Congress Allows Medicare Advantage to Deny Coverage

Advocacy

by | Jan 9, 2025 | Advocacy, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage Bill Dies in Congress

The 118th United States Congress, ran from January 3, 2023 to January 3, 2025. This Congress’s first law was passed on March 20, 2023, much later than most previous congressional sessions. In its first year, it passed only 34 bills. In the two years of this congressional run, the 118th passed 209 public laws, almost half the average since 1989. Among the many bills that died on the floor before time ran out was the Improving Seniors’ Timely Access to Care Act (H.R. 8702/S. 4532). Senate and House members introduced the bill on June 12, 2024.

Improving Seniors' Timely Access to Care

In June of 2024, senators and representatives introduced bipartisan legislation that would have curbed Medicare Advantage’s ability to deny claims. The bill included language that allowed CMS the authority to establish standard timeframes for electronic prior authorizations requests including expedited requests and real-time decisions for routinely approved services. The bill also included requirements for transparency and reporting, including:

    • establishing an electronic prior authorization process
    • establishing a process for real-time decisions for routine services
    • providing more detailed reports on use of prior authorization including
      • rates of approvals
      • denials
      • average time for approvals
    • pressing Medicare Advantage providers to incorporate input from health care providers on their authorization processes and decisions
    • adopting prior authorization programs that adhere to evidence-based medical guidelines
    • requiring Medicare Advantage providers to report on the percentage of denied claims that were later overturned

Overwhelming Support

At the time this bill was reintroduced to Congress in June, 135 House co-sponsors and 44 Senate co-sponsors signed on. By the end of July, the bill had been read, sent to the House Ways and Means Committee, and passed. Representative Mike Kelly (R-PA) noted that more than 500 organizations had endorsed the act. 

Urgent Need for Change

In early 2024, an audit from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS) revealed that Medicare Advantage plans eventually approve 75% of authorization requests for services that were initally denied. More recently, HHS OIG released a report showing that MA plans incorrectly denied services to beneficiaries even though they met the requirements for coverage. Following the report, HHS OIG made the following recommendations to CMS:

    • issue new guidance on the use of MAO clinical criteria in medical necessity reviews
    • update audit protocols for Medicare Advantage to address the issues of MAO use of clinical critera and examining service types
    • direct MAOs to indentify and address the causes for manual review errors and system errors.

CMS agreed with all three recommendations.

Dead in the Field

Despite the bipartisan, bicameral support of this much needed overhaul of Medicare Advantage providers, the bill is currently in pile of unaddressed issues that the 118th Congress just didn’t get to. Despite having it in front of them for five months, and despite passing nearly half the legislation of the 17 most recent congressional sessions, the bill that would keep MA beneficiaries from waiting inordinate amounts of time for routine care will have to wait for the next session to resume. Let’s hope the 119th Congress is more productive.

Medicare Advantage 118th Congress

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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 .She also has a master’s degree in business administration and marketing and 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

©2025 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

 

Good News for Veterans and Care at Home

Advocacy

by | Jan 9, 2025 | Advocacy, Hospice, Regulatory

by Kristin Rowan, Editor

Biden's Final Acts

With only a short number of days left in office, President Joe Biden has been making headlines. Not all of his final decisions have been met with absolute approval, but his latest one will make a difference for our veterans wanting Care at Home. On Thursday, January 3, 2025, President Biden signed into law the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act.

The Dole Act

The Elizabeth Dole Act improves upon much of the benefits, programs, and services provided by the Department of Veterans Affairs (VA). Some of these changes include providing protections for care agreements between veterans and clinicians, modifications to educational assistance programs and benefits, expansion of the Native American Direct Loan program, increases per diem rates for veteran transitional housing, and various administrative and oversight tasks.

Elizabeth Dole Home Care Act

The Elizabeth Dole Home Care Act is a bill within the larger act specific to home- and community-based services (HCBS). The home care act aims to enhance veterans’ access to the Program of All-Inclusive Care for the Elderly (PACE) nationwide. The new law also allows the VA to increase funding for HCBS. Prior to this, the VA was able to allocate 65% of nursing home care to home care services.

Additionally, the home care bill will provide support and benefits to caregivers of some disabled veterans, start a pilot to provide non-medical supportive care at home to veterans with limited access to home health aides, and increase access to HCBS for Native American Veterans.

The Industry Responds

The National Alliance for Care at Home responded to the landmark legislation, specifically siting section 301 of the bill, known as Gerald’s Law. Gerald’s is so named for a Michigan veteran who was denied his non-service related burial and plot benefit after he died at home while under VA hospice care. Gerald’s Law requires the VA to provide a burial and funeral allowance for veterans who were receiving VA hospice care in a home or other setting outside a hospital or nursing home.

“We are deeply grateful for the bipartisan support of Gerald’s Law and its inclusion in the Dole Act. This legislation ensures that Veterans and their families can choose hospice care in the setting that best meets their needs without risking the loss of crucial burial benefits. We thank Senators Moran, Tester, and Hassan, Representatives Ciscomani, Bost, Brownley, and Takano, and many others for their leadership, as well as President Biden for signing this important bill into law.”

Dr. Steve Landers

CEO, The Alliance

HCAOA, Leading Age, National PACE Association (NPA), and many others joined the Alliance in applauding Biden for signing the bill into law. They noted that providing care at home and in the community improves the quality of life for veterans and their caregivers. HCBS also come at a much lower cost than hospital and institutional care. 

HCAOA said in a statement that the bill is “…a crucial victory for both veterans and their caregivers.” The President and CEO of NPA said the bill would dramatically increase options for veterans who want to age in place and that Congress can “…easily implement PACE for hundreds of thousands of additional seniors and their families.”

The VA has found that HCBS can delay or remove the need for nursing home or assisted living admission. Care at Home also reduces the risk of preventable rehospitalizations. 

Final Thoughts

Once again, it seems the world is “discovering” that which we have known for ages: Home based care is better, cheaper, and more effective than institutional care. In the last few years, doctors and hospitals have figured this out and implemented hospital at home care. Now, the VA has finally figured it out as well. When this law takes effect, we as an industry will breathe a collective sigh when our veterans see better outcomes, their caregivers are better supported, the cost for their care decreases, and especially when our veterans enjoy a better quality of life in their final days without sacrificing the benefits to which they are so richly entitled. 

One small step for veterans, one giant leap for Care at Home.

# # #

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 .She also has a master’s degree in business administration and marketing and 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

©2025 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

 

Pharmacy and PBM Separation Pushed by Congress

Advocacy

by | Dec 19, 2024 | Advocacy, Regulatory

by Kristin Rowan, Editor

Bi-Partisan Bill Introduced

The final session of this Congress may not be as “lame” as anticipated. On December 11, 2024, Senators Elizabeth Warren (D-Mass.) and Josh Hawley (R-Mo.), with the support of Representatives Diana Harshbarger (R-Tenn.) and Jake Auchincloss (D-Mass.) introduced the Patients Before Monopolies Act.

The bill, if passed, would prohibit any company from owning both a Pharmacy Benefit Manager and a Pharmacy. Joint ownership of both creates a “gross conflict of interest” that allows companies to increase their own profits at the expense of patients and independent pharmacies.

Pharmacy Benefit Managers

Pharmacy Benefit Managers (PBMs) act as middlemen between consumers, health insurance companies, drug manufacturers, and pharmacies. They were designed to negotiate reimbursement and dispensing fees in pharmacies, negotiate drug prices from manufacturers, and manage drug costs for insurance companies. The PBM Act claims that PBMs have manipulated the market, increased drug costs, and are driving independent smaller pharmacies out of business. 

In Their Own Words

“PBMs have manipulated the market to enrich themselves — hiking up drug costs, cheating employers, and driving small pharmacies out of business. My new bipartisan bill will untangle these conflicts of interest by reining in these middlemen,” said Senator Warren.

“The PBM industry is rife with self-dealing that raises costs for patients and bankrupts independent pharmacists. No PBM should be allowed to own pharmacies, because it poses an unacceptable conflict of interest when it then sets reimbursement rates for its own versus external pharmacies. Independent pharmacies deserve fair play,” said Representative Auchincloss.

Pharmacy Benefit Managers

“As a life-long pharmacist, I know first-hand how unchecked PBM consolidation and vertical integration have allowed these shadowy middlemen to self-deal and manipulate the system in ways that are driving up drug costs, limiting patient choices, and putting the financial screws to independent community pharmacies,” said Representative Harshbarger.  “I’m a proud conservative Republican, but we have antitrust laws for a reason. That’s why I’m joining my colleagues in introducing the bipartisan Patients Before Monopolies Act, which will protect consumers and taxpayers, and ensure fair competition by breaking-up these anticompetitive, conflict-of-interest arrangements. Federal regulators should never have let this excessive concentration of our healthcare industry happen in the first place, and so it’s up to Congress to get the job done.”

Issues Addressed

The PBM Act aims to address the issues of higher drug costs, fewer independent pharmacies, and larger profits for corporations. The PBM Act would:

    • Disallow the parent company of any PBM or insurer from owning a pharmacy
    • Require any PBM or insurer that also owns a pharmacy to sell the pharmacy business within three years
    • Allow the FTC, DHHS, DOJ Anti-Trust Division, and state attorneys general to issue orders requiring the divestiture of pharmacies by owners of PBMs or insurers
    • Allow the same to sieze revenue made from the pharmacy business from any owner of a PBM or insurer
    • Distribute the funds to communities and consumers who have been overcharged by these pharmacies
    • Mandate the reporting of all divestments of pharmacies to the FTC
    • Allow the FTC to review any and all future acquisitions

PBMs have manipulated the market to enrich themselves — hiking up drug costs, cheating employers, and driving small pharmacies out of business. My new bipartisan bill will untangle these conflicts of interest by reining in these middlemen.

