the calendar year (CY) 2022 Medicare Advantage (MA) and Part D Advance Notice recently released by the Centers for Medicare & Medicaid Services (CMS). MA plans can expect an average 2.82% bump in revenue in 2022, according to Part II of the notice, up from 1.66% for CY 2021. To follow are four key takeaways from Cotiviti’s analysis of the 2022 Advance Notice.
Home-based care company Prospero Health announced Tuesday it is expanding into 16 additional states to serve 8,000 new patients in 2021.
That vastly increases the company’s footprint. Previously just in 10 states, the move now puts Prospero into 26 states total, allowing it to serve 25,000 patients on behalf of its partners, namely the Medicare Advantage insurer UnitedHealthcare.
The Boston-based company offers both non-medical home care and home health care services through a team of doctors, nurses and social workers. It also provides telehealth support for its patients and helps mitigate environmental hazards for seniors, such as fall risks at home.
“The pandemic accelerated the need for the services we provide,” Prospero President Dr. Dave Moen told Home Health Care News. “And our ability to do work virtually, as well, allowed us to expand into geographies that were previously not reachable by an in-person model.”
Founded in 2019, Prospero’s original plan was not to move this fast. But as of July, the average age of the patients Prospero was serving was 83 years old.
COVID-19 brought with it extenuating circumstances that kept seniors in their homes and insurers scrambling to figure out ways to keep them healthy.
“UnitedHealthcare, our biggest customer, saw that our results were solid,” Moen said. “And they were very confident that we had a team in place to actually be able to deliver a high-quality product. It was really about building trust and credibility with our customers.”
“It was about them seeing results that met their goals of high member satisfaction, and decreases in unnecessary hospitalization and ER visits,” he added, noting there are ample tailwinds for all forms of home-based care.
Prospero is based in Boston, but a large chunk of its employees are based in Memphis, Tennessee. This past summer, it began expanding in southern states, including Alabama. The company does not open brick-and-mortar offices when it expands, but instead leverages scheduling software programs that match patients’ needs with the right clinicians in their area.
When it did begin serving Alabamans, the company was already working on its next move and surveying the landscape for what came next. Now, Prospero is set to be in nine more states by Jan. 1 — and the majority of states in the U.S. by the end of 2021.
When considering expansion, Prospero is “very informed” by UnitedHealthcare’s membership data, as well as its own algorithm identifying the types of patients that are best served by its offerings, Moen said. Its virtual capabilities have given the company the confidence to move into markets that have less dense populations, but still have seniors with qualifying needs.
“When we look at [strictly] in-person visits, there’s a certain density that allows us to reach a certain number of people that allows us to staff appropriately,” Moen said. “The virtual model allows us to reach a lower-density geographies.”
An example of lower-density geographies is rural areas, which have traditionally dealt with issues when it comes to access to health care.
Earlier in 2020, Prospero partnered with the technology company GrandPad, which provides tablets specifically built for people over the age of 75. GrandPad helps Prospero facilitate its live video chats with patients.
In Memphis, the company has also invested heavily in its Care Support Center.
In order to expand as quickly as it has, Prospero has had to build goodwill with staff across the country in a hurry.
As part of its care plan strategy, nurse practitioners do all the initial evaluations on patients, either virtually or in person. After that, an interdisciplinary team comprised of physicians, nurses and social workers meets to discuss the patients’ needs.
“We assign patients based on their needs, and then we risk stratify and segment them,” Moen said. “Some patients are followed by a nurse practitioner, some are followed by an RN. And those two roles are supported by a physician or social workers who were brought in as appropriate for those patients.”
The key to any company’s growth is to be able to build and sustain workers across the country.
Moen is bullish on the tailwinds for home-based care persisting, especially when it comes to staffing. It’s his belief that building a workforce will be easier moving forward due an increased interest for working in what he’d call “a purpose-built care delivery model” for the elder population.
“We’re big enough that workers can now talk to our team members who have worked with us long enough to give them a true report of what it’s like to work in a company like this,” Moen said. “And we’re fortunate that we are off to a good start.”
Prospero is still in a position where it’s fielding multiple applicants for its open positions, which is a welcoming sign for the company in terms of its future outlook.
“I think, professionally, lots of people are interested in finding a career that has a deeper meaning and a deeper connection to what they care about,” Moen said. “The mission is compelling because people see the need. I think as we continue to establish credibility and tenure in the space — and people see it not as an under-supported career, but a very intentional, purposeful career — I do think that it’ll create more momentum in attracting more workers into this part of care delivery.”
The health insurer and Michigan-based physician organization are partnering to expand access to in-network care for around 40,000 individual and group Medicare Advantage plan members. The partnership will go into effect Dec. 1.
CVS Health named a new CEO in its earnings call on Friday. Between plans to further integrate its pharmacy and insurance businesses, and discussion about how a Covid-19 vaccine would be distributed, here are four other things the company is preparing for in the coming months.
A number of major Medicare Advantage (MA) carriers are expanding their supplemental benefit offerings shaped around in-home care next year. UnitedHealthcare, the insurance arm of UnitedHealth Group (NYSE: UNH), is among them.
Overall, UnitedHealthcare partners with more than 1.3 million physicians and care professionals across the U.S., plus another 6,500 or so hospitals and other care facilities. In 2020, UnitedHealthcare had more MA enrollees than any other group.
“We know the majority of older adults want to stay in their homes and communities as they age, and UnitedHealthcare continues to design plans that place the home at the center of health care support and delivery,” Steve Warner, senior vice president of Medicare Advantage in UnitedHealthcare’s Medicare & Retirement division, told Home Health Care News.
America’s largest health insurers — UnitedHealthcare, Humana Inc. (NYSE: HUM), Aetna, Blue Cross Blue Shield plans and others — have built out their home strategies in a variety of ways.
In some cases, that has meant the launch of internal in-home primary care and remote monitoring programs to better track members’ social determinants of health. In others, it has meant partnering with in-home care providers to offer the types of new supplemental benefits that the U.S. Centers for Medicare & Medicaid Services (CMS) has increasingly signed off on over the past few years.
“The interconnectedness of the health care system means that every touchpoint along a consumer’s health care journey is important,” Warner said. “Particularly for high-risk individuals and others who depend on a variety of needs being addressed from home, the people who provide these services are an integral piece of a shared community of support.”
On its end, UnitedHealthcare says it’s doing more than ever to support health and wellness from the comfort, safety and convenience of the home.
In 2021, most of its plans, for example, will include HouseCalls, a program that offers Medicare and Medicaid members a yearly in-home visit with a licensed clinician. The company expects to complete nearly 1.7 million HouseCalls visits for members in 2020.
HouseCalls has been particularly valuable during the COVID-19 pandemic, too, with the number of home visits in the third quarter growing by nearly 30% year over year, according to UnitedHealth Group CFO John Rex, who addressed the topic during an Oct. 14 earrings call.
“We continue to deepen our engagement with those seniors most in need, increasing the distribution of remote digital sensor kits to collect and monitor vital health data and address gaps in care generated by the pandemic,” Rex said at the time.
‘Health is more than medical care’
Apart from its HouseCalls program, at least six UnitedHealthcare plans are offering in-home support services under the “primarily health-related” supplemental benefit pathway in 2021, according to state-level data compiled by Washington, D.C.-based research and consulting firm ATI Advisory.
In comparison, only two UnitedHealthcare plans offered in-home support services supplemental benefits this year.
Geographically, the two UnitedHealthcare plans offering in-home support services in 2020 covered slightly more than two dozen counties. Next year, the six plans doing so will cover more than 250 counties, according to ATI Advisory’s data.
“They have made a very significant, clear increase in the coverage,” ATI Advisory CEO Anne Tumlinson told HHCN. “I think it speaks a lot to the power of these benefits.”
Overall, 429 MA plans will offer in-home support services across 36 states and Puerto Rico next year. Many more will also likely offer home-focused supplemental benefits through the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway in 2021.
These trends in supplemental-benefit design are, in part, linked to the realization that a large chunk of a person’s health is ultimately impacted by functional ability and social factors, including access to food, friends and transportation.
“We know that health is more than medical care, and that factors outside a doctor’s office play a significant role in influencing a person’s health and well-being,” Warner said. “This reality factors into how we design our plans and support older adults.”
UnitedHealthcare isn’t just coordinating and covering services that take place within its members’ homes.
At times, it’s even helping to provide the home in the first place.
