The Right Way to Use AI in Healthcare

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by | May 16, 2024 | Admin, Artificial Intelligence, Clinical, New Tech, Outcomes, Product Review, Vendor Watch

by Tim Rowan, Editor Emeritus

For better or worse, healthcare has begun the inevitable adoption of Artificial Intelligence. Before you consider adopting AI technology, know that there is a wrong way and a right way to use AI in healthcare. In a companion article this week, we describe the criticism insurance companies are getting for deploying AI in healthcare to harm patients. As a balance, here is a review of a product that we find to be using AI in healthcare to help both patients and Home Health Agencies.

The Problem 

Home Health referral documents from physicians or hospitals can consist of more than 100 electronically transmitted pages. Some agencies report occasional packets exceeding 1,000 pages, often in a variety of data formats. Some are standard data formats, such as a face sheet, but most are unstructured, consisting of images or narrations, sometimes in paragraphs, sometimes in incomplete sentences. Worse, patient data interoperability can be limited by unstructured data.Too Much Paperwork

More often than not, most of these pages are never read. Thoroughly interpreting that much data is nearly impossible for a human. Consequently, nurses too often approach an admission evaluation visit with an incomplete picture of a patient. The result can be gaps in care or treatment, inaccurate OASIS assessments, incomplete or poorly sequenced diagnosis codes, and improper care plans. These obstacles can impact both patient outcomes and agency revenue.

One Newly Available Solution for the Right Way to use AI in Healthcare

We recently attended a product demonstration and followed it up with updated descriptions to learn details about new product developments. Over the next three months, Select Data, in full disclosure one of our sponsors, will be introducing an AI-powered suite of products that has been designed over many years of development to support clinical, data driven decision-making. One by one, it addresses the problems described above.

The new system, SmartCare, empowers clinicians to harness previously hidden insights while reducing bias and cognitive overload. It enables them to steer their decisions with enhanced precision while maintaining their pivotal role in patient care, eliminating one of the common reasons many Home Health administrators hesitate to invite AI into agency processes. It does, however, make the care team’s job easier and facilitates better decision-making.

  • AI can read those 100 to 1,000 page referral documents in minutes, where a human may require days. The Power of AI with SmartCare
  • SmartCare uses AI to synthesize relevant medical history to provide a care snapshot highlighting the key diagnosis, focus and considerations for care, and recommended OASIS clinical discipline. It highlights any areas for clarification needed from physician or admitting nurse.
  • Clinicians can search and index specific words in unstructured data, such as narratives, to instantly identify any detail of a patient’s condition in an easy-to-read interface. Nurses approach the initial OASIS visit armed with all of a referring clinician’s relevant care findings.
  • Recommendations for diagnostic codes strictly follow Medicare PDGM guidelines.

Suite of Tools

1 – RISE stand for Rapid Intake Summary & Evaluation. This component of the suite summarizes all clinical data from referral sources and your EHR. It compiles this data to provide clinically relevant diagnoses, focus of care, and recommendations for skilled disciplines. This is the part of the tool that reads referral documents and supports informed decision-making. The advantages we detected go a bit beyond the technical.

When clinicians, reviewers, coders, and office staff all have access to the same patient information, it would seem that communication among disciplines would improve and that care coordination would be enhanced. It also seems logical that continued experiences of advanced access to previously hard-to-find physician comments would gradually break through the AI fear barrier reported by so many clinicians and other professionals. Select Data will provide us with actual client experiences to verify our assumptions once they have been compiled.

Right AI Healthcare Select Data

2 – ACE, or Admission Clinical Evaluation is SmartCare’s clinical support summary tool. It deploys AI to understand accepted OASIS assessment criteria. It then uses this knowledge to extract assessment and narrative data from nursing and therapy evaluations. With streamlined, pertinent data at the point of care, the entire care team has the same patient data. Having the same patient data enables more informed decision-making.

ACE links all patient data back to its source assessment. Doubt about the AI’s credibility should gradually diminish, even among the most AI-resistant users. Every analysis and recommendation is explained in clear language so that clinicians are likely to understand the rationale behind them. The goal is to replace every “I’m not going to let a machine tell me what to do” with “I’ll take this information into consideration with my human insights.”

Pricing

We are honoring Select Data’s request to allow them to build personalized price quotes to every prospective client. They will be represented at several state and national conferences this year. Alternatively, interested HHA representatives can contact EVP Ted Schulte at Ted.Schulte@SelectData.com

Tim Rowan, Editor Emeritus

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

The Wrong Way to Use AI in Healthcare

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by | May 16, 2024 | Admin, Artificial Intelligence, CMS, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

Lawsuits are beginning to pile up against insurance companies participating in the Medicare Advantage program. The complaint? The wrong way to use AI in healthcare is with faulty algorithms to approve or deny claims. While AI can be extremely helpful in streamlining administrative tasks — comparing physician notes with Home Health assessments and nursing notes or reading hospital discharge documents — it seems not to be any good at deciding whether to approve or deny care.

The Wrong Way to Use AI in Healthcare Example 1

The Minnesota case, November, 2023, UnitedHealth Group:

    • An elderly couple’s doctor deemed extended care medically necessary
    • UnitedHealth’s MA arm denied that care
    • Following their deaths, the couple’s family sued UnitedHealth, alleging:
      • Straight Medicare would have approved the extended care
      • United uses an AI model developed by NaviHealth called nH Predict to make coverage decisions
      • UnitedHealth Group acquired NaviHealth in 2020 and assigned it to its Optum division
      • nH Predict is known to be so inaccurate, 90% of its denials are overturned when appealed to the ALJ level
      • UnitedHealth Group announced in October, 2023 that its division that deploys nH Predict will longer use the NaviHealth brand name but will refer to that Optum division as “Home & Community Care.”

The family’s complaint stated, “The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth’s] AI model ‘disagrees’ with their real live doctors’ determinations.”

The Wrong Way to Use AI in Healthcare Example 2

The Class-Action case, December 2023, Humana:

    • A lawsuit was filed on December 12, 2023 in the U.S, District Court for the Western District of Kentucky
    • It was filed by the same Los Angeles law firm that filed the Minnesota case the previous month, Clarkson
    • The suit notes that Louisville-based Humana also uses nH Predict from NaviHealth
    • The plaintiffs claim, “Humana knows that the nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs but continues to use this system to deny patients’ coverage.”
    • The suit says Medicare Advantage patients who are hospitalized for three days usually are eligible to spend as many as 100 days getting follow-up care in a nursing home, but that Humana customers are rarely allowed to stay as long as 14 days.
    • A Humana representative said Humana their own employed physicians see AI recommendations but make final coverage decisions.

What Makes This Possible

According to experts we speak with, there are many ways to use data analytics. The insurance companies named in the lawsuits use predictive decision making. This way of analyzing data compares a patient to millions of others and deduces what treatment plan might be suitable for one patient, based on what was effective for most previous patients. Opponents of this method have called it “data supported guessing.”

A superior analysis method experts are coming to understand  is prescriptive decision making. This is taking all of the available historical and current data surrounding a patient and making a clinical decision specifically designed to that patient’s age, gender, co-morbidities, doctor recommendations, and treatment records.The Power of AI with SmartCare

Until recently, predictive analysis was the preferred method because of its resource efficiency. Examining the data of every individual patient used to be prohibitively labor-intensive, requiring hours of reading hospital records, physician notes, and claims. Today, however, AI tools are able to do that work in seconds, making prescriptive analytics and customized plans of care possible.