Elizabeth Warren

Senator, D-Mass.

Who is Impacted?

CVS Health, Cigna, and UnitedHealth Group, among others, would be required to sell their pharmacy businesses within three years.

Caremark, owned by CVS, Express Scripts, owned by Cigna, and OptumRX, owned by UnitedHealth Group, are three of the largest PBMs in the country. Together, they control about 80% of all prescription drug claims.

Not surprisingly, the Pharmaceutical Care Management Association, a lobbying group for PBMs, has contested the claims made in the bill and by its supporters. They argue that PBMs offer convenient, affordable access to medications.

Similarly, CVS said that its integrated business model, both a PBM and pharmacy, helps connect people to accessible, affordable care. The pharmaceutical giant claims it has lowered out-of-pocket drug costs more than 25% in the last ten years and that it reimburses independent pharmacies at a higher rate than its own CVS pharmacy locations.

A spokesperson for CVS Caremark said that policies designed to limit their ability to negotiate with drug manufacturers and pharmacies would increase the cost of medicine. He also said these policies would be a “handout” to the pharmaceutical industry.

Supporters

The bipartisan, bicameral Act has support from the American Economic Liberties Project (AELP), National Community Pharmacists Association (NCPA), American Pharmacy Cooperative Inc (APCI), Pharmacists United for Truth and Transparency (PUTT), Patients Rising, and AffirmedRx.

Public statements on behalf of the PBM Act harshly criticize PBMs, private health insurers, and the healthcare system as a whole.

Giant PBMs and insurers owning their own pharmacies has driven independent pharmacies out of business and reduced patient access to quality care. The Patients Before Monopolies Act addresses the root cause of this problem — consolidated market power — by eliminating the inherent conflicts of interest within the big three PBM business model. We are thrilled to see Sen. Warren and Sen. Hawley lead this bipartisan effort to lower drug costs, protect independent retail pharmacies, and improve patient access to care.

Morgan Harper

Director of Policy and Advocacy, American Economic Liberties Project

A particularly egregious result of the vertical integration of PBM-insurers with retail and mail-order pharmacies is that the PBM – which competes with independent pharmacies and others – decides what their rival pharmacy will be reimbursed and which patients will be allowed to use them. There are also countless examples of PBMs paying their pharmacies much higher reimbursement than non-affiliated pharmacies and using patient data to steer patients to their own pharmacies. We’re grateful to Sens. Warren and Hawley and Reps. Harshbarger and Auchincloss for introducing the PBM Act, which will go a long way in eliminating the conflicts of interest that currently exist in this space.

Anne Cassity

Senior VP of Government Affairs, National Community Pharmacists Association

The inherent conflicts of interest between PBMs owning their own retail, mail-order, and specialty pharmacies have resulted in higher drug costs, reduced patient choice and access to care, and unsustainable reimbursements to non-PBM affiliated pharmacies. With retail pharmacies closing at an alarming rate and patients fighting life threatening diseases being steered to PBM owned pharmacies and often overcharged thousands of dollars for medications, Senator Warren’s Patients Before Monopolies Act couldn’t come soon enough. This commonsense legislation strikes at the heart of anti-competitive PBM behavior and roots out conflicts of interest by prohibiting ownership of both a PBM and a pharmacy. American Pharmacy Cooperative, Inc, is grateful to Senator Warren for her work and leadership on this issue and looks forward to fighting for this critically important piece of legislation.

Greg Reybold

VP of Healthcare Policy and General Counsel, American Pharmacy Cooperative, Inc.

While there are a variety of conflicts of interest that can compromise the intended role of PBMs to act as counterweights to inflated drug prices, one of the chief areas of system misalignment arises from PBM ownership of pharmacies. As these large vertically integrated companies serve as both price-setter and price-taker for pharmacy transactions, PBM incentives to reduce drug markups and to manage pharmacy reimbursement and network decisions in an unconflicted manner are significantly undermined. In our work advising government programs and commercial plan sponsors, we stress that minimizing or eliminating these areas of misalignment are foundationally critical in order to achieve greater balance for medicine accessibility and affordability.

Antonio Ciaccia

President, 3 Axis Advisors

For too long vertically integrated PBMs have put profits over patients, driving up costs, limiting access to essential medications and forcing countless independent pharmacies to close their doors. The Patients Before Monopolies Act is a step toward breaking these monopolies, restoring fairness and competition and, most importantly, ensuring patients get the care they need at a price they can afford. At the heart of our mission is the belief that transparency and integrity should be the foundation of health care. I congratulate Senators Warren and Hawley, and Representatives Harshbarger and Auchincloss for putting patients first, and urge Congress to pass this bipartisan bill.

Greg Baker

Pharmacist and CEO, Affirmed Rx, a transparent PBM

This bill is the next step in urgently-needed legislation to eliminate the profiteering and other conflicts of interest that exist when private health insurers and their pharmacy benefit managers are allowed to design and sell health benefit plans while also owning pharmacies, clinics and other point-of-care entitiesm Vertical integration among the largest healthcare insurers has only served to saddle Americans with the priciest possible premiums for impossibly high-deductible plans that provide fewer options and ultimately result in poorer health outcomes. We applaud Senators Warren and Hawley for recognizing the need to dismantle the current system, which has failed consumers and taxpayers at just about every level.

Monique Whitney

Executive Director, Pharmacists United for Truth and Transparency

Across the country, patients feel increasingly disenfranchised by the healthcare system. The culprit: a complex web of powerful health conglomerates including health insurers, Pharmacy Benefit Managers (PBMs), and their affiliated pharmacies. Patients Rising applauds Senators Elizabeth Warren and Josh Hawley, along with Representatives Diana Harshbarger and Jake Auchincloss for putting forward bi-partisan legislation to put patients before monopolies. It is critical we crack down on health conglomerate conflicts of interest and encourage businesses to operate in the interest of patients’ long term health and wellbeing.

MacKay Jimeson

Executive Director, Patients Rising

The New York Times stated their uncertainty over whether this bill would gain any traction. With so much support, both across the aisle, across congress, and from outside entities, it seems likely it will move ahead. However, Congress has run out of time to pass any bill during this term and will have to be reintroduced in January.

The Rowan Report will continue to follow the progress of the PBM Act next year.

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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

Employee vs Independent Contractor

Admin

by | Dec 19, 2024 | Admin, Advocacy, Caring for the Caregiver, Regulatory

by Kristin Rowan, Editor

Follow the Rules

The very nature of care at home lends itself to different organizational structures. Hourly vs. per visit compensation. Employee vs. independent contractor. Shift work vs. standard schedules. Each decision can have its own advantages and disadvantages.

Two agencies were in the news this week after the Department of Labor determined they had misclassified employees as independent contractors and failed to pay overtime wages. In addition to back wages, these agencies were ordered to pay damages and civil penalties.

The Rowan Report has researched the 2024 Department of Labor Final Rule: Employee or Independent Contractor Classification Under the Fair Labor Standards Act, RIN 1235-AA43. We’ve provided our synopsis below to help you determine the classification of your workers to avoid similar penalties.

Employee vs Independent Contractor

The Fair Labor Standards Act, from the Department of Labor provides information on how to classify workers. Prior to 2021, the DoL used the economic reality test, used by courts to determine status. This test used economic factors including nature and degree of control over work, and the worker’s opportunity for profit or loss. These two factors weighed more heavily than the remaining three: the amount of skill required, how permanent was the relationship between the worker and the employer, and whether the work is part of an integrated unit of production (meaning all work leads to the same end product that cannot be completed without each person’s part.)  

Totality of the Circumstances

Because the courts openly admitted that the final three factors would likely never outweigh the first two, the DoL moved to establish a different rule, using the five factors to determine a “totality of circumstances” without the predetermined weight. It also bent the final factor to include the work being an integral part of the business, not of production. Also included is the discussion of how scheduling, supervision, price setting, and the ability to work for others are considered within the control factor.

This final change is what will impact most care at home agencies. As defined in the Final Rule (795.110(B)(1)), this factor considers whether a worker has control over their own profit or loss, has control over their own schedule, advertises on their own behalf to get more work, and generally engages in managerial tasks such as hiring, purchasing materials, and/or renting space for themselves.