“At an enterprise level, UnitedHealthcare continues to make significant investments in affordable housing as part of the company’s ongoing efforts to remove social barriers to better health for people in underserved communities,” Warner said.
Since its affordable housing initiative kicked off in 2011, the company has worked with a range of advocates to invest more than $500 million in developments that increase access to housing, health care and social services.
Telehealth is ‘here to stay’
The U.S. tallied 91,530 new COVID-19 infections on Election Day, adding to the skyrocketing cases numbers reported in the past week.
The COVID-19 pandemic is changing the health care landscape, Warner recognized, but it isn’t altering UnitedHealthcare’s commitment to helping members access the care they need. That’s true whether they reside in a clinical setting or at home, he added.
To maintain that commitment, UnitedHealthcare has turned to more telehealth solutions.
“In just one month earlier this year, for example, more than 12% of our UnitedHealthcare Medicare members had a telehealth visit with their doctor – up from just a fraction of a percent last year,” Warner told HHCN.
In 2021, all standard MA plans from UnitedHealthcare will offer telehealth visits with a $0 copay.
“As in-person visits resume, telehealth utilization is moderating, but remains significantly higher than the pre-COVID baseline,” Warner said. “We believe higher utilization and increased comfort level in embracing telehealth is here to stay.”
Humana Inc. (NYSE: HUM) continues to shift its operations toward value-based care payment models, both with internal service lines and with external provider partnerships. The Louisville, Kentucky-based insurance giant is also doubling down on social determinants of health at the same time.
Those are just a couple key takeaways from a Tuesday conference call with investors and analysts to discuss Humana’s third quarter financial results.
With full-year expected individual Medicare Advantage (MA) growth of about 375,000 members, Humana is one of the largest MA entities in the nation. In addition to its MA business, Humana oversees a vast collection of in-house health care services, many of which are wrapped around the home.
“The Medicare Advantage program incentivizes a holistic focus on health,” Humana President and CEO Bruce Broussard said during the call. “And because of this, it offers an opportunity for private organizations like Humana to partner with providers on value-based care models customized to meet both the unique dynamics of the local market and the risk tolerance of a given provider.”
Currently, about two-thirds of Humana’s individual MA members are cared for by providers in value-based arrangements. Of those arrangements, nearly one-third are for full risk, meaning a provider is responsible for the entirety of the member’s care for a capitated payment.
Generally, value-based care payment models pay providers for the value of their services instead of volume. While some providers have been hesitant to move away from the predictability of fee for service, most of the ones working with Humana on a value-based care basis have ended up making money.
In fact, 86% of Humana’s value-based care partners were in a surplus in Q3 2020, receiving a higher level of payment than they would have in a fee-for-service arrangement.
Internally, Humana’s provider organizations that are part of this value-based care shift include its senior-focused and payer-agnostic primary care centers launched through a strategic partnership with PE powerhouse Welsh, Carson, Anderson & Stowe (WCAS). They also increasingly include its Kindred at Home operations and its Conviva care centers, which are separate from the WCAS partnership.
“We do continue to also want to grow the value base from us building our clinics and our home health side,” Broussard said. “You see the Partners in Primary Care product, the Conviva product, along with some of our home solutions moving more and more to value-based payment models.”
Home health admissions
Humana expects to grow its individual MA membership by 350,000 to 400,000 members in 2021, which represents growth of about 9% to 10%, according to the company.
It likewise anticipates further building out its primary care network.
Despite operational challenges related to the COVID-19 pandemic, Humana has opened up five new Partners in Primary Care centers with WCAS in the Las Vegas market over the last 45 days. It plans to open another three centers in Las Vegas later this year or in Q1 2021, while also deepening its Houston footprint.
Combined with its Conviva clinics, Humana will operate about 160 clinics by the first quarter of next year.
Regarding Kindred at Home, home health admissions were adversely impacted by the COVID-19 virus in early spring. As the year progressed, however, volumes began to stabilize, Humana CFO Brian Kane said during Tuesday’s call.
“Early signs of a rebound in demand are beginning to materialize,” Kane said. “Further, the company has been able to offset these initial challenges with strong clinical and overhead cost controls across the organization.”
Humana reported consolidated revenues of about $20.08 billion for Q3 2020, up 24% compared to $16.24 billion in the same period last year. Revenue for Humana’s health care services segment, which includes Kindred at Home, totaled $7.13 billion in Q3 2020, up 8% compared to $6.60 billion in the prior year’s quarter.
Although the health insurance giant is preparing for a possible loss in Q4, its strong first half of 2020 should set it up for potential M&A opportunities, Kane suggested.
“We do have ample capital and flexibility, which we believe is important,” he said. “I would say that over the next few years, we expect to have a balanced capital-deployment strategy. We’re always on the hunt for M&A opportunities in the strategic priority areas that we’ve identified, whether it’s around the home, primary care or pharmacy.”
‘The smallest actions’
Among Humana’s most visible initiatives around addressing social determinants of health has been its partnership with Papa, the startup that connects isolated older adults and others with a “Papa Pal.”
The Miami-based Papa announced a Series B round of $18 million in September, with investment led by Comcast Ventures, Comcast Corporation’s investment arm. On its end, Humana began working with Papa in 2018.
The COVID-19 pandemic has further highlighted the importance of social needs, such as social interaction, Broussard said on the Q3 earnings call. In response to those needs, Humana has extended its program with Papa.
Broussard specifically shared the story of a Humana member named Otis.
While registering Otis for the Papa program, a case manager noticed it was his birthday. The case manager, in turn, began singing happy birthday to him over the phone.
“Otis was overcome with emotion, noting it had been years since someone had even wished him a happy birthday,” Broussard said. “Sometimes the smallest action can make a big difference in someone’s life. Programs like Papa are an important element in addressing the holistic needs of our members.”
The ongoing expansion of Medicare Advantage (MA), a federal minimum-wage hike and additional support for front-line health care workers during the COVID-19 public health emergency.
These are just a few of the industry-shaping topics that home health insiders are following going into Election Day this Tuesday. While each presidential election is important, 2020 will help set the trajectory of U.S. health care policy for years to come.
No matter who wins between President Donald Trump and former Vice President Joe Biden, one thing is clear: In-home care gained a larger role in the overall continuum of care this year — and that momentum isn’t going away.
To get a deeper understanding of the 2020 election and what it means for home-based care operators, Home Health Care News reached out to several stakeholders for their perspective. Their responses are provided below, edited for length and clarity.
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Regardless of who wins, the fundamentals for home health care remain the same. There is a growing need for more care and higher levels of care in the home. The pandemic has only accelerated this trend as family members eschew institutional care settings. Meanwhile, telemedicine and virtual care will play the dual role of supporting quality care in the home — particularly for patients who need fewer services — and blurring the lines of what is considered traditional home care.
As state Medicaid budgets tighten, care for dually eligible individuals who have chronic and long-term care needs will need to be addressed. These individuals account for 20% of Medicare and 15% of Medicaid enrollment, yet account for about a third of spending for each. In-home care and care management can play a critical role in improving outcomes while reducing the overall cost of care. However, the U.S. Centers for Medicare & Medicaid Services (CMS), Congress and state Medicaid programs will need to figure out the right models to integrate this care while figuring out who pays for what and who gets the savings.
Ensuring that home health agencies can fully participate in virtual care initiatives — including reimbursement for such services — and ensuring that dual eligible integrated care efforts fully value the impact of care in the home are two of our top priorities.
— Marki Flannery, president & CEO of the Visiting Nurse Service of New York (VNSNY)
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The health care industry experienced unprecedented strains this year, but we also made strides in many areas. At the highest level, we saw bipartisan cooperation in the time of crisis that led to solutions for those acutely impacted by the pandemic, from telehealth coverage to Paycheck Protection Program (PPP) loans.
Regardless of the 2020 election outcome, in 2021, we’re turning our focus to a few key areas based on lessons learned from the public health emergency. Further elevating home health care as a viable care alternative is crucial. Whether it was helping to divert the surge on hospitals or sending patients home to recuperate from the effects of the virus in order to free up ICU beds, home care really rose to the occasion.
While there has been an increased appreciation and awareness of the power of home health care, there is still an opportunity to elevate understanding around the need for better home care reimbursement rates, fueled by an authentic understanding of the tireless value skilled and direct care workers provide. We are also working towards ways to secure and drive more competitive pay so that the home health care industry can more effectively fill the labor demand needed to support Americans who want to heal and thrive safely at home. We are continuing to see how cost-effective and truly preferred the home setting is for seniors who desire to age in place safely and securely. We want to do everything in our power to make this option more accessible.