Fix May Be in the Works

In a February 6, 2024 memo to all Medicare Advantage Organizations and Medicare-Medicaid Plans, CMS explained the difference between predictive and prescriptive analytics. The memo said these plans may not make coverage determinations based on aggregated data but must look at each individual:

“For Medicare basic benefits, MA organizations must make medical necessity determinations in accordance with all medical necessity determination requirements, outlined at § 422.101(c)1 ; based on the circumstances of each specific individual, including the patient’s medical history, physician recommendations, and clinical notes; and in line with all fully established Traditional Medicare coverage criteria.”

In response to a request for clarification, the CMS memo laid out its rule in specific language:Wrong AI in Healthcare Prescriptive Analytics

An algorithm or software tool can be used to assist MA plans in making coverage determinations, but it is the responsibility of the MA organization to ensure that the algorithm or artificial intelligence complies with all applicable rules for how coverage determinations by MA organizations are made. For example, compliance is required with all of the rules at § 422.101(c) for making a determination of medical necessity, including that the MA organization base the decision on the individual patient’s circumstances, so an algorithm that determines coverage based on a larger data set instead of the individual patient’s medical history, the physician’s recommendations, or clinical notes would not be compliant with § 422.101(c).
(emphasis added)

“Therefore, the algorithm or software tool should only be used to ensure fidelity with the posted internal coverage criteria which has been made public under § 422.101(b)(6)(ii).”

In further responses to questions in the same memo, CMS made it clear MA plans must make the same coverage decision original Medicare would make. The only allowable exception is that plans may use their own criteria when Medicare Parts A and B coverage criteria “are not fully established.”

Knowledge of this CMS directive may give Home Health agencies one more arrow in their quiver when going to battle with powerful, profit-oriented insurance companies over harmful, illogical AI algorithm decisions.

For information on the right way to use AI in healthcare, see our complimentary article in this week’s issue.

 

Tim Rowan, Editor EmeritusTim 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

Navigating the Home Care Revolution

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by | May 10, 2024 | Admin, Caring for the Caregiver, Clinical, Marketing, Recruitment & Retention, Regulatory

by Kristin Rowan, Editor

I was honored to have been a guest on Health Futures – Taking Stock in You Radio Show on Money Radio 1510 AM discussing navigating the home care revolution. Health Futures is hosted by HomeCare expert Bob Roth, owner of Cypress HomeCare Solutions. Cypress just celebrate its 30th anniversary last week and is the recipient of a Grant to Innovate within Medicaid in partnership with PocketRN and is the 2013 & 2018 winner of the BBB Torch Awards for Ethics. You can listen to the full radio show here. Below is the blog based on the show, written by the CEO of Strait Talk PR, Lauren Strait.

 

Home Care Revolution bob roth kristin rowan
Home Care Revolution bob roth kristin rowan

by Lauren Strait, CEO Strait Talk PR

The Aging Population Tsunami

By 2050, the 85-year-old population in the United States is expected to quadruple. As this massive demographic shift unfolds, the already strained home care industry will face unprecedented challenges in meeting the escalating demand for quality care services.

Bob Roth, Managing Partner of Cypress HomeCare Solutions, recently had Kristin Rowan, of The Rowan Report on the radio show and podcast to discuss this trend and everything a consumer needs to know about the homecare industry and how it will affect them.

A Trusted Voice Amid Industry Upheaval

In the latest episode of “Health Futures, Taking Stock in You” hosted by Bob Roth of Cypress Homecare Solutions, Kristin Rowan, Owner and Editor of The Rowan Report, offered insights into how her publication is guiding the industry through this seismic transition.

The Rowan Report’s Unbiased Expertise

What began as a print magazine reviewing home health technology has evolved into a comprehensive digital hub covering regulatory updates, workforce solutions, marketing strategies, and groundbreaking innovations. Rowan emphasized the publication’s commitment to neutrality when evaluating new products and services.

“We do our best to remain as neutral as possible…that’s one of the things that Tim [her father and the founder] established early on in his relationships with tech providers.”

Empowering a Strained Workforce

With a redesigned website offering robust search capabilities, The Rowan Report curates resources to help agencies streamline operations and alleviate administrative burdens on overstretched staff. “The solution is not more people because they’re just not there,” Rowan stated. “But the solution is collaboration to better utilize the people that you have.”

The publication explores leveraging AI, voice technologies, automated claims processing, and outsourcing to reduce paperwork and maximize efficiency, enabling care professionals to concentrate on frontline patient care.

Preparing for the Age Wave

As the population ages, The Rowan Report recognizes the need to educate professionals and families on navigating the complexities of long-term care. By convening experts, the publication covers crucial topics like choosing providers, understanding Medicare/Medicaid, and planning for future care needs.

An Indispensable Industry Guide

With over 25 years of experience, The Rowan Report stands as an indispensable guide for the home care industry as it braces for the challenges and opportunities of an aging America. Access their insights at www.therowanreport.com.

# # # 

Bob Roth is Managing Partner of Cypress HomeCare Solutions. He assisted in creating Cypress HomeCare Solutions with his family in 1994. Bob brings the depth and breadth of his nearly 36 years of consumer products, health care and technology experience to the home care trade. Over the years, Bob has received a number of awards. These include the January 2014 CEO of the Month and finalist for the 2015 Phoenix Business Journal’s Healthcare Heroes award. Cypress won the Better Business Bureau’s Business Ethics award in 2013 and 2018.

In March 2017, Arizona Governor Bob Ducey appointed Bob to the Governor’s Advisory Council on Aging. This was the first time in the Council’s 40 years that a home care/home health care agency owner/manager has served on the Council. Nationally, Bob serves on the Board of Directors for the Home Care Association of America (HCAOA). Locally, he serves on the Board of Directors for DUET Partners in Aging. Additionally, he is on the ambassador committee for Aging 2.0 – Phoenix Chapter. On September 11, 2019 Bob won the Home Health Care News Future Leader Award. The award recognizes up-and-coming leaders elevating the home health industry. When he’s not working, Bob enjoys spending time with his wife Susie, their three daughters, and playing golf, tennis, hiking and walking with Ruby and Lacey, our pet therapy dogs.

Bob Roth
Bob Roth

Bob Roth is Managing Partner of Cypress HomeCare Solutions. He assisted in creating Cypress HomeCare Solutions with his family in 1994. Bob brings the depth and breadth of his nearly 36 years of consumer products, health care and technology experience to the home care trade. Over the years, Bob has received a number of awards. These include the January 2014 CEO of the Month and finalist for the 2015 Phoenix Business Journal’s Healthcare Heroes award. Cypress won the Better Business Bureau’s Business Ethics award in 2013 and 2018.

In March 2017, Arizona Governor Bob Ducey appointed Bob to the Governor’s Advisory Council on Aging. This was the first time in the Council’s 40 years that a home care/home health care agency owner/manager has served on the Council. Nationally, Bob serves on the Board of Directors for the Home Care Association of America (HCAOA). Locally, he serves on the Board of Directors for DUET Partners in Aging. Additionally, he is on the ambassador committee for Aging 2.0 – Phoenix Chapter. On September 11, 2019 Bob won the Home Health Care News Future Leader Award. The award recognizes up-and-coming leaders elevating the home health industry. When he’s not working, Bob enjoys spending time with his wife Susie, their three daughters, and playing golf, tennis, hiking and walking with Ruby and Lacey, our pet therapy dogs.