Qualifying as an Employee vs Independent Contractor

In order to qualify as an independent contractor, a worker:

    • Must have control over their own profit and loss.
        • If a worker can choose to accept or deny and job offered through the agency, therefore making more or less money, they may be an IC.
    • Should be engaged for short-term projects with identified end dates.
        • This is vague in relation to care at home. An employer could argue that each home visit is a short-term engagement. However, the worker might say that the opportunity is on-going with no end date.
    • Invests in the building of their business.
        • If a worker uses all their own equipment, is free to take shifts or jobs from other agencies, and promotes their skills in order to attract more work from outside your agency, they are likely an IC.
        • If, however, the worker takes shifts from other agencies and promotes their skills to others because your business has predictable down-times, rather than of the worker’s own choice, they are likely an employee.
    • Should have control over multiple aspects of the job.
        • A common misperception is that if an employee controls their own schedule, they are automatically an IC. Many employees have flexible scheduling, work from home opportunities, and other controls over their schedule. Care at home workers make less money when they choose to change their schedule, indicating economic dependency on the company. Further, many agencies have a minimum hour requirement with disciplinary action or consequences for not meeting that minimum. These factors, regardless of scheduling flexibility, mean the worker is not an IC.
        • Nurses who have control over their own schedules do not control, for example, the rate they are paid for their services. When the employer controls prices for services, workers are likely employees.
        • How a job is performed should be a considerable factor. If the worker is free to determine how they actually do the work once they take a job, then they are likely an IC. This may be possible for non-medical supportive care at home, but is less likely for home health and hospice settings that are highly regulated.
    • Should not be supervised either in person or by technology, using a device or other electronic means. Ongoing and continuous supervision is not required to classify a worker as an employee, only that the employer maintains the right to supervise. Supervision in this case is not limited to watching the worker during a shift. Supervision also includes training and standards established during hiring, remote monitoring of a job using an electronic visit verification system, and/or the oversight of completed work in the case of a QA audit of documentation.
        • For home health and hospice agencies, this almost assuredly makes all nurses employees. However, exceptions may exist in the case of specialties such as wound care, physical or occupational therapy, ostomy care, and respiratory care.
        • For non-medical care at home, this factor should be weighed based on your agency’s protocols.
    • Must be able to work for others.
        • An employer who limits a worker’s ability to work for other agencies and/or put such constraints on a person’s schedule as to make it impossible to work for others has employees, not ICs.
        • Non-compete clauses and fines for taking clients outside of the agency point to employee status.
        • Working part-time and having the ability to work for another company, also part-time, does not necessarily make someone an IC.
    • Should not be an integral part of the business.
        • If the business cannot function without the service performed by the worker, the worker is an employee.
        • Similarly, if the work itself depends on the existence of the business, the worker is an employee.
        • Generally speaking, if a the primary business is to make a product or provide a service, then any worker involved in making that product or providing that service is integral to the business.
          • This final clarification from the DoL may require all care at home workers to be classified as employees.
Employee vs Independent Contractor

Implications for the Industry

If most care at home workers should be classified as employees, not independent contractors, you should expect to make significant changes if you currently have your workers classified as ICs.

  • Higher expenses in the form of taxes and benefits
  • Negotiations for paid vacation, personal, and sick leave
  • Potential auditing of prior business structure and classification
  • Complete overhaul of back-office hiring processes and software needs for onboarding employees instead of independent contractors

Employee vs Independent Contractor Corrective Action

  1. If your workers are misclassified as independent contractors, take steps to correct this effective January 1st so your new tax year is correct.
  2. Plan ahead to incorporate required taxes coming from your budget.
  3. Determine whether you may have workers who are owed back wages, overtime pay, or other benefits and take steps to rectify the situation before you end up on the Department of Labor radar.
Employee vs Independent Contractor

Final Thoughts

I’ve heard a lot of conversations from home health and non-medical supportive care agency owners about the policies they have in place for their caregivers. The new laws around non-compete clauses as well as this updated Independent Contractor test leads me to this conclusion:

Most workers in care at home are employees, not independent contractors. If you wish to classify your workers as independent contractors, do your research, reorganize your business, and make sure you are following the totality-of-the-circumstances test. 

If organizational change is not possible, look at transitioning your workers to employees before the start of the year and hire a consultant to help you with the changes you need to make.

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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

Health Insurance Impact after Thompson’s Death

Advocacy

by | Dec 12, 2024 | Advocacy, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Will Thompson's death change healthcare?

It's all Relative

On the same day that Brian Thompson died, Blue Cross Blue Shield announced a reversal of an earlier planned policy change. In November, the insurance giant announced it would change its process for anesthesia claims. The change would start in three states and begin on February 1st, 2025. The new process would limit the amount of time the company would cover anesthesia for surgeries and other procedures that called for anesthetization.

The announcements said the company would deny any claim for a surgery or procedure needing anesthesia that goes beyond the time limit they established. Reportedly, the policy would not apply to people under 22 or any maternity related care. A press release from the American Society of Anesthesiologists criticized the policy. It said BCBS “will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, regardless of how long the procedure takes.”

The new policy was confusing. Some reports indicated there would be a time limit set by the insurer and all claims over that time limit would be denied. Another interpretation said the company would initially approve the claim but would only cover the anesthesia up to a point, leaving the balance to the insured. Yet another report implied BCBS shield would still pay for the surgery, surgeon, and facility, but not for any of the anesthesia.

Reversal of Fortune

Though the initial announcement received backlash from anesthetists, surgeons, insured patients, and Connecticut Senator Chris Murphy, the policy was not widespread news. That is, until the shooting of Brian Thompson shed light on all health insurance company policies. Citing “misinformation” the company announced on Thursday, December 4, that it would not proceed with the policy change.

To be clear, it never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services. The proposed update to the policy was only designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines.

Spokesperson

Anthem Blue Cross Blue Shield

Social Media Backlash

The New York Times referred to the reactions to Thompson’s death as “morbid glee.” Comments on social media posts, videos, and news stories include:

“Thoughts and deductibles to the family.”

“Unfortunately my condolences are out-of-network.”

“I pay $1,300 a month for health insurance with an $8,000 deductible. When I finally reached that deductible, they denied my claims. He was making a million dollars a month.”

“Cause of death: Lead poisoning! It’s a pre-meditated condition. Payout denied.” 

UnitedHealth Group Responds

UnitedHealth Group CEO Andrew Witty called the media interest in Thompson’s death “aggressive” and “frankly offensive.” In a video to UnitedHealth Group employees, Witty said, “I’m sure everybody has been disturbed by the amount of negative and in many cases citriolic media and commentary…particulary in the social media environment.” Witty noted there were few poeple who had a “bigger positive effect” on the U.S. healthcare system than Thompson.

From Bad to Worse

Witty’s leaked internal video compounded the negativity towards health insurance companies. Witty decryied the media and public vitriol. He then praised Thompson’s impact on healthcare and defended the company policy.

“Our role is a critical role, and we make sure that care is safe, appropriate, and is delivered when people need it,” Witty said, “What we know to be true is the health system needs a company like UnitedHealth Group.” Witty followed his seemingly innocuous statement with, “We guard against the pressures that exist for unsafe care or for unnecessary care to be delivered in a way which makes the whole system too complex and ultimately unsustainable.” Public outcry was amplified after the video was leaked, with insured persons using this as proof that the company’s policy is to deny care.

Health Insurance Impact

Experts Weigh In

Ron Culp, a public relations consultant at DePaul University said if the attack is related to health insurance policies it “could cause companies in the sector to make some changes,” noting that, “empathy and potential alternative solutions will play greater roles.”

Fortune predicts that the incident will cause fewer people to aim for the corner office.

While disgruntlement with corporate America is not new, The Wall Street Journal said this incident is “tinged with class rage and anti-corporate venom….[The] current outpouring is on a grander scale….”

Loss of Faith in Insurance Stock

Between close of business on Tuesday, December 3, the day before Thompson’s shooting, and Tuesday, December 10, major insurance stocks have dropped more than 6%. This includes UnitedHealth, CVS Health, and Cigna, three of the largest private health insurers in the country.

Jared Holz, a health-care equity strategist, said the stock performance appears to be in response to the rhetoric condemning health insurance business models that include denied claims in deference to higher profits.

Final Thoughts

After just one week, the public is still uncovering and pronouncing issues with the healthcare insurance industry. The long-term health insurance impact regarding company policies, denial rates, or anything else remains to be seen. The Rowan Report will never condone violence against another person. However, if Thompson’s death brings about changes in the corruption of for-profit insurance companies, we will all be the better for it.

This is an ongoing story. The Rowan Report will continue to provide updates as they become available.

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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

The 4 M Framework for Age-Friendly Care

Admin

by | Dec 11, 2024 | Admin, Advocacy, Clinical, Outcomes

by Kristin Rowan, Editor

Pitfalls of Care at Home

Patient assessment has largely used the same formula for years. Patient care is more successful and less expensive in the home, but it is not without its frustrations. Agency owners and managers know that patients won’t always follow recommendations. Some patients leave an acute-care setting without understanding their own diagnosis or after care. Disruption from depression, dementia, or delirium impacts recovery. There are a reported 36 million falls among older adults in the U.S. And the list goes on.

Age-Friendly Health Systems

The care provided to older adults both in acute and post-acute settings is not always designed around the patient. Age-Friendly Health Systems is a joint initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA).

Age-Friendly Health Systems, according to the John A. Hartford Foundation, is a movement helping hospitals, medical practices, retail pharmacy clinics, nursing homes, home-care providers, and others deliver age-friendly care. 

Components of an Age-Friendly Health System:

    • Follow an essential set of evidence-based practices in the 4Ms Framework
    • Cause no harm
    • Align with What Matters to older adults and their family caregivers

The 4Ms Framework

What Matters

Know and align care with each older adult’s specific health outcome goals and care preferences including, but not limited to, end-of-life care, and across settings of care.

Medication

If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation across settings of care.

Mentation

Prevent, identify, treat, and manage dementia, depression, and delirium across settings of care.

Mobility

Ensure that older adults move safely every day in order to maintain function and do What Matters.