— Jennifer Sheets, president & CEO, Interim HealthCare
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Regardless of the outcome of the election, the prospects for positive legislation impacting the home health sector in 2021 are promising. The new Congress will be interested in making policy changes to strengthen the Medicare program, examining the needs of the Medicare population and building off of lessons learned because of COVID-19. One of these lessons is that access to home health care for vulnerable populations can and should be optimized, particularly at times when the Medicare patient population is uniquely vulnerable. The home health community has developed policy solutions that offer Medicare beneficiaries a wider array of post-acute care options, including those that expand the availability of care at home.
Being able to “choose home” for more Medicare patients who need care, as an alternative to other institutional care, can not only ensure that high-quality clinical care is available to a wider Medicare population, but can also ensure safety and increased patient choice.
We have also seen that care in the home should be optimized through increased use of technology. The availability of telehealth should be expanded upon for Medicare home health patients, particularly in times when infection risk is high, as was the case during COVID-19. The Partnership believes that telehealth opportunities should be optimized to ensure continuity of care for our nation’s most vulnerable patients.
— Joanne Cunningham, executive director, Partnership for Quality Home Healthcare (PQHH)
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I’m hopeful that the current election will have a very positive impact on the home health industry going forward. That is because our industry has done a wonderful job over the years of advocating for our interests with a paramount emphasis on bipartisanship that is clearly evidenced in the recently introduced federal legislation calling for home health telehealth reimbursement during national emergencies.
In both the House and the Senate, these bills are being sponsored and supported by both Democrats and Republicans. That is extraordinarily significant. And coupled with the magnificent work our industry has done treating those in need during the current pandemic, the message has been communicated far and wide that our industry’s support spans the partisan political divide and is here to simply treat patients, clients and families with the health care services they need, when they need them, in the comfort, safety, security and familiarity of their homes.
— Dean Chalios, president & CEO, California Association for Health Services at Home (CAHSAH)
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Home care and hospice have the advantage of being supported by both parties. As such, whatever the outcome of the election, we expect any health care reforms to embrace health care at home as the awareness of its value has grown significantly during the pandemic. Once the dust settles after the election, we are prepared to work with the incoming Congress and administration to further advance home care and hospice.
— William A. Dombi, president of the National Association for Home Care & Hospice (NAHC)
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The outcome of the 2020 presidential election could greatly impact legislation, support, attention and funding for home health care workers and agencies. Additionally, if the non-chronic illness Medicare-eligibility age is reduced to age 60 vs. 65, that will be a tremendous game-changer for payers, providers, patients and the entire health care ecosystem.
— Cleamon Moorer, Jr., president & CEO, American Advantage Home Care Inc.
For 2021, the average Medicare beneficiary has access to 33 Medicare Advantage plans, the largest number of options available in the last decade, and can choose from plans offered by eight firms. Among the majority of Medicare Advantage plans that cover prescription drugs, 54 percent will charge no premium in addition to the monthly Medicare Part B premium. As in previous years, the vast majority of Medicare Advantage plans will offer supplemental fitness, dental, vision, and hearing benefits. In addition, virtually all will also offer telehealth benefits in 2021.
This issue brief provides an overview of the Medicare Part D prescription drug benefit plan landscape for 2021, with a focus on stand-alone drug plans. It includes national and state-level data on plan availability, premiums, benefit design, cost sharing, information about premium-free plans for low-income beneficiaries, and information about the national Part D drug plans available in 2021.
With hundreds of plans reportedly offering in-home support services in 2021, the coming year is certain to bring more Medicare Advantage (MA) opportunities for home care agencies.
But some home care operators will have more opportunities than others due to geographic variability across the MA landscape. To find leads, agency leaders will need to understand what’s going on in their market and identify plans to go after.
“We’re seeing a few states sort of rise to the top, with a number of plans offering in-home supports under Medicare Advantage,” Tyler Cromer, a principal at Washington, D.C.-based research and advisory firm ATI Advisory, told Home Health Care News.
To help home care operators with their MA strategies, ATI Advisory recently released its 2021 Medicare Advantage Supplemental Benefits State Report. Broadly, the report maps out where MA plans are operating while highlighting the supplemental benefits they’ll offer next year, including in-home support services.
It currently focuses on the 738 plans that will offer “primarily health-related” supplemental benefits in 2021.
“After going through this research process a few times with different organizations last year, we decided, this year, we’re going to package all the data up and put it on our website,” ATI Advisory CEO Anne Tumlinson told HHCN. “We learned that it’s actually kind of challenging for individual agencies and even corporate leadership to navigate government data this way. That’s our expertise.”
While the report comes at a cost, ATI Advisory shared key state-level takeaways with HHCN.
Of the 738 plans offering primarily health-related supplemental benefits next year, 429 will offer in-home support services, doing so across 36 states and Puerto Rico. Florida and California will have the most plans offering in-home support services in 2021, with 103 and 57, respectively.
“There are probably no surprises there, given the size of their population,” Cromer said. “And each has a lot of Medicare Advantage plans.”
Texas, Michigan and Ohio round out the top-five states for in-home support services, with 36, 31 and 24 plans offering in-home support services.
Meanwhile, in-home support services are newly available in six states in 2021, ATI Advisory data shows. Those states are Alabama, Iowa, Minnesota, Nevada, Oklahoma and Utah.
In terms of carriers, Anthem Inc. (NYSE: ANTM) and Centene are the leaders in the space, with each offering in-home support services and other expanded primarily health-related benefits in over 100 plans. Generally, 14% of all Medicare Advantage organizations will offer in-home support services in at least one of their plans next year.
“We’re actually seeing just more coverage of in-home support services geographically, across the country,” Cromer said. “We’re seeing real growth in this space, particularly around in-home support.”
When it comes to hunting for MA opportunities, home care operators need to take a two-pronged approach.
First, Tumlinson said, they must look internally to identify their value — and how they measure it.
“Do you have a digital platform for collecting information? Do you have electronic visit verification? What kind of data do you have on your employees? What can you say about your quality?” she said. “You want to look at all of those things and what makes you a strong operator relative to your competition.”
While looking inward, home care leaders must also conduct their own market intelligence to figure out the MA plans they want to appeal to.
Then, it’s all about shaping an agency’s Medicare Advantage pitch. If an MA plan is interested in working with an agency, it will then assist with final steps like credentialing and more.
“Once you’re in a conversation with a plan about how to be part of their network of providers, either they or some other third-party intermediary will assist with making sure that you’re a credentialed provider for the purposes of being in-network, that you’re set up to submit claims and things like that,” Tumlinson said. “Those pieces are hard, but they’re all problems you can solve.”
“The relationship is the hardest part,” she added.
Updated data from the Centers for Medicare & Medicaid Services (CMS) shows that MA penetration has reached 40% of the total Medicare-eligible population for the first time in history. There were about 25.4 million MA beneficiaries nationwide for the month of October, with a total Medicare-eligible population of 62.4 million.
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.
This analysis shows that more than half of Medicare beneficiaries do not compare coverage options annually during the open enrollment period, despite the fact that Medicare Advantage and Part D plans often change from one year to the next, which could lead to unexpected and avoidable costs for beneficiaries who do not review their options annually. It also highlights that many beneficiaries have difficulty understanding the Medicare program and comparing coverage options. Further, it shows that most beneficiaries do not use Medicare’s official information resources.
As Medicare Advantage (MA) enrollment explodes and plans begin to offer more benefits to members, home health and home care agencies alike need to prove their value in order to gain new business.
Specifically, home health providers need to demonstrate how they can lower costs and potentially add members for MA plans.
“The important thing is to make sure that we understand the Medicare Advantage plan’s goals, and what the value proposition that home health agencies can provide to them is,” Jeff Aaronson, the consulting director at McBee Associates, said Monday at the National Association for Home Care & Hospice’s (NAHC) 2020 conference.
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 health care continuum.
Overall, MA enrollment increased by 60% from 2013 to 2019, according to recent statistics compiled by actuarial consulting firm Milliman. During that same period, enrollment in traditional Medicare increased by only 5%.
On their end, that’s what MA payers want more than anything — more individuals signing up under their plans. But they also want to see cost containment and to find better models for care, Aaronson said.
