by Tim Rowan | Apr 4, 2024 | Clinical, Editorial
by Tim Rowan, Editor Emeritus
For as long as I can remember, Home Health and Home Care owners and advocates, including their national and state associations, have struggled to develop concrete data to prove what we all know to be true: In-home care is a great deal for payers, both public and private. Underpaying our sector in a misguided attempt to reduce costs results in paying more in the long run. Buying more in-home care translates into lower overall cost.
This is one part of the story, and we continually search for the proof our sector so desperately needs. But there is another aspect to the Home Health, Home Care advantage that must not be overlooked as we focus on payer finances.
Patient care and safety
One need look no further than our post-acute care neighbor, Skilled Nursing Facilities, to understand how much better off elderly citizens are when in-home caregivers and clinicians enabled them to stay in their own homes and avoid institutionalized care. A new, peer-reviewed study titles “Profits Over Patients” was published in the online collective The Conversation. If unfamiliar, think of it as The Huffington Post for scholars and researchers.
In the exposé, investigators Sean Campbell and Charlene Harrington reveal that for-profit organizations have been infiltrated by Wall Street investors and other venture capitalists, seeking quick turnarounds and handsome profits. Founders and other SNF owners gladly accept generous offers to be acquired or partner with investors who immediately begin to impose cost-cutting measures and maximize profits. The probe, which paired an academic expert with an investigative reporter, discovered a number of startling findings:
“The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under weak and poorly enforced regulations with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health.”
Campbell and Harrington also looked at the ineffectiveness of state inspectors, who have limited ability to impose meaningful fines for violations. One startling example in the report is that of a Louisville SNF. The care was found to be “abysmal” when Kentucky inspectors filed their survey report.
“Residents wandered the halls in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate with a stick, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead gash. That person was allowed to roam and enter the beds of other residents. In another ase, there was sexual touching in the dayroom between residents, according to the [surveyor’s] report.
“Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors.
“Overall, there was a critical lack of training, lack of staff, and lack of supervision.”
The report said state inspectors found 29 deficiencies, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The fine imposed was $319,000 — more than 29 times the average for a nursing home. Payments from Medicare and Medicaid were suspended. The investors and owners chalked the fine up to a normal cost of doing business and, five months later, inspectors found six additional deficiencies “of immediate jeopardy,” the highest level.
The parent company of the Kentucky SNF, Infinity Healthcare Management, owns 58 facilities across five states. Since 2021, Infinity has been hit with nearly $10 million in fines, more than 4.5 times the national average.
Cut staff, save money, hide money
The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, endangering patient health. “Meanwhile,” the authors assert, “owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporation
s. Federal regulators have neglected the problem as each year likely billions of dollars are funneled out of nursing homes through related parties and into owners’ pockets.”
The report points out that problems of this magnitude are found far less often in small, single-location facilities and in national chains and franchises. The sweet sport for abuse seems to be in the mid-range, for-profit organizations that have been taken over by far-away investors. Sadly, 72 percent of the SNF’s in this category are for-profit. “While such chains account for about 39 percent of all facilities, they operate 11 of the 15 most-fined facilities.
Relevance
A frequent message at Home Healthcare conferences in recent years has been the renewed interest in our sector from big money investors. While quick profits and the enticement of early retirement might bring Home Health and Home Care owners to the negotiating table, this exposé may be a reason to take a breath and think it through. Most of you who nurtured your company from startup to attractive acquisition target did so as much out of compassion as entrepreneurship. Would you not wonder, from your perch on the sun deck of a cruise ship, whether your legacy is being dragged in the mud and your patients and employees reduced to a Wall Street cost column?
Read the entire report here.
Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com or Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
by Tim Rowan | Mar 20, 2024 | CMS, Editorial
by Tim Rowan, Editor Emeritus
This week, we look at the state of the healthcare industry, vis a vis payers that do not pay.
While Home Health and Hospice leaders talk at every gathering about refusing to accept Medicare Advantage clients, some large Integrated Healthcare Systems are actually doing it. Other hospitals are responding to difficult payers by laying off staff, or even closing. The HHS Office of Inspector General repeatedly fines insurance companies for upcoding to gain inflated, unjustified monthly payments. Meanwhile, insurance companies report record profits, with their MA divisions leading the way. The fines go into the “cost of doing business” column.
March, 2024, Becker’s Hospital Review: Bristol (Conn.) Health will eliminate 60 positions, 21 of which are currently occupied and will result in layoffs at Bristol Hospital. The hospital’s CEO, Kurt Barwis, told a local newspaper a lack of reimbursement from insurers left the hospital without a choice but to cut staff.
October, 2023, NPR: Since 2010, 150 rural hospitals have closed. Under CMS’s “Critical Access” designation, Medicare pays extra to those hospitals to compensate for low patient volumes. MA plans do not. Instead, they offer negotiated rates that are lower than what traditional Medicare would pay.