4Ms Framework CHAP Age-Friendly

CHAP Certification for Age-Friendly Care

The Rowan Report spoke with Teresa Harbour, COO of CHAP, about the 4M Framework. CHAP has developed a standardized form that agencies can use to educate patients and families and find out what matters most to them. The 4Ms Framework changes the perspective on patient care by looking at the 4Ms as a set, rather than as separate assessments. Resources, standards, and learning modules for your agency are also included and can be downloaded. The Age-Friendly Care at Home Certification is included at no charge with your CHAP Accreditation.

First Age-Friendly Certification Awarded

On December 2, 2024, St. Croix Hospice announced its achievement of Age-Friendly Care certification across all 70+ locations. Harbour said in a statement, “This effort not only raises the bar for compassionate, patient-centered care but also underscores St. Croix Hospice’s role as a leader in the hospice field.”

St. Croix Hospice is dedicated to providing compassionate, individualized care tailored to the unique needs of older adults. It’s especially important to us that this certification is recognized across our entire organization, reflecting the unified efforts of our teams to ensure every patient receives the highest quality care they deserve.

Heath Bartness

Founder & CEO, St. Croix Hospice

# # #

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

Meet the CMS Administrator Nominee

Admin

by | Dec 6, 2024 | Admin, Advocacy, Breaking News, CMS, Hospice, Medicare Advantage

by Tim Rowan, Editor Emeritus

Mehmet Oz, MD, MBA is the CMS Administrator nominee in the new administration that assumes power on January 20. A popular TV personality and former gubernatorial candidate, the public side of Dr. Oz is well known, but the details of his life and his qualifications to head a $1.16 trillion government program less so. We reached out to the nominee’s PR firm on November 22 to request an interview but have not received a response. We gathered the following background information from his web site and other sources.

Heritage and Education

Mehmet Cengiz Öz was born on June 11, 1960 in Cleveland, Ohio, of Turkish immigrant parents. Raised in Wilmington, Delaware, he holds dual U.S. and Turkish citizenship and comes from healthcare roots. His father, Mustafa Oz, graduated at the top of his class at Cerrahpaşa Medical School in 1950 and moved to the United States to join the general residency program at Case Western Reserve University in Cleveland, where Mehmet was born. His mother, Suna Atabay, was the daughter of an Istanbul pharmacist.

Mehmet graduated with a biology degree from Harvard University in 1982. He earned an MD at the University of Pennsylvania School of Medicine and an MBA from Penn’s Wharton Business School in 1986. He completed his surgical training at NewYork-Presbyterian Hospital and served as a professor of surgery at Columbia University.

CMS Administrator Nominee Dr. Oz

Completing his general surgery residency and cardiothoracic fellowship at Columbia-Presbyterian Medical Center in New York City, Oz became an attending surgeon at NewYork-Presbyterian Hospital/Columbia University Medical Center in 1993. He was later appointed professor of surgery at Columbia University in 2001. An advocate for integrating alternative medicine with conventional practices, he co-founded the Cardiac Complementary Care Center in 1995.

During his time at New York-Presbyterian, Oz patented the Mitraclip, a small implantable clip that can be placed using a catheter to repair the heart’s mitral valve. Oz reported earning over $333,000 in royalties from that product in his 2022 disclosures.

Rise to Fame

Oz gained national attention through appearances on “The Oprah Winfrey Show.” Winfrey’s production company, Harpo Productions, and Sony Pictures produced the daytime syndicated program, “The Dr. Oz Show,” which debuted in 2009. It won 10 Emmy Awards during its run.

The program, which focused on health and wellness topics, aired until 2022, when he left it to run for the U.S. Senate in Pennsylvania, winning the Republican nomination and eventually losing to Democrat John Fetterman. Oz is also a prolific author, with eight of his books on the New York Times bestselling list. The Dr. Oz Show gained in popularity during its run but occasionally faced criticism for promoting unproven health products and practices.

Finances

Most of what can be learned about Oz’s personal finances comes from disclosures he made during his Senatorial campaign. He reported a salary of $2 million as host of The Dr. Oz Show and $7 million from his stake in Oz Media. He was also paid $268,000 as a guest host on Jeopardy in 2021. In addition to salaries, Oz and his wife, Lisa, reported investments in big tech, health care, private equity funds, and various real estate holdings.

Oz’s 2022 financial disclosures showed Amazon stock worth up to $25 million; Microsoft, Apple, and Alphabet (Google) stock, each valued up to $5 million, and Nvidia stock valued up to $1 million. He also owned stock in UnitedHealth Group worth up to $500,000, and in CVS Health (Aetna), valued at up to $100,000. They also owned shares in privately owned gas station and convenience store chain Wawa valued between $5 million and $25 million. His 2022 disclosures showed he earned $5 million in dividends from his investment in Wawa.

The Oz’s also reported a real estate portfolio that includes residential and investment properties in New Jersey, New York, Pennsylvania, Florida, Maine, and his parents’ native country, Turkey, each valued from $1 million to $25 million. His 2022 disclosures also showed an investment property in Palm Beach and a cattle farm in Okeechobee, Florida, worth up to $5 million each, and $500,000 worth of cattle.

In addition to these investments, Oz currently runs the non-profit organization HealthCorps, which trains teenagers to share the organization’s curriculum on mental health, physical health, and nutrition. He also serves as Global Advisor and Stakeholder at iHerb, a company that sells supplements, personal care, grocery, and beauty products.

CMS Administrator Nominee

What Kind of CMS Would Oz Create?

What we know of Dr. Oz’s opinions regarding Medicare and Medicaid we learned from his 2022 Pennsylvania campaign message. During that campaign, Oz was a vocal supporter of privatizing Medicare. In 2020, Oz co-wrote an opinion piece in Forbes, suggesting “an affordable 20% payroll tax” to fund a “Medicare Advantage For All” program that could replace private insurance.

His plan, co-authored with Steve Forbes, suggested a 20% payroll tax, half paid by the employer, which the government would use to purchase a Medicare Advantage plan for everyone. The proposal did not explain how this would replace private insurance as MA plans are administered by insurance companies. Of course, this was four years ago, before it was widely known that MA plans pad patient assessments and deny care at a higher rate than straight Medicare does.*

CMS Administrator Nominee Outlook

Uncertainties to keep watch over include the CMS Administrator’s supervision over Medicaid and negotiating Medicare drug prices. If confirmed by the Senate, Oz would have the power to approve states’ requests to change their Medicaid plans, such as adding work requirements for beneficiaries.

He will also oversee drug price negotiations. The Inflation Reduction Act gave CMS the power to negotiate with pharmaceutical marketers to reduce the price of popular medications for people covered by Medicare Part D. The first round of negotiations concluded in August, and the next slate of drugs up for negotiations will be announced in February.

In nominating Dr. Oz, the President-elect said Oz will “help cut waste and fraud.” Whether that goal or seeing to the health of the more than a third of Americans insured through CMS programs becomes Mehmet Oz’s priority should be the first question asked in his Senate confirmation hearings.

Statement from National Alliance for Care at Home

I congratulate Dr. Oz on his nomination for CMA Administrator, I believe it generally is a good thing for patient care when physicians engage in public service and public policy leadership. I am still learning about his priorities and approaches for CMS and am looking forward to speaking with him about the importance of a vibrant and growing care at home sector. Home care and hospice offers CMS the greatest win-win opportunity in American healthcare; people get the independence and dignity they want and deserve while the taxpayers and families save on the costs of unnecessary hospitalization and institutionalization.

Steve Landers, MD, MPH

Chief Executive Officer, National Alliance for Care at Home

* Click to read previous Rowan Report news articles and analyses of Medicare Advantage plans.

# # #

Tim Rowan, Editor Emeritus

Tim Rowan is a 31-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

Healthcare is Heading Home

Advocacy

by | Nov 21, 2024 | Advocacy, Editorial, Other Sites

Web Golinkin, Forbes Books Author

Healthcare is Heading Home, and That's a Good Thing!

Healthcare is heading home

As the Baby Boomer generation ages, the home healthcare market is expanding. GETTY

During my long career in healthcare, one of the biggest trends in healthcare delivery has been the shift from hospital / inpatient to outpatient care. The compound annual growth rate (CAGR) of outpatient services was roughly 8 percent from 2017 to 2022, while inpatient services grew 1-3 percent during the same period. Outpatient services now represent more than 50 percent of total U.S. healthcare spending.

Particularly during the past 20 years, there has been significant growth in new outpatient facilities and channels, including retail-based and urgent care clinics, freestanding ERs, imaging centers, dialysis centers, ambulatory surgery centers, rehabilitation clinics, behavioral health clinics, and telehealth / virtual care.

The shift towards outpatient care has been driven by multiple factors, including patient desire for convenience, the need to reduce costs, and rapid advances in medical science and technology. Now, however, a new trend in healthcare is pushing the boundaries of outpatient care increasingly into the home.

This article explores the rapid expansion of home healthcare, the factors driving its growth, and the important distinctions between home care, home health care, and hospital-at-home models.