Kristin Rowan, Editor
Kristin Rowan, Editor
Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.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

Connecticut Senate and House Pass Home Care Worker Safety Bill

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by | May 10, 2024 | Admin, Caring for the Caregiver, Clinical, Regulatory

by Kristin Rowan, Editor

Last week, we reported on the proposed Bill in the Connecticut Senate and House to provide additional precautions for home care worker safety. In wake of the Elara Caring at Fault Joyce Grayson Home Care Worker Safety Joyce Grayson murder during a home health visit, leadership in Connecticut aimed to safeguard home health and home health aide workers and collect risk assessment data on the same.

On May 6, 2024, CT legislature passed bills in both the Senate and House of Representatives. Instead of the proposed bills that we reported on previously, both branches added amendments to previous bills. The bills include provisions for cyberattack readiness, child safety, and other items not related to care in the home.

First Stage of Home Care Worker Safety

Some of the provisions in the final bill are effective July 1, 2024. As we previously reported, hospice agencies are currently exempt from these provisions and the CT legislature will address hospice agencies in their next session.

On and after July 1, 2024

The Commissioner shall increase the fee payable to a home health care or home health aide agency that provides escorts for safety purposes to staff conducting a home visit to cover the costs of providing such escorts.

The Commission of Public Health will establish and administer a home care staff safety grant program to provide grants to home health and home health aide agencies for staff safety technology, including, but not limited to :

  1. A mobile application for staff to access safety information about a client
  2. A method for staff to communicate with either local police or other staff in the event of an emergency
  3. A global positioning system-enabled, wearable device that allows staff to contact local police
Effective July 1, 2024

The sum of one million dollars is appropriated to the Department of Public Health for the the fiscal year ending June 30, 2025, to establish and administer the aforementioned grant program.

The Commissioner of Public Health and the Commission on Community Gun Violence Intervention and Prevention, will develop or find educational material about gun safety practices and provide such to primary care providers to give to patients who are 18 years of age or older.

Second Stage of Home Care Worker Safety

Some of the provisions in the final bill are effective October 1, 2024. Home health and home health aide agencies have five months to comply with these measures.

Effective October 1, 2024, home health and home health aide agency must collect and provide to assigned workers information about:

The client, including as applicable;

  1. psychiatric history
  2. history of violence
  3. history of substance use
  4. history of domestic abuse
  5. current infections, if any, and treatment received
  6. whether diagnoses or symptoms have remained stable over time
Home Care Worker Safety
Other persons present or anticipated to be present at the location of care including, if known to the agency:

  1. name and relationship to client
  2. psychiatric history
  3. history of violence or domestic abuse
  4. criminal record
  5. history of substance use

Location where employee will provide services including, if know to the agency:

  1. the crime rate for the municipality in which employee will provide services
  2. the presence of any hazardous materials, including, but not limited to used syringes
  3. the presence of firearms or other weapons
  4. the status and of the fire alarm system
  5. the presence of any safety hazards, including, but not limited to, electrical hazards
By October 1, 2024, each home health and home health aide agency must:

Provide staff training consistent with the health and safety training curriculum for home care workers, including but not limited to:

  1. Training to recognize hazards commonly encountered in home care workplaces
  2. Applying practical solutions to manage risks and improve safety

Conduct monthly safety assessments with each staff member and

Provide staff with a mechanism to perform safety checks, which may include, but need not be limited to:

  1. A mobile application that allows staff to access safety information about the client
  2. A means of communicating with local police or other staff in the event of an emergency
  3. A global positioning system-enabled, wearable device that allows staff to contact local police by pressing a button or through another mechanism
Effective October 1, 2024

Each home health and home health aide agency shall, in a manner prescribed by the Commissioner of Public Health:

  1. Report each instance of verbal abuse that is perceived as a threat or danger to the staff
  2. Report each instance of physical, sexual, or any other abuse by a client against a staff member

Third Stage of Home Care Worker Safety

No later than January 1, 2025

Beginning January 1, 2025 and annually therafter, the commissioner shall report to the joint standing committee:

  1. The number of reports of violence and abuse received
  2. The actions taken to ensure the safety of the staff member about whom the report was made
Effective January 1, 2025

Each individual health insurance policy shall provide coverage for escorts for the safety of home health care agency or home health aide agency staff

The joint standing committee of the General Assembly will convene a working group to study staff safety issues affecting home health and home health aide agencies, including but not limited to the following members:

  1. Three employees of a home health care or home health aide agency
  2. Two representatives of a home health care or home health aide agency
  3. One representative of a collective bargaining unit representing home health care or home health aide agency employees
  4. One representative of a mobile crisis response services provider
  5. One representative of an assertive community treatment team
  6. One representative of a police department; and
  7. One representative of an association of hospitals in the state

Implications

As we mentioned before, these regulations will become mandates across the country soon. OSHA has found the home care agency in Connecticut at fault for failing to implement safety procedures and precautions in the death of Joyce Grayson. The nurse’s family is suing the home health agency for wrongful death. Connecticut has established a protocol for safety measures, committees, reporting, and grant programs to implement immediate safety procedures across home health and home health aide agencies in the state. Before these provisions are passed on a national level, and before you have to tell the family of one of your staff that they aren’t coming home…

 

We urge you to:
  1. Create a safety committee within your agency
  2. Invest in training on de-escalation, workplace violence prevention, and self-defense
  3. Research and invest in a GPS-enabled emergency alert system for your staff. We recommend POM Safe and Katana Safety
  4. Insist on background information on all clients and others living in the home upon intake and BEFORE the first home visit
  5. Create a safe and comfortable way for your staff to report verbal abuse, violence, or uneasiness from any in-home visit
  6. Invest in escort and/or paired visits for high-risk clients, first-time clients, or any other situation that warrants it

We will continue to follow this story and provide updates as we receive them.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.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

UnitedHealth Grilled by Congress, Fired by Walmart

Admin

by | May 2, 2024 | Admin, Privacy and Security, Regulatory, Telehealth

by Tim Rowan, Editor Emeritus

You know the routine. Everyone does. You log into your bank, airline account, or health insurance web portal, enter the correct password, and are directed to look on your smartphone UnitedHealth Grilled MFAfor a code to enter to fully authorize your login. The name for this is Multi-Factor Authentication, or MFA. Lack of MFA procedures leaves your company at risk, which UnitedHealth discovered when it was grilled by Congress about the cyberattack on Change Healthcare.

United Health Grilled by Congress

In his testimony to the House Energy and Commerce Committee Wednesday, UnitedHealth Group CEO Andrew Witty blamed the absence of MFA as the weak link that allowed a ransomware attack to cripple subsidiary Change Healthcare in February. The breach had ripple effects throughout healthcare, given Change’s role as fiscal intermediary for thousands of providers. Healthcare systems on every level were unable to file claims and receive payments.

Asked by the committee why Change Healthcare, which United acquired in late 2022, did not have MFA in place, Witty testified, “Change Healthcare was a relatively older company with older technologies, which we had been working to upgrade since the acquisition. But for some reason, which we continue to investigate, this particular server did not have MFA on it.”