“[These payers] are looking at how to develop new effective models of care and how can they take better care of their patients,” Aaronson said. “So they’re very much a disruptive force in the industry — but in a very positive way — looking for creative ways to reduce hospital stays, reduce trips to the emergency rooms [and much more].”
To forge successful MA relationships, home health agencies need to use data to prove their worth across multiple areas.
That shouldn’t be too difficult for agencies. Most have spent years working with complex patients, individuals that MA payers need help keeping healthy if they are going to continue to add beneficiaries while keeping costs manageable.
“They want to align with the best of the best,” Aaronson said.
Being “the best of the best” means having good star rating patient-satisfaction scores. It also means constantly lowering rehospitalization and ER rates while filling care gaps across settings.
Increasingly, Medicare Advantage entities are additionally looking to contract with providers that have a larger array of services. That has been a persistent trend in the home health space, as more agencies enter into palliative care and other service lines.
“A way to better enhance your value and to better enhance your negotiating standpoint is having a bundle of service lines to provide, such as home health, hospice, personal care [and others],” Aaronson said.
Agencies that can operate across the continuum of care are immediately more valuable to MA plans because of their flexibility.
Additionally, having non-traditional capabilities in line with the new Supplemental Benefits for the Chronically Ill (SSBCI) program is also an advantage.
Broadly, SSBCI is all about keeping patients healthy before their condition becomes acute. Pre-acute care — the category of non-medical home care that agencies have increasingly been paid by MA plans to provide — is very valuable from a cost perspective.
That pre-acute care includes having the capability to keep members from falling, for example. It likewise includes helping them with transportation and nutrition, among other activities of daily living.
“Can you provide some of those services within your organization that will appeal to the MA plans to help keep those patients healthy and avoid expensive hospital stays?” Aaronson said.
Keeping track of fall rate statistics is a good place to start for home health agencies looking to market themselves to MA organizations. Tracking data, in general, is vital, including an agency’s cost-per-visit, supply cost and cost-per-beneficiary.
Geography can similarly be beneficial, depending on where an agency is located, especially if it operates in a certificate of need state.
“Specific counties that you operate in may have very little competition,” Aaronson said. “There might not be that many different agencies in certain counties. If you can find where [the] map of MA plans matches your map, there’s a great opportunity there.”
Home health is a relationship-based business. But in the MA world, contracts depend on what an agency can do for plans and their ability to prove that value.
“If you can’t provide value to those MA plans, then it just becomes a transactional relationship, … and that’s what we don’t want in this industry,” Aaronson said. “We want to be partners with the MA plans.”
In-home care providers with a mission to serve particularly vulnerable populations often target “dual eligibles,” or individuals signed up for both Medicare and Medicaid benefits.
The focus on dual-eligible populations is partly driven by mission and values, but it’s also supported by reimbursement. While in-home care providers sometimes struggle operating purely in the Medicaid long-term care space due to stagnating reimbursement rates, the dual-eligible landscape offers more financial sustainability.
Take, for example, Huntington Beach, California-based Landmark Health, a company that coordinates and delivers in-home medical care to mostly older adults with complex conditions.
Landmark currently operates across more than a dozen states, with dual-eligible beneficiaries being an important part of its overall patient mix of roughly 114,000.
CEO Nick Loporcaro discussed the strategic value of duals Thursday during the Better Medicare Alliance (BMA) Medicare Advantage Virtual Summit.
“If you look at the Medicaid population, due to what I call a flawed reimbursement system …, we have a tough time justifying the costs around that,” Loporcaro said. “Now, if I’ve got the MA advantage, I get to address and take care of a population that I would have struggled to justify bringing in. So, we actually like duals and perform well with duels.”
Specifically, Loporcaro was referring to dual-eligible beneficiaries enrolled under Medicare Advantage — a rapidly growing population.
Of the roughly 9.6 million full or partial dual-eligible individuals in 2013, about 2.4 million — or about 25% — enrolled in Medicare Advantage, according to a new report from actuarial consulting firm Milliman and BMA. By 2019 the number of total dual eligibles increased to 12.3 million individuals, with 5.4 million — or about 44% — enrolling in Medicare Advantage.
That’s a jump of about 125% over six years. From 2013 to 2019, the number of dual-eligible beneficiaries enrolled in traditional Medicare dropped by 5%.
“[With] dramatic growth in enrollment among dual-eligible beneficiaries, we know that supporting health coverage for our most vulnerable seniors means supporting these individuals’ choice of Medicare Advantage,” BMA President and CEO Allyson Y. Schwartz said in a press release touting the report.
Dual-eligible individuals typically have more social determinants of health needs, possibly one reason for the increase under Medicare Advantage, especially as more plans offer home-focused supplemental benefits.
Medicare Advantage growth
The sharp rise in dual eligibles in Medicare Advantage is an important consideration for in-home care providers attempting to move away from fee-for-service Medicare.
Of course, it’s not just the duals population that is increasing, as overall Medicare Advantage continues to climb as well, the BMA-Milliman report shows.
In 2019, there were about 64 million Medicare beneficiaries in total, with roughly 24 million — or more than 37% — enrolling in a Medicare Advantage plan. The Congressional Budget Office (CBO) projects that Medicare Advantage enrollment will grow to nearly 50% by 2029.
Former CMS Administrator Tom Scully — who helped create the Medicare+Choice model, a precursor to today’s Medicare Advantage program — touched on that growth during BMA’s virtual summit.
“I’m very bullish on the future of Medicare Advantage. I think it’s a great program,” Scully said. “The growth is going to continue, and that’s because seniors like it, seniors support it and, economically, it makes a whole lot of sense.”
While the Medicare Advantage population grew by 60% from 2013 to 2019, the fee-for-service Medicare population only grew by 5%.
The U.S. Centers for Medicare & Medicaid Services (CMS) last month released new Medicare Advantage (MA) figures highlighting a massive expansion of plans offering home-focused supplemental benefits in 2021.
The agency shared additional data on Wednesday — and it now appears the ongoing home care MA movement is even bigger than originally anticipated.
“These benefit offerings are growing,” Tyler Cromer, a principal at Washington, D.C.-based research and advisory firm ATI Advisory, told Home Health Care News. “And they’re growing substantially.”
CMS’s Medicare Advantage preview from September revealed that 738 plans are offering supplemental benefits under the “primarily health-related” pathway in 2021, a 46% increase compared to the nearly 500 plans that did so in 2020.
The preview similarly showed that 920 plans are offering benefits under the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway next year, a nearly four-fold increase compared to the 245 plans that did so this year.
The latest data from last week offers deeper insights around the primarily health-related pathway, according to ATI analyst Elexa Rallos.
“These data show all of the benefits that the entire universe of Medicare Advantage plans offers,” Rallos told HHCN. “We’re able to go in and really dig into which plans are offering what, then pull all the information on a high level about the availability of these benefits.”
So what’s the big news for home care operators? Of the 738 plans operating in the primarily health-related MA pathway in 2021, 430 are offering “in-home support services,” or services that typically fall under a home care agency’s core business mix.
For context, just 223 plans offered in-home support services through the primarily health-related MA pathway in 2020.
“When we are able to dig into the data a little bit more, we’re able to see that there’s almost a two-fold increase in in-home support services,” Cromer said. “There’s also more than double the number of plans offering home-based palliative care compared to 2020. There’s a lot of growth here — and that growth is being driven by services provided in the home.”
To Cromer’s point, just 61 MA plans offered home-based palliative care under the primarily health-related pathway last year. More than 130 will do so in 2021, a trend that illustrates older adults’ overwhelming preference to age in place and avoid facility-based care.
“I think, again, that reflects the desire to meet Medicare beneficiaries where they are,” Cromer added. “The idea is to give them services that really add value and allow them to stay at home, to live their lives the way they want to.”
Anthem Inc. (NYSE: ANTM) and WellCare are the leading MA plans offering in-home support services in 2021, according to ATI’s analysis. Both Anthem and WellCare offer in-home support services in more than 100 plans, Rallos noted.
Martin Esquivel, VP of product management and strategic initiatives for Anthem, previously discussed the insurance giant’s approach to supplemental-benefits design with HHCN.
“We recognize that beneficiaries that experience limitations in [ADLs] are at … greater risk for a fall, greater risk of social isolation and more likely to have access-to-care issues,” Esquivel said in October 2019. “Helping create a stable, safe environment in the home, we see that as a first step toward helping beneficiaries down a path toward a more comfortable, sustainable health care experience.”