Macro Growth Drivers

The U.S. home healthcare market has experienced exponential growth, projected to reach nearly $510 billion by 2027 (roughly equaling the projected size of the outpatient market), according to various industry reports. This represents a CAGR of approximately 8 percent from 2020 to 2027. Several factors contribute to this rapid expansion:

  1. Aging Population: One of the primary drivers of growth in home health care is the aging population. As the Baby Boomer generation reaches retirement age, there is a significant increase in the need for healthcare services tailored to older adults, many of whom prefer receiving care in the comfort of their homes.
  2. Rising Chronic Conditions: The prevalence of chronic diseases such as diabetes, heart disease, and respiratory illnesses is increasing. Home healthcare services, including skilled nursing and rehabilitation therapies, provide essential support for managing these conditions.
  3. Technological Advancements: Innovations in telehealth and remote monitoring technologies have transformed healthcare delivery. Patients can now receive real-time consultations and monitoring from healthcare professionals, reducing the need for in-person visits and enhancing the appeal of home healthcare .
  4. Cost-Effectiveness: Home healthcare is often more cost effective than traditional hospital care. By providing services at home, patients can avoid expensive hospital stays, and insurance providers are increasingly recognizing the value of home-based care, offering incentives for its use.
  5. Patient Preference: There is a growing preference among patients for receiving care in their own homes. This trend is driven by the desire for comfort, familiarity, and independence, as well as the recognition that home care can lead to better health outcomes.

Main Types of Service

Three basic types of home healthcare have emerged. It is important to understand the differences between them, as each type serves different needs and patient populations and requires different kinds of providers and support:

  1. Home Care: This term typically refers to non-medical assistance provided in a patient’s home. Services may include personal care (such as bathing and grooming), companionship, meal preparation, housekeeping, and transportation. Home Care is often used by individuals who need assistance with daily living activities but do not require regular medical intervention.
  2. Home Health Care: In contrast, Home Health Care involves medical services provided by licensed healthcare professionals. This may include skilled nursing, physical, occupational, and speech therapy, as well as home health aide services. Home Health Care is typically prescribed by a physician and is intended for patients recovering from illness, surgery, or managing chronic health conditions.
  3. Hospital-at-Home: This model represents a more recent innovation in home healthcare, allowing patients to receive acute-level care in their homes instead of in a hospital setting. Hospital-at-home programs provide comprehensive medical services, including monitoring and treatment for serious conditions, under the supervision of healthcare providers. This model aims to reduce hospital congestion, lower healthcare costs, and improve patient satisfaction by delivering hospital-level care in a familiar environment. In addition, there is growing evidence that it improves clinical outcomes and reduces hospital readmissions.

Future Growth Drivers

Several key drivers will underpin further growth of home healthcare:

    • Policy Changes and Regulations: Government policies have increasingly supported home health care. Centers for Medicare & Medicaid Services (CMS) and other government programs incentivize home-based care, reflecting a broader strategy to reduce healthcare costs and improve care quality.
    • Healthcare Provider Initiatives: Many providers are expanding their services to include home healthcare options as part of their overall care continuum. This integrated approach helps streamline patient transitions from hospital to home, improving coordination and outcomes.
    • Market Competition: The growing number of home health care agencies and providers has fostered competition, driving innovation and improvements in service delivery. This competition encourages providers to adopt new technologies and practices that enhance patient care.
    • Public Awareness and Education: Increasing awareness of home health care options has led to more patients and families opting for these services. Educational campaigns and outreach initiatives have helped to demystify home health care, making it a more accepted alternative to traditional care settings.

Obstacles to Growth

Despite its rapid growth, the home healthcare sector faces several challenges:

    • Workforce Shortages: The demand for qualified home health care professionals exceeds supply, leading to staffing shortages. This is exacerbated by the demanding nature of home health work and competitive wages offered by hospitals and other healthcare and non-healthcare settings.
    • Regulatory Hurdles: Navigating the regulatory landscape can be complex and burdensome for home healthcare providers. Compliance with Medicare and Medicaid requirements, as well as with state regulations, often demands significant administrative resources. This can restrict the ability of smaller agencies to scale and compete effectively.
    • Insurance Reimbursement Issues: While insurance providers increasingly cover home health services, reimbursement policies can be inconsistent. Challenges related to payment models, including delays and denials, may hinder access to necessary care for patients and impact the financial viability of home health agencies.
    • Technology Adoption: Although technology is a key growth driver, some providers and patients resist adopting new tools. Ensuring that healthcare professionals are adequately trained in using telehealth platforms and remote monitoring devices is critical for successful implementation.

Positive Future Outlook

The outlook for home health care remains positive, as the sector adapts to evolving consumer needs and preferences. Several trends are expected to shape its future:

  1. Integration of Technology: The continued integration of telehealth and artificial intelligence (AI) into home healthcare will enhance service delivery and patient monitoring. Wearable devices and remote patient monitoring systems will likely become standard tools for managing chronic conditions at home.
  2. Focus on Value-Based Care: As healthcare systems shift toward value-based care models, home healthcare will play a pivotal role in managing patient outcomes and costs. Providers will increasingly be held accountable for the quality of care delivered at home, leading to a greater emphasis on patient engagement and satisfaction.
  3. Expanding Service Lines: Home healthcare providers and agencies will likely expand their service offerings to include mental health support, palliative care, and specialized rehabilitation services. This diversification will cater to the broader needs of patients, particularly those with complex medical conditions.
  4. Enhanced Collaboration: There will be a growing emphasis on interdisciplinary collaboration among healthcare providers, including hospitals, primary care providers, and home health agencies. This collaboration will facilitate smoother transitions of care and improve overall patient outcomes.
  5. Increased Investment: As the demand for home health services continues to escalate, investment in the sector is expected to grow. Venture capital and private equity firms are increasingly recognizing the potential of home healthcare, leading to innovations and improvements in service delivery.

The growth of home healthcare is a testament to the changing landscape of healthcare delivery. Driven by demographic shifts, technological advancements, and evolving consumer preferences, this sector is poised for continued expansion.

As challenges such as workforce shortages and regulatory hurdles persist, the future of home health care will depend on the ability of providers to innovate and adapt.

Nevertheless, healthcare is moving inexorably towards the home. That is good news for millions of patients who need acute, transitional or long-term care in the most comfortable environment, and for providers and third-party payers who are seeking to maximize the value of care being delivered.

# # #

Marcylle Combs Care at Home Worker Safety
Web Golinkin
Web Golinkin has focused his career on making health information and care more accessible and affordable. He has done this as CEO of five companies over the past 35 years, including three he co-founded.

These companies include the largest cable TV network devoted to health (America’s Health Network), one of the nation’s largest operators of retail-based clinics (RediClinic), a leading population health management company (Health Dialog), and one of the nation’s largest operators of urgent care clinics (FastMed). Web also co- founded the Convenient Care Association and served as its Chair for many years. He has been widely covered in the national media and has spoken at numerous healthcare conferences.

A magna cum laude graduate of Harvard, Web grew up in New York City and Long Island but has lived in Houston since 1988, so he is almost a Texan. A longtime runner and fitness enthusiast, Web enjoys tennis and golf—as long as he can walk and carry his bag. Web has been married to the same extraordinary woman for 39 years, and they have two amazing sons who make him proud every day.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Forbes Author Posts. For more information or to request permission to use, please contact Forbes.

2025 Final Rule

Advocacy

by | Nov 8, 2024 | Advocacy, CMS, Regulatory

by Kristin Rowan, Editor

CMS Releases Home Health Final Rule 2025

Last week, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) final rule. Included in the final rule are updates the Medicare payment policies and rates for Home Health Agencies (HHAs), intravenous immune globulin (IVIG) items, and payment rates for Durable Medical Equipment (DME) suppliers. Estimates indicate that CMS payments to HHAs will increase by 0.5% over 2024.

Partnership for Quality Home Healthcare

The Partnership for Quality Home Healthcare issued a press release in response to the final rule.

[We] were again disappointed that the Centers for Medicare & Medicaid Services (CMS) continued its policy of cuts by finalizing a -1.975 percent permanent cut to home health.

The Partnership for Quality Home Healthcare

The Partnership urged Congress to intervene to “fix the broken payment system” that continues making payment rate cuts year after year. The cuts are reducing patient access. According to recent data, patient visits per 30 days are down nearly 20 percent. The partnership notes workforce shortages, capacity limitations, and closures of providers as the primary reasons behind the decline in patient visits. 

Legislative Action

As we have reported previously, a number of organizations have worked together to advocate for home health with members of Congress. NAHC and NHPCO (Now The National Alliance for Care at Home), The Partnership for Quality Home Healthcare, and others, have proposed bipartisan legislation, the Preserving Access to Home Health Act (S. 2137/H.R. 5159).

NAHC last year filed a lawsuit claiming that CMS used flawed formulae in their calculations of budget-neutrality. That lawsuit has been paused while NAHC/NHPCO follow administrative processes required by the judge. Once those administrative paths are exhausted, The Alliance will look at next steps to continue their objections to the pay cuts. The overturning of “Chevron Deference” will open new avenues for The Alliance as well.

CMS Facts

CMS published its Final Rule Fact Sheet after the issuance of the final rule for CY 2025. According to the fact sheet, the 2025 rule:

    • Finalizes a permanent prospective adjustment of -1.975% (half of the calculated permanent adjustment of -3.95%) to the CY 2025 home health payment rate to account for the impact of implementing the Patient-Driven Groupings Model (PDGM)
    • Includes the final CY 2025 home health payment update of 2.7%
    • Adds an estimated 1.8% decrease to reflect the permanent behavior adjustment
    • Also has an estimated 0.4% decrease that reflects the updated FDL

This yields an aggregated 0.5% increase in payment rates over 2024. 

Increase=Decrease

Despite the overall 0.5% increase in payment rates, PQHH, The Alliance, and many other organizations see this as a drastic pay cut. The increase will not account for inflation, higher operating costs, or any other adjustments. These organizations continue to call upon you to contact your Senators and Representatives as well as to support them in their ongoing efforts with the bipartisan bills and the lawsuit. 

