House Bill Looks to Keep Medicare Sequestration ‘Holiday’ in Place for Home Health Agencies, Others

U.S. Representatives Brad Schneider (D-Ill.) and David McKinley (R-W.Va.) introduced the Medicare Sequester COVID Moratorium Act last week.

If passed, the bill would extend the temporary suspension of Medicare sequestration payment reductions, giving home health agencies and other providers more financial flexibility headed into an uncertain 2021.

Since 2014, the U.S. Centers for Medicare & Medicaid Services (CMS) has been cutting Medicare reimbursements to home health providers by 2%, as directly by Congress. Under the law, payments that exceed Medicare’s cap must be returned to CMS.

As part of a larger COVID-19 relief effort, home health providers received a reprieve from sequestration when the CARES Act passed in March. CMS suspended the 2% Medicare sequestration, effectively boosting reimbursement rates during a period some health care experts referred to as a “holiday.”

The provision is soon set to expire at the end of December, but the newly introduced legislation would extend the temporary suspension of Medicare sequestration to an undetermined date.

The aim of the bill is to help providers focus on responding to the COVID-19 emergency instead of financial challenges that may arise during this time.

“At a time when health care workers are on the front lines battling the COVID-19 pandemic, Congress should be doing everything within their power to ease their burden,” Rep. McKinley said in a statement. “America’s health care providers continue to be stretched thin and face serious financial challenges as a result of the economic and public health crisis.”

For many home health agencies, CMS pressing pause on Medicare sequestration payment reductions has ensured that they have the resources to provide care during the public health emergency while staying afloat financially.

If the legislation doesn’t pass, this could mean trouble for providers, Matt Wolfe, a partner at law firm Parker Poe, told Home Health Care News.

“The CARES Act’s temporary suspension of Medicare sequestration payment reductions has allowed home health providers to purchase PPE, train staff, and otherwise invest in keeping patients and staff safe during the pandemic,” Wolfe said. “If this bill does not become law and the sequestration is reinstated, it will be a devastating blow for home health providers at a terrible time.”

With this in mind, the bill has also drawn support from organizations such as the Partnership for Quality Home Healthcare (PQHH).

“The Partnership, alongside the broader home health community and every other provider sector, is supportive of extending the suspension of the 2% sequestration cut for Medicare providers,” Joanne Cunningham, executive director of PQHH, told HHCN. “With COVID cases on the rise, the entire health care system continues to be challenged.”

Suspending the 2% reduction beyond 2020 is “a prudent step” that will provide much-needed support to the entire Medicare provider community and patients, she added.

PQHH is a home health care advocacy organization based in Washington, D.C.

Additionally, the bill has garnered support from organizations including the American Association for Homecare, LeadingAge, the Visiting Nurse Associations of America and the National Association for Home Care & Hospice (NAHC).

“We see an extension of the sequestration moratorium as a high priority for all Medicare providers in order to preserve our very fragile health care system,” NAHC President William A. Dombi told HHCN. “Reducing payments to health care providers, already stressed to a breaking point during the height of the pandemic, will add unnecessary risks to care.”

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On Heels of CDC Vote, Home Health Providers Grapple with COVID-19 Vaccine Mandates

On Tuesday, the CDC’s Advisory Committee on Immunization Practices (ACIP) — in an overwhelming majority — voted to recommend that health care workers, among others, get first priority on a COVID-19 vaccine when one is authorized.

In light of this latest development, the question now becomes: Should home health providers mandate vaccinations for employees?

The news of the federal advisory committee’s vote should come as no surprise, given the significant toll COVID-19 has taken on the health care community, including home health workers.

More than 200,000 U.S. health care workers have now contracted the virus. More than 800 have died from COVID-19, according to the CDC’s latest count.

Vaccinating health care personnel — which the CDC defines as those working in home health, hospitals, long-term care facilities, outpatient clinics, pharmacies, emergency medical services and other settings — supports the principle of maximizing benefits and minimizing harms, Dr. Kathleen Dooling, a medical officer at the CDC, said during a recent ACIP meeting.

“Protection of health care personnel leads to preservation of health care capacity — and better health outcomes for all,” she said. “Vaccinating health care workers promotes justice because health care personnel put themselves at risk and will be essential to carry out the vaccination program.”

If home health providers were to mandate vaccinations for employees, the move would not be unprecedented.