In addition to those offering in-home support services and home-based palliative care in 2021, 127 plans will offer adult day health services, 176 will offer therapeutic massage and 95 will offer some type of service aimed at caregiver support.
In terms of geography, the MA plans offering in-home support services under the primarily health-related pathway next year operate in 36 states and Puerto Rico. On a county level, there appears to be a particularly strong concentration in New York, Michigan, Indiana, Maine and a handful of other states.
Exactly 11 states have MA plans offering home-based palliative care in at least one county in 2021, according to ATI.
While home care operators should be excited about the spike in plans offering in-home care benefits, they should also remember that most plans are working with limited resources. That means benefits aren’t always robust or equivalent to what home care agencies do for their typical, private-pay client.
“These are limited benefits … that MA plans are providing with limited dollars,” Cromer said. “Benefits we’re seeing are generally ranging from, let’s say, roughly 24 hours to 200 hours a year of services, or per discharge from the hospital.”
Stay tuned on SSBCI
ATI Advisory is currently working on an even deeper analysis of CMS’s Medicare Advantage data dump from Wednesday. Toward the end of this week, the firm hopes to share detailed information on what plans are doing state by state, county by county.
Part of that effort is to give home care operators a better understanding of what MA plans are doing in their individual markets.
As for the SSBCI pathway, which is arguably the even bigger opportunity for the home care industry, ATI Advisory likely won’t have anything new to share until early 2021. CMS releases its MA numbers as part of what’s called the “plan benefit package files,” updated quarterly.
“We expect an additional tranche of data to come out in early 2021,” Cromer said. “And that will include information about Special Supplemental Benefits for the Chronically Ill, along with some other information.”
CMS first introduced the primarily health-related flexibility under MA in 2018 for the 2019 plan year.
Broadly, “primarily health-related” can include services that diagnose, prevent or treat an illness or injury. It can also include services aimed at lessening or improving some sort of functional impairment that hinders an individual’s ability to perform activities of daily living.
When it announced plans to go public through a blank-check company, Clover Health shared ambitious projections for its future membership. Much of that growth is pinned on plans to launch a direct contracting business.
Today on Health in 2 Point 00, Jess and I gossip about the wild rumor that UnitedHealthcare is acquiring Amwell. On Episode 157, we discuss Lark raising $55 million in a Series C along with a deal with Anthem to be their preferred DPP provider, Medicare Advantage plan Clover going public with a valuation of $3.7 billion, NOCD raising $12 million in a Series A providing specialized CBT and virtual OCD treatment, Cerebral raising $35 million in a Series A for its comprehensive digital mental health offerings, and Express Scripts adding to their digital health formulary with offerings targeting things like women’s health, tobacco cessation, muscle and joint pain, and more. —Matthew Holt
– 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
Clover Health recently announced that it will go public through a merger with a special purpose acquisition company (SPAC), Social Capital Hedosophia Holdings Corp. III.
“Going public will enhance our ability to execute on our mission of improving every life, providing significant capital for the company to scale and improve health outcomes for seniors across the United States,” Andrew Toy, president of Clover Health, told Home Health Care News in an email.
Clover Health is a San Francisco-based Medicare Advantage insurer. The company’s in-home care model utilizes technology, including data analytics and machine learning, to identify its highest-risk members. It then finds solutions to lower their risk of adverse health events.
Since its launch in 2013, Clover Health has raised more than $900 million. The company has 57,000 members across seven states.
The deal, which values Clover Health at $3.7 billion, is expected to provide up to $1.2 billion in cash proceeds. This includes up to $828 million of cash held in Social Capital Hedosophia Holdings’ trust account.
Additionally, Clover Health will receive up to $728 million of the transaction proceeds, and up to $500 million will go to the company’s existing shareholders.
Broadly, SPACs are an alternative to the traditional route to going public. SPACs raise money through an IPO and then search for an acquisition target. Once a merger has been completed, the target becomes a listed stock.
Over the past several years, Clover Health has been positioning itself to go public, according to Toy.
“We’ve generated incredible business momentum and have a well-defined and exciting growth strategy and a highly scalable approach,” he said. “We’ve also assembled a strong management team that has extensive experience across the health care and technology industries.”
As part of the transaction, Clover Health’s leadership team — including Toy and CEO Vivek Garipalli — will stay on and continue to serve in their roles. Chamath Palihapitiya, founder and CEO of Social Capital Hedosophia, will join Clover Health as a senior advisor to the management team.
The news of Clover Health’s plans to go public is fresh off the heels of a recent partnership with retail giant Walmart (NYSE: WMT). Last week, the company announced that it was teaming up with Walmart to make Medicare Advantage plans available in eight Georgia counties.
The Clover Health-Social Capital Hedosophia transaction is slated to close in the first quarter of 2021.
– Walmart announced it will begin selling Medicare
insurance plans during this year’s annual enrollment period, Oct. 15 through
announced the launch of Walmart
Insurance Services, LLC, a licensed insurance brokerage, which will assist
people with enrolling in insurance plans—and simplify what’s historically been
a cumbersome, confusing process. Walmart Insurance Services will begin selling
Medicare insurance plans during this year’s Annual Enrollment Period (AEP),
Oct. 15 through Dec. 7.
Walmart Insurance Service Offerings
Starting today, Walmart Insurance Services will provide Medicare plans (Part D, Medicare Advantage, and Medicare Supplement plans) offered by Humana, UnitedHealthcare, Anthem Blue Cross Blue Shield, Amerigroup, Simply Health, Wellcare (Centene), Clover Health, and Arkansas Blue Cross and Blue Shield. More carriers may be added in the future. The brokerage is licensed in all 50 states, plus Washington D.C. Walmart has built a team of licensed insurance agents who can help people find the right insurance plan for them.
“We want customers to feel confident in selecting a Medicare plan that best fits their needs, budget and lifestyle,” said David Sullivan, general manager of Walmart Insurance Services. “And we want to be a trusted partner on their health care journey. Helping customers select the right Medicare insurance plan to meet their needs aligns with Walmart’s mission of helping people save money and live better.”
People 65 and older, who have been hardest hit by COVID-19 in terms of hospitalizations and deaths, are also at high risk of severe flu illness and are more likely to die of the flu than younger people. This analysis explores variation in the rate of flu vaccination among adults ages 65 and older covered by Medicare, and reasons cited for not getting vaccinated, based on data from the 2018 Medicare Current Beneficiary Survey.
– Independence Blue Cross and Signify Health launches
social determinants of health network, CommunityLink to connect data from multiple
CBOs to integrate social directly into medical care in the Philadelphia area.
– CommunityLink represents one of the first examples
nationwide of combining in-home health with social care.
Independence Registered Nurse Health Coaches, Signify Health
social care coordinators, and local community-based organizations are now all
connected via the CommunityLink network and are able to coordinate on behalf of
Independence Medicare Advantage members and other people throughout the region
for non-medical services. Starting in 2021, clinicians and other healthcare
providers will be able to use CommunityLink to refer patients as well.
Independence and Signify Health are now among the first in
the nation to have designed a community-based network that combines management
of social determinants of health with in-home health visits. The new
community-based network expands Independence’s existing relationship with
Signify Health, which sends clinicians into the homes of Independence Medicare
Advantage members to assess overall health, facilitate the management of
chronic conditions, and provide diagnostic and other clinical services.
By using Signify Health’s privacy-enabled collaboration platform, organizations can leverage CommunityLink to safely and securely collaborate, share, and track an individual’s whole-health needs longitudinally across different care settings to address their social determinants of health. This gives Independence – as well as other community-based organizations that may be referring to CommunityLink – the ability to track and measure an individual’s whole-health needs over time as they interact with multiple social and clinical providers and community organizations.
“Creating a more equitable health care system includes acknowledging that health not only happens in the doctor’s office, but in our members’ homes and communities. That is why we are so pleased to work with Signify Health on developing CommunityLink,” said Daniel J. Hilferty, Independence Blue Cross President and CEO. “We will be able to identify obstacles our members may be facing and offer solutions that are available to them right where they live through this new network.”
– Cone Health has signed a letter of intent to merge with
Norfolk, Virginia-based Sentara Healthcare for a combined $11B in assets.
– The merger creates one large health system totaling of
17 hospitals – 11 Sentara hospitals in Virginia and one in Elizabeth City,
N.C., and five Cone Health hospitals in the area surrounding Greensboro.