CMS Proposed Rule CY 2025

Ongoing Updates

The information in the 2025 final rule is still being analyzed and is further complicated by the change in leadership at the national and local levels after this week’s election. Please see our Upcoming Events section on the website for several webinars discussing these issues. The Rowan Report will continue to bring additional insights as they become available.

# # #

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

End of an Era

Advocacy

by | Oct 25, 2024 | Advocacy, CMS, Editorial, Regulatory

by Kristin Rowan, Editor

NAHC President Bill Dombi Retires

Earlier this year, with the announcement of the merging of NAHC and NHPCO, Bill Dombi announced his retirement from his position as President of the Association. Shortly after that announcement, The Rowan Report interviewed Bill and asked about the ongoing litigation against CMS as well as his thoughts on his tenure at NAHC. At the time, Bill was not prepared to speak about his upcoming retirement.

Remembering the Past

This week, at his final Annual Convention & Expo as association President, Bill shared his vision for the future of home health and hospice. Bill shared the story of the first time he faced an adversary…way back in kindergarten. He met his first bully and it took only a day for him to stand up to his nemesis and fight back. His bully walked away with a broken nose and Bill spent time with his nose in a corner.

“I was smiling the entire time,” Dombi shared, “and learning that’s not the way to do it. You’ve got to go to law school instead.”

How it Began

A young litigator, bright-eyed and ready to take on the world, Bill was initially hired to tackle a lawsuit against the Medicare program for denying care that should have been offered. He walked into the office that day and found boxes upon boxes with thousands of patient records and denied claims. Bill had to comb through each of these to select the 12 best plaintiffs to be named in the case. The amount of information was overwhelming, he recalled. It got a little easier when he was able to add members of Congress to the plaintiff list.

Nearly 40 years have passed since that day. “That day that I said yes was the beginning of a stunning opportunity that I had to be a part of an incredible team of people,” Bill reminisced.

First Steps Forward

That day will live in NAHC history as the first day of Bill’s tenure with the association. He promised his wife and children they’d be in Washinton D.C. for “just three or four years.” They stayed for 37. This day led to his first case against Medicare, Duggan v. Bowen. A case that rewrote the Medicare home health benefit. “It’s not perfect, but it was a monumental move forward,” Bill stated.

A Career Marked by Achievements

While is Bill is often hesitant to take full credit for what he has accomplished, and regularly credits his team for the strides made for home health and hospice patients, there is no doubt that he has been a driving force behind NAHC’s momentum and a key player in its advances at state and federal levels. 

Among Bill’s many accomplishments are:

  • Creating the Medicare Hospice Benefit. Today, one out of every two decedents have used hospice in the last 12 months of their life, which is an enormous increase since its launch.
  • The growth of the Medicaid program. The program went from having no home services in 1965, to being the largest home health program in the world.
  • Increasing access of care for pediatric patients, those receiving private duty nursing, the severely disabled and the elderly.
  • The transition of making hospital-at-home care permanent in Medicare.
  • Ever-growing technologies and improving the focus on in-home care.
  • Several lawsuits that Dombi led at NAHC against private insurers and others, to ensure that specific patients—including several with amyotrophic lateral sclerosis (ALS)—weren’t arbitrarily denied the coverage they needed.
NAHC President Bill Dombi Retires

“That’s where my heart, my soul is; that’s where my aggressiveness is born, representing those very vulnerable people.”

Bill Dombi

President Emeritus, National Association for Home Care & Hospice

Where it's Going

As Bill wrapped up his final appearance on stage as NAHC President, he made some predictions and shared his hopes for the future of care at home. “I see a future where we see a whole transformation of health care. A future where the minds, hearts, operations, payments, and everything else are focused arund a home care direction,” he shared, “Not everyone can or should receive care at home, but it would be the ideal default before someone is hospitalized or moved to a nursing facility.”

Bill’s more specific hopes for the future of care at home include:

  • Nursing school curricula specific to care at home
  • Physician education including care at home
  • The leaders of CMS and/or DHHS have backgrounds in or a deep understanding of care at home
  • Technology visionaries working on tech solutions for care at home
  • Every state of the union and Presidential debate includes a discussion on care at home

Dream Big

Bill openly admits that his “wish list” for care at home may be fantastical, but he will continue to encourage all those who work in the care at home industry to continue to fight to move in that direction.

“We have to stand ready and be capable of working in all forms to defend ourselves against being bullied around,” he said. In typical fashion, Bill’s statements brought the crowd to its feet. He fittingly exited the stage to a standing ovation with Tom Petty’s “I Won’t Back Down” echoing through the hall. 

As the music faded on Bill’s tenure, The Alliance CEO Steve Landers offered, “Bill, we won’t back down. Just so you know, we’re not going anywhere.”

The Legacy Lives On

Bill may be retiring from his post as President of NAHC, but his accomplishments, his passion for care at home, and his legacy will live on. National Alliance for Care at Home has established The William A. Dombi Scholarship Fund at his alma mater, the University of Connecticut. Bill’s contributions to care at home can hardly be overlooked when the scholarship fund has nearly doubled its initial goal of $50,000. 

Incoming and continuing students at UCONN who are majoring in political science can apply for the scholarship. The scholarship prioritizes awarding money to students focused on public policy and/or health care policy. Contributions to the scholarship fund can be made here. 

On a Personal Note

I spoke with Bill briefly during this week’s national convention & expo. I couldn’t let the event pass without acknowledging his contributions personally. When I started working in the care at home industry nearly 16 years ago, I saw Bill speak at a convention. Most of what he said was beyond my limited knowledge of care at home at the time. But, when I introduced myself afterward, he was gracious and offered any assistance he could offer in the future. Since then, as I have delved deeper into the world of care at home, Bill has been a voice of reason, of passion, of resilience, and of steadfast commitment to advocating for the current and future recipients of care at home. He has impacted countless lives. For his guidance, for his character, and for his relentless pursuit of reform for care at home, I can only echo the sentiments of my colleagues and friends:

“Thank you, Bill, for everything.”

# # #

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

National Alliance for Care at Home: An Interview with Dr. Steve Landers Part 1

Admin

by | Oct 25, 2024 | Admin, Advocacy, Regulatory

by Kristin Rowan, Editor

Alliance CEO Landers

For more than a year now, The Rowan Report has been providing updates on the merger between the National Hospice and Palliative Care Organization (NHPCO) and the National Association for Home Care & Hospice (NAHC). This week, we attended the first National Alliance for Care at Home (The Alliance) Annual Home Care and Hospice Conference and Expo. We had the opportunity to sit down with Dr. Steve Landers, inaugural Chief Executive Officer of The Alliance.

Dr. Steven "Steve" Landers

Dr. Steven Landers brings his almost 20 years of experience to The Alliance as its first CEO. Dr. Landers is a board-certified physician in family medicine, geriatric medicine, and hospice and palliative medicine. He has dedicated his career to seeking home- and community-based solution to traditional healthcare. His focus is on providing compassionate, dignified, and cost-effective care to patients.

Dr. Landers graduated from Case Western Reserve University School of Medicine, where he completed a geriatric medicine fellowship at the Cleveland Clinic.

Dr. Landers is no stranger to NAHC and NHPCO, having previously served on the board of directors for NAHC.  He has met with Congress, state legislatures, CMS, and PAC officials, providing testimonies, discussing home care policy and regulation, and advocating for care at home.

Steve lives in Little Silver, New Jersey, with his wife, Allison, and their three sons. His hobbies include golfing, fishing, hiking, traveling, enjoying good food and watching horse racing. When he is not taking part in these activities, you can find him cheering on his sports teams — the Browns, Cavaliers, Guardians and Indiana Hoosiers.

The Alliance Landers
The Alliance Landers

Dr. Steven Landers: On the Record

The Alliance Landers
The Rowan Report:

What do you know about the status of the ongoing lawsuits, going back to the 2024 final rule?

Dr. Steven Landers:

One, we should probably bring Bill [Dombi] into it because he’s truly a technical expert on it and I’m still getting up to speed on it. My understanding is there is no active lawsuit at the moment. We were asked to go back and take some additional administrative steps, which we’re doing. Then we’ll be able to evaluate what further legal paths are possible.

RR: 

That leads me to, not a question, but an observation I’d like you to comment on, Steve. For 45 years, the organization has been run by attorneys and the emphasis in lobbying and advocacy has been ‘you need to stop this cut because it’s hurting businesses and also it’s hurting patients.’ The way you’re talking, you emphasize as you begin with how it’s hurting patients. And so I’m wondering if the organization being run by a physician and not an attorney indicates that different emphasis going forward.

Steve: 

I certainly am going to do everything I can to tell the story of how policies impact patients and families. That will be part of what I try to do every single day using my experiences as a physician to do that.

RR:

Would it be exaggerating to say “new day, new emphasis” at The Alliance?

Steve:

Well, The Alliance is new in and of itself, so The Alliance is a new day for the industry, a hundred percent. We brought together two legacy organizations. The opportunity to have a stronger voice is very real and certainly I am going to bring a clinical perspective. I’m also a family caregiver. I have my own personal experiences with home care and hospice that have instructed how I think about these things.

And there is every opportunity here to get stronger, to try to make a bigger impact. I would not diminish the truly heroic work that’s been done by advocates within our associations in the past. There’s a lot of love and care that’s happening out in our country because of the leadership that’s been in place. But as you can see by some of the things that we’re talking about, we need to do better. We need to find another way to tell these stories to somehow get somebody to listen.