CBS News reported that Change Healthcare processes 15 billion transactions a year. “The scale of the attack,” their report stated, “meant that even patients who weren’t customers of UnitedHealth were potentially affected. Personal information that could cover a ‘substantial portion of people in America’ may have been taken in the attack.” The breach has already cost UnitedHealth Group nearly $900 million, plus the $22 million ransom Witty decided to pay to the hackers.

The Russia-based ransomware gang, ALPHV, or “BlackCat,” claimed responsibility for the attack, bragging that it stole more than six terabytes of data, including “sensitive” medical records. The attack triggered a disruption of payment and claims processing around the country.

We followed up our initial report on the attack with CMS guidance on March 20, 2024 and an update on April 11, 2024, with reports that Change Healthcare was being blackmailed again by another ransomware gang, RansomHub, who claimed to have 4TB of data from Change Healthcare and demanded another ransom payment.

Walmart & Optum, UnitedHealth Trouble Spots?

UnitedHealth Group is also in headline news this week for two other reasons. The company’s Optum division, which owns home care giant CenterWell,UnitedHealth Grilled Optumformerly Kindred at Home, and which is awaiting government approval for its bid to acquire Amedisys, has quietly been executing a reduction in force. Reports are that the bulk of the layoffs are hitting “Optum Virtual Care,” the name given to naviHealth following its $1 billion acquisition in 2020. Following a surge in demand during the pandemic, the company is apparently abandoning telehealth services.

A planned 10-year collaboration between UnitedHealth and Walmart to provide virtual healthcare services ended Tuesday after only one year. On April 30, the retail giant announced that it will close its 51 health centers across five states due to the “challenging reimbursement environment” and rising operating costs, which have resulted in a lack of profitability. Like Optum Virtual Care, the centers were providing virtual services via telehealth.

A sign of the post-pandemic times? Perhaps. We will keep watching.

 

Tim Rowan, Editor EmeritusTim 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

Understanding Differences in Medicare Policy and Conditions of Participation

Admin

by | Apr 26, 2024 | Admin, Clinical, CMS, Regulatory

by Johnathan Eaves, Senior Director of Communications, Axxess

Treating Medicare patients comes with a level of nuance that is important to understand to ensure that organizations remain compliant and patients receive appropriate care. Standards for quality care and payment can sometimes be dictated by Medicare’s payment policies and at other times be decided by the Conditions of Participation. There is an important difference between these two governing principles that providers should understand to ensure compliance.

Care at home industry veteran and Axxess Senior Vice President of Clinical Services Arlene Maxim RN, HCS-C, offered insights into the differences between Medicare’s policy and its Conditions of Participation during a recent webinar.

Explaining the DifferenceMedicare Policies

Maxim pointed out that the differences between policy and the conditional requirements comes down to what can be billed and what are the quality standards for the services provided.

“The Conditions of Participation are dealing primarily with quality, whereas Medicare policy is related to payment,” said Maxim. And while there is a difference, that doesn’t mean both aren’t important and must always be followed.

“If Medicare policies are not followed, you are audited and if you do not have documentation to support those policies, you’re not going to get paid,” said Maxim “Oftentimes, with PDGM, staff members are not getting past that first 30 days. They’re not understanding what they need to do to keep that patient who continues to qualify for services on for longer.”

Maxim says that the problem is often that clinicians do not understand Medicare policy. “Every piece of documentation we submit to the Medicare program for review [needs to be] as pristine as we can possibly get it,” she said.

Assessment and Documentation

Proper assessment and documentation is something Maxim feels is critical in ensuring quality care, meeting Medicare requirements, and receiving payment for services.

“Complete and detailed documentation is going to be the key for agency payment by the Medicare program,” Maxim said.

Maxim pointed out certain services covered under Medicare policy may include observation and assessment, management and evaluation of a care plan, maintenance therapy, teaching and training activities, administration of medications, wound care, ostomy care, rehab nursing, venipuncture, skilled nursing visits, and more.

She also cautioned that agencies need to be prudent with the funds they receive from Medicare, viewing them as a potential “short-term, interest-free loan” until undergoing any audit. Until their documentation is reviewed and approved, there are no guarantees.

“Medicare is an insurance and it’s not free,” said Maxim. “Medicare policy provides us with a list of covered items. If experiencing an audit, and if the documentation is not there to cover the covered service, you’re not in compliance with that Medicare policy and you will not be paid for the services.”

Communicating With Physicians

Maxim further emphasized the importance of frequent contact with physicians, adherence to care plans, and ensuring that care plans are simple with individualized plans and goals that are achievable.

“You want to make sure that you have orders that physicians are actually going to read and to determine that they make sense and they’re going to sign off on them,” said Maxim.

“Keep your plan of care simple.”

# # #

Axxess Home Health, a cloud-based home health software, streamlines operations for every department while improving patient outcomes.

© 2024 Axxess. For reprint permission, please contact The Rowan Report: kristin@therowanreport.com

Adding Insult to Injury: Change Healthcare Attacked Again

Admin

by | Apr 11, 2024 | Admin, CMS, Regulatory

by Kristin Rowan, Editor

For a few weeks now, we have been covering the Change Healthcare cyberattack by ALPHV/BlackCat and the subsequent updates from CMS. Pharmacy and medical orders have been delayed, providers and patients are suffering, and CMS has issued “guidance” with no real solution. Underground reports indicate that Change Healthcare paid $22 million to BlackCat following the first cyberattack and that BlackCat stole 6TB of data from the system. Change Healthcare has refused to respond to questions about the alleged payment. Three weeks after the attack, Change Healthcare started to come back online, starting with the pharmacy services, which returned on March 7th. Parent company UnitedHealth Group indicated that other services would return in the coming weeks.

Legal Action

More than 87% of physicians are see more than a 20% drop in daily claim submissions. As of April 9th, physicians are still reporting issues with cash flow and anticipate higher than expected losses due to financing and loans that may be needed to cover them as the effects of the attack continue. Rivals of Change Healthcare are reportedly onboarding hundreds of customers who have left the organization. One of these, Availity, has processed more than $5 billion in claims that were left unprocessed by Change Healthcare’s system and has onboarded 300,000 providers with a backlog of more than 50 health systems waiting to start using the platform.

The attack has caused long-term disruptions, delays, cash flow problems, patient care disruptions, prescription delays, and billing issues. Some physician practices have started using personal money to cover payroll and other expenses. The US Department of Health and Human Services (HHS) has launched a formal inquiry into Change Healthcare’s data protection standards. This inquiry follows six class action lawsuits filed against the organizations. Physicians were still reporting significant impacts on their claims.

Adding Insult to Injury

Change Healthcare has barely gotten their systems up and running were still putting out fires when they were hit again. CyberAttackOn April 8, RansomHub contacted Change Healthcare and alleged to have 4TB of data stolen from the system and are demanding an extortion payment to keep the data private . RansomHub has threatened to sell the data, which includes US military personnel and patient data, medical records, and financial data, to the highest bidder in 12 days if the ransom isn’t paid.

Among the prevailing theories as to why Change Healthcare has been hit again is that the first ransom was supposed to have been split between ALPHV/BlackCat and an associate known as “notchy”, but ALPHV absconded with the ransom, leaving the other with nothing. Looking for a payout equal to what they lost, notchy partnered with RansomHub to try to recoup their losses. A second theory is that ALPHV and RansomHub are one in the same and that ALPHV went to ground after the ransom payout and have resurfaced as RansomHub. RansomHub, however, claims that after ALPHV went to ground, some of their affiliates joined the RansomHub operation and this is how they came by the data. Either way, it seems that the data stolen in the first attack was not returned after the ransom was paid and Change Healthcare is still susceptible to further extortion. This also means that the Change Healthcare system was not hacked a second time, but rather this is just an extension of the first data breach.