Cone Health has signed a letter of intent to merge with Norfolk, Virginia-based Sentara Healthcare. The merger will create a combined organization with a unique value-based approach that is focused on keeping people healthy and well, while providing high-quality, accessible and affordable health care in more ways and in more places. The Cone Health Board of Trustees voted unanimously to move forward with this letter of intent.
Cone Health, a not-for-profit integrated healthcare network
consists of five hospitals in North Carolina. The system employs more than
13,000 people, including nearly more than 600 physicians and advanced practice
providers, and operates more than 100 care sites. Its Medicare Advantage health
plan, HealthTeam Advantage serves 15,000 members.
“Cone Health is among the highest-quality health care organizations in the nation, and we are financially strong. With the right partner, we can build on what we’ve created and do even more for those we are privileged to serve,” says Terry Akin, CEO, Cone Health. “We have long said that Cone Health doesn’t intend to grow simply for the sake of growth. Instead, we are partnering for inspiring possibilities.”
Sentara Healthcare is an integrated, not-for-profit system
comprised of 12 hospitals in Virginia and Northeastern North Carolina. The
health system employs more than 1,200 physicians and advanced practice
clinicians, 30,000 team members and operate hundreds of sites of care. Our
Optima Health Plan and Virginia Premier Health Plan serve 858,000 members in
Virginia, North Carolina and Ohio.
Merger Impact for Community
The resulting organization would have a combined $11B in
assets, with Sentara representing about $8.7 billion in assets and Cone Health
representing $2.8B in total assets, according to 2019 audited statements.
The communities served by Cone Health and Sentara do not
overlap. As a result, the combined organization will ensure that consumers have
more choices for healthcare and insurance plans, not fewer. The merger will
deliver healthcare in more ways and more places with more options to pay for
“This rapidly changing healthcare environment requires tremendous transformation and innovation to ensure the long-term success of each respective health system and, most importantly, the very best for those we are privileged to serve,” said Howard P. Kern, president and chief executive officer of Sentara Healthcare. “We can either react to change, or we can shape it. We are choosing to shape change and will lead this transformation of healthcare together.”
Howard P. Kern will oversee the combined organization and
the corporate headquarters will remain in Norfolk, Va., and Greensboro, N.C.,
will serve as the regional headquarters for the Cone Health division. Terry
Akin will remain in Greensboro as the president of the Cone Health division. Cone
Health representatives will join the Sentara Healthcare board, with membership
on all board committees and meaningful roles in all aspects of governance.
Additionally, there will continue to be a Cone Health Regional Board that will
be composed of community members, medical staff and Sentara representation.
The combined organization is subject to state and federal
regulatory review and customary closing conditions and is anticipated to close
in mid-2021. Following that, it is expected to take up to two years to fully
combine and integrate.
A recently unsealed whistleblower case filed by the Department of Justice accuses Cigna of fraudulently overbilling for its Medicare Advantage plans. Allegations claim the company submitted unsupported diagnoses that resulted in “billions” in overpayments.
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.
Oak Street Health, which operates primary care centers for Medicare patients, went public on Thursday for $328 million. Its capitation payment model has helped the company continue on where many clinics have struggled during the Covid-19 pandemic.
Humana’s (NYSE: HUM) long-standing home- and community-based focus served the insurer well in Q2 2020 — a quarter dominated by the COVID-19 emergency. The coronavirus pushed more senior care into the home, boosting business for Louisville, Kentucky-based health insurance giant.
As a result, the insurer doubled down on home-based care initiatives in Q2 2020 and will continue to do so going forward.
“We believe consumer demand for high-quality home-based care models will continue to increase,” Humana CEO and President Bruce Broussard said on the company’s Wednesday earnings call. “And COVID has reinforced this belief as we see increased awareness and interest in home-based care models by consumers.”
Humana has long been bullish on home- and community-based care. In 2017, the company, along with two PE firms, announced the acquisition of Kindred at Home, the largest home health provider in the country.
“Heal will serve as our preferred home-based primary care model, which is inherently more capital efficient and scalable, allowing Humana to offer high-quality, value-based primary care to more members than a clinic-based strategy,” Broussard said on the call. “The ability to deliver emergency room and hospital-level care in the home through partners like Dispatched Health is highly complementary and allows patients to recover in the safety and comfort of their home. [It also] reduces caregiver burden and avoids the risk of secondary infections and further health declines often experienced at the result of inpatient hospital stay.”
Additionally, Humana has continued to invest in Kindred at Home, most recently by working on developing new clinical models and operational enhancements for the service line. Broussard did not elaborate on what those look like.
Humana also saw the fruits of its home-based care efforts partly in the form of increased Medicare Advantage enrollment in Q2.
“Medicare Advantage plans were some of the first organizations to proactively identify and implement policy and benefit changes at the outset of the pandemic,” Broussard said. “These actions addressed testing and treatment costs associated with the coronavirus, identified and tackled social determinants needs such as food insecurity, and ensured continuity of care for our members.”
One reason for MA’s success amid the coronavirus is that supplemental benefits allow plans to offer members services such as home-based care, food delivery and more, lessening the risk of seniors’ virus transmission while also addressing some of the effects of loneliness and isolation.
Bolstered by the COVID-19 emergency, MA’s popularity at Humana is only expected to grow more in the months to come.
The insurer raised its expected MA growth projections as a result of the strong performance it’s posted so far this year. Humana increased its individual MA growth range for 2020 from 300,000 to 350,000 new members to 330,000 to 360,000 by the end of the year.
For the quarter ended June 30, Humana saw its profits soar to $1.8 billion, or $13.75 per share. That’s double the $940 million in profit the company posted a year earlier in Q2 2019, with a nationwide delay of elective procedures largely to thank for the spike.
Humana’s Q2 revenues totaled $19.1 billion, up from $16.2 billion year-over-year.
MA competition, synergies
When asked about competition in the MA market, Broussard acknowledged that a number of smaller plans grew substantially last year, orienting recruitment around member experience.
“They’re always a concern to us, but we continue to believe our brand is strong in the markets that we compete with them,” he said. “Our value proposition is strong both with our customers and with our providers.”
Humana has technology on its side, as well as potentially Walmart, which recently announced it would get in the MA game.
“They’re not really getting into the MA business; they’re getting into the MA distribution business, and they have been in that business for a long period of time,” Broussard said. “So they would distribute Humana products but also competitor products. … We frankly look at it as a great complement to us, as they can continue to be a distributor for us.”
Humana’s stock price was $403.91 at the end of the day Wednesday.
Home health admissions saw a slight decline in volume during the fourth quarter of 2019. Meanwhile, referral trends appear to be holding steady.
That’s according to recent data from PlayMaker Health, a post-acute growth platform that serves hundreds of organizations across the country.
Specifically, Q4 saw a 2.45% decline in home health admissions, nationally. The decline in home health admissions in Q4 was on par with the previous quarter, which saw a 3.38% decrease in patient volumes, nationally.
When looking at data from the same period, 60% of home health referrals were from community sources, while 40% of referrals were from institutional sources.
This isn’t a major change from Q3 2019, which saw 59.9% of home health referrals coming from community sources and 41.1% coming from institutional sources.
After the implementation of the Patient-Driven Groupings Model (PDGM), experts predicted that providers would largely focus on referrals from institutional sources. Under PDGM’s 432 case-mix groupings, reimbursement is usually higher when caring for patients discharged from institutional settings, including hospitals or skilled nursing facilities (SNFs).
In reality, there was only a tiny increase in the percentage of institutional sources.
“If you look at Q4, it shows that people were starting to implement their plan to make sure there was an emphasis on institutional referrals,” Holly Miller, chief revenue officer at PlayMaker Health, told Home Health Care News. “I think what I’m pleased to see is people aren’t shying away from community referrals, which I think everybody was worried would happen. That wasn’t the case.”
As the home health industry begins to see more post-PDGM data, it may also start to see a further increase in institutional referrals.
“Post-PDGM data, meaning Q1 and Q2 2020, we’ll start to see those numbers increase on the institutional resources, but I don’t think it’ll be dramatic,” Miller said. “I think it will start to level out.”
The public health emergency may also impact these numbers, as providers have already reported that they are treating COVID-patients and others in the home.
Additionally, Q4 2019 data showed that patients are using Medicare Advantage (MA) at a rate of 34% of Medicare. This is a 4% increase over the prior period, which saw patients using MA at a rate of 29%.