The Alliance
RR:

You recently released a statement about your position as CEO of The Alliance and your vision going forward. There was a commitment attached to that. Can you speak to that?

 

Steve: 

Yeah, so that’s one of the things that I’m really happy we’re doing very early in our work with the Alliance. For membership, whether to join or to renew membership, we are requiring an attestation from our members around their commitment to quality and to compliance. We’re requiring any provider member to attest to having a program in place for quality and compliance. And we’re requiring that they attest that they monitor the OIG exclusion list and don’t take referrals for employees that are people that are on that list. Also for home health and hospice providers, we’re asking that they attest that they do their level best to participate in the Medicare Home Health and the Medicare Hospice Quality Reporting program.

In order to make a difference on behalf of our members and make a difference on behalf of the people that need care at home, we have to have as credible and high integrity of a voice as possible. And so this is just one simple step of additional things that we’ll consider going forward. We want to make sure that our alliance, our coalition is high integrity and has a deep commitment to quality and compliance.

RR:

It’s one thing to ask people to sign an attestation. It’s another to find the bad players and help CMS to get rid of them.

Steve:

And we’re right there as a partner in that. I think you’ll see more announcements from us in the future about what we’re doing to help with that. I mean, on one hand, we’ve made many proposals around fighting fraud and hospice in particular. If you followed the hospice policymaking, both Legacy NAHC and Legacy NHPCO over the last year have made many policy recommendations. And you’ll definitely see us both advocating for anti-fraud measures as well as having resources within our association to focus on those topics.

The Alliance Landers
Interviewer 1:

Just to clarify, did either of the legacy organizations have this same kind of attestation?

Steve:

No, this is new. The impact of the legacy organizations cannot be questioned. It’s been amazing. But, it’s a new day and we are looking at ways to increase our impact. So, this is a new part of our membership process that we feel strongly about to just take another step to ensure that our coalition, our membership, is of the highest integrity possible. We are walking the walk and talking the talk with respect to quality and compliance.

RR:

Thank you, Dr. Landers

This article is part 1 of 2 interviewing Dr. Steven Landers. Read the rest of the interview here.

# # #

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

An Interview with Dr. Steven Landers, Part 2

Advocacy

by | Oct 25, 2024 | Advocacy, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage is Killing Us...Literally

This is part 2 of 2 in the interview with Dr. Steven Landers. You can read part 1 here.

Medicare Advantage article by Dr. Landers

Earlier this week, Dr. Landers published an article in the NAHC Report. The article cited three studies and analyses on the number of enrollees in both Medicare and Medicare Advantage who do not receive the care to which they are entitled. During our recent interview with Dr. Landers, he addressed this article.

Dr. Steven Landers: On the Record

The Rowan Report:

You wanted to address something you recently wrote. Is this the same topic you mentioned the opening session, or is this something else?

Dr. Steven Landers:

No, this is a focused piece on the emerging research that we’re seeing around when people miss out on home health. It’s a life and death issue. I want to be sure that we, as an alliance, I, as a physician, and us, as advocates, that we are conveying that these issues around home health cuts and barriers are potentially deadly. This is not a trivial matter. It’s not an administrative or technical financial issue. It’s about people’s lives.

RR:

The article mentioned a study that said that the numper of people not getting the home care that they’re entitled to is almost double with Medicare Advantage enrollees over traditional Medicare.

Steve:

That was from a study that’s referenced there from a few years ago. The Partnership for Quality Home Health Arcadia Analysis that came out this year actually showed that those trends are worsening. We know that they’re not getting the needed care in Medicare Advantage and traditional Medicare.

In both cases it’s too high, but it’s higher in Medicare Advantage. It’s more common that people don’t get the prescribed care in Medicare Advantage. And we also know that that’s going up in both traditional Medicare and Medicare Advantage. The access has gotten worse because of the Medicare home health policy and because of the way that Medicare Advantage has grown and handled these issues.

Medicare Advantage Landers
Interviewer:

I guess the big giant question is what do we do, especially when margins for both traditional Medicare and Medicare Advantage are so low?

Steve:

One, we’ve got to start improving access to home healthcare. And the way that we do that is we end this march of payment cuts that are being set forward by Medicare. I mean, right now the leaders of Medicare are in their rulemaking process and they have choices to make. They can either do things that reverse this trend and put us on a path to better access or I think continuing these cuts will hurt beneficiaries.

And the other piece is the Medicare advantage front. We need more scrutiny and evaluation and potentially oversight here to make sure Medicare Advantage beneficiaries have access to high quality home healthcare.

“The results of this study demonstrate that among MA members referred to home health after acute hospitalization, those who did not receive home health services experienced higher mortality and lower readmissions than those who received these services.”

Unfulfilled Home Health Referrals Lead to Higher Mortality Among Medicare Advantage Members

Elan Gada, MD, Paul Pangburn, MHA, Chris Sahr, MS, MBA, Chad P. Schaben, MPH, Richard Young, MS

RR:

Where does the problem lie?

Steve:

People don’t get home health when it’s prescribed and mortality rates are substantially higher. There could be [anecdotal] reasons that this is happening. I’ve tried to think of them. I can’t really come up with them when you see it in three different analyses, especially one done within the Medicare Advantage plan. They have great data. It was well thought out and this is serious business and it really should be a kitchen table discussion for families like ‘what’s going here?,’ because obviously home healthcare is a beloved service that families care deeply about.

We’ve seen home care become a presidential campaign issue because it’s good policy and also because the folks running, Vice President Harris, who brought it up, and former President Trump, who chimed in sort of a me too, being enthusiastic about the concept. They’ve got to know that this polls well, that the families care about this stuff.

Editor Emeritus Tim Rowan provides an analysis of the study from UnitedHealth Group here.

# # #

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

Introducing “The National Alliance for Care at Home”

Admin

by | Oct 25, 2024 | Admin, Advocacy, Regulatory

by Tim Rowan, Editor Emeritus

National Alliance for Care at Home

The merger of the National Association for Home Care and Hospice and the National Hospice and Palliative Care Organization, which was inked on July 1, became official this week in Tampa, Florida. The new National Alliance for Care at Home said farewell to retiring NAHC President Bill Dombi and gave a rousing welcome to incoming Alliance CEO, Steven Landers, MD. Both Bill’s farewell address and Dr. Landers’ introduction speech ended with the same theme. We do what we do for the good of our patients. Yes, there is money. Yes, there are politics. In the end, our legacy and our future are about people.

Dr. Steven Landers

Integrity, Quality and Compliance

That future will begin with a commitment to patient care excellence. Dr. Landers closed his opening address with an announcement. From now on, every member, upon beginning or renewing their annual membership, will be asked to sign an attestation pledging their company and themselves personally to commit to Integrity, Quality, and Compliance. “Our members will be known to the world as the best in the industry,” he proclaimed. “They will assure patients, families, and payers that they participate in Medicare and Medicaid quality performance standards.”

In a press conference the next day, Dr. Landers elaborated that NAHC and NHPCO have always worked with public and private payers and law enforcement agencies to rid our industry of those who are not in it for noble reasons. Those cooperative efforts will continue, he told the reporters. The new attestation will further assure the world that members of The Alliance publicly join that mission. One is reminded of a code of conduct common to all our national military academies. “We will not lie, steal, or cheat, nor tolerate among us anyone who does.”

Emphasis on Advocacy

The Alliance is new, and Dr. Landers candidly admits he is gradually learning his new role as he goes along. But he is guided by a commitment to care in the home that has been with him since medical school. “I didn’t want to be just another cog in the system,” he told 2,000+ attendees. “The first time I went along on a home visit, I immediately realized that this is what I wanted to commit my career to.” Through his years at the VNA and Cleveland Clinic, he saw the power of in-home care, including its ability to extend live expectancy and reduce the total cost of care.

Bill Dombi

A Semi-Farewell at Best

National Alliance for Care at Home Dombi

Bill Dombi will serve the new Alliance through the end of this year before fully entering retirement. Following his closing address on the last day of the conference, during which he summarized his 38 years with NAHC (years that began with a promise to his wife Lynn that they would only have to leave their home in Connecticut for the DC area for three to four years), I asked him what he planned to do that first day in January. He said that he accumulated a ton of frequent flyer miles during his career and that they would love to travel somewhere other than state and national association conference cities.

He also mentioned the ongoing legal actions he initiated to force CMS to develop more honest formulae for calculating Home Health reimbursement and added, “It is very difficult to change litigators in the middle of a lawsuit.” Draw your own conclusion but take it from one who knows how difficult it is to completely walk away from this mission and its people. We may not have heard the last of William A. Dombi.

# # #

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

National PACE Awareness and National Fall Prevention Month

Advocacy

by | Oct 10, 2024 | Advocacy, Clinical

by Kristin Rowan, Editor

New Fall Prevention Study: An Interview with Dr. Ann Wells

Fall Prevention Month

September was National Fall Prevention month. Accidental falls are the number one cause of injury and death among adults over the age of 65. Fall Prevention month attempts to raise awareness on preventing falls, reducing the risk of falls, and helping older adults live without the fear of falling. The National Council on Aging also promotes advocacy on behalf of fall prevention funding and offers training and other materials to help prevent falls. Read our complimentary article this week about a nurse charged in the death of a patient who fell here.

