MA Past, Present, and Possible Future: Nothing Good to Report

CMS

by | Jul 26, 2024 | CMS, Editorial, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

Past

For at least the last five years, every Home Health conference this reporter has attended has featured at least one keynote speaker or expert panelist complaining about sparse and shrinking payments from Medicare Advantage plans. As thousands of seasonal TV ads convince more and more Medicare beneficiaries to enroll in what insurance company executive-turned-whistleblower Wendell Potter called “neither Medicare nor an advantage,” the calls from Home Health executives to turn away MA members, following the lead of many hospitals, have grown louder and more frequent.

Originally designed to extend the lifespan of the Medicare Trust Fund by bringing managed care practices to the federal healthcare program for seniors and disabled, Medicare Advantage has failed to do so. As long ago as 2021, an exposé by Fred Schulte in Kaiser Family Foundation Health News found that MA costs to taxpayers began to explode in 2018 and today equal 119 percent of what traditional Medicare should cost. We looked at more recent studies and found similar reports.

From the Experts

Referencing a study by Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, Schulte said, “his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. A third of that overpayment occurred in 2018 and 2019.”

Since Kronick’s 2021 report, more beneficiaries have opted in to Medicare Advantage. So far, just over half have switched from straight Medicare, with or without a supplement, and that number may reach 100 percent if those who profit most from the option have their way.

Present

In recent months, we have investigated and reported on the insurance industry’s practice of exaggerating MA member health conditions and denying care that traditional Medicare would have covered, collecting from both ends of the CMS trough. We have also mentioned several federal and state lawsuits piling up against insurance companies for both of those practices. One of our sources, The Center for Economic and Policy Research, said this in the Executive Summary of its detailed, September 2023 study:

Profiting at the Expense of Seniors: The Financialization of Home Health Care

“The nonpartisan Medicare Payment Advisory Commission (MedPAC) estimates that upcoding by MA plans that make enrollees appear to be sicker than they are costs CMS 106 percent of what traditional Medicare costs; adding in the quality bonus payments brings it to 108 percent. MA plans also enroll healthier Medicare beneficiaries, increasing their operating surplus by another 11 percent, making the payments to MA plans 19 percent higher than the payments to traditional Medicare. 

CMS’s announced goal for traditional Medicare beneficiaries is to move all of them to Accountable Care Organizations, which use the valued-based payment model, or other similar care arrangements, by 2030. CMS’s leading model to accomplish this shift is ACO REACH — a gentler, kinder version of the Trump administration’s backdoor enrollment of traditional Medicare beneficiaries in a capitated payment model.”

The Center for Economic Policy Research

Future

Past Present Future Medicare Advantage

Depending on results in the unpredictable world of politics later this year, CMS may or may not see its shift to value-based ACO models come to fruition. Kaiser News‘ Schulte examined the Heritage Foundation’s “Project 2025,” the conservative think tank’s blueprint for any possible future Republican administration, and found an entire section on the Department of Health and Human Services.

Within its “Mandate for Leadership,” the authors identify Medicare and Medicaid as “the principal drivers of our $31 trillion national debt.” While admitting that Medicare and Medicaid “help many,” the authors assert that the programs “operate as runaway entitlements that stifle medical innovation, encourage fraud, and impede cost containment, in addition to which their fiscal future is in peril.”

Rebuttal

Commenting on the Heritage Foundation’s claim, researcher Sonali Kolhatkar, writing for “OtherWords.org,” counters that this opinion is often used to justify ending social programs, but actual CMS data indicates that per person Medicare spending has plateaued for more than a decade and represents one of the greatest reductions to the federal debt. Even with 10,000 to 11,000 Boomers reaching Medicare eligibility every day, total per beneficiary expenditures have stopped climbing, hovering around $12,000 per year since 2010. Before reaching that 2010 plateau, per beneficiary spending had steadily risen from $2,000 at the program’s 1965 inception.

Medicare Advantage for All

Project 2025 proposes making Medicare Advantage the default enrollment option rather than a choice beneficiaries can opt into. With 100 percent of seniors on MA plans, already historic insurance profits will skyrocket further. But will Medicare beneficiaries benefit as well?

The Center for Economic and Policy Research cites multiple lawsuits that have proven eight of the ten largest MA plans routinely add chronic conditions – some non-existent – to patient assessments at enrollment…or later. We reported recently that UnitedHealth Group, operator of the largest MA plan, recently began sending nurses into homes to search for additional health conditions that would raise company payments from the trust fund. The report we quoted included evidence that these home visit upcodes do not lead to any treatments. The Center added that MA’s “heavily restricted networks damage one’s choice of provider along with introducing dangerous delays and denials of necessary care.”

As we have mentioned before, Medicare Advantage is neither Medicare nor an Advantage.

Medicaid also Attacked

Project 2025 also proposes restrictions on Medicaid eligibility by imposing work requirements. The blueprint sees the program for low-income Americans as a  “cumbersome, complicated, and unaffordable burden on nearly every state.” Their plan includes bringing private insurance companies in to “manage” care.

A June, 2024 report by the Center on Budget and Policy Priorities concluded that the ACA’s expansion of Medicaid helped millions of Americans who would otherwise be uninsured, and that its enabling and encouragement of preventive care actually saved money in state budgets. Last month’s report asserted “the people who gained coverage have grown healthier and more financially secure, while long-standing racial inequities in health outcomes, coverage, and access to care have shrunk.”

Project 2025 authors make no mention of a KFF News report from April 2023 that said most Medicaid-eligible people are already working. Nor does it take into account a Government Accountability Office report to Congress October 2020 and again in 2023 that determined that hourly wages in many large companies are low enough to keep even full-time workers eligible for Medicaid and SNAP. Walmart and McDonalds, to name two, land in the top five in almost every state for having Medicaid-eligible workers.

EVEN THE WALL STREET JOURNAL IS CRITICAL

Under the front page Headline “Medicare paid $50 billion to insurers for untreated ills,” a detailed WSJ investigation highlighted a number of findings, including:

  • “The questionable diagnoses included some for potentially deadly illnesses, such as AIDS, for which patients received no subsequent care, and for conditions people couldn’t possibly have, the analysis showed. Often, neither the patients nor their doctors had any idea.”
  • “Instead of saving taxpayers money, Medicare Advantage has added tens of billions of dollars in costs, researchers and some government officials have said.”
  • “Medicare Advantage has cost the government an extra $591 billion over the past 18 years, compared with what Medicare would have cost without the help of the private plans, according to a March report of the Medicare Payment Advisory Commission, or MedPAC, a nonpartisan agency that advises Congress. Adjusted for inflation, that amounts to $4,300 per U.S. tax filer.”
  • “The Journal reviewed the Medicare data under an agreement with the federal government. The data doesn’t include patients’ names, but covers details of doctor visits, hospital stays, prescriptions and other care.”
People voting

Now it is in the Hands of Voters

Home Health, Hospice, and Home Care owners, management, and workers will be voting in November. Consideration of what four years under a Project 2025-friendly administration will mean to businesses dependent on Medicare and Medicare will weigh heavily on their minds as they enter their polling booths.