December, 2023, Becker’s Financial Management: 13 additional hospital systems cut ties with Medicare Advantage plans since October.
What is going on?
The Medicare Payment Advisory Commission, MedPAC, believes it has learned the answer. In its March 15, 2024 report to Congress, the Commission called for a “major overhaul” of Medicare Advantage policies. It says it found that the program, designed to lower costs and extend the lifespan of the Medicare trust fund, does not save money but costs the fund more than if all beneficiaries were on traditional Medicare, $83 billion more in 2024.
Calling it, too politely, “coding intensity,” MedPAC concurs with the OIG that MA plans routinely exaggerate patient conditions. The report claims it will amount to MA clients appearing to need 20% more healthcare than fee-for-service beneficiaries, when they do not. Padded coding, MedPAC says, will increase Medicare premiums by $13 billion in 2024.
“A major overhaul of MA policies is urgently needed for several reasons,” the commission wrote in its report. MedPAC cited several problems that need to be addressed, including the disparity in costs between beneficiaries in fee-for-service Medicare and MA, a lack of information on the use and value of supplemental benefits, and challenges setting benchmark payment rates.
A proposal currently making its way through Congress would reduce supplemental payments to insurers, who threaten to raise premiums and cut benefits if their inflated benchmark payments are lowered.
“If payments to MA plans were lowered, plans might reduce the supplemental benefits they offer,” MedPAC wrote in its report. “However, because plans use these benefits to attract enrollees, they might respond instead by modifying other aspects of their bids.” The barrage of TV ads, featuring aging celebrities, have been found to be deceptive and too often backed by shady front companies representing brokers, not insurance companies. The brokerage company behind the Joe Namath ads, for example, has reorganized and changed its name three times.
Pushback from AHIP, the insurance industry lobbying organization, has been as expected. “MedPAC’s estimates are based on ‘speculative assumptions’ and ‘overlook basic facts about who Medicare Advantage serves and the value the program provides.'”
MedPAC asserts that its estimates are based on history, not speculation.
Healthcare Providers Beg to Differ
A lack of payments from Medicare Advantage plans is one reason the Connecticut hospital is laying off staff, the Hartford Courant reported March 14. CEO Kurt Barwis told the newspaper Medicare Advantage plans have been denying claims more frequently while delaying payments for the claims they do approve. “Our primary care is to take care of patients, their single focus is shareholder value and profits,” Mr. Barwis told the Courant. “The Medicare Advantage abuse is outrageous.”
The strategy insurance companies deploy to avoid providing care, Barwis continued, is excessive prior authorizations, coupled with delayed payments. This obstacle to care is directly in opposition to CMS policy. MA divisions of large insurers respond that they are private insurance and allowed to impose their own treatment approval policies. MedPAC says this claim is incorrect.
Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. Kronick added that there is “little evidence” that MA enrollees are sicker than the average senior, though risk scores in 2019 were 19 percent higher in MA plans than in original Medicare. That gap continues to widen.
Where does this excess taxpayer money go?
2023 Medicare Advantage business division profits and 2022 CEO compensation reported by publicly traded companies:
UnitedHealth Group: $22.4 B (Andrew Witty $20,865,106)
Aetna (CVS): $8.3 B (Karen Lynch $21,317,055)
Elevance Health (Anthem): $6 B (Gail Boudreaux $20,931,081)
Cigna: $5.1 B (David Cordani $20,965,504)
Centene: $2.7 B (Sarah London $13,246,447)
Humana: $2.5 B (Bruce Broussard $17,198,844)
We found one curious outlier. Molina Health, with annual revenue 10 percent of UnitedHealth Group’s income and 2.16 percent of the market, paid its CEO $22,131,256 in 2022.
Download the entire MedPAC 2024 report here. Chapter 7 is the Home Health section. A summary of MedPACs recommendations begins the chapter thus, “For calendar year 2025, the Congress should reduce the 2024 Medicare base payment rates for home health agencies by 7 percent.”
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Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan | Mar 6, 2024 | Admin, Clinical
by Tim Rowan, Editor Emeritus
[Editor’s note: this article is based on a recorded video interview with Barbara Karnes. To see the full conversation in her own words, click here.]
For longer than most of us have been in home care, in fact, for longer than some home care workers have been alive, Barbara Karnes has lived and breathed hospice. From young nurse in 1980 to administrator to author and video producer, she continues into her mid-80’s to teach young nurses and distraught families about the dying process and the grief experience.
Last autumn, however, she was suddenly transported to the other side of the classroom. The death of her husband, a longtime chain smoker, introduced her to cancer, hospice, death, and grief from the perspective of the heart, after decades of dealing with it only intellectually. Barbara graciously agreed to speak with me late last month. Having been through the experience myself, I thought it best to wait a few months after his death to extend my interview invitation.