Over the years, many providers have mandated flu vaccinations, but when it comes to COVID-19, some companies have expressed concerns.

“There are a number of home care companies that have mandated flu vaccines, but in talking to some of those companies, they’re hesitant to mandate this vaccine,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “And lawyers could come up with a whole series of reasons to go after a health care provider that mandates a vaccine. I’ve even heard some lawyers talking about various Constitutional rights under the First Amendment.”

Indeed, providers could potentially land in legal hot water if employers don’t navigate this action carefully.

“The research that I’ve done on this one leads me to a position of, there’s no real solid advice, in the absence of specific legislation that lawyers can give, other than to tell people, ‘It’s going to create risk for you.’” Dombi said. “It created risk with the flu vaccine, but this one may create even more risk because of the clinical aspects of this vaccine.”

A major factor for providers: Some employees are still likely to be skeptical despite promising results from Pfizer and Moderna on their COVID-19 vaccine trials.

About 79% of health care workers said they haven’t received enough information about the COVID-19 vaccine, in terms of safety, side effects and administration, according to a recent survey conducted by the American Nurses Foundation.

On the flip side, there are many home health providers that are hopeful about the vaccine and applaud ACIP’s recent vote.

“I’m very pleased that home health care workers are in that conversation … and part of the front-line workers,” Cleamon Moorer Jr., president and CEO of American Advantage Home Care Inc., told HHCN. “Oftentimes, hospitals, of course, are the top priority, and then outpatient clinics. But I’m glad that home health care workers are included on the front end.”

Dearborn, Michigan-based American Advantage Home Care Inc. is a provider of home health care and rehab services, plus specialty care and medical social work. The agency operates across nearly a dozen Michigan counties.

Moorer also believes there are a host of reasons why it may be difficult for providers to mandate vaccinations for employees.

“Some of our home health care workers could be pregnant or planning for a family,” he said. “In that event, we’re often concerned about the impact of vaccines on pregnant women. Secondly, there are some individuals who for religious and/or ethnic purposes find themselves averse to vaccines. We definitely want to be sensitive to this.”

For context, Pfizer and Moderna’s vaccine trials haven’t included people who are pregnant.

Still, for people who don’t fall into the previously mentioned categories, strongly encouraging and incentivizing employees to take the vaccine — rather than mandating — might be the best option for providers.

“[Providers could potentially] offer a monetary incentive, for those that take on a high volume of patients, especially for those that continuously see patients who have been diagnosed with COVID-19,” Moorer said.

In cases where an employee may decide to forgo the COVID-19 vaccine, there are administrative actions that providers can take.

“They could take the staff that’s refusing to be vaccinated and only assign them to patients who are low risk and are not in a position to transfer the virus from patient to provider,” Dombi said.

Typically during flu season — October through March — American Advantage Home Care Inc. makes multiple in-services available to employees. This means providing education around the flu vaccine and presenting the option for workers to receive the shot or decline, as well as keeping documentation of this information.

The company plans to approach the COVID-19 vaccine in a similar manner, once it’s available. Moorer urges providers to lean on educating workers in the coming weeks and months.

“I think that education is of the utmost importance for health care workers,” he said. “It tends to be one of those forks in the road where a person considers what is the lesser of the two burdens, perhaps contracting COVID-19 versus experiencing some unknown side effects of the vaccine. I think many who have seen the death toll, as related to the virus, would perhaps look at the vaccine as the less of two burdensome outcomes.”

Ultimately, the COVID-19 vaccine could serve as another safety tool.

“The best thing that I’ve heard from anybody so far, is the vaccine … becomes another tool, but you don’t drop your guard on everything else that you’re doing in infection control,” Dombi said. “It doesn’t mean you stop wearing the mask. It doesn’t mean you start gathering with large numbers of people or start getting reckless.”

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Non-Physician Certification in Home Health Care Blocked by State-Level Barriers

Over the past several years, it seems as though the home health industry has been inching closer and closer toward the elimination of Medicare’s strict physician-certification policy. Now — thanks to the CARES Act — nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs) are able to certify eligibility for home health.

While Congress paved the way for non-physician certification in March with support from the Centers for Medicare & Medicaid Services (CMS), a closer inspection reveals that states ultimately have the final say when it comes to this matter.

Home health industry insiders have long been vocal about Medicare’s physician-certification policy — a rule many see as antiquated and overly rigid. Generally, those critics argue the policy created roadblocks that made it more difficult for older adults to gain access to home health care, in turn impacting providers’ bottom lines.