National PACE Awareness Month

September was also PACE Awareness Month. The Program of All-Inclusive Care for the Elderly )PACE) is a Medicare and Medicaid program that helps seniors with long-term care needs to live independently and age in place. The program includes an interdisciplinary team of professionals working together to coordinate care. There is no co-pay, deductible, or coverage gap and the amount paid each month doesn’t change, no matter what care services the patient needs. All Medicare and Medicaid services are covered as well as medically-necessary care and services that are not typically covered. Coverage includes prescription drugs, doctor care, transportation, home care, checkups, hospital visits, and nursing home stays when necessary.  Access more information about PACE here.

InnovAge Fall Prevention Dr. Wells

InnovAge has been tapped to participate in a fall prevention study. The study is conducted by LeaHD, a research and training center established in partnership with Brown University, Boston University, and University of Pittsburgh in the Center on Health Services Training and Research. The Rowan Report sat down with Dr. Ann Wells, Chief Quality and Population Health Officer of InnovAge. Dr. Wells said of the study, “[it] will help us better understand the multi-faceted factors contributing to falls among seniors and develop intervention strategies tailored to their unique needs.”

Dr. Ann Wells, Chief Quality and Population Health Officer

Rowan Report:

Dr. Wells, thank you for taking the time to speak with me today. Why don’t we start with a little background on you. How did you come to be involved in elder care and PACE programs?

Dr. Ann Wells:

By trade, I am in internal medicine doctor, focused on the geriatric population. I have spend 20 years in medical leadership working in population health. Population health is the approach to healthcare that evaluates and improves outcomes in subgroups with similar needs and the populations as a whole through team care and analytics. Through my work in medical leadership and population health, I was approached by InnovAge to be part of their leadership team.

RR:

You mentioned the PACE program. What do you think is the key difference, or differences, between PACE programs and other types of senior care?

Ann:

The PACE model is health care’s best kept secret and we don’t want it to be a secret anymore. Most patients and families don’t want institutional care. 86% of seniors value remaining in the communities in which they live.

In order to qualify for PACE programs, the patient has to qualify for nursing home levels of care. The program delivers services designed to help them stay in the community. PACE leverages an 11-member interdisciplinary team that includes a primary care provider, a registered nurse, a driver, a master-level social worker, PT, OT, a dietician, a PACE center manager, a home care coordinator, and a personal care attendant. The team coordinates care for medication, medical care and transportation with wrap-around social support and in-home support to help with bathing, shopping, and dressing. They also coordinate specialty care, make appointments with contracted specialists, provides transportation and a chaperone if needed, sends medical records in advance of the appointment, and gets notes back from the specialist.

Participants can come to a center for primary care, PT, or OT. They can also enjoy the center for socialization and activities. Patients provide permission to talk to each caregiver to make sure they are getting the care they need. Almost 90% of patients are dual-eligible. Roughly 10% are Medicaid only. The small remainder are Medicare only and pay the difference out of pocket.

RR:

There is a lot of information about the PACE program that I didn’t know before. Thank you for that. Can you tell us a little about InnovAge?

Ann:

InnovAge is the largest provider of the PACE program based on number of participants. They are both a delivery arm and a health plan. InnovAge administers care from 20 centers in six states.

RR:

And what your role is as Chief Quality and Population Health Officer?

Ann:

The Clinical Value Initiative aims to ensure the company is managing revenue and participant expenses including risk adjustments, ensuring the most accurate risk score, resource management, payment integrity or a claims audit process, and network optimization. Through these initiatives, the average inpatient rate for hospital admissions was 5.5% and the average time from enrollment to placement in a nursing home is three years. These initiatives and the PACE program are reducing hospitalizations for participants and keeping patients in their homes and in their communities longer.

RR:

September was National Fall Prevention Month. The number of injuries and deaths due to falls among seniors over age 65 is staggering. But, InnovAge, using the PACE model, has reduced falls. How does that program work?

Ann:

Any fall that has a major fracture is very difficult to recover from. InnovAge leverages the STEADI program. Stopping Elderly Accidents, Deaths, and Injuries (STEADI). This program includes screening, assessing, and intervening.

Screening

All participants are asked intake questions to screen for risk. Have you fallen in the last year? Do you have a fear of falling? Statistically, once a patient has fallen once, the risk is much higher for another fall.

Assessing

At enrollment, and again yearly, the patient receives an in-home assessment with an environmental safety evaluation. We look at things like lighting, rugs, grip bars, ramps, a non-slip rug in the bathroom. PACE arranges for installation and payment for any items they might need to lower the risk of falls. OT & PT conduct yearly evaluations as well. Do they need a walker? Do they have proper footwear? Have they had a recent eye screening and do they have glasses? They also evaluate leg strength and balance. If there is a deficit, the patient can do PT at the center.

In addition to the in-home assessment, we conduct a root cause analysis if there is a fall to determine why they fell and what they need to prevent a future fall. Clinical pharmacists also evaluate medicine regiments and optimize medications to reduce or eliminate side effects and improve safety.

Intervention

When there is a patient at high risk for a fall, due to any of the factors we find in the screening and assessment, we employ some intervention. PERS units, emergency alert pendants and wristwatches, are provided for high-risk patients. Units with fall detection and emergency activation buttons place automatic calls to a call center. The call center will try to contact the patient and send an ambulance if they can’t be reached or need assistance.

RR:

InnovAge has recently been selected to participate in a national study for the prevention of falls. Tell us about that study and how InnovAge will participate.

Ann:

LeaHD approached InnovAge to help improve their training for chronic care. InnovAge has a population that aligns with their research. The research topic is to evaluate whether they can predict risk of falling with new enrollees. From there, we will assess whether we can create more tailored interventions to lower risk. The hope is that the study will inform us, as an industry, what we should be asking a new patient to determine their actual risk of falling. In turn, the study will inform caregivers on how they can identify high risk patients and prevent future falls.

Fall Prevention InnovAge Dr. Ann Wells
RR:

What is the timeline and goal of the study?

Ann:

The study will run for one year, starting in October, 2024. There is a data scientist working on the project who will conduct and write the study. We are hoping to publish sometime in 2026. The goal is finding interventions; gaining insight on which systems can be executed to reduce the risk.

RR:

That sounds fascinating. I can’t wait to read the results of the study. Is there anything else about InnovAge that you’d like to share?

Ann:

Just that our mission is to help seniors live independently in the community and to advocate for the PACE model of care. We are excited to have three new centers – one in California and two in Florida. The goal is to spread the PACE model and grow the individual centers. InnovAge is the largest provider of PACE based on number of patients enrolled. We are dedicated to expanding and serving more seniors across the country.

RR:

Thank you, Dr. Wells for your time and your insight. It’s been a pleasure talking with you. Please stay in touch and keep The Rowan Report updated on the progress of your study.

# # #

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

Home Health in a Post-Chevron World

Admin

by | Sep 27, 2024 | Admin, Advocacy, Audits, Regulatory

by Elizabeth E. Hogue, Esq.

The "Wicked Witch" Chevron is Gone

On June 28, 2024, the U.S. Supreme Court overturned a decision of the Court in 1984 often referred to as “Chevron.” The Chevron case said that Courts must defer to administrative actions that are reasonable interpretations of ambiguous statutory language.

 In Loper Bright Enterprises v. Raimondo, however, the U.S. Supreme Court abandoned the decision in Chevron and said that:

    • The “deference that Chevron requires of courts reviewing agency action cannot be squared with” the Administrative Procedure Act (APA). The APA “specified that courts, not agencies, will decide ‘all relevant questions of law’ arising on review of agency action…even those involving ambiguous laws – and set aside any such action inconsistent with the law as they interpret it.” 
    • The framers of the U.S. Constitution envisioned that the final “interpretation of the laws” would be “the proper and peculiar province of the courts.” 
    • The views of the executive branch should inform the judgment of the judiciary, not supersede it. 
    • “Chevron’s presumption is misguided because agencies have no special competence in resolving statutory ambiguities. Courts do.”

What Does it Mean for Providers?

The short answer is that we don’t know yet. It is unclear how the new standards of the Loper Bright decision will be applied and affect health care providers. The Supreme Court said that the recent Court decision does not call past cases into question that were based on Chevron, but existing regulations are not insulated from challenges. It is likely that several providers will “swing for the fences” for favorable rulings based on Loper Bright!

One possible “candidate” for disruption is the reliance of administrative law judges (ALJs) on Chapter 8 of the Medicare Program Integrity Manual. This section offers an overview of use of inferential statistics and statistical sampling to estimate overpayments in Medicare audits. Chapter 8 of the Manual is only nine pages long. ALJs routinely use this section of the Manual to hamper providers’ ability to mount a compelling defense that challenges auditors’ methods using widely accepted standards within the statistical community. Challenges to this practice based on Loper Bright may prevent ALJs from reliance on these sections of the Manual.

Chevron Deference Gone

Another possible target is the use of sub-statutory and even sub-regulatory guidance from the Centers for Medicare and Medicaid Services (CMS) and the Medicare Administrative Contractors (MACs) by fraud and abuse enforcers to make determinations about illegal conduct, especially under the False Claims Act (FCA). Defendants arguably now have a better chance to challenge the basis of claims of illegal conduct in light of Loper Bright. 

The story of Loper Bright has not been written by any means. Surely providers should use this significant change in the law to their benefit whenever possible.

# # #

Elizabeth E. Hogue, Esq.
Elizabeth E. Hogue, Esq.

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

©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

©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.