“I have always been the kind of person who operates out of the head more than the heart,” she began. “Putting on the shoes of a spouse caregiver, and suddenly living what I have taught for decades, put a whole different perspective on it. Even though I knew better, I sometimes did things I tell people not to do.”
She told me about the urge to do those things. “I kept pushing food and the need for nutrition on him,” she remembered. “Then, one day, I finally realized I was trying to keep him alive while his body was trying to die. And with that realization, I began to do what I always recommend everyone else do, always offer and never force.”
“As a professional, I observe the dying and grieving processes. With my husband, I was feeling it. I was in the shoes, and I responded like a family member, not like a hospice expert.”
I Wanted to Know, But He Did Not
Barbara talked about the anguish of not knowing how much time her husband had left once he was diagnosed. “When he decided that he was not going to treat his cancer with chemotherapy, that included the decision not to bother with a lung biopsy just to see what type of cancer he had. ‘If I’m not fighting it, what difference does it make what kind it is?’ he said, and I couldn’t argue. There are fast and slow kinds [of lung cancer] and I wanted to know which it was so I could prepare myself. With my knowledge, I could have estimated how long his death process would take and known when to begin hospice care. I hoped it was one of the slow-growing types rather than small-cell carcinoma, but I realized that was a wish on my part, not realistic, and not what he wanted.”
Hospice Has Changed
In a side conversation, Barbara reminisced about the way hospice care was conducted in her early years as an RN and turned it into advice for today’s nurses.
“Our goal was always to be there with the family at the moment of the patient’s death. Today, hospice is much more medical, more medication oriented. I like the “End-of-Life Doula” movement today. Their companion model reminds me of the way we used to do hospice.”
As it turned out, he was diagnosed in May and passed away in September. He entered hospice right after Labor Day, even though she called to arrange services the Friday before. “Hospices should not do that,” she asserted. “When people are dying, holidays should not be a reason to delay starting care.” Nevertheless, due to this combination of circumstances, a fast-acting cancer and a slow-acting hospice, the husband of a foremost expert on death and grieving was in hospice for the all too common two weeks.
“To be fair, he was driving himself to massage appointment through August,” she clarified. “It was the day he was unable to get off the massage table that we knew it was time.”
Sometimes the Heart Wins
“It was as though I had a split personality,” she said, as I tried to gently encourage her with more personal questions. “There were parts of me that, from the day he was diagnosed, were thinking about him dying. There were parts of me, intellectually, that knew but didn’t want to see all that was unfolding. It’s a kind of confusion.”
Finally, the renowned Barbara Karnes offered the conclusion I had hoped to hear but was reluctant to directly ask. “I don’t know if my knowledge helped or not. There were signs, but I didn’t want to see them. When you’re in it, it is a different experience than when you’re teaching about it.”
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Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan | Feb 7, 2024 | Admin, Vendor Watch
by Tim Rowan, Editor Emeritus,
Advertising in The Rowan Report comes with a few perks! Our CEO interview with Tim is one of them. Advertisers with a full-year contract receive one annual CEO interview with Tim. If you’re not an advertiser, CEO interviews can be purchased as well. Highlight the expertise of your leadership with a one-on-one industry overview and company update with Tim, published on The Rowan Report website, social media, and YouTube channel.
Click on these titles to view each episode of our “Meet the CEO” video interview series.
Andre Gomez, Bedrock Healthcare at Home, January 2024
Rich Berner, Complia Health, December, 2022
Emmet O’Gara, Sandata, September, 2022
Roger Shindell, Carosh Compliance Solutions, June, 2022. HIPAA risk assessment workshops
Michael Gelman, CareConnect, May, 2022, Workforce Management
Jim Bland, Seniors Home Services, November, 2021, A menu of products from remote patient monitoring to home modifications, all with revenue sharing for home care partners
Ashley Wharton and Jenna Schwartz, Savii, March, 2021, Private Duty Agency Management Software
Eric Becker, CEO, MiliMatch, on technology to improve recruiting and retention
Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com
© 2024. All content is produced by The Rowan Report. All rights reserved.
by Tim Rowan | Jan 31, 2024 | Clinical, Marketing
by Tim Rowan, Editor Emeritus
Counter-intuitive but true. Over-the-top customer service, intended to delight rather than merely satisfy, creates no more customer loyalty than very good customer service.
Speaking to a crowded room at last week’s Home Care 100, Ian Goddard, of Challenger Performance Optimization, Inc., raised a lot of eyebrows when he presented findings of an extensive research project that surveyed 125,000 customers and 5,000 customer service reps across a range of unrelated industries.
- Lousy customer service discourages return customers.
- Good customer service increases customer loyalty.
- Great service leads to a high level of loyalty, but that is as high as it goes.
Over-the-top, he called it “delight service,” results in the same level of loyalty as great service.