Before the CARES Act, home health services had to be certified — and recertified — by a physician. That process often resulted in heavy delays, especially when physicians were busy.

PAs, in particular, are fairly autonomous in terms of their ability to practice. They are often not in the same location as the physician with whom they collaborate or work with, according to Michael Powe, vice president of reimbursement and professional advocacy at the American Academy of PAs (AAPA).

“For that reason, it’s important for PAs to have the ability to take care of the complete range of services their patients need,” Powe said. “If you’re a PA in a satellite clinic, that might be 25 miles away from the collaborating physician. You don’t want to have to run to that physician to have them sign-off on a certification for home health.”

AAPA is an Alexandria, Virginia-based nonprofit advocacy organization that represents more than 131,000 PAs across the U.S.

When patients aren’t able to get home health care services in a timely manner, those delays drive up costs and result in negative health outcomes.

“They may be in another situation, such as being in a hospital for an extra day or two if can’t get the home health services they need,” Powe said. “That simply runs up the cost of health care for the entire system. If those [home health services] aren’t being provided in a timely manner, then you’re more likely to have a patient who suffers an adverse medical consequence.”

The CARES Act was an attempt to course correct and avoid those issues. It pulled from the April 2019 Home Health Care Planning Improvement Act, which previously sought to give NPs, PAs and CNSs the ability to certify home health permanently.

“It makes it a much more manageable relationship between the home health agency and the attending practitioner for the patient,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told Home Health Care News. “Everything from the original plan of care, to changing orders, to signing the documents on a timely basis in order to then submit and get payment — it really reduces some administrative and care roadblocks.”

Despite federal regulations, there are a number of state-level challenges that stand in the way for NPs, PAs and CNAs.

For example, the scope of practice for NPs is an issue in some states. NPs are divided into two classes: independent practice and collaborative practice with a physician. Less than half of states allow for full, independent practice, according to Dombi.

Meanwhile, most states require PAs to work under the supervision of a physician. PAs are allowed to take on the tasks of ordering care and certifying eligibility, provided that supervisory status exists.

Another issue comes by way of licensure in the states, according to Dombi.

“[About] 35 states have full-blown licensure for home health agencies,” he said. “That licensure generally is fashioned consistent with the Medicare Conditions of Participation (CoPs). While the [CoPs] for Medicare have changed, states have to take the step of changing and updating their own licensure standards to mirror those.”

Another challenge comes from the Medicaid side. There are many states where the Medicaid payment rules need to be updated to allow for a practitioner — and not just a physician — to authorize plans of care and certify eligibility.

Dombi pointed out that the issues surrounding Medicaid payment rules and state CoPs likely have more to do with timing, meaning state governments may just be slow to catch up with federal changes, than a difference of opinion in regard to policy.

On the flip side, Dombi stresses that the scope of practice issues are more serious.

“Some states may never allow non-physician practitioners to have independent practice, and that’s within the state authority to do so,” he said.

As things stand, larger providers that run multi-state operations will have the major task of figuring out the rules and regulations in each state.

“They definitely carry a lot of risks, if they think that a non-physician practitioner can do everything in all of the states,” Dombi said. “Having to manage that on a state-by-state basis creates a burden, of sorts, for them. If you’re in a single state, as a small company, find out what the rules are — and follow them.”

Moving ahead, Dombi believes advocacy will continue to be important to help get state policies to catch up with federal law.

“We’ve worked with many of the state home care associations, which are taking the step to do that,” he said. “Those voices within home health care and the non-physician practitioner community have to step up … and initiate the advocacy to make that happen.”

Overall, 30 states have recently taken temporary or permanent actions to authorize NPs to order home health services. In the last week alone, both California and New Mexico updated their regulations to permanently authorize NPs to order home health services, according to the American Association of Nurse Practitioners (AANP).

Austin, Texas-based AANP is a national advocacy organization that represents the interests of more than 270,000 NPs.

So far, NAHC has worked with state associations in Massachusetts, New York and California, according to Dombi.

Additionally, organizations such as NAHC, AAPA, the American Academy of Home Care Medicine, LeadingAge, Visiting Nurses Association of America and others collaborated on a letter addressed to the National Governors Association, encouraging policymakers to recognize the federal change and provide flexibility.