No word yet on whether Change Healthcare and UnitedHealth Group will pay the second ransom demand.

We will continue to follow this story and provide updates as it impacts payment and claims processing.

# # #

Kristin RowanKristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. www.therowanreport.com One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

1 Thing You Must Do At Work During National Stress Awareness Month

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by | Apr 4, 2024 | Admin, Caring for the Caregiver, Recruitment & Retention

by Bryan Robinson, PH.D. Contributor
author of Chained to the Desk in a Hybrid World: A Guide to Balance

April is National Stress Awareness Month with the goal of raising awareness of the impacts of stress. According to the American Psychiatric Association, 26% of respondents anticipate they will be more stressed in 2023 and their mental health will be worse. Two out of five adults ranked their mental health from “fair” to “poor.” When you have fewer stressors, you have increased emotional stability, better moods and overall superior health. This month is a time to pay special attention to how you can remain stress-free throughout your workday, and you can do that in very simple ways. You don’t have to quit your day job or even work fewer hours. You can continue your daily work routines while practicing stress reducers at the same time. The one thing you must do is have a stress awareness plan that you can practice at work.

A Stress Awareness Plan Keeps Job Stress At Bay

My 2023 New Years Resolution was to do one kind thing each day for someone—especially strangers. It has heightened my awareness of how important and easy it is to be kind to others without taking extra time. Plus, how simple it is to practice and how good it makes me feel (and hopefully the other person) in just minutes. A work stress awareness plan has the same effect. Here’s how it works. Simply choose one thing to commit to each day that you can accomplish in three to five minutes to mitigate stress during your workday.

A max of five minutes of chill a day can have mental and physical benefits to keep you engaged, calm and energized on the job. These short work breaks lead to higher job engagement and performance as well as better sleep, increased immunity, lower blood pressure, improved digestion and increased emotional well-being. In fact, research from scientists at North Carolina State University shows the value of what I call Microchillers or taking what the researchers call Microbreaks throughout the workday. These short breaks—I recommend five minutes or less—are effective energy management strategies as simple as stretching, walking up and down stairs, gazing out a window at nature, snacking or having a five minute mindful meditation.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Forbes. All rights reserved. For information on reprinting any of our articles, contact editor@therowanreport.com

Little Clinical, Cost Benefit to Diabetes Tech

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by | Mar 28, 2024 | Admin, Clinical, Partner News, Telehealth

CONTACT: Shannon Bishop-Green, SBishopGreen@MessagePartnersPR.com, (860) 305-3197
NEW REPORT FINDS THAT DIGITAL DIABETES MANAGEMENT TOOLS FAIL TO DELIVER MEANINGFUL HEALTH BENEFITS TO PATIENTS WHILE INCREASING SPENDING
Independent evaluation from Peterson Health Technology Institute recommends new directions for digital diabetes solutions
NEW YORK — Peterson Health Technology Institute (PHTI), an independent organization that evaluates healthcare technologies to improve health and lower costs, today released a new evaluation of digital diabetes management tools. These solutions are used by millions of Americans and have been funded by $58 billion of investment and mergers and acquisitions, yet the evidence shows that the technologies do not deliver meaningful clinical benefits, and result in increased healthcare spending.
The analysis, conducted by a team of health technology assessment experts and informed by clinical advisors, evaluated eight widely used digital tools that people with Type 2 diabetes use to track and manage blood glucose using a noncontinuous glucometer.
The report found that people who use these tools achieve only small reductions in hemoglobin A1c (HbA1c) compared to those who do not, and these reductions are not sufficient or sustained enough to change the trajectory of their health, care, or long-term prognosis, including cardiovascular risks. The solutions also result in increased overall healthcare costs. One promising solution, Virta, supports nutritional ketosis to achieve diabetes remission in patients who follow the rigorous diet modifications.
“When these digital diabetes management tools launched more than a decade ago, they promised to improve health outcomes for people with diabetes and deliver savings to payers. Based on the scientific evidence, these solutions have fallen short, and it is time to move toward the next generation of innovation,” said Caroline Pearson, executive director of PHTI. “Patients with diabetes invest time, energy, and resources in these tools, and they deserve to experience meaningful, positive benefits for their health. The healthcare sector as a whole needs transparent, accurate information about the clinical and economic impact of these digital tools that are taking up precious healthcare dollars.”
PHTI’s rigorous analysis incorporated an evidence-based assessment framework and review of more than 1,100 articles, including 120 submitted to PHTI by companies evaluated in the report. PHTI’s ratings are at the category level, including remote patient monitoring solutions that support providers, and behavior and lifestyle modification solutions that engage users to improve their diet, exercise, and self-management.
HbA1c is the standard form of measurement of glycemic control in diabetics. The studies show that these digital tools deliver small reductions in HbA1c of 0.23 to 0.60 percentage points compared to usual care. These results are generally below industry standards for Minimal Clinically Important Difference (MCID) of 0.50 percentage points. Further, the evidence indicates that this small improvement is not durable because the reduction is not sustained over time.
Additionally, PHTI’s analysis did not find evidence to demonstrate that digital diabetes management tools improve other health factors, including weight loss, body mass index, blood pressure, cholesterol, or other common conditions impacting people with diabetes. The analysis also concluded that, despite the disproportionate impact of diabetes on low-income and racially and ethnically diverse communities, these tools are not currently being deployed in ways that improve health equity.
PHTI’s evaluation further determined that these tools increase net healthcare spending. This is due to the fact that price for the solutions exceeds the associated healthcare cost savings, because the minimal clinical benefit does not enable the patient to avoid other care or treatments. For patients using tools in the remote patient monitoring category, annual spending is projected to increase by $2,002 for commercial insurance patients, by $1,011 for Medicare patients, and by $723 for Medicaid patients, as a result of higher provider payments. For patients using tools in the behavior and lifestyle modification category, annual spending is estimated to increase by $484 for commercial insurance patients, by $513 for Medicare patients, and by $574 for Medicaid patients. For all payers, the increased spending associated with virtual diabetes solutions has a significant impact on total spending given how many people are eligible to use the solutions, including 4.3% of those with commercial insurance, 17.0% of those with Medicare, and 4.8% of those with Medicaid.
In addition to its scientific literature review, PHTI proactively engaged the companies included in the report and provided an opportunity for them to share data and product information. Companies in PHTI’s evaluation include DarioHealth, Glooko, Omada, Perry Health, Teladoc (Livongo), Verily (Onduo), Vida, and Virta. The evaluation considered evidence about which populations stand to benefit the most from using the technology, as well as the durability of clinical impacts given the importance of sustained glucose control to achieve health benefits. The economic analysis modeled expected healthcare savings resulting from improved glycemic control for patients using digital diabetes management solutions who are enrolled in Medicare, Medicaid, and commercial insurance.
PHTI identified two potential bright spots for digital diabetes management tools. Initial data showed that Virta users are much more likely to achieve clinically meaningful benefits in glycemic control, including diabetes remission and the ability to reduce or eliminate their diabetes medications, if they can maintain the rigorous dietary requirements of the intervention. The other area of greater potential is among patients with higher starting HbA1c levels who are newly starting insulin. By engaging these patients at an early critical transition point in their care, digital solutions could have more impact by helping establish good self-management habits among these higher-risk patients.
Category-level ratings are available here.
In the United States, about one in seven adults—more than 38 million living in the U.S.—has Type 2 diabetes, which is the eighth leading cause of death. At over $400 billion of total healthcare spending annually, diabetes is the most expensive chronic condition to treat and manage. Given the critical role of patient self-management, investment in digital health tools has surged in recent years.
Throughout the assessment process, PHTI worked with a range of independent evaluation partners, clinical advisors, patients with Type 2 diabetes, and other stakeholders. Report contributors and reviewers included:
  • Curta: assessed the clinical and economic impact of these technologies using the published ICER-PHTI Assessment Framework for Digital Health Technologies, including the systematic literature review and budget impact assessment
  • Charm Economics: identified what technologies cost to deliver, how they work, and their impact on patients and purchasers
  • Institute for Clinical and Economic Review (ICER): co-developed the ICER-PHTI Assessment Framework for Digital Health Technologies, and was consulted to review its implementation in this report
  • Ami Bhatt, MD, chief innovation officer of the American College of Cardiology
  • Richard Milani, MD, chief clinical innovation officer, Sutter Health; former innovation lead at Ochner Health System
  • Karen Rheuban, MD, co-founder and director of the University of Virginia Center for Telehealth
“Managing diabetes is complex and essential to future cardiovascular health. Patients will gain agency and drive better clinical benefit if they direct their time and effort towards effective interventions rather than tools that provide marginal or no benefit,” said report contributor Ami Bhatt, MD, chief innovation officer of the American College of Cardiology.
“New diabetes technologies need to be easier to use, by the people who need them most, at lower cost than standard care, and provide real health benefits,” said report contributor Richard Milani, MD, chief clinical innovation officer at Sutter Health. “This evaluation suggests there is room for new innovations that deliver for patients and address worrying increases in healthcare spending.”
The PHTI report provides recommendations and best practices for innovators, providers, and payers. The next generation of diabetes management solutions should aim for clinically meaningful improvements in glycemic control, potentially integrating continuous glucose monitors and new GLP-1 obesity medications. Solutions should also generate sufficient evidence to support broader adoption, and they should prioritize access for populations who need them most. Providers of diabetes care should have clarity about the performance of these digital solutions when recommending them to their patients. Payers, including health plans and employers, should adapt their contracting approach to require transparency about the solution’s usage and benefits within their covered population and to include financial performance guarantees tied to clinical outcomes.
“PHTI is filling an important role in delivering actionable and market-facing information to digital health purchasers about what solutions will make a meaningful impact on health outcomes for members, making them worth investment,” said Peter Long, PhD, executive vice president, Strategy and Health Solutions at Blue Shield of California and a PHTI Advisory Board member. “Having an organization like PHTI cut through the noise of digital health options helps payers make faster and more effective decisions for members so that we can focus on the big work of transforming the healthcare system.”
PHTI has announced that future assessment areas include virtual physical therapy, blood pressure monitoring, and mental health tools.
# # #
About the Peterson Health Technology Institute
The Peterson Health Technology Institute (PHTI) provides independent evaluations of innovative healthcare technologies to improve health and lower costs. Through its rigorous, evidence-based research, PHTI analyzes the clinical benefits and economic impact of digital health solutions, as well as their effects on health equity, privacy, and security. These evaluations inform decisions for providers, patients, payers, and investors, accelerating the adoption of high-value technology in healthcare. PHTI was founded in 2023 by the Peterson Center on Healthcare. For more information, please visit PHTI.com.