Most people have heard the stories. Anyone who has taken a sales training class know about the Nordstrom’s employee who refunded money to a customer who was dissatisfied with a tire. She had bought the tire at that location when the building housed a tire store, before it was a Nordstrom’s.
Goddard told a similar one about a stuffed giraffe that was left behind at a Ritz-Carlton when the family left for the airport. At bedtime, the giraffe’s poor little owner was distraught. Dad called the hotel and soon began to receive photos of the giraffe “on vacation” but coming home soon. The enthusiastic employee took pictures of the giraffe sunning himself by the pool, having a drink at the cafe, and sleeping in a big comfortable bed. The little guy was at peace and slept well. The father flooded social media, singing the praises of Ritz-Carlton. “I’ll never stay anywhere else,” he proclaimed.
According to the Challenger survey, that enthusiasm does last for a while, but not forever. If that grateful dad’s next vacation is in a city without a Ritz-Carlton, or if there is another upscale hotel with a better price, loyalty takes a back seat. His social media campaign, of course, has a long-lasting ripple effect. Word of mouth today is online, not over the backyard fence.
Effortless Customer Service
The survey discovered that there is, however, one customer service experience that impacts loyalty more than any other, even more than service that delights a customer. “Your customers do not want to talk to you,” Goddard asserted. “The most important experience is the one that requires the least effort on the part of the customer. The customer service rep who acts as your advocate cuts through red tape, solves your problem, and takes steps to avoid you having to call again about the same thing. Advocacy is the characteristic of the rep who creates loyalty. Think of your own customer service experiences. If you have to work, or wait on hold, to get a problem solved or to fix something broken, you come away unhappy, meaning less loyal to the brand, even if your issue is finally resolved.
Out of eight personality types typically found in customer service positions, Goddard said, the “controller” type is the most effective. This is the agent who says, “Hold on, I’m going to take care of this for you,” and then comes back a few minutes later with, “all done, problem solved.”
Avoid the Next Service Issue
Goddard told the story of the customer with a broken vacuum cleaner belt. The service rep recognized the issue and told him, “Your replacement part is already on its way.” When he received two belts instead of one, he called back. She said, “We have learned that some customers have trouble installing the belt and they break it the first time. So, we send two, hoping they will learn what they did the first time and install it correctly with the second part.”
“Thinking forward like this vacuum cleaner company does cost a few extra cents with every replacement, but avoids a far more expensive service rep interaction in the future and cements customer satisfaction,” Goddard explained.
Effortless Service in Home Care
Ryan Iwamoto, owner of 24 Hour Home Care, interpreted this way of thinking about customer loyalty for our industry. Asking, “How do we get effortless experience into our organization?” he partnered with a company called Tethr that listens to and analyzes phone conversations. It then coaches the customer service person on ways to improve effectiveness, think like an advocate, and improve satisfaction. Realizing that his caregivers are much like customers, he uses Tethr for them as well.
From the start of the Tethr implementation to the present, advocacy on all calls increased from 26.3% to 34.1%. Difficult calls decreased from 8.3% to 7.9%. Average call length decreased from 4 minutes, 15 seconds to 3 minutes, 52 seconds. Customer Effortless Score, which was tracked at the company, region, office, and individual level, increased 39 percent. Phone calls tracked came from all customers: clients, caregivers, and referral sources.
Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
by Tim Rowan | Jan 24, 2024 | CMS, Regulatory
by Tim Rowan, Editor Emeritus
T
he battle for stable Home Health reimbursement rates continues full speed ahead on Capitol Hill, but the advocacy organizations engaged on the front lines of that battle are losing ground. The Partnership for Quality Home Healthcare and the National Association for Home Care and Hospice have deployed weapons from educating Congressional staffers to suing CMS. Those traditional methods appear to be insufficient, as the specter of draconian rate cuts casts a larger and larger shadow.
Missing from the conflict is the only effective weapon, flooding lawmakers with messages from their constituents.
According to Joanne Cunningham, CEO of the Partnership, the time is now to bring that weapon to the front. She told over 600 attendees at this week’s Home Care 100 event in Scottsdale that she and Bill Dombi have done everything they can up to now, adding that the only way to stop $3.5 to $5 billion in Medicare cuts is for every person of voting age whose livelihood depends on Home Health care to call or write their House Member and Senators.
STEP ONE: A "Must-Pass" Bill
“Preserving Access to Home Health Act of 2023,” is a pair of bi-partisan bills introduced into the House and Senate in the summer of 2023. (S.2137/H.R. 5159) They would prevent CMS from making new cuts to the PDGM payment system, both now and in the future, by blocking annual “recalculations” that traditionally use flawed formulae.