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Perspectives: Home Health Insiders Sound Off on the 2020 Election

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.

* * *

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)

* * *

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

* * *

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)

* * *

​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)

* * *

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)

* * *

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.

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Lack of Stimulus Bill Could Lead to Rise in COVID-Related Lawsuits

Throughout 2020, there have been a number of new laws and legal trends that could have major impacts on the in-home care industry. In order for providers to be successful in the long run, it’s important to remain abreast of the latest developments.

That was the message delivered by Angelo Spinola, an attorney and shareholder at Littler Mendelson, during this year’s National Association for Home Care & Hospice (NAHC) annual conference.

Among key legal developments, Spinola touched on the Families First Coronavirus Response Act (FFCRA), which creates paid leave — both sick leave and family medical leave — for employees who satisfy certain conditions.

When it comes to the FFCRA, the status of the health care provider exemption should be an area of interest to providers, according to Spinola.

When the law originally went into effect in April, the U.S. Department of Labor (DOL) created a broad exemption for health care providers.

“It certainly covered home health providers … and arguably covered most of the non-medical home care providers as well,” Spinola said. “What the [DOL] allowed companies to do, if you did meet the exemption, is exempt everybody within the entity, meaning it wasn’t specific to the employee. It’s whether the employer would qualify as a health care provider.”

Under the law, providers who qualified for the exemption could elect to not offer coverage to any of their employees, or they could offer partial coverage, such as paid sick leave, but not paid family medical leave.

“There were many home care agencies that were doing just that; they were offering the paid sick leave, but not the paid family medical leave,” Spinola said. “The reason for that decision is that companies were really concerned about losing caregivers for an extended period, for 12 weeks of time, because their children were out of school. [They were concerned about] not having anyone available to care for their clients.”

Recent rumblings in New York have caused confusion around what companies qualify for the exemption, however.

The state of New York issued a legal challenge to DOL regulations, effectively saying that the department exceeded its authority in making the health care provider exemption so broad.

Generally, the state of New York challenged four elements of the FFCRA regulations including the work availability requirement, the definition of health care provider, intermittent leave and the documentation requirement.

The state won on all grounds.

“What does this mean for you?” he said. “It means that if you were relying on a health care provider exemption to exclude coverage under the FFCRA, … there’s some risk to you for having relied on that exemption. You were relying on a broader exemption that has now been struck down.”

The DOL has since revised regulations, and providers need to determine whether their agency is subject to the FFCRA.

As far as other steps providers should take, it’s crucial to determine whether it’s in the company’s best interest to provide full or partial FFCRA benefits to all employees. Providers should also communicate with employees, as well as implement an arbitration program, according to Spinola.

Stimulus package, qualified immunity

The next coronavirus-related stimulus package remains top of mind for providers.

When it comes to advocacy initiatives, most providers had five key areas of focus.

These areas include increased pay for front-line workers to discourage many from going on unemployment, child care support for caregivers, priority access to personal protective equipment (PPE), qualified immunity and the creation of an “HCBS Direct Care Worker Fund.”

In May, House Democrats unveiled the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, a COVID-19 stimulus bill. The bill included most of the five industry initiatives except for qualified immunity.

Ultimately, the bill passed out of the house, but couldn’t pass in the Senate.

Another stimulus package, the Health, Economic Assistance, Liability Protection and Schools (HEALS) Act, was introduced in July. Out of five industry initiatives, the bill only included paid child care and qualified immunity. The legislation failed to pass out of the Senate.

“The problem that we are seeing is there’s no movement right now,” Spinola said. “They’re $2.5 trillion apart. There are significant differences between the two acts.”

While it’s impossible to say what will happen, Spinola pointed to the state of the economy as an indicator of the future.

“I think that what might happen is directly tied to the state of the economy,” he said. “We saw the economy really tank. We saw record unemployment claims. …I think we are seeing now because the economy is starting to rebound, there’s less pressure on Congress to create this stimulus package.”

As the election draws closer, there will be less focus on the stimulus bill.

“That’s concerning because that means a lot of the things that we were hoping to accomplish, … we might not get,” Spinola added.

In particular, if qualified immunity doesn’t pass, it puts the industry in a very vulnerable spot for litigation.

Overall, there have been at least 792 COVID‐related labor and employment lawsuits filed against employers, and more than 2,000 general COVID‐related lawsuits. More than 10% of these cases include class-action claims.