Meet the Remarkable Women of the International Home Care Nurses Organization

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by | Mar 6, 2024 | Admin, Clinical, Vendor Watch

By Kristin Rowan, Editor

Last week, I had the honor of speaking with three of the dynamic leaders of the International Home Care Nurses Organization (IHCNO). Between them, they have more than 150 years of nursing and administrative experience. Beyond that, they are some of the most engaging and amazing women I’ve had the pleasure of interviewing.

Meet the TeamBoard Members of IHCNO

Barbara Piskor is the outgoing President of IHCNO. She started working as a nurse in 1964 and has held positions in home health nursing, clinical nursing, administration, national surveying with the Joint Commission, and consulting.

Marilyn Harris is the IHCNO Treasurer. She became a visiting nurse in 1960, was an administrator for the VNA, and spent 20 years as a hospital-based agency administrator.

Susan Hinck is the incoming President of IHCNO. She become a home health nurse in the 1980s and has been a clinician, educator, administrator, and advance practice nurse.

History of IHCNO

IHCNO started as a grassroots organization to serve the care needs of nurses. Between 2009 and 20012, there were concerns about teaching and practice. The industry was expanding and was in need of consistency. This launched the development of a communication network of home care nurses. Their mission is “To communicate, connect, and collaborate with home care nurses around the globe.”

The first members of IHCNO identified then-current home care nurse issues and developed action plans, a committee, and the first international conference event, which was attended by nurses from thirteen countries its inaugural year. They have since added webinars, outreach, and organizational development and are working on developing international guidelines and standards.

The Conversation

Rowan Report: “Barbara, as the outgoing President, what do you hope for the future of IHCNO?”

Barbara Piskor: “For IHCNO to be effective in helping to develop the area of global excellence in home-based nursing. To be recognized as the “go-to” organization for what’s happening in home-0based care related to nursing, from prenatal through to aging in place. To give the message that real health care is in the home; it’s a privilege to be a guest in the home, delivering care. It’s how you get to know the person, their family, and their home situation.

RR: “Susan, as the incoming President, what are your plans and goals for IHCNO for 2024 and beyond?”

Susan Hinck: “IHCNO has always been a volunteer organization, which comes with some challenges. We are contracting with a management company to provide stability and continuity for the organization. The same committed group of people working full0time to grow the organization will benefit from having a management company overseeing logistics so we can focus on additional projects and work more with home care nurses in different countries. There are some countries and continents where home care is not as well developed. For example, South America and Africa have well developed programs for maternity and pediatric home care, but not for older adults.”

RR: “Marilyn, the IHCNO has offers research grants in your name. Tell me about the IHCNO research.”

Marilyn Harris: “The Marilyn D. Harris research grant offers financial support for nurse researchers around the world. After the submission period, applications go through an international review board and one research topic is chosen. In the past, we have funded research on topics like the use of simulation tools in home care and the transition from home care to hospice. This year we will award our sixth research grant.

“We also have a very active internal research department. We are currently studying the scope and standards of home-based nursing around the world. All countries have scope and standards of practice for nursing, but they are not specific to nurses in home-based care. There are a lot of differences in practice across countries.”

RR: “You also have an award program, right?”

Harris: “Yes, that’s right. The Daisy Foundation was established by Bonnie and Mark Barnes to honor their sone. The Daisy award is given to home nurses for extraordinary compassion and care. It’s a worldwide initiative awarded through nomination and blind review. You can find the criteria and nomination forms on our website: https://www.ihcno.org/.”

RR: “Barbara, besides the research, are there other initiatives IHCNO is working on?”