This growth is partly due to the high number of plan options.
There was also more aggressive growth in newer markets, according to Miller.
“This makes sense based on the number of Medicare Advantage plans coming to the market, which is causing a shift,” she said. “If you break it down by various states, several had double-digit growth for Medicare Advantage. [Even] states that we don’t typically see pop up. For example, Michigan had 11% growth and Indiana had a 10% growth. Mississippi had a 13% growth.”
One factor to keep in mind when evaluating home health care data trends in recent quarters is the mergers-and-acquisitions activity that took place during the time, Miller noted.
“Some of these numbers are the result of the tremendous amount of mergers and acquisitions that happened from 2018 to 2019,” Miller said. “For example, over that time period, I think we had a 3.6% decrease in agencies overall from 2018 to 2019, because of [M&A activity].”
On top of that, MA plan reimbursement for home-based care providers is notoriously low. Amedisys Inc. (Nasdaq: AMED) President and CEO Paul Kusserow painted a picture of MA home health rates — different from home care rates — during a recent presentation.
“I still think that Medicare Advantage is the place to be for us, but not under the current reimbursement,” Kusserow said. “Average reimbursement on a visit for Medicare Advantage is $125 a visit, versus $165 for fee-for-service Medicare.”
While such figures and statistics have been well-publicized, the actual day-to-day of what it’s like to provide home care to MA beneficiaries is not. In fact, that’s another common criticism of MA partnerships — few people really know what they’re like.
As such, Home Health Care News set out to learn more.
To discuss the more granular details of working with MA plans, HHCN recently connected with Gavin Ward, a regional director of strategy for 24 Hour Home Care. The Los Angeles-based home care provider is one of the few agencies nationwide to have secured those highly sought after MA partnerships.
Ward dove into what services his agency provides to MA beneficiaries, how often it provides them and more — including how much of 24 Hour Home Care’s revenue was funded by MA plans in 2019.
You can read HHCN’s conversation with Ward below, edited for length and clarity.
HHCN: First of all, how many hours on average do you spend caring for MA beneficiaries per month?
Ward: Our partners are grateful for the flexibility we have in caring for their members, as MA plans are not currently designed to fund full-time caregiving long-term.
Authorizations vary per plan, and most are short-term, averaging less than a month of care and during a transition. An average length authorization would be for 20 total hours of care.
What’s the most common type of home care service you provide for MA members?
Most of the members receiving care from us require some form of personal care and transfer assistance.
Our caregivers receive additional training upon hire to ensure they are safely and properly caring for members’ needs, especially during the pandemic — which is why we’ve developed safety protocols with our team, which includes an infectious disease physician.
I’m interested in hearing more about what the process looks like when you get a request for service from an MA plan. Can you provide more details on that and how it differs from the intake process for other clients?
Each health plan varies, but we continuously work to understand our partners’ ecosystems and to serve as an extension of their teams.
Like most contracted partners outside of the MA world, we serve alongside a case manager or social worker, care coordinator, and/or authorization assistant for each client. Our plan partners appreciate that we have dedicated care coordinators for each client as well as a dedicated intake team seven days per week to accept new cases.
The main difference with MA clients and our general client base is that we are not accepting payment information, nor discussing the cost of care.
How does payment work? Generally, do you get paid more during months when you care for more MA beneficiaries or is it more of a flat monthly rate?
While I can’t go into the fine details of the payment process, what I can share is that we file via a third-party claims system, which could present a challenging onboarding process if an in-home care organization is not equipped with the right personnel and systems.
Smaller firms may struggle learning and adapting to these systems, but we have a strong, knowledgeable accounting team that has learned these systems and can invoice properly.
Some MA plans are also not used to working with non-medical agencies and may go through their own challenges ensuring their systems are designed to properly accept non-medical home care claims.
Do you have any statistics you can share regarding how much of your revenue is attributable to MA plans?
MA plans are still in their infancy stages, and we are appreciative of the opportunity to be selected and partner with them to provide care to members that are in need. As a result, it is still too early to disclose impact, which the plans themselves will also likely state.
Less than 1% of our revenue was funded by MA plans in 2019.
Oak Street Health, a Chicago-based company that operates primary care centers for Medicare patients, filed initial IPO paperwork on Friday. The company has not yet priced the offering, but it plans to use the proceeds to repay a loan and grow its business.
Securing stockpiles of personal protective equipment (PPE), doubling down on company-wide training efforts and implementing educational initiatives are just some of the responsibilities that home care leadership teams have taken on during the COVID-19 crisis.
While most home care agencies were navigating the public health emergency over the past few months, Synergy HomeCare’s CEO had the additional responsibility of getting acclimated to his new role.
In April, Charlie Young took the reins of Synergy as its chief executive officer. Young is only the second person to lead Synergy, taking over the role from founder Peter Tourian, who is now the company’s executive chairman.
NexPhase Capital-backed Synergy is a Gilbert, Arizona-based non-medical home care franchise that offers companionship services, in addition to personal assistance, housekeeping, live-in care and 24-hour home care services. Currently, the franchise company operates throughout the U.S., serving roughly 25,000 clients and employing about 20,000 people.
Home Health Care News recently caught up with Young to discuss the company’s newly launched educational campaign, its growth strategy and why Young isn’t ready to walk away from Medicare Advantage (MA) opportunities just yet.
Below are highlights from HHCN’s conversation with Young, edited for length and clarity.
HHCN: We last connected with Synergy in 2019. Can you recap the company’s highlights and challenges since then?
Young: Here’s what I can share with you from my perspective. Synergy HomeCare is a really cool and unique company in the home care space. It’s a company that has been franchising since August of 2005 — 15 years. We now have 160 or so franchise partners that operate in 350 markets around the United States.
I think there was a time period in 2009 through a couple of years ago where Synergy was focused on growing its business and building out the foundation of what the brand would stand for, not only for its franchisees but also for the caregivers and the clients we serve.
There’s been a renewed interest in the growth of Synergy. Two years ago, the company was sold. We are now owned by NexPhase Capital, a private equity company. I, along with others, was brought into the fold to bring Synergy to the next chapter of growth. That’s where we’re focused now going into the future.
COVID-19 has moved home care into the spotlight. Can you talk about how your company has handled the public health emergency?
We’ve handled COVID-19 by recognizing the role that we play in the health care continuum, more specifically in helping our clients maintain their independence and livelihood at home.
We’ve seen two things happening: We’re seeing people move out of hospitals, skilled nursing facilities (SNFs) and nursing homes. We are also seeing people who were at home and well cared for needing to have that care continue. Our franchise partners around the country– and their caregivers — are the front lines.
Many of our operations around the country are working with COVID patients and making sure that they’re maintaining safety standards. As a company, we are making sure caregivers have access to PPE and proper training on how to keep themselves safe, too.
On the client side, it has been about attacking social isolation. Through our senior connections program, we make sure that the clients we serve are staying connected to the communities around them. This means, in some instances, enabling connections with our clients and their loved ones through video chat and other communications.
In many cases, our franchisees around the country are making sure that the match between caregiver and client is a good and solid one. They are maintaining consistency and continuity between the client and the caregiver. We think it’s important at this time to have that level of continuity for safety and to ease any concerns.
We’re also focused on helping our franchise partner locations around the country recruit new caregivers. With the economic fallout that has come from COVID-19, we have a great service to bring to the community and a lot of opportunities for caregivers. We’re finding that there are new types of caregivers coming to the market, as hospitality workers, restaurant workers and retail workers are out of work because of the pandemic.
How have you handled being a relatively new CEO during a public health emergency?
Before I started, there was a lot of anxiety and apprehension about starting this role during these times. However, I think that now that I’ve been at it for three months, I can take a step back and say it’s been a hidden blessing.
When you start a new job as a CEO, you’re thinking about how to bring the team together. You’re thinking about the process of sitting down in person with your employees. Since Synergy is a franchise company, I thought about getting out on the road and going to visit franchisees and spending a lot of time in the field. Obviously, these things couldn’t happen. Our corporate office was shut down. I couldn’t travel to see our franchisees and I’ve been heavily reliant on Zoom. What I’ve found is that I’m able to have much more intentioned conversations with our employees and with our franchise partners. I’ve also been forced to be more creative than maybe I would have been otherwise.