“Not surprising that since COVID hit, we’ve seen an increase in related cases,” Spinola said. “Each month, the number gets higher and higher, and we’re going to continue to see this. Unfortunately, we are seeing it specifically in the health care space.”

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Private-Duty Home Care Providers Poised to Play Leading Role in Pop Health Models

As health care spending continues to rise, private-duty home care agencies will likely play increasingly important roles in population health management.

In total, U.S. health care spending is expected to reach $4.8 trillion by 2025.

Often, it’s chronic conditions, social determinants of health and functional limitations that drive that spending upward. The combined pervasiveness of those three factors creates a “high-cost trifecta,” according to Cindy Campbell, the director of operational consulting at WellSky.

WellSky is a rapidly growing international software and professional services company with clients that include home health providers, hospital systems, blood banks, labs, hospices, government agencies and human services organizations. The PE-backed company announced plans to acquire CarePort Health from Allscripts Healthcare Solutions (Nasdaq: MDRX) for $1.35 billion on Oct. 13.

Campbell made her comments during a presentation on Tuesday at the 2020 National Association for Home Care & Hospice (NAHC) annual conference.

When thinking about managing health care and expenses over time, the goal should be to deliver care in the least restrictive, least expensive and most satisfying place. This place is the home, according to Campbell.

Broadly, private-duty home care agencies already offer services that address social determinants and functional limitations.

“Home care providers have really been doing this in many ways for a long time,” Lucy Andrews, owner and CEO of At Your Service Nursing & Home Care, said during the presentation. “We know how to support functional needs for people. We know how to keep them home, as they progress through chronic comorbidities, diseases, new diagnoses. We know that incrementally the value of this expertise provides the market with an exceptional opportunity to innovate to be part of this process.”

At Your Service Nursing & Home Care is a Santa Rosa, California-based personal care provider. The company’s services include companionship, respite care, medication reminders, housekeeping and dementia care.

Home care generates considerable cost savings for complex and chronic patients with functional limitations while supporting a compelling business case for its value in population health management. As payers look for ways to reduce spending, the focus may shift to private duty, according to Campbell.

In other words, If population health management isn’t already on a provider’s radar — it should be.

“The first thing to do is really understand why this matters,” Andrews said. “We have the ideal platform because we have supply and demand.”

When it comes to population health management, having access to data and analytics that can reflect performance will be important for providers.

“How are you ultimately going to measure your success?” Campbell said. “What are those key performance indicators that you’re going to be looking for? These are the outcomes that you want to achieve. Think of the value proposition to a managed Medicare or managed Medicaid program, or to human beings in general, if we reduce hospitalization rates. That’s a good measure.”

Other potential performance indicators for private-duty home care agencies are emergent care rates, plus patient and family satisfaction scores. Any metrics related to a provider’s ability to keep patients in the home are also critical.

In population health models, it’s also important for providers to be able to identify when their high-risk patients are most at risk.

“Make sure that you’re looking within your organization at how you quantify risk for the people you serve,” Campbell said. “Who is in that top percentage of need out there that you want to focus on in your program?”

For providers, this could mean addressing transportation needs, risk of medication non-compliance, home-safety concerns and more.

Additionally, it’s important for providers to learn how technology can support their business.

In cases where a provider is caring for someone with chronic obstructive pulmonary disease (COPD), for example, having the right telehealth solutions in place can make a real difference, according to Campbell.

“We know that there’s a challenge within COPD, and solutions that employ and integrate telehealth really [can help] make it work,” she said. “If we can add messaging to that, really adjusting and fine-tuning the dial through this type of a virtual platform, then we can help people adjust in real-time to their needs, stabilize condition and reduce their readmissions.”

Overall, the COVID-19 emergency has placed home care in the spotlight. It’s the perfect time for providers looking to gain a “seat at the table,” Melanie Stover, owner of Home Care Sales, also said during the presentation.

“The time is now,” she said. “It is an urgent time to skill up and put metrics in place so that you can serve more clients, impact more families and increase your revenue. We have been incrementally moving the agenda of home care forward.”

Home Care Sales is a Fairhope, Alabama-based home health, hospice, and private-duty home care sales consulting firm.

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NAHC Pushing for Palliative Care, SNF-at-Home Medicare Benefits

As home health and home care operators move toward the ninth month of the COVID-19 pandemic, it’s important to take stock of what has been accomplished from a policy perspective. Many of 2020’s regulatory changes will be fleeting, but others will shape the future of post-acute care for years to come.