Piskor: “A lot of our focus has been on short-term post-acute care for recovery and rehabilitation. But, custodial care, long-term skilled care, especially for younger adults who need long-term help is one of the fastest growing segments in the home care industry, but it is hampered by reimbursement. Intermittent visit programs are partially covered by Medicare and some Medicaid reimbursement, but isn’t covered by private insurance unless the patient is placed in a nursing home.”

Hinck: “The U.S. can learn a lot from other countries. We spend twice as much on healthcare but are in worse health and have higher mortality rates.”

Piskor: “That’s so true. Another initiative we have is working with provider, practice-based, and educational entities to let people know that home care is a thing. Clinical rotations in home care are necessary in nursing programs. More people need home-based care than ever before and there aren’t enough nursing students aware that home care is an option for them.”

RR: “Susan, IHCNO recently became a membership organization. Can you tell our readers about the member benefits you offer?”

Hinck: “That’s correct. As of January, 2024, IHCNO is a member organization. The biggest benefit of being a member is having a community of nurses to talk to who know what it’s like to be a home care nurse. You can check in and let people know how things are going in your part of the world. We are fostering communication and collaboration among home care nurses around the globe.

“Membership also gets you discounts for IHCNO hosted conferences and webinars and a discount for our multidisciplinary journal Home Health Care Now. We also have individual and corporate-level memberships available.”

RR: “Thank you all for taking the time to share your story with us.”

We will continue to bring you research and news from IHCNO, starting with some of the published works that have come from the past research grant winners. If you have any questions about membership, the grants, the Daisy award nominations, or any of the resources and support available through IHCNO, please reach out to them through their website: https://www.ihcno.org/

# # #

Kristin Rowan

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.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

 

CMS Announces Multi-Pronged Effort to Strengthen Direct Care Workforce

Admin

by | Mar 6, 2024 | Admin, CMS, Regulatory

by Elizabeth E. Hogue, Esq.,

CMS recently issued guidance about how to build and maintain worker registries, i.e., management platforms, that make qualified health workers easy to find so that more individuals who receive Medicaid-covered home and community-based services (HCBS) can receive care in settings of their choice. Worker registries are designed to answer these questions: Who is qualified to provide HCBS in each state and how can Medicaid recipients find them?

On February 27, 2024, CMS announced several new initiatives and Resources from the Administration for Community Living’s (ACL) Direct Care Workforce (DCW) Strategies Center to address the shortage of workers who provide direct care to elderly and disabled clients. New initiatives include several types of assistance that are intended to help states strengthen their systems for recruiting, retaining, and developing direct care workers; and a national hub to connect states, stakeholders, and communities to best practices and other resources related to the direct care workforce.

Specifically, DCW Intensive Technical Assistance will facilitate collaboration among state agencies and with stakeholders to improve recruitment, retention, training, and professional development of direct care workers. The DCW Strategies Center will provide up to two hundred fifty hours of individualized technical assistance on a variety of issues for up to six teams involving multi-agency state teams.

A coach will be assigned to each team and have access to subject matter experts to support them in addressing states’ unique needs. Support provided through this initiative will be coordinated by a consortium led by ADvancing States in partnership with the National Association of State Directors of Developmental Disability Services and the National Association of State Medicaid Directors.

The DCW Peer-Learning Collaborative will bring representatives of four to six states into working groups focused on a particular topic. The DCW Strategies Center will host monthly virtual meetings focused on group learning to facilitate information sharing on best practices, innovative strategies, and demonstrated models for growing the direct care workforce. In addition, each participating state will receive up to seventy hours of individual technical assistance on a topic or issue important to each state. Each participating state is expected to accomplish at least one policy or program-related milestone as a result of participation in this initiative.

CMS also announced the official launch of the DCW Strategies Center website at https://acl.gov/dcwcenter. This website is intended to serve as the national hub for resources about best practices, promising strategies, upcoming events, webinars, and technical assistance opportunities to strengthen and expand local direct care workforces.

CMS acknowledges in the announcement that low wages, lack of benefits, limited opportunities for career growth, and other factors have resulted in a continuing shortage of critical workers. The shortage reached crisis levels, says CMS, during the COVID-19 pandemic and currently continues, with more than three-fourths of service providers that decline new clients and more than half of providers cutting services.

According to CMS, the problem described above must be addressed in order to help ensure that people who need assistance have options other than moving to a nursing home or other institutional setting.

Now is the time for providers of private duty or home care services and the associations that represent them to work intensively with state programs, especially Medicaid Programs, to maximize available assistance as described above.

©2024 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Cyberattack Interrupts Pharmacy Operations

Admin

by | Mar 6, 2024 | Admin, CMS, Regulatory, Vendor Watch

By Kristin Rowan, Editor

**March 6, 2024 Update** As the previously reported cyberattack on Change Healthcare continues, the US Department of Health and Human Services issued a statement on March 5, 2024 outlining immediate steps CMS is taking to assist providers. CMS is strongly encouraging Medicaid and CHIP plans to waive or relax prior authorization requirements. They’ve also urged providers to offer advance funding to providers.

According to feedback from NAHC members, the impact of this cyberattack on home health and hospice providers has remained minimal. However, for those experiencing delays in claims processing and payments, some providers are unable to meet payroll or pay for patient care items.

**February 29, 2024 UPDATE** We’ve just been contacted by a home care agency out of Charlotte, NC who told us, “For our home care agency we can’t submit claims for VA clients (ChangeHealthcare [sic] has been totally taken off line), and we aren’t having remittance records from Optum feed through ChangeHealthcare [sic] to Wellsky.”

February 28, 2024

The news broke last week that another cyberattack is impacting healthcare. This time, it is Change Healthcare, a division of UnitedHealth Group, that processes insurance claims and pharmacy requests for more than 340,000 physicians and 60,000 pharmacies. In response to this attack, UnitedHealth Group separated and isolated the effected systems, causing delays in claim payments and backlog pharmacy orders.

The attack was first reported on February 21, 2024 and the outage is still ongoing. Former FBI cyber official and current adviser for cybersecurity and risk at the American Hospital Association warns that the longer this outage persists, the worse it will get and it will start to impact patient care. UnitedHealth Group claims that fewer than 100 pharmacy orders and claims have been interrupted across its insurance and pharmacy plans. But, at least on health insurer is claiming a 40% drop in claims since the system went down.

Source of the Attack

Initially, UnitedHealth Group blamed an unknown “nation state” for the cyberattack. The FBI found no evidence of this and has since named Blackcat ransomware gang culpable in the attack. Blackcat ransomware gang has attacked numerous hospitals and the FBI seized their website and servers in December, 2023. Blackcat accessed the Change Healthcare system through vulnerabilities in the ConnectWise ScreenConnect remote desktop and access software.

Implications

The American Hospital Association has urged all healthcare organizations that work with Optum, Change Healthcare, and UnitedHealth Group to weigh the risk of the connection to Change Healthcare against the possible clinical and business disruptions cased by severing that connection.

Health-ISAC anticipates additional cyberattack victims in the coming days. ConnectWise has alerted its users to the remote code execution flaw and has urged all users to update immediately to prevent attacks.

Point of View

This is not the only story this week about UnitedHealth Group. Backlogged pharmacy orders, healthcare claims, and payments, add further credence to the Antitrust probe filed this week by the Justice Department, investigating UnitedHealth and Optum. Should one healthcare group have this much influence over insurance, physicians, pharmacies, and home care?