The bills would require MedPAC to perform more comprehensive calculations before it makes recommendations to Congress. Currently, the Commission only considers revenue and profit margins from traditional Medicare. They determine that Home Health margins are too high without looking at the small-to-negative margins providers accrue from Medicare Advantage, Medicaid, the VA, and private insurance. Medicare profit margins make it possible for HHAs to care for patients with stingier payers. Reducing those margins too far, which MedPAC recommends every year, would remove access to care for millions of beneficiaries.
STEP TWO: Educating Congress
Ms. Cunningham emphasized that elected officials, as well as bureaucrats who write the regulations to implement the “will of Congress,” have yet to understand the impact in-home care has on overall healthcare spending and access to care. “We have to get bureaucrats to look at our data,” she said. “We know we save the trust fund more than we take from it, and we know that we are turning patients away because we cannot pay enough to attract clinicians in sufficient numbers. We have to educate them all.” She offered a few concrete suggestions.
-
- Data, data, data. The most effective policy argument starts with independent analysis from outside the industry.
- Tell stories. Elected officials and their staffers respond to real-life experiences of people within their districts and states. A group from Inhabit Health, for example, sat Congressional staffers down and told them about individual patients who had been kept out of hospitals and EDs, about great care they had received. They added summaries of their typical patients as well.
- Listen. Staffers will challenge your assertions and ask hard questions. They will help you identify your ‘Achilles Heels.’ See this as helpful preparation for meeting the Member or Senator.
- See them at home. Cunningham underscored the importance of making appointments and meeting with House members and Senators away from DC, for two reasons.
- “A lot of people approach a Member on the way out of a church they both attend. What they don’t realize is that they are one of ten who will do the same thing between the church door and his car, from ten different industries. You just become ‘part of the clutter’ and are quickly forgotten.”
- Back home advocacy is the most important thing you can do; it is even better than going to DC. Their main interest is re-election and they respond to messages from constituents. The purpose of advocacy is to cut through the noise. At home, you can say, “Hey, I know you; you’re my neighbor; listen to me!”
- Repetition is key. When you write a letter, it goes on a list. Staffers count up how many constituents have written about each issue. The best strategy is to make them feel pressure from back home. Marshall all the political pressure you can, but fill it with data.
Ms. Cunningham told about leading a group of Home Health providers from Oregon to meet with Senator Ron Wyden in his home office. To make their case for Home Health reimbursement support, they showed him their books, which proved that MedPAC is wrong about Home Health profit margins. They changed his mind. She said that meeting was so powerful and successful, it has become a model for working with other states.
STEP THREE: Expose Medicare Advantage
The Partnership’s goal is to ensure alignment of the MA home health benefit with traditional Medicare – as all Medicare beneficiaries are all entitled to the same home health benefit, regardless of the payor.
“MedPAC met during the first week of January to discuss Medicare Advantage. The meeting, which included a focus on the methodology of payments, was contentious at times.” Cunningham said. “In its January 12 report to Congress, The Medicare Advantage Program: Status Report, MedPAC forecast that CMS will overpay MA plans as much as $88 billion in 2024, based on prior year behavior.”
Higher coding organizations have a competitive advantage because they receive larger payments for enrolling the same beneficiaries as other organizations, and they can offer more extra benefits and attract new enrollees simply because of their coding efforts
Principal Policy Analyst, MedPAC
MA’s focus on extras such as Silver Sneakers, vision care, and basic dental care, along with low or zero premiums added to the Medicare Part B premium that all beneficiaries pay, are what MA plans emphasize in their annual barrage of TV commercials. Never mentioned on TV or in direct mail brochures are two practices that impact many times more dollars than gym memberships and low premiums. The undeserved $88 billion mentioned in the MedPAC report comes from exaggerating initial assessments of plan enrollees. Payments from Medicare to a plan hinge on patient acuity. When improperly padded, acuity robs the trust fund and pads insurance company profits.
The second downplayed practice is on the care side of the equation. The largest MA plans have often been found to deny procedures that traditional Medicare standards would have covered. When they do pay for care, especially Home Healthcare, they pay rates below traditional Medicare rates, often lower than provider costs. Cunningham concluded her comments with a description of the Partnership’s efforts to bring pressure from MedPAC and the HHS OIG to force MA plans to comply with regulatory requirements. “We are all of one mind regarding MA. I think we are going to see practices change.”
The Partnership for Quality Home Healthcare was established in 2010 to work in partnership with government officials to ensure access to quality home healthcare services for all Americans. Representing community- and hospital-based home healthcare agencies nationwide, the Partnership is dedicated to developing innovative reforms to improve the program integrity, quality, and efficiency of home healthcare for our nation’s seniors.
pqhh.org
Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan | Jan 24, 2024 | Regulatory
Untitled Document
Analysis by Tim Rowan, Editor Emeritus
P
erennial Home Health enemy MedPAC angered a different group last week by releasing a status report on insurance companies participating in the Medicare Advantage program.1
The report details the way in which giant, for-profit, health insurance companies improperly increase per-customer payments by upcoding their health assessment at enrollment, and then slash costs by denying coverage for healthcare services that traditional Medicare would have honored. MedPAC was also critical of the practice of requiring prior authorizations, backed up by utilization review algorithms that are supposedly intended to “minimize furnishing unnecessary services” but which effectively increase denials for necessary care.