That was the message delivered Monday by National Association for Home Care & Hospice (NAHC) President William A. Dombi during the nonprofit advocacy organization’s annual conference. In addition to providing a regulatory recap, Dombi hinted at new Medicare benefits on the horizon and explained how the value of home-based care is at an all-time high.

“There has been an increased awareness of the breadth and depth of care at home, and this will have a long-standing impact on policy and politics as well,” he said. “There has been an absolute, exponential increase in respect for what you do in the home care setting. We took the stresses of the pandemic head-on and proved that care in the home is not only essential but [the best option].”

During Monday’s Washington update, Dombi revealed that 67% of in-home care providers are serving COVID-19-positive patients.

To support them in delivering that care, providers have been able to lean on a variety of lifelines, including funds from the CARES Act Provider Relief Fund and the Paycheck Protection Program (PPP). Providers have also received essential-worker classification and greater telehealth flexibilities.

Additionally, the U.S. Centers for Medicare & Medicaid Services (CMS) has recognized that virtually the entire Medicare population meets homebound status requirements.

“When you’re Medicare eligible, over the age of 65 or on disability, and you need health care services, you have a compromised condition to put you at even greater risk of fatality,” Dombi said. “CMS agreed with our position on this and issued interpretive guidance indicating that individuals who need to leave the home for services, it is medically contraindicated, thereby meeting the homebound standard.”

During the public health emergency, CMS also paused claims audits and the Review Choice Demonstration (RCD), a regulatory initiative designed to reduce improper billing in home health care. That has since been restarted, with temporary administrative flexibilities.

COVID-19 testing, non-physician certification

At the end of September, the U.S. Department of Health & Human Services (HHS) announced that home health and hospice agencies would receive 10 million rapid COVID-19 tests from a federal inventory of about 150 million. Dombi likewise touted that as a win.

In the first week of distribution alone, he noted, about 160,000 tests were distributed to home health and hospice agencies.

“The fact that HHS recognized that home care was an essential part of health care services and made us part of that allocation in itself is a notable success,” Dombi said. “Just being recognized, not being considered some stepchild in health care.”

Among the other topics he touched on during his Washington update, NAHC’s president highlighted excitement around non-physician certification, something the home health industry had been working toward for years.

Senator Susan Collins (R-Maine) first introduced legislation that pushed for this change in 2007.

“We found ourselves in the middle of discussions, negotiations and advocacy with the CARES Act, and Senator Collins said, ‘I think this is our chance to get it done.’ [She] was able to convince the Senate that now is the time to allow non-physician practitioners to have equal status with physicians, to the extent that the state law allows it within the Medicare home health benefit,” Dombi said.

New Medicare benefits

Despite making major inroads across various fronts, there are still a number of measures that need to be taken.

For one, providers are still on the lookout for the next coronavirus-related stimulus package, which was originally expected before the July 4th Congressional recess, then again before the August recess.

“This is a back and forth that’s happening between the House and the Senate, between Republicans and Democrats,” Dombi said. “We’re still looking to see if we can have something before they go on recess in October, but we’re planning also for a lame-duck session on it.”

As far as what providers hoped to see in the next package, the list includes continued funding for the Provider Relief Fund, plus expanded funding for Medicaid home- and community-based services. The list also includes premium pay for front-line workers and litigation immunity.

Another area of focus for NAHC is palliative care. The organization is moving to get revisions in the Medicare coverage manual under home health care to fully recognize palliative care as one of the services provided as part of the existing benefit.

“We don’t think we need Congressional action to get there,” Dombi said. “Some of you — maybe many of you — are already doing things that would qualify as skilled palliative care under the benefit and getting Medicare to pay for it.”

Home health providers can also expect to see the 2021 payment rule finalized before the end of October or during the first few days of November. NAHC is calling on CMS to roll back the 4.36% behavioral adjustment in the Patient Driven Groupings Model (PDGM) ahead of the announcement of the final rule.

“It’s not just because we are in this unprecedented year of COVID-19,” Dombi said. “CMS projected a decrease in [Low Utilization Payment Adjustments], as they thought home health agencies would try to maximize 30-day episodic reimbursement. We have seen just the opposite of that, partially influenced, of course, by COVID-19.”