# # #

Kristin Rowan

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.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

 

 

 

Sources:

Fox. February 22, 2024. Change Healthcare Experiencing a Cyberattack. Retrieved from: https://www.healthcareitnews.com/news/change-healthcare-experiencing-cyberattack

Fox. February 27, 2024. Change Healthcare Cyberattack Still Impacting Pharmacies, as H-ISAC Issues Alert. Retrieved from: https://www.healthcareitnews.com/news/change-healthcare-cyberattack-still-impacting-pharmacies-h-isac-issues-alert

Pashankar & Tozzi. February 28, 2024. Change Healthcare Cyberattack is Still Disrupting Pharmacies, Other Providers. Retrieved from: https://finance.yahoo.com/news/change-healthcare-cyberattack-still-disrupting-211913516.html

Satter & Bing. February 26, 2024. US Pharmacy Outage Triggered by ‘Blackcat’ Ransomware at UnitedHealth unit, Sources Say. Retrieved from: https://www.reuters.com/technology/cybersecurity/cyber-security-outage-change-healthcare-continues-sixth-straight-day-2024-02-26/

 

Hospice Expert Talks About Her Own Grief Journey

Admin

by | 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.”

# # #

Tim Rowan

 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

 

Justice Department Launches Antitrust Probe Against UnitedHealth Group

Admin

by | Feb 28, 2024 | Admin, Regulatory

by Kristin Rowan, Editor

DOJ Blocks Acquisition

History

The Biden administration has recently increased its efforts at antitrust enforcement against some of the largest companies in the U.S. These include Apple, Amazon.com, Live Nation Entertainment, and Alphabet’s Google unit. The enforcement of antitrust laws would restrain monopolies in the U.S. Thus far, the Justice Department has had questionable success in stopping mergers, but continues its crusade on monopolies. The administration has stated the the healthcare industry is a priority in its antitrust efforts.

The Wall Street Journal reported on February 27, 2024, that a new Antitrust investigation has been launched into UnitedHealth. This is not the first antitrust action against UnitedHealth Group. In 2022, the Justice Department sued to block UnitedHealth’s plan to buy Change Healthcare. That lawsuit was unsuccessful.

Current Action

According to the WSJ, The Justice Department has spent the last few weeks interviewing industry representatives in markets where UnitedHealth operates.

Investigators asked about relationship between UnitedHealth and Optum, the health-services arm of the company, which owns physician groups, surgery centers, and pharmacy-benefit managers. They specifically asked about the effects on the doctor-group acquisitions on rivals and consumers.

UnitedHealth Group

UnitedHealth has been under scrutiny for some time by the Justice Department. They have twice asked for information about the planned merger with Amedisys, a home health company. UnitedHealth is also facing a private antitrust lawsuit by a hospital system in California, siting strong-arm tactics to exert control over its affiliated physician groups and primary-care doctors.

Additional Inquiries

The DOJ isn’t stopping at antitrust probes. A concurrent investigation is looking into UnitedHealth’s Medicare billing issues, including documentation of patients’ illnesses. The more health conditions a patient has, the higher the Medicare payments. The DOJ is looking into “aggressive documentation” practices by UnitedHealth doctors and other healthcare providers.

Additionally, the merger between UnitedHealthcare and Optum medical groups could violate federal rules that cap the amount a health-insurance company retains from premiums. Health insurance plans should keep 15-20 percent of premiums for administrative costs, with the balance spent on patient care or sent as a rebate back to customers. Because UnitedHealthcare keeps their percentage of premiums and collects additional money from Optum, they may be well above the federal cap.

Response

UnitedHealth has denied any antitrust claims, stating that United Health and Optum don’t favor one another, and routinely work with competitors. UnitedHealth Chief Executive Andrew Witty testified that Optum has an “arm’s length relationship” with United Healthcare.

In an ongoing investigative series about CareMount/Optum, The Examiner News reporter Adam Stone, spoke with an anonymous insider who said, “If they are stopped before they become a monopoly, than that’s great, but they are headed down that road.” That same source has reported massive layoffs, mostly among C-suite executives, in the wake of the antitrust “document preservation notice” from the DOJ.

We will continue following the antitrust lawsuit and the objection to the merger with Amedisys.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing.  Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

 

Sources:

Mathews & Michaels. February 27, 2024. U.S. Opens United Health Antitrust Probe. Retrieved from: https://www.wsj.com/health/healthcare/u-s-launches-antitrust-investigation-of-healthcare-giant-unitedhealth-ff5a00d2?st=30zpi0dw9hktzlj&reflink=desktopwebshare_permalink

Stone. February 26, 2024. Justice Department Probing UnitedHealth/Optum Over Antittrust Concerns; Local Layoffs Enacted, More Forecast. Retrieved from: https://www.theexaminernews.com/justice-department-probing-unitedhealth-optum-over-antitrust-concerns-local-layoffs-enacted-more-forecast/

Enforcers Target Discharge Planners/Case Managers Yet Again

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by | Feb 21, 2024 | Admin

By Elizabeth E. Hogue, Esq.

Case managers/discharge planners continue to come under fire from fraud enforcers for violations of the federal anti-kickback statute. This statute generally prohibits anyone from either offering to give or actually giving anything to anyone in order to induce referrals. Case managers/discharge planners who violate the anti-kickback statute may be subject to criminal prosecution that could result in prison sentences, among other consequences.

A U.S. District Judge in California sentenced an owner of a post-acute provider to eighteen months in prison for one count of conspiracy to commit health care fraud and one count of conspiracy to pay and receive health care kickbacks. From July of 2015 through April of 2019 the provider paid and directed others to pay kickbacks to multiple case managers/discharge planners for referrals of Medicare patients, including employees of health care facilities and employees’ spouses. Recipients of the kickbacks included a discharge planner/case manager at a hospital, and discharge planners at skilled nursing and assisted living facilities.

Payments of kickbacks resulted in over eight thousand claims to Medicare for patients referred to the provider. Medicare paid the provider at least two million dollars for services provided to patients referred in exchange for kickbacks. Because the provider obtained patient referrals by paying kickbacks, the provider should have not received any Medicare reimbursement. The discharge planners/case managers who received kickbacks from the provider also pled guilty and will be sentenced soon.

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), the primary enforcer of fraud and abuse prohibitions, says that discharge planners/case managers and social workers cannot accept the following from providers who want referrals:

  • Cash
  • Cash equivalents, such as gift cards or gift certificates
  • Non-cash items of more than nominal value
  • Free discharge planning services that case managers/discharge planners and social workers are obligated to provide

Discharge planners/case managers and social workers provide extremely important services that are valued by many patients and their families, but their credibility and trustworthiness is destroyed when they make referrals based on kickbacks received.

A word to managers and all the way up the chain of command to CEOs: whether or not you know when case managers/discharge planners accept kickbacks, the OIG may also hold you responsible.

You may be responsible if you knew or should have known. The OIG has made it clear that your job is to monitor and to be vigilant. A good starting point is to put in place a policy and procedure requiring discharge planners/case managers to report in writing anything received from post-acute providers. Even better, how about a policy and procedure that prohibits all gifts?

Now a word to post-acute marketers: do not give kickbacks to discharge planners/case managers and social workers. It is simply untrue that you must give kickbacks in order to get referrals. The proverbial bottom line is: Do you like the color orange? Is an orange prison uniform your preferred fashion statement? Please stop now!

Reprinted with permission from ©2024 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.