According to the report, MedPAC expects CMS to pay MA plans $88 billion in 2024.
On January 12, a meeting to discuss the report ended in what one reporter politely described as “a kerfuffle.” Other witnesses to the meeting chose to describe it as a shouting match.
“One member, Brian Miller, MD, MPH, of Johns Hopkins University in Baltimore, accused panel leadership of issuing a negative status report on MA plans’ market dominance, saying it had been ‘hijacked for partisan political aims to justify a rate cut to Medicare Advantage plans.’
“Miller said the analysis … ‘appears to be slanted to arrive at a foregone conclusion in order to set up and provide political cover’ just before the Centers for Medicare & Medicaid Services prepares its annual rate notice for MA plans, expected in coming weeks. ‘The chapter reads like attack journalism as opposed to balanced and thoughtful policy research.'”2
Report authors fired back, citing numerous ways MA plans generate higher revenue, including enrolling people who are relatively healthy, known as favorable selection. They then vigorously scan patients’ medical histories and charts to code for health factors that generate higher per-capita payments, known as coding intensity, often spending less on services. Coding intensity is also the difference between a risk score that a beneficiary would receive in an MA plan versus in fee-for-service. Though MA plans skew toward healthier enrollees, MedPAC found that MA risk scores are about 20.1% higher than scores would be for the same beneficiaries had they enrolled in Fee For Service Medicare.
Namath, Walker, Shatner and Brokers
Criticism of MA plan behavior did not only come from MedPAC commissioners and report authors. For example, Lynn Barr, MPH, founder of Caravan Health, which was acquired by CVS Health through its acquisition of Signify Health, exposed what the annual TV ads do not make clear, that their 800 numbers go to brokers, not to any one plan.
“This is not the big, lovely, glowing success that everybody says it is. And we continue to create policies that drive people into these plans. Medicare allows money paid to MA plans to be used for broker commissions as high as “$600 to recruit them, plus $300 a year every year that they stay in the MA plan.
“We have allowed MA to buy the market, and that is why MA is growing. It’s not because the quality’s so great. People don’t love the prior auth, people are leaving their plans a lot. Aside from Medicaid, Medicare is the least profitable payer for doctors. And at the same time, we give all this money to the plans. It’s unconscionable.”
Adding to the “kerfuffle” with a powerful anecdote, Stacie Dusetzina, PhD, of Vanderbilt University Medical Center in Nashville, Tennessee, noted that even cancer patients often have trouble getting necessary care because of the plans’ limited networks. She referenced a January 7 NPR story3 about an MA enrollee who could not get the cancer care he needed from his MA plan, and could not get out of the plan without facing 20% in expensive copays. In all but four states, supplemental plans that could pick up the difference can reject patients with costly conditions.
“When you are 65 and aging into the program,” Dr. Dusetzina summarized, “you are healthy at that time and may not be thinking about your long-term needs. [If you did], it would push you to think harder about the specialty networks that you may or may not have access to when the MA plan is making your healthcare decisions.”
1 A 30-page slide presentation is available to the public at medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf. The complete report is available only to MedPAC commissioners. The charts on slides 26 and 27 show how MA plans learned to pad profits in 2018 and increased the practices exponentially since then.
2 Cheryl Clark, MedPage Today January 16, 2024 medpagetoday.com/special-reports/features/108275
3 npr.org/2024/01/07/1223353604/older-americans-say-they-feel-trapped-in-medicare-advantage-plans
Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. RowanResources.com; Tim@RowanResources.com
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan | Dec 6, 2023 | CMS, Regulatory
by Tim Rowan, Editor Emeritus
MA Plans Continue to Exaggerate Patient Conditions for Profit
As we reported in October (More MA Plans Caught Inflating Patient Assessments, 10/11/23), insurance companies operating Medicare Advantage plans routinely pad the patient assessments that set their monthly revenue from the Medicare Trust Fund. Worse, CMS bowed to industry pressure earlier this year and agreed not to extrapolate the amount of the fraudulent payments, as it does with Home Health and Hospice overpayments (Government Lets Health Plans That Ripped Off Medicare Keep the Money, 2/22/23).
Now, we hear that the HHS OIG has totaled its 2023 audits and announced it found over $213 million in padded Medicare Advantage overpayments so far this year. In its latest semiannual report, covering fraudulent patient assessments between April and September, the OIG said it recovered $82.7 million. Total recoveries would have been higher except for that CMS ruling that prevents the agency from extrapolating payments before contract year 2018.