Since I wasn’t able to go visit our franchise locations, I built a series of CEO roundtable discussions. I met with over 100 franchise partners, either one-on-one conversations or through the roundtable. For the roundtables, we would put 10 franchise partners on a Zoom call with me for an hour and a half. I had a set of questions for them, but I also gave them plenty of time to ask me questions as well. In the span of seven days, I was able to meet with an incredible number of franchise partners and hear from them about what they thought the opportunities were for Synergy HomeCare.
It was a level of exposure to the grassroots of the business that I wouldn’t have had if I was physically traveling to our locations.
One of the secret weapons of Synergy HomeCare is the connected nature of our network and how we learn from each other and support each other in normal times, but also during the pandemic.
Synergy recently launched an educational campaign about a technique called “benevolent probing” that can assist adult children in determining if their parents could benefit from home care. What’s that about?
We know that oftentimes home care comes because of a life event. There’s been a hospitalization, a surgery, a fall in the home or some other event that has caused the loved ones of the client to rally and evaluate whether they need care. This program is designed to help family members identify and keep track of where “mom and dad” are in terms of their need for extra support in advance.
We know that if you can proactively provide care, then you can extend the independence cycle of the time by which our clients are active at home — even if they need a little assistance and support to do that.
This program is about a series of questions and things that loved ones can look for when interacting with seniors and their families. Things that might tip them off about change taking place in the home. It’s all about tracking activities of daily living (ADLs) and keeping up with them.
Helping people have these hard conversations earlier, in a more productive manner, is going to serve our clients in the end.
For the last 10 years, Synergy has grown at an average rate of 20% year over year. This has largely been due to organic growth. Can you talk about the company’s growth plans moving forward?
We’re still in the early stages of formulating strategy. When you think about growth, there are two primary ways that will grow Synergy. One: We currently occupy about 350 territories around the U.S. I think there’s plenty of upside growth for more Synergy outlets and markets that we’re not serving at the moment. The demand for Synergy HomeCare franchises is strong. I think the pandemic is only fueling that demand for franchise territory. I think that our challenge in that process will be to make sure that we’re bringing the highest quality franchisees into our system.
The second: Organic growth. My definition of organic growth would be, “How do we take our existing franchisees and help drive growth into their business?” I think we’ll be focused on that quite significantly. We will be looking at how we can drive a deeper penetration into our markets through marketing and sales activities, by forming new referral relationships at both a local and national level. I think that there is a definite upside for growth within our existing system.
Beyond referrals, I think product and service offerings are an area that we will take a closer look at. What are the things we can do for our clients that we are not focused on today? I think technology will have a bigger role in how we provide service to our clients.
When I connected with your predecessor last year, Medicare Advantage was the growth avenue the company was most excited about. Can you talk about the inroads the company has made on the MA front?
Everyone in the home care industry is bullish on the fact MA will be an opportunity in the future.
However, we have not seen the Medicare Advantage switch being turned on yet. Payers are just not there yet when it comes to offering home care as part of the plans. But we are not walking away from it.
What area will be the company’s main point of focus for the rest of the year?
For the rest of the year, we will be very much focused on helping our franchise partners and the caregivers that work for them settle into the new normal of the pandemic. No one should think or believe that it will be going away anytime soon. These are the conditions by which we’re working. That means making sure that everyone is up on the latest protocols and has appropriate levels of PPE.
Beyond that, our focus will be on figuring out how we provide care to growing populations, as we see the number of hours for home care starting to come back. There are COVID-diagnosed patients that need care — and clients who don’t have the virus and also need care. We need to be able to provide services to both of those populations and prepare our franchisees to do that.
I think that Synergy is poised for significant growth in this industry. It’s a young industry, and there are many players in the home care space. I think over the next several years, you’re going to start to see the industry mature and certain players within the playing field will mature faster than others.
The coronavirus could be the match that finally sparks the Medicare Advantage (MA) boom for home care.
The explosion has been a long time coming. It all started when the Centers for Medicare & Medicaid Services (CMS) first expanded the scope of MA supplemental benefits in April 2018.
The move opened the door for MA plans to cover in-home care for the first time, creating new, highly sought after opportunities for home-based care providers. However, those opportunities were few and far between, with only 3% of plans offering in-home support services in 2019.
Adoption rates improved slightly but significantly for 2020, thanks in part to CMS yet again widening the scope of which supplemental benefits MA plans could offer. In 2020, 148 plans decided to cover in-home support services, compared to only 51 the year before, according to international actuarial consulting firm Milliman.
But that increase could be nothing compared to what the MA industry will see as a result of COVID-19.
Thanks to mid-year MA flexibilities from CMS and the country’s current aversion to congregate senior care settings, the virus is poised to throw even more fuel on the MA home care fire, according to Catherine Murphy-Barron, a principal and consulting actuary at Milliman.
Murphy-Barron recently connected with Home Health Care News to share her outlook on the MA landscape amid the coronavirus, as well as what she expects to see from plans and CMS on the home care front in the year ahead.
You can find the conversation below, edited for length and clarity.
HHCN: What big-picture changes are you seeing in MA amid the coronavirus?
Murphy-Barron: It’s hard to even know yet what 2020 is looking like, except that it’s all quite in upheaval.
When the coronavirus was just starting out in March and April, we were trying to put together bids for 2021 — so it was sort of shooting in the dark because we were still trying to understand what’s happening in 2020.
Obviously, consistent with every line of business, Medicare is experiencing huge drops in discretionary services. At the same time, the Medicare population is the age bracket that is really most at risk related to COVID.
So how are those factors offsetting each other — and how do you deal with the implementation of telemedicine and all of that?
It’s still playing out. Telemedicine obviously has a huge impact on Medicare. The ability to use that and the expansion of that benefit this year has been large. Hopefully that will continue into the future.
For the dual plans, particularly the special needs plans (SNPs) and the institutional special needs plans (I-SNPs), they’ve taken a huge hit. I have a number of provider-owned Medicare Advantage clients, so they tend to be smaller and they tend to be dual.
They tend to have gotten hit quite hard with regard to if they have beneficiaries who are in skilled nursing. They’ve seen a huge hit with regard to their enrollment — obviously they’ve lost quite a few of their members and some of their staff.
The impact is quite different depending on who you are, what kind of a plan you are and where you are in the country. Trying to figure out what that will mean for 2021 has been quite difficult.
So what are you expecting for 2021?
That depends on the client and what they think.
What we’re trying to do is figure out: What do we know? What would it look like if it was a normal year? And how do we adjust that based on how we think this will play out?
Part of what is helping is some of the expansions CMS has made in the past few years with regard to supplemental benefits [like in-home care].
People aren’t able to go into a nursing facility or don’t want to stay in a hospital long term. So [plans] can now provide some of the home care and in-home support services that previously were quite limited unless you were a dual special needs plan.
As we think about going into 2021 … people will probably still be somewhat uncomfortable with group settings like adult day care or skilled nursing facilities. You might see the use of these [in-home] benefits as a way to supplement some of the care and get people the care they need without having to put them at risk from a COVID perspective.
This was going to happen anyway. Supplemental benefit flexibility was a huge plus for MA from a social determinant of health perspective. I think COVID is reinforcing some of the steps that CMS was already taking.
Initially, MA plans were slow to adopt in-home supplemental benefits. Do you think COVID-19 will add fuel to that fire?
I think it will, especially on the dual side of things.
It gives options to beneficiaries. The people who have been caring for them at home because they’ve been working from home will eventually have to go back to work. How do you balance the fact that you need additional care? You don’t particularly want to have in-patient or facility-based [care right now].
Having those options gives people more choice.
CMS recently gave MA plans new mid-year flexibilities in light of the coronavirus, so plans hypothetically could be adding new in-home care benefits right now. Do you have any idea how many are doing that?
We don’t yet. It’ll be a couple months.
But generally, if you look at what was happening for 2020 with last year’s bids, plans definitely were taking advantage on the home care front, and I don’t think that will change for 2021.
We’ve seen CMS announce new in-home supplemental benefit allowances the past two years in a row. Do you think we’ll see any further expansion of those allowances this year?
They gave plans a lot of choice with regard to what they could do under those benefit expansions. So I think what we’re gonna see is that plans will experiment over the coming years.
I haven’t heard that CMS is planning to add more or change anything, but they definitely are expecting to see plans take advantage of this. I think the number of plans offering these in-home flexibilities will only continue to grow as plans get more comfortable with what they can do and how they can use them.