# # #

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

BREAKING NEWS: Warren, Cassidy React to Supreme Court Ruling

CMS

by | Jul 26, 2024 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

The Background

Senators Warren and Cassidy react to the landmark decision by the Supreme Court in Loper Bright Enterprises v. Raimondo. That decision effectively overturned the Chevron Doctrine, which gave deference to federal agency decisions in interpreting ambiguous statutes. Eliminating the Chevron Deference puts more responsibility on federal agencies to show reason behind their interpretations. Likewise, it requires Congress to be less ambiguous in its wording of statutes. This decision would impact CMS’s ability to create their own definitions of terms when calculating reimbursement rates, implementing rules.

Senator Elizabeth Warren Reacts

Warren Chevron Bill

Senator Elizabeth Warren (D-MA)

Less than one month after the U.S. Supreme Court decided the case that overturned Chevron Deference, Senator Elizabeth Warren (D-MA) introduced a bill in the Senate that would override the Supreme Court’s decision and establish Chevron Deference as law.

“Giant corporations are using far-right, unelected judges to hijack our government and undermine the will of Congress,” Warren said. According to Warren, the pending legislation, “The Stop Corporate Capture Act”, will stop corporate interest groups from using their own interpretations of statutes over the judgment of Congress or expert agencies.

Senator Cory Booker (D-NJ) called the Supreme Court decision “an egregious power grab from the US Supreme Court.”

Warren asserts that the overturning of Chevron Deference would put more power in the hands of industry-backed lobbyists who already have more negotiating power than the general public. This assertion is contrary to the majority opinion from Chief Justice John Roberts, who wrote, “Courts must exercise their independent judgment in deciding whether an agency has acted within its statutory authority.”

Increasing Congressional Authority

In addition to making Chevron Deference law, the Stop Corporate Capture Act would also:

Modernize and Reform the Regulatory Process

    • Streamline the White House’s review period for regulations, creating a 120-day time limit for review.
    • Authorize agencies to reinstate rules that are rescinded by Congress through the Congressional Review Act.
    • Reform agencies’ cost-benefit analysis to emphasize public benefits of a rule, including non-quantifiable benefits like promoting human dignity, securing child safety, and preventing discrimination.

Empower and Expand Public Participation in Rulemaking

    • Create an Office of the Public Advocate to help members of the public participate more effectively in regulatory proceedings.
    • Strengthen agency procedures for notifying the public about pending rulemakings.
    • Provide the public with greater authority to hold agencies accountable for unreasonable delays in completing rules. 
    • Require agencies to respond to citizen petitions for rulemaking that contain 100,000 or more signatures.

Increase Transparency and Protect Independent Expertise in Rulemaking

    • Require all rulemaking participants to disclose industry-funded research or other related conflicts of interest.
    • Require any submitted scientific or other technical research that raises a specified corporate conflict of interest be made available for independent public review. 
    • Bring transparency to the White House regulatory review process by requiring disclosure of changes to draft rules during that process and the source of those changes.
    • Require agency officials to provide justification when the regulatory review process ends with a rule being withdrawn.  
    • Establish financial penalties for corporate special interests that knowingly submit false information during the rulemaking process. 

Senator Bill Cassidy Responds

At the same time that Warren introduced her bill overriding Loper v. Raimondo, Senator Bill Cassidy (R-LA) introduced the “Upholding Standards of Accountability (USA) Act of 2024.” Cassidy’s bill takes the removal of the Chevron Deference further than simply overturning the previous ruling. According to the description, the USA Act imposes additional accountability in agency rulemaking. 

Senator Cassidy is the ranking member of the Senate Health, Education, Labor, and Pensions (HELP) Committee. He stated, “For decades, the executive branch has exploited Chevron deference to increase its power beyond what Congress intended, all while skirting congressional oversight. Now, with Chevron deference overturned, Congress must work to rein in the executive branch and hold it accountable to the people and their elected representatives.”

Cassidy Chevron Bill

Senator Bill Cassidy (R-LA)

Decreasing Agency Authority

The direct impact of the Supreme Court decision is that federal agencies do not get preferential treatment when interpreting a statute. Cassidy’s bill requires the head of any federal agency signing a major rule to testify before the committee of jurisdiction within 30 days of the rule’s publication.

Additionally, the bill would:

    • Require each person nominated to a Senate-confirmed position to testify before the committee of jurisdiction prior to Senate confirmation; 
    • Improve cost-benefit analyses by requiring federal agencies to conduct retrospective reviews of such analyses for major rulemakings within five years of each rule’s effective date; 
    • Clarify that federal agencies are permitted to communicate with Congress at all times regarding proposed rules; and  
    • Require timely, substantive responses to congressional oversight from federal agencies. 

Cassidy Challenges Existing Rules

Immediately after the Loper v Raimondo decision, Sen. Cassidy sent a letter to the U.S. Secretary of Education Miguel Cardona asserting that the Education Department has established rules outside of the authority given to it by Congress. He specifically alluded to the new Title IX rule. Cassidy asked Cardona, “How will the department change its current practice to enforce the laws as Congress writes them, and not to improperly legislate via agency action?”

Given Cassidy’s position in the Senate HELP Committee and his previous statements on medical debt, the multitude of bills he introduced on transparency, accountability, and decreasing authority, this is likely not Cassidy’s last attempt to challenge agency rules.

Likely Outcomes

Senator Warren's Bill

There are ten co-sponsors of Warren’s bill and a long list of endorsing organizations. Despite that, experts say the bill has only a slim chance of passing in an election year in the Senate, where Democrats currently have a narrow majority control. The bill is even less likely to pass in the Republican controlled House of Representatives. 

Senator Cassidy's Bill

Similar to Warren’s bill, Cassidy’s bill has a low likelihood of passing. The Democrat majority in the Senate may dismiss the bill before it ever reaches the house. In 2023, the 118th Congress passed only 34 bills, the lowest number in decades. With only a few months remaining for the Congress, and the focus turning to a new Democratic nominee, passing this, or any other, bill seems improbable.

Final Thoughts

Regardless of your political affiliation, the overturning of the Chevron Deference is good news for home health, hospice, and palliative care. This ruling puts more pressure on CMS to justify its reasoning for certain decisions it has made. Senator Warren’s bill threatens the advantage given to the home health industry related to NAHC’s senate and house bills and pending lawsuits. Senator Cassidy’s bill ensures federal agency oversight and requires CMS to rationalize their decisions and prove budget-neutrality.

We will continue following these and other Chevron Deference related stories.

# # #

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

Payer or Competitor?