Will SEC Allow Cigna/Humana Marriage?
Early last month, Bloomberg broke the news that Cigna was in talks to sell its Medicare Advantage business to Health Care Service Corporation, the parent company of BCBS in Illinois, Texas, New Mexico, Montana and Oklahoma. Should that sale be approved, it would remove an obstacle to Cigna’s rumored desire to merge with Humana.
Though approval is uncertain — the SEC has squashed more than one similar attempt under both the current and former Presidents — it would create what Axios called “another Titan” that would rival UnitedHealth Group and CVS Health in size. CVS acquired Aetna in 2018. It would also combine two Pharmacy Benefit Managers, giving the new entity control of a third of the market, which would be equal to the market share owned today by CVS.
In 2017, a proposed merger between Cigna and Elevance Health, formerly Anthem, was struck down in court. A proposed merger between Humana and Aetna was also canceled in a federal court the same year. Large, powerful insurers, and the PBMs they own, have come under increased scrutiny from federal regulators.
The Biden administration has already launched a warning shot, indicating it will be scrutinizing private equity acquisitions in health care. In September, the Federal Trade Commission sued private equity firm Welsh, Carson, Anderson & Stowe after it bought up nearly all of the anesthesiology practices in Texas and then, with competition removed, began to jack up prices. FTC chair Lina Khan made it clear the suit was intended to send a message to all consolidation attempts that might harm patients.
United to Change Prior Authorization Policy
According to a November 27 policy update from UnitedHealthcare (UHC), the payer is updating its Home Health prior authorization and concurrent review process for services that are delegated to Home & Community Care, the payer’s home care division.
The updated policy, which are set to take effect January 1, will affect United’s Medicare Advantage and Dual Special Needs plans in 37 states, a UnitedHealthcare news release stated.
In Summary
- Start of care visits still do not require prior authorization.
- Providers must notify Home & Community Care of the initiation of home care services. UHC encourages providing notice within five days after the start of a care visit to help avoid potential payment delays.
- Before the 30th day, providers must request prior authorization for days 30 to 60, by discipline, and provide documentation to Home & Community Care.
- For each subsequent 60-day period, providers must request prior authorization, by discipline, and provide documentation to Home & Community Care during the 56- to 60-day recertification window.
UHC says it will respond to questions about the prior authorization approval process at HHinfo@optum.com
In related news, in its annual investor conference call, the company projected “revenues of $400 billion to $403 billion, net earnings of $26.20 to $26.70 per share and adjusted net earnings of $27.50 to $28.00 per share” for 2024. Cash flows from operations are expected to range from $30 billion to $31 billion.
Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com
©2023 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com
by Tim Rowan | Nov 15, 2023 | CMS, Editorial, Regulatory
Dear Friends,
I have some news that may be upsetting. Frankly, that is my intention, to frighten you into action.
In August, a Home Health provider in New York paid an $$866,339.25 fine for violating the “Civil Monetary Penalties Law.”* The Chinese-American Planning Council Home Attendant Program had employed an individual, in connection with the New York State Consumer Directed Personal Assistance Program (CDPAP), who was excluded from participation in the New York Medicaid program and was not eligible to furnish services under the CDPAP.
Georgia provider Agape Hospice Care paid $250,993.97 in penalties, the specific amount it had paid in salary and benefits to two unlicensed nurses.
If this law is unfamiliar to you, it is the requirement that you may not employ any individuals who are not eligible to work within the Medicare system.*
This is only one example of a new OIG crackdown!
- Bridges MN, a non-profit with services to the disabled, was fined $150,171.96 for employing a single excluded individual.
- Vicki Roy Home Health Service paid a $38,000 fine for employing one excluded caregiver.
- Providence Health System-Southern California, doing business as Providence Little Company of Mary Medical Centers, which includes two hospitals, agreed to pay $141,562 in connection with the employment of an excluded emergency services technician from Aug. 8, 2016, to June 5, 2019. (Note that this person was employed for nearly three years without the health system knowing, as they are required to know, that he or she was excluded.)
- Joseph Health Personal Care Services, doing business as Nurse Next Door, agreed to pay $32,244 in connection with the employment of an excluded constant care attendant from Nov. 2, 2017, to Aug. 8, 2019.
My friends, the list goes on and on, and these are just the Home Health agencies:
- Serenity Home Healthcare Services Agreed to Pay $146,000
- Professional Home Health Care 2: $77,000
- Chinese-American Planning Council Home Attendant Program: $866,000
- Visiting Angels of Rhode Island: $158,000
I learned of at least 25 other healthcare providers that were fined under this law. Clearly, the HHS OIG is on the warpath. This is not a regulation you are wise to ignore.
That is why I write you today. I have found an affordable service that performs monthly OIG exclusion screening for you. Doing it yourself would require a dedicated FTE and hours of painstaking work.