Additionally, NAHC is pushing for the creation of a new benefit that will allow for a skilled nursing facility (SNF) level of care at home.

“We have designed a [SNF-at-home] benefit to give individuals on the Medicare program the option of going home with expanded services,” Dombi said. “We think the design will work to be a win for the Medicare program as well. It’s been proven that you can provide less costly and high-quality care at home.”

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In-Home Care Providers on the Lookout for Next Stimulus Package

Although concrete details are largely unknown, in-home care providers remain on the lookout for the next coronavirus-related stimulus package.

Specifics on a possible fifth stimulus package could be released as early as this week, policy experts believe. 

“I think that’s the question, whether or not a package comes together that everyone agrees to before the August recess — or potentially after it,” Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare (PQHH), told Home Health Care News. “We’re seeing new spikes in different parts of the country, which has added renewed pressure.”

PQHH is a home health care advocacy organization based in Washington, D.C.

Senate Majority Leader Mitch McConnell (R-Ky.) and Treasury Secretary Steven Mnuchin have reportedly been working on a draft of the legislation for the past several weeks, with Mnuchin saying the next phase of relief should go toward industries hardest hit by the coronavirus.

“We are monitoring economic conditions closely,” Mnuchin testified on Friday in front of the House Committee on Small Business. “Certain industries, such as construction, are recovering quickly, while others, such as retail and travel, are facing longer-term impacts and will require additional relief.”

Broadly, a fifth stimulus package will likely focus on a number of topics, including funding for school reopenings, litigation immunity for certain industries and continued unemployment benefits, according to reports from The Hill.

“One thing the majority leader in the Senate has said is that there needs to be some form of business immunity from potential liability related to COVID-19,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told HHCN. “The other forces that are in play range from an extension of the federal unemployment insurance to further expansion of the Paycheck Protection Program (PPP).”

NAHC is also a D.C.-based trade organization. Its provider members span the full spectrum of home-based care.

So far, more than 15,000 home-based care companies have received more than $666 million in PPP loans of under $150,000, an HHCN analysis found.

Additionally, the next potential stimulus package could pave the way for an expansion of the Provider Relief Fund. It could also provide added federal support for state and local governments.  

One question that looms large is the total amount of the next stimulus package, according to Dombi.

“I think we’ve moved from whether there would be one, to how much it will be and what will be in it,” Dombi said. “Is it going to be a $1 trillion program, a $2 trillion program or a $3 trillion program? This seems to be somewhat fluid. The bill that came out of the House earlier — the HEROES Act — was over $3 trillion.”

The White House has, informally, indicated that a $2 trillion package is a possibility. Meanwhile, McConnell’s office reportedly wants the next stimulus bill to be around $1 trillion. 

In-home care providers may benefit from another stimulus bill in several different ways.

One is an additional injection of cash into the Provider Relief Fund. There are parts of in-home care that haven’t received funding, including private-duty home care and private-pay services, for example.

Some providers have only received 2% of their total revenue in terms of financial support, but are experiencing a cost increase that is close to 10%, according to Dombi.

Another measure that would help providers is special funding for front-line workers, who are facing additional risk due to the public health emergency.

“It goes by many different labels: premium pay, hazard pay, combat pay,” Dombi said. “There needs to be something to encourage people to come into doing that work, particularly at the lower end of the wage scale.”

Dombi also called for child care support for essential front-line workers.

“If the schools will not be uniformly open five days a week for all students, somebody is going to need to care for those children,” he said. “Generally, that falls on parents, unless those parents also need to go to work. So how do we take care of those child care needs for those front-line workers?”

On the Medicare home health side, NAHC would like to see authorization for reimbursement of telehealth services.

“Without a doubt, important advances have happened to provide some flexibility, but we think it’s falling short of realizing its value by not having any direct reimbursement for those services,” Dombi said.

For in-home care providers, now is the time to advocate for the industry at the grassroots level, as the situation remains fluid.

“[Providers] need to be engaged and explain why there is still a greater need for support for health care providers than currently exists, and that in-home care needs those supports as much as hospitals do,” Dombi said. “By our very informal count, there are more patients with active COVID-19 infections in home settings than there are in hospital settings. We have opportunities — we have no guarantees that further supports will be made available.”

Top Republicans in Congress planned to meet Monday with President Donald Trump to discuss the next COVID-19 aid package, The Associated Press reported.

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