Admin

by | Jul 19, 2024 | Admin, Editorial, Medicare Advantage

by Tim Rowan, Editor Emeritus

UnitedHealth Making Home Health Visits

Payer or Competitor…that is the question. According to a report in the Wall Street Journal, and questioned by the insurance industry’s lobbying arm, AHIP, UnitedHealth Group has increased its revenue from the Medicare Trust Fund by $50 billion by “finding” additional health issues during home visits to its MA customers.

In a July 16 investor call, CEO Andrew Witty said UnitedHealth clinicians made more than 2.5 million home health visits to UnitedHealthcare MA members in 2023. Following these visits to more than 500,000 seniors, UnitedHealth upgraded over 300,000 of them to higher payment levels by uncovering health conditions the individual seniors did not know they had.

The WSJ investigation found that between 2018 and 2021, insurers received $50 billion for diagnoses they added to members’ charts. Many of these diagnoses were “questionable,” according to that investigation.

Questionable Visits

Uncover versus Discover United Health

Though a UnitedHealth spokesperson called the analysis “inaccurate and biased,” former UnitedHealth employees told the Journal home visits are often used to add diagnoses. Clinicians say they use software during visits that offer suggestions as to what illnesses a patient might have.

CEO Witty maintained in the investor call that the practice is good for seniors. “UnitedHealth clinicians discovered more than 3 million gaps in care through home visits in 2023,” he reported, “and 75% of patients receive follow-up care in a clinic within 90 days of a home visit.” 

He added that the United home visit program “helps patients live healthier lives and saves taxpayers money,” concluding. “…Medicare Advantage makes programs and results like this possible.” 

The Journal concluded with the finding that few of these upgraded seniors are ever seen by a physician for their newly discovered health conditions. 

# # #

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. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Chevron Deference Derailed

Advocacy

by | Jul 12, 2024 | Advocacy, CMS, Regulatory

by Kristin Rowan, Editor

Chevron Deference

“A government agency must conform to any clear legislative statements when interpreting and applying a law, but courts will give the agency deference in ambiguous situations as long as its interpretation is reasonable.”

This statement followed the unanimous (minus the three who did not take part in the decision) U.S. Supreme Court decision in the Chevron U.S.A., Inc. v. National Resources Defense Council. The case is known for establishing the extent to which a federal court should defer to a government agency’s interpretation of an ambiguous statement when constructing statutes.

Breaking Down Chevron Deference

For those of you who don’t have a law degree, here’s what that means:

  • When a statutory term (required by law) is not explicitly defined and explained by Congress, there is room for interpretation
  • When a government agency interprets that statutory term, the interpretation may come under question
  • As long as the interpretation is not arbitrary (random), capricious (impulsive or unpredictable), or contrary to the statute (opposite the intent when put into practice), federal courts should give more weight to the government agency’s interpretation than to any other interpretation

Implications

At the time, the Supreme Court argued that if Congress leaves a term open to interpretation, it is either stated openness to interpretation, or an implied openness to interpretation. If a statute is implicity open, the intent of Congress is to allow a government agency to create provisions and regulations from that statute as they see fit. 

No one foresaw the impact this ruling would have on commerce and regulation in the U.S. To date, the Chevron Doctrine has been cited nearly 18,000 times in federal court decisions. The application of a statute based on agency interpretation could no longer be questioned or changed by judicial review.

Chevron Deference in Home Health

Since the advent of the PDGM model, CMS has calculated payment rates based on its interpretation of budget neutrality. The National Association for Home Care and Hospice has disputed the validity of both the interpretation of budget neutrality and the formulas used to calculate it.

Last year’s 2024 CMS Proposed Rule cut payment rates even further with a 2.890% Budget Neutrality permanent payment rate adjustment and a temporary rate adjustment to account for alleged overpayments from 2020-2022.

The lawsuit filed against CMS in response to the 2024 Final Rule was dismissed. NAHC began pursuing an administrative review with CMS. However, CMS has already stated that their final position is that budget neutrality has been calculated within the law. 

NAHC Comment: 2023 CMS Rule

“That proposal also fails logically in that it puts care access in severe jeopardy in applying a budget neutrality reconciliation methodology that takes PDGM-induced behavior changes to assess what otherwise would have been expended by Medicare in the absence of PDGM. In doing so, CMS fully fails to meet its obligation to ensure that the transition to a new payment model is budget neutral.”

  1. NAHC Comment Source

Chevron Deference Repealed

In a landmark ruling on Friday, June 28. 2024, the Supreme Court removed the power of federal agencies to interpret laws and ruled that the courts should rely on their own intrepretation of ambiguous laws. Justice Elena Kagan, who dissented the ruling, predicts this change “will cause a massive shock to the legal system.”

Chief Justice John Roberts explained in his opinion that the Chevron Deference is inconsistent with the Administrative Procedure Act (APA). The APA is a federal law which contains instructions for courts to review actions by federal agencies. According to Roberts, the APA directs courts to decide legal questions using their own judgment. Therefore, he noted, agency interpretations of statutes are not entitled to deference. “…it remains the responsibility of the court to decide whether the law means what the agency says,” concluded Roberts.

NAHC to Refile Lawsuit after Chevron Deference Repeal

2024 Final Rule

In April, 2024, the lawsuit filed against CMS regarding the methodology for calculating budget neutrality was dismissed. Now, NAHC can refile the lawsuit and force CMS to justify its decision to enact repeated reimbursement cuts for home health.

In an interview on Wednesday, Bill Dombi told The Rowan Report, “This improves the chances of success for our lawsuit. CMS is going to have to support their regulatory interpretations going forward. Congress is going to have to offer more detail in its legislative language, leaving less to being open to interpretation.” Regarding the PDGM lawsuit, CMS argued that the law was clear and the agency’s interpretation was valid. The overturning of Chevron Deference allows the possibility of arguing that CMS’s interpretation of the law is flawed. 

80/20 Rule

Dombi also explained that the Ensuring Access to Medicaid Services rule, also known as the 80/20 rule, was “drawn out of a whole cloth.” Previously, there were limited avenues available to challenge this rule. The repeal of Chevron Deference significantly improves the ability to challenge the 80/20 rule. The argument now, Dombi told The Rowan Report, is “Does CMS even have the authority to do this?”

More to Come

The Rowan Report anticipates more news coming out of Washington D.C. and the NAHC office regarding the 2024 pay cuts and the 80/20 rule. We will provide ongoing updates and information as it becomes 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

Poor Joe is Out of A Job

CMS

by | Jun 27, 2024 | CMS, Medicare Advantage

by Tim Rowan, Editor Emeritus

We have been keeping an eye on the Medicare Advantage business as the number of beneficiaries who switch exceeds fifty percent. In past reports, we have described the federal lawsuits that accuse MA insurance companies of illicitly padding revenues while illegally denying treatments that straight Medicare would have covered. (See MedPAC Exposes More Medicare Advantage Crimes – 3/20/24)

Until now, we haven’t gone into detail about those independent brokers with the continuous TV commercials every November. It turns out, they may be even more dishonest than the insurance companies themselves.

Poor Joe

Perhaps the most famous of these brokers is the one that put Broadway Joe Namath in our living rooms a hundred times a day. The company started life as Health Insurance Innovations, owned by Chicago-based private equity firm Madison Dearborn Partners. After accusations of fraud, the company folded and re-emerged as Benefytt. When the same accusations returned, the owners shut that company down and came back as Blue Lantern Health.

According to Healthcare Uncovered, the firm filed for a state-level bankruptcy equivalent in Delaware last April, called “assignment for the benefit of creditors.” Blue Lantern’s website is down, as are MedicareCoverageHelpline.com and HealthInsurance.com, their signature assets. Nobody answers the 800 number Namath hocked for years.

A History of Fraud

The bankruptcy litigation revealed a database of 7 million seniors who had been bombarded by 17 million phone calls. The bankruptcy was apparently precipitated by the Federal Trade Commission, which forced Benefytt to pay $100 million to the people it had scammed by selling sham Obamacare plans, with checks distributed to victims in March. The Securities and Exchange Commission forced Health Insurance Innovations and the company’s co-founder Gavin Southwell to pay a $12 million settlement. Another close associate of the company, Steven Dorfman, was convicted of wire fraud in February.

Deceptive Practices

Tolerance for the firm’s deceptive advertising scheme ended with changes to the Medicare Advantage rule in 2023 that took effect in 2024. Blue Lantern stated after the fines were imposed that the new rule was critical to the company’s downfall,

Previously, former HHS Security Alex Azar characterized the Namath ads as “real savings, real options” in Medicare Advantage, ignoring the studies showing that the MA program costs the Trust Fund not less but $140 billion more than original Medicare.

Healthcare Uncovered concluded with this observation, “Further rules imposed since then by the Biden administration are putting even more pressure on Medicare Advantage lead generators, also called ‘third-party marketing organizations.’ (TPMOs) Beginning October 1 of this year, CMS will require that TPMOs get express consent from individuals before selling contact information to other marketers and brokers — a key loophole that enabled the growth of Blue Lantern and its predecessors.”

 

Don’t worry about Joe Namath’s retirement income though.
He has already landed a gig hawking hearing aids.

Joe Namath TV ad

# # #

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. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

The Future of Care at Home

Admin

by | Jun 27, 2024 | Admin, Clinical, CMS, Regulatory, Telehealth

by Kristin Rowan, Editor

Home Nurses are joining unions. The advent and unionization of Hospital-at-Home (H@H) is changing the care at home landscape. Large hospital systems across the country have engaged in H@H studies and launched H@H programs, providing hospital-level ambulatory services in their communities. As H@H continues to take a foothold in the healthcare landscape, what do those changes mean for care at home?

Hospital at Home Popularity

Most of the existing H@H programs are operating under a CMS waiver. A few of the H@H programs use a private pay model. The CMS waiver needs to be extended in order to continue the programs. As many H@H organizations are pushing for CMS to extend the waiver, they are looking to patients for advocacy.

A recent survey by Vivalink showed that 84% of U.S. individuals over the age of 40 are interested in H@H monitoring after a hospital visit so they can return home sooner. 77% of respondents said they would trust a recommendation that included at-home monitoring. Respondents who had been hospitalized three or more times in the past 12 months were more interested in H@H programs than those who had been hospitalized less.

Massachusetts Ambulatory Nurses Unionize

On May 20, 2024, 33 ambulatory nurses from Martha’s Vineyard Hospital (MVH) filed with the National Labor Board to join a union that is already active within the hospital, the Massachusetts Nurses Association (MNA). The MNA currently represents 23,000 hospital workers from 85 healthcare facilities across the Commonwealth of Massachusetts. The hospital denied the request to join the union. The group of ambulatory nurses joined MVH through an acquisition of a physician’s group. Therefore, those nurses were not recognized under the existing collective bargaining agreement.

Hospital-at-Home Nurses at Mass General Unionize

The Hospital-at-Home nurses at Mass General Brigham (MGB) have unionized in the hopes of influencing the future of in-home acute care. They are also hoping this will encourage more people working in home healthcare to join unions. In the last seven months of 2023, almost half of all registered nurses working in home health care and non medical care at home left their jobs within a year. One registered nurse from MGB said she hopes HaH nurse unions become more common as HaH expands across the country.

The clinicians in the MGB home care segment are hoping to follow the H@H group into unionization soon. The home care segment, which includes home health, palliative, and other care at home services, are currently voting on whether to unionize.

Hospital-at-home nurses unionize at Mass Gen

Among the listed reasons for considering unionization are changes in expectations on productivity, and wages. Some of the more recent changes at MGB were rolled out across the company and did not take into consideration the territories and limitations that care at home clinicians have. More than 400 clinicians are in the care at home side of MGB and they have all received ballots to vote on unionization.

Home Health Unionization

hospital-at-home changing home health unions

The nature of care at home clinicians is disparate. Therefore, it is difficult to organize them into one cohesive group. Recently, though, more home health workers are looking to service workers and healthcare workers unions for better pay, better working conditions, and more buy-in on the day-to-day operations of the agency.

Opponents of unionization among home health clinicians argue that pay rates are largely set by CMS reimbursement rates. Employers may want to raise rates but are unable to do say because they accept Medicare and Medicaid. Home health unions could force employers to pay more than the set CMS rates.

CMS Response to Union Backlash

Otherwise known as the 80/20 rule, CMS responds to agencies worried about unionization with a mandate to pay their workers 80% of total Medicaid payments. Some agency owners say the proposed rule ignores the low reimbursement rates and further burdens agencies that are barely making a profit now. It is unlikely that CMS will see the unionization of home health clinicians as a reason to increase reimbursement rates. Experts advise agencies to start working on contract negotiations within the VBPM, to engage in risk-sharing and cost-benefit analyses with all parties within the VBPM. For example, Remote Patient Monitoring (RPM) is Medicare reimbursable, but not through home health use. However, a home health agency can share the benefits of RPM when it is billed through an approved provider for Medicare reimbursement. These strategies can lower overall care costs, increasing the share of reimbursement flowing to HHAs.

Maximize VBPM with Technology

Technologies available today include RPM, generative AI for data analytics, automated scheduling, and apps for secure communication, among others. Technology can lower overhead costs, allow you to eliminate some FTEs, and provide added value to providers during contract negotiations. If you don’t already have a robust tech-stack, look at some of our most recent product reviews, or contact The Rowan Report for more information about technology adoption consultations.

# # #

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

BREAKING NEWS – CMS Proposed Rule for 2025

CMS

by | Jun 27, 2024 | CMS, Regulatory

by Kristin Rowan, Editor

CMS Proposed Rule for 2025

Citing “budget neutrality adjustments”, the Centers for Medicare & Medicaid Services (CMS) June 26 issued its proposed rule for 2025 for the home health prospective payment system. Here are the highlights:

  • Overall net reduction in home health payments by $280 million dollars
  • Market basket update of 3.0%
  • Productivity adjustment of -0.5%
  • Base payment rate reduction of 4.067% due to PDGM
  • Update fixed dollar loss for outlier payments
  • Update LUPA thresholds, functional impairment levels, and comorbidity adjustment subgroups
CMS Proposed Rule CY 2025

We did the math. This is an overall reduction in payment by 3.6%. This come after multiple years of similar adjustments that reduced the overall payment rates.

Included in the proposal is an additional adjustment to the fixed-dollar loss amount for high-cost outliers. This will reduce payments another 0.6%.

As we focus primarily on the payment reductions, CMS is looking at additional data. CMS provides a detailed account of the requirements for behavior assumptions and actual changes, as outlined in earlier rules. Using CY 2023 claims, and the methodology from the CY 2023 final rule, CMS believes they paid more under the PDGM system than they would have under the old system, leading to the deduction in base payment rate.

HHA Conditions of Participation

In addition to the payment cuts, CMS is also proposing an update to the Conditions of Participation. This new standard would require HHAs to develop, apply, and maintain a policy for accepting new patients into service.

According to the proposal, CMS is not moving to add or modify any quality measures from the Quality Reporting Program. They do, however, propose to modify some patient assessment items related to health-related social needs. This would require HHAs to collect and report data related to living situation, food, and utilities. This proposed modification would be implemented beginning with the calendar year 2027 QRP.

COVID-19 Reporting

Also included in the CY 2025 proposal is a revision to the infection prevention and control requirements for long-term care facilities. The revision calls for an extension on reporting some of the Covid-19 data elements to the Centers for Disease Control and Prevention. It also requires influenza and RSV reporting beginning January 1, 2025.

Additional Items

CMS also used data from OASIS-D and OASIS-E, making adjustments for missing and altered data from the two different information sets. The proposed rule includes a new methodology to address the issue of varying data sets from OASIS-D to OASIS-E.

LUPA add-ons are meant to establish equitable compensation for all home health services. CMS is proposing an occupational therapy (OT) specific LUPA add-on factor, rather than continuing to use the PT add-on factor for OT.

Payment groups under the PDGM model use an associated case-mix weight and LUPA threshold, specific to each of the 432 payment groups. CMS is proposing a recalibration of the case-mix weights, including funtional levels and comorbidity adjustment subgroups.

Request for Information: CMS is seeking feedback on Future Performance Measure Concepts for the expanded HHVBP Model. New proposed measure include care activities like bathing and dressing, which are not currently included in the function measures. Additional potential measures include family caregiver status and claims-based falls with major injuries.

Feedback

The American Hospital Association has expressed “serious concerns” about the payment rate adjustments in the proposed rule. “We urge the agency to adequately resource HH providers as they are a critical part of the care continuum,” AHA wrote. “We are particularly concerned about the substantial size of the agency’s proposed budget neutrality adjustment, a cut of 5.653%, and again call on CMS to withdraw it.” The AHA has asked CMS to revise its accounting methodology to more accurately account for changes in the payment system and care delivery due to PDGM.

President of the National Association for Home Care and Hospice (NAHC), Bill Dombi, today released a statement:

“The 2025 proposed version of Medicare home health payment rates shows the ongoing and predictable rate reductions impacting home health agencies since the beginning of the new payment model in 2020. That decline is solely due to a fatally flawed budget neutrality methodology that CMS employed to arrive at the rate adjustments,” stated NAHC President William A. Dombi.

“While this means that Medicare spending on home health services will continue to decline as costs continue rise, the more important element is that care access and utilization continues to decline at significant levels. When Congress set Medicare payment reform in motion starting in 2020, it was not planned or even expected that the outcome would be that nearly 500,000 Medicare beneficiaries would be able to access care or that those who could find care would get fewer services,” he added.

“Congress must step in immediately to put an end to this dismantling of the Medicare home health benefit. The value of home health services is not only undeniable; it has been proven by CMS in its analysis and expansion of the highly successful Home Health Value Purchasing demonstration project. We call on Congress to correct what CMS has done and prevent the growing harm to the millions of highly vulnerable home health patients that depend and will depend in the future on this essential Medicare benefit. Fortunately, longstanding advocates for home health care, Senator Debbie Stabenow (D-MI) and Senator Susan Collins (R-ME) have introduced S. 2137 to eliminate the rate cuts. We urge the Congress to support this legislation and enact it into law before the end of the year. The 2025 rate cuts must not take effect” Dombi added.

Comments

CMS has issued a fact sheet with more details on their assumptions and calculations. You can access the fact sheet here. The proposed rule can be downloaded here.

CMS will accept comments on the proposed rule through August 26th.

# # #

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

NAHC and NHPCO Sign Affiliation Agreement

Admin

by | Jun 21, 2024 | Admin, Advocacy, CMS, Regulatory

by Kristin Rowan, Editor

BREAKING NEWS

In a joint statement on June 18, 2024, NAHC and NHPCO announced that the Board Chairs and CEOs of each organization met in Washington. During this meeting, they formally signed the affiliation agreement. This is a union of the two largest advocate organizations for care at home providers. They hope to unify the voice of the care at home community. The combined resources of the organizations will provide education, expert advice, and increased advocacy for policies that help deliver the best care to those who need it most.

After 18 months of discussions, meetings, and challenges, the two organizations have agreed on terms for the combining of the two groups.

 

“The affiliation of NAHC and NHPCO is a historic event,” said NAHC President and CEO William A. Dombi. “Unifying the voice of health care at home has been a longstanding goal of NAHC, as it is the essence of the original formation of NAHC in 1982. Combining our two organizations will significantly strengthen that voice for the benefit of our members and the patients they serve.”

Read the full press release from NAHC and NHPCO 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

Preventing Violence: More Action Items

Admin

by | Jun 20, 2024 | Admin, Caring for the Caregiver, Clinical, CMS

By Elizabeth E. Hogue, Esq.

Violence in Healthcare

According to a recent analysis of Bureau of Labor Statistics data, healthcare is one of the most dangerous places to work. Homecare field staff members who provide services on behalf of private duty agencies, hospices, Medicare-certified home health agencies, and home medical equipment (HME) companies may be especially vulnerable. Contributing to their vulnerability is the fact that they work alone on territory that may be unfamiliar and over which they have little control. Staff members certainly need as much protection as possible.

 

Preventing Violence Bureau of Statistics Graph

Must-Haves

First, regardless of practice setting, management should develop a written policy of zero tolerance for all incidents of violence, regardless of source. The policy should include animals. The policy must require employees and contractors to report and document all incidents of threatened or actual violence, no matter how minor. Emphasis should be placed on both reporting and documenting. Employees must provide as much detail as possible. The policy should also include zero tolerance for visible weapons. Caregivers must be required to report the presence of visible weapons.

Below are some additional important actions for healthcare organizations to take that are based on UCHealth’s SAFE Program:

  • Encourage staff members to STOP if they feel unsafe for any reason.
  • Workers should pause to generally ASSESS their environments. Staff members should think about what has happened and observe what is currently occurring. Is there, for example, mounting frustration or anger?
  • Staff should then FAMILIARIZE themselves with the room. Who is the patient? Where is the patient? Are there any factors that might escalate behaviors? Staff members should also consider putting themselves in positions where they have a route to escape, if necessary.
  • Practitioners should also ENLIST help. Getting help may, for example, include pushing panic buttons on mobile devices.

Here is what Chris Powell, Chief of Security at UCHealth said in Becker’s Hospital Review on June 4, 2024:

“You can’t just talk about the shrimp and give you a good picture. We have to talk about the roux and the rice and everything else that goes into this for a good picture to be painted so people have an understanding. We want to solve this with an electronic learning or a 15-minute huddle, but we can’t. This is continuous and a persistent pursuit toward educating, communicating, recognizing, responding to, reporting and recovering from workplace violence.”

Every caregiver matters. The healthcare industry has lost caregivers to violence on the job in the past. Let’s not repeat these terrible events.

©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.

The Future of NAHC: An Interview with Bill Dombi

Admin

by | May 30, 2024 | Admin, Advocacy, CMS, Regulatory

by Kristin Rowan, Editor

NAHC President Bill Dombi announced at last week’s CAHSAH annual meeting and expo that he would end his tenure at NAHC and retire at the end of 2024. We reached had an interview with Dombi on Thursday, May 23rd. He said he was not prepared to speak yet about his upcoming retirement, but we should hear more about that soon.

In the meantime, he provided additional details from his session at CAHSAH. We also discussed updates on the lawsuit against CMS and the status of the merger between NAHC and NHPCO. Tim’s article from last week talks about Dombi’s progress with Senator Wyland.

Ongoing Litigation

When we last spoke with Bill, he told us about the lawsuits filed against CMS. The suit claims that the budget-neutral calculations were based on faulty data and outdated software. These calculations determined the reimbursement rate reductions. Dombi explained the process for those lawsuits.

“The first round of the battle is around whether the court has the power to hear the case either at all or at that point in time. The courts are littered with litigation that have been dismissed on jurisdictional grounds,” Dombi offered. The court dismissed the lawsuit and the case is now closed. The Department of Justice (DoJ) attacked jurisdiction to get the case dismissed. Most concerning, according to Dombi, was the DoJ’s question of whether the statute passed by Congress precluded any litigation. If the courts had found in their favor, they would have dismissed the lawsuit no further suits could be filed. Luckily, that argument didn’t hold. The second attack was whether NAHC had expedited administrative review, which is the argument that caused the dismissal. Now, they have to establish that it would be futile to get CMS to agree to expedited judicial review.

Next Steps

In light of the dismissal, NAHC had to decide whether to appeal the ruling, exhaust the expedited review step with CMS, or both. Ultimately, they decided not to appeal and is pursing the review with CMS. This process could take up to 6 months, according to Dombi. Although they are pursuing the review, CMS has already stated that their final position is that the budget neutrality has been calculated within the law. Dombi feels the review is futile because CMS is not going to change their position. Now, they just have to prove the futility.

Two-Step Approach

Advocacy from NAHC, NHPCO, and other individuals and organizations was always intended to be a two-pronged effort: Litigation and Congress. The two do not interfere with each other. Even though the court dismissed the litigation suit in favor of judicial review, the approach in Congress continues. Of Senator Wyland, Dombi said, “A year ago at this time, his view was that home health agencies needed no relief. Now, he’s indicated a willingness to find a way to help home health agencies and recognizes that the cuts have been harmful to home health agencies and others that provide care.” According to Dombi, it was the personal stories and individual provider information that was crucial in swaying Wyland. The organizations continue to meet with other members of Congress to persuade them in the same way.

Dombi Provides Merger Update

Last year, NAHC and NHPCO announced they would join forces and merge into a new, as yet to be named, organization. That merger is still moving forward, but there are a lot of odds and ends to tie up. Dombi told us, “Nothing is final, final, but I don’t see anything but tailwinds moving forward.” The two organizations are still hoping for a July 1, 2024 launch of the organization. There is an active, open search for a new CEO to actively run both organizations as one. According to Dombi, no one has been slated for that position yet, so they may end up launching before there is a CEO in place.

The two organizations have already started integrating. They have lobbied together and they have worked on policy together. Additionally, they are integrating the association management system and building a website. “We feel confident enough that it’s going to reach the finish line that we’re investing time and money in these elements,” Dombi said. The two organizations can continue to operate together without a CEO, but there are a lot of decisions that need to be made that won’t be made until after there is a CEO.

After the Merger

Once the merger is complete and the two organizations operate under a new name with a new CEO, Dombi and his counterpart Bill Marcantonio of NHPCO will stay on for some time. Dombi will take the title President Emeritus and Council to the organization and Marcantonio will become the Chief Integration Officer. The new name of the organization has not been announced. Dombi says a lot of things are tied together, from an action standpoint, and it’s better to announce all of those details together along with the new name.

Reflections From Bill Dombi

When asked what was next for him after the merger is completed and he moves to retirement, Dombi reflected on his career:

 

“I’m proud of what I’ve accomplished in my life, but I’m more proud of what the people I work with I have accomplished. It’s not the first time we’ve tried to merge the two organizations, but this time, we had all the right ingredients and I’m proud of that. I live with the confidence that my constituency is up to the challenge. Every time they get kicked back, they’re right back at it.

To see where we are today compared to the 70s, we are so many light years ahead of where we were then. I mean, we’re talking about a hospital level of care at home. That was part of the dream. The fore-runners of healthcare at home truly believed those things were possible. The problems that caused the workforce shortage are multi-faceted, so the solutions are multi-pronged.”

Bill Dombi Spring Tour
We will continue following the story of both the lawsuits and the merger and update you as soon as there is more information.
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

Bill Dombi Spring Tour has two Major Announcements

Admin

by | May 22, 2024 | Admin, CMS, Regulatory

by Tim Rowan, Editor Emeritus

Bill Dombi Spring Tour

For the last time, NAHC President Bill Dombi is spending another Spring on airplanes. It is state association meeting season, and the Bill Dombi Spring Tour has been bringing his regular Capitol Hill update from coast to coast, this time adding the announcement that he will retire at the end of the year.

After 40 years with NAHC, the lengthy standing ovation Californians gave him at the end of his Tuesday speech was well-deserved.

Advocacy and Change

Bill’s core message has not changed, though the details of his ongoing battle to force CMS to take HHAs and Hospices more seriously has its 2024-2025 nuances. “Letting Congress know that you are an important healthcare sector, and clearly the most popular sector, is not NAHC’s job alone. Every one of you has power. Use it. Make your voices heard.”

Meetings with the Senate Finance Committee

To illustrate the point, he related a story about his recent visit to Portland to meet with the Chair of the Senate Finance Committee, Ron Wyland (D-OR).

“Senator Wyden has been one of the major roadblocks to Medicare agencies getting fair payment rates. I went to see him with a group of agency owners and workers to describe the hardships the current and planned pay rate cuts will impose, and to explain the exact problems with the dumb formula CMS is using to calculate those pay rates.

“The Senator said, ‘But MedPAC says you make too much money and rates should be cut. Were they wrong? Or has something changed?’

Reaching Agreement…Almost

“Both, the group and I harmonized. One by one, each agency representative told him about the growing demand of an aging population, the difficulty hiring staff with the salaries our low pay rates allow them to pay, and a full litany of all the problems with Medicare Advantage.

“By the end of our meeting, we hadn’t turned him 180 degrees, but I could see he was beginning to turn.”Later, Dombi added, he met with Senator Debbie Stabenow (D-MI), who is not only a member of the same Finance Committee but the fourth in line in the Senate pecking order. She offered to have a conversation with her colleague, and that turned Senator Wyden the rest of the way toward changing his position 180 degrees.

You Can Make a Difference

“If you think you as an individual owner have no power in Sacramento, Congress, or the White House,” Dombi concluded, “think again.”

See sidebar for the complete list of Finance Committee members. Everyone has power, but if you are a voter in one of their states, you have an even more powerful voice.

The Bill Dombi Spring Tour will continue throughout the year until his retirement. Join Dombi at the 2024 Financial Management Conference & Expo in Las Vegas, July 21-23 and at the 2024 Home Care and Hospice Conference and Expo in Tampa, October 20-22.

Bill Dombi Senator Wyden

Senator Ron Wyland (D-OR)

SENATE FINANCE COMMITTEE MEMBERS

Chair: Ron Wyland (D-OR)
Ranking Member: Mike Crapo (R-ID)
Debbie Stabenow (D-MI)
Chuck Grassley (R-IA)
Maria Cantwell (D-WA)
John Cornyn (R-TX)
Robert Menendez (D-NJ)
John Thune (R-SD)
Thomas Carper (D-DE)D-
Tim Scott (R-SC)
Benjamin Cardin (D-MD)
Bill Cassidy (R-LA)
Sherrod Brown (D-OH)
James Lankford (R-OK)
Michael Bennet (D-CO)
Steve Daines (R-MT)
Bob Casey (D-PA)
Todd Young (R-IN)
Mark Warner (D-VA)
John Barrasso (R-WY)
Sheldon Whitehouse (D-RI)
Ron Johnson (R-WI)
Maggie Hassan (D-NH)
Thom Tillis (R-NC)
Catherine Cortez Masto (D-NV)
Marsha Blackburn (R-TN)
Elizabeth Warren (D-MA)

# # #

Tim Rowan, Editor Emeritus

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

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

The Wrong Way to Use AI in Healthcare

Admin

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

by Tim Rowan, Editor Emeritus

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

The Wrong Way to Use AI in Healthcare Example 1

The Minnesota case, November, 2023, UnitedHealth Group:

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

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

The Wrong Way to Use AI in Healthcare Example 2

The Class-Action case, December 2023, Humana:

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

What Makes This Possible

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

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

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

Fix May Be in the Works

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

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

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

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

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

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

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

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

 

Tim Rowan, Editor EmeritusTim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

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

Understanding Differences in Medicare Policy and Conditions of Participation

Admin

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

by Johnathan Eaves, Senior Director of Communications, Axxess

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

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

Explaining the DifferenceMedicare Policies

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

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

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

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

Assessment and Documentation

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

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

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

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

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

Communicating With Physicians

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

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

“Keep your plan of care simple.”

# # #

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

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

80/20 Finalized Rule

CMS

by | Apr 26, 2024 | CMS, Recruitment & Retention, Regulatory

by Kristin Rowan, Editor

The Centers for Medicare and Medicaid Services (CMS) has finalized the “Ensuring Access to Medicaid Services” rule, more commonly known as the 80/20 rule. The 80/20 finalized rule requires at least 80% of Medicaid payments for home care services goes to caregiver wages. No more than 20% can be spent on administrative or other overhead costs. The White House, citing a study by The Commonwealth Fund, says that higher wages for caregivers will reduce turnover. Facing massive workforce shortages, home health, hospice, and supportive care at home agencies have been struggling to recruit and retain an adequate number of caregivers. The higher wage will also increase the quality of care, according to the study.

Prior to the 80/20 rule, there was no law or rule requiring home care agencies to report how they were spending money from federal medical payments. The rule includes requirements for states to create advisory groups to consult on rates and compensation. This changes the current Medical Care Advisory Committee regulations by increasing the percent of beneficiaries on the committee from 10% to 25% over the next two year. The Home Care Association of America (HCAOA) and the National Association for Home Care & Hospice (NAHC) argued that the rule adds administrative requirements to home care agencies while simultaneously reducing the resources available to fund them. NAHC President Bill Dombi said, “We all agree that more needs to be done to support the direct care workforce; however, this policy will make things worse, not better.” NAHC suggests the policy will force some agencies to close and others will leave the Medicaid program altogether, causing patients to have even more problems accessing care.

Exceptions to the Rule

From the text of the final rule, CMS acknowledges additional comments that the minimum direct payment to caregivers in this rule will create hardships for some agencies. Across the country, there are substantial differences among waiver programs for HCBS that are not accounted for in the rule. There is some flexibility built into the rule to account for these factors, according to CMS. Some of the flexibilities include:

  • Excluding some costs from the calculation
  • Including clinical supervisors in the calculation
  • Allowing states to set a different minimum for small providers
  • Allowing states to develop their own criteria to qualify as a small provider
  • Allowing states to develop criteria to exempt some providers from the rule
80 20 rule finalized
  • Exemption from the minimum payment rule for all Indian Health Service and Tribal health programs

The final rule also changes the timeline for complying with the rule from four years after the date of publication to six.

Objections to the Rule

Other comments included the need to address various reasons for the workforce shortage. In addition to low wages, commenters cited the social valuation of direct care work, lack of governmental support for some workforce pipelines, and immigration policies as deterrents to recruitment. One suggested that CMS start looking at creative strategies for developing an atypical workforce.

There were several submitted comments stating the either HHS or CMS or both does not have the authority under the Affordable Care Act to make specific requirements for minimum payments, but only to ensure that each State is assessing payment regulations and ensuring payments are economical, efficient, and ensure quality of care. A specific section of the Affordable Care Act, section 2402(a)(1) requires the Secretary of the Department of Health and Human Services (HHS) to ensure states implement service systems to allocate resources. The provision does not give HHS the authority to dictate the terms of those service systems, only to ensure the states develop those systems. Not surprisingly, CMS disagreed with those comments.

Many people questioned the 80% as being unrealistic, too high, and not based on quality data. CMS cited data from several states, who have pass-through requirements of 80-95% for all rate increases. This is not a minimum payment from all Medicaid payments, only a requirement for a minimum pass-through to direct care workers of increases in rates. Two states, Minnesota and Illinois, currently have minimum payment requirements set at 72% and 77%, respectively. CMS used these two states as justification for the 80% rule, acknowledging that it is higher than both states while also acknowledging that they did not perform a state-by-state study of the impact the 80% rule will have. CMS states the rate was set higher than those states to “encourage further steps towards improving compensation for workers.” CMS believes that requiring HCB agencies to pay their direct care workers a higher percentage of Medicaid rates than any state currently does will somehow make those agencies want to voluntarily pay even more.

The 80/20 Rule and Technology

Technological advances in telehealth, remote patient monitoring, revenue cycle management, scheduling, employee benefits, assistive technology, EVVs, EMRs, CRMs, and other software solutions can and will lower overhead costs and increase efficiency in your agency. Paperwork automation can reduce the time spent on documentation by a significant percentage. Revenue Cycle Management software can reduce claim denials and decrease reimbursement payment cycles so you can get your money faster. They can also reduce the number of unpaid claims. Employee benefit and training software can reduce responsibilities for HR teams, lessen the requirements for clinical supervisors, and cut training time in half, getting your newly recruited caregivers out in the field faster. Scheduling and onboarding software can increase your intake capabilities. The advances in generative AI allow you to create robust reports almost instantly so you can see your agency’s strengths and weaknesses and create plans for improvement.

Some of these costs will be excluded from the calculations for the 80% rule. Now is the time to invest in technology for your agency. Not only will your agency be more efficient and more effective, but you will be able to care for more patients with the same staff you have now, and the software solutions are as close to cost-neutral as they will ever be. We have a list of technology solutions that we’ve recently discovered and will be writing about in the next few weeks. If you are in immediate need of a software solution, contact us directly for a consultation.

# # #

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

HOPE is on the Way: Part 3

CMS

by | Apr 26, 2024 | CMS, Medicare Advantage, Regulatory

By Beth Noyce, RN, BSJMC, BCHH-C, COQS
CHAP-certified home health & hospice consultant

This is part 3 of the 3 in the series, outlining the discussions and implications in adopting new outcome and process measures for Hospice care. The final segment addresses future process and outcome measures that the board discussed, but did not yet implement. Read Part 1 on Outcome Measures and Part 2 on Process Measures.

The TEP discussed potential future process and outcome measure concepts that Abt Associates presented to the panel as well.

The process measures included:

  • Education for Medication Management
  • Wound Management Addressed in Plan of Care
  • Transfer of Health Information to Subsequent Provider
  • Transfer of Health Information to Patient/Family Caregiver

Hope-based outcome measures were:

  • Patient Preferences Followed throughout Hospice Stay
  • Hospitalization of Persons with Do-Not-Hospitalize Order

Developing education for medication management as a process measure was a popular concept, and the top priority of the recommended measures with the TEP as they “broadly agreed that CMS should develop this measure,” the report says, citing “a significant need for training in medication management for patients and their caregivers.” They recommended that the measure weigh more heavily when care is provided in a home setting than in a facility setting because hospices are unable to control facility training and hiring practices. One panelist commented that including the phrase “during today’s visit” in the measure is important.

Whether CMS should further develop the process measure addressing wound management in the plan of care was less straight-forward, as panelists provided varied feedback. They generally agreed that this measure is important, as having a record of wound management addressed in the plan of care can hold the staff accountable for treating the wounds. But some members recommended measuring wound management with outcome measures rather than process measures. One panelist cited potential problems from patients’ deterioration over time and another noted that the time frame of this measure is important, and encouraged recording the process of getting care in place once a wound is identified.  The panel agreed CMS should carefully define the measure’s specifications.

Because standard practice for most agencies is, when a patient is discharged live, to transfer health information to the subsequent provider and to the patient and family or caregiver, TEP members expressed that the two measures were likely to “top out,” meaning they would almost always be marked “Yes,” making them of no value in differentiating between hospice providers. The group generally discouraged developing these process measures.

The group strongly rejected any merit in developing two outcome measures concerning Patient Preferences Followed Throughout Hospice Stay and Hospitalization of Persons with Do-Not-

Hospitalize Order. The report says “Multiple TEP members described situations in which patients who had preferred not to be hospitalized changed their minds when a crisis occurred. Patients’ preferences and unexpected crises are usually out of the hospice’s control. Although it is still important for hospices to ask patients about their preferences as part of patient-centered care, the TEP did not believe these two items would be practical measures of a hospice’s care quality.”

Dr. McNally expects that Abt. Associates will apply the HQEP TEP’s suggestions to the HOPE tool.

“Oh yeah, they did it,” he says. “Abt would come to a specific meeting with information, data, suggestions, and specific information about how these things would be measured. We’d give feedback. Then they’d come back to the next meeting having incorporated our suggestions,” he explains. “All of us felt very much heard and responded to. It didn’t feel in the least bit perfunctory.”

Whatever specific measures are eventually included in the HOPE tool, Lund Person sees value in its implementation. “Hospice providers have had a woeful lack of outcome measures for hospice patients, which has made the evaluation of quality hospice care based only on process measures and the family’s evaluation of hospice care in the CAHPS® Hospice Survey, she explains. “Implementing HOPE will begin to identify outcome measures that can be compared between providers.”

Lund Person warns of potential challenges as well. “The selection of risk adjustment and stratification must be carefully done to minimize bias and maximize effectiveness of measures,” she says. “In addition, hospice providers have been awaiting the release of the HOPE tool with significant anxiety about content and administrative burden.”

Dr. McNally is confident the HOPE tool will be a healthy change for hospices.

“A lot of my role as a medical director and hospice physician is supporting our nurses,” he says. “They do 95% of the work. I really would like to see this not be burdensome for our hospice nurses. I’m looking forward to seeing what the [HOPE tool] beta testing translates to in our own hospice world.” He added “What I would hope to see is that the tool feels user-friendly to the hospice team, the people who have to use it, and that it also provides useful information to patients and families.”

NAHC’s Wehri says that standardizing processes through the HOPE tool is the key foundational element for the hospice industry. “High quality care is driven by reducing variance through standardized processes, Wehri writes. “Also, CMS will have a better idea of how the type of population a hospice serves impacts some of the clinical care.” This small glimpse into hospice variances that CMS does not currently have could be very helpful in future policy and payment decisions, according to Wehri. “What CMS finds in terms of differences between hospices and their care for patients may be a bit of a surprise to CMS,” she says.  “I hope they are pleasantly surprised with the overall quality of care that is revealed.”

# # #

Beth Noyce provides education, consulting, mentoring, compliance assessments and auditing services to home health and hospice agencies and their clinicians in several states. She also now provides patient and family guidance concerning hospice and home health services. Beth loves teaching and helping others succeed. She also makes available recordings of much of her education for her clients’ convenience.

©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