I would be honored if you would accept my introduction to the company that provides this service. If the fines I listed above grabbed your attention, you can see that a service of this type is like an insurance policy that costs a fraction of the disaster it can prevent.
The company is called Carosh Compliance Services. The monthly service is called “OIG Express.” I know and trust the founding CEO, Roger Shindell. To contact Roger and learn more about this necessary service, use this link: https://oig.hhs.gov/faqs/exclusions-faq/
Sincerely,
Tim Rowan
Editor Emeritus
The Rowan Report
Tim@RowanResources.com
by Tim Rowan | Nov 15, 2023 | Vendor Watch
by Tim Rowan, Editor Emeritus
In September, we posted the announcement from HHAeXchange about their inking a deal to provide EMR and EVV software to Gentiva Personal Home Care. We had some questions about the partnership and both HHAeXchange president Stephen Vacarro and Gentiva president Richard Bruner took the time to speak with us.
Background and Context
Gentiva Health Services is a provider of Home Health and Hospice services. Headquartered in Atlanta, the company became an independent business unit of Kindred Healthcare in October, 2014. At the time of the acquisition, it had been a Fortune 100 company with over $1.7 billion in annual revenue.
Today, Gentiva provides in-home care to over half a million patients annually through over 420 locations in 40 states.
The Rowan Report: Can you provide an update about Gentiva and your role?
Bruner: Gentiva Health Services is a network of compassionate caregivers, clinicians, support personnel, and information technology teams who provide superior outcomes for patients across the post-acute continuum. Originally part of Olsten Corporation, Gentiva officially became an independent company on Aug. 6, 1999. Our services include personal care, palliative care, and hospice care. Through our personal care offerings, we deliver services to patients across Texas, Arkansas, Arizona, California, North Carolina and Missouri.
Through my role as Gentiva’s personal home care president, I oversee strategic planning for the company’s personal care programs, establish protocols and quality standards, drive key initiatives, build sustainable growth, and am responsible for day-to-day administrative operations.
RR: How did the partnership with HHAeXchange and Gentiva come about?
Bruner: Gentiva connected with HHAeXchange years ago through mutual industry contacts and kept up with the company’s progress. Later, when we began to evaluate our Texas agencies’ need for a new solution, we spent 18 months investigating and vetting major vendors in the homecare management software space.
Seeking a third-party, EVV-agnostic, cloud-based system, we narrowed the pool to two vendors who could meet our company’s needs while enhancing caregivers’ mobile experiences through simplified scheduling and coordination options. However, cost effectiveness and EVV prowess factored heavily into the final decision, which led to our selection of HHAeXchange.
RR: The Texas market is notoriously difficult. How does HHAeXchange differ from previous providers that gave up and left the state?
Vacarro: Texas is a large state with hundreds of thousands of patients receiving homecare on a regular basis from an incredibly broad roster of agencies and providers. While no two situations are alike and no two agencies do things exactly the same way, there is a commonality: the services they provide are incredibly valuable.
Because HHAeXchange understands the complex needs of homecare recipients and the critical work agency staffers are tasked with, we put considerable thought into the development of our EVV platform, its implementation, and its continued usage across Texas. We intend to differentiate ourselves and surpass standards set by our predecessors through our commitment to functionality.
We can’t custom-make solutions based on agencies’ and patients’ individual needs, but we can provide a platform with features versatile enough to be convenient and helpful to any user, no matter their agency size, location, workload, technological expertise or experience.
The HHAeXchange team also understands the importance of laying a solid foundation on which to build a new partnership and preparing for key transitions. So, for months ahead of our launch in Texas, our team spent a considerable amount of time hosting informational sessions for caregivers and agency owners and leading road shows throughout the state, demonstrating the EVV platform, answering questions, and getting more acquainted with the market.
I should add that, as part of our partnership with the Texas Health and Human Services Commission (HHSC), our Portal is available at no cost to program providers, financial management services agencies, and Consumer Directed Services (CDS) employers. We’ve taken steps to offer simple and convenient access, enabling homecare providers to easily meet Texas state requirements while offering a streamlined experience for both back-office staff and service providers.
RR: Is HHAeXchange compatible with EVV aggregators in all of the states where Gentiva operates?
Vacarro: Yes, HHAeXchange seamlessly connects payers and providers across the homecare ecosystem. Our platform allows for the accurate capture and transmission of all visit data, regardless of which aggregator a state selects and which EVV vendor and tools a provider uses.
We regularly partner with Medicaid agencies and MCOs in open and closed model states, where our platform is utilized to submit agencies’ data to another aggregator. This is how we work in Pennsylvania, North Carolina and now in Texas, for example.
RR: Thank you, gentlemen. For background on the HHAeXchange-Gentiva partnership, see our September posting of their joint news release at:
