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Private Duty Home Care in Fraud Enforcers’ Crosshairs

Clinical

by Elizabeth E. Hogue, Esq. | Apr 18, 2024 | Clinical, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Some owners and managers of private duty home care agencies mistakenly think that fraud and abuse prohibitions apply only to services paid for by the Medicare Program. In fact, fraud and abuse prohibitions apply to providers if they accept any state or federal funds, including, but not limited to, Medicaid, Medicaid waiver, VA, and Tri-Care. Many private insurers have adopted the prohibitions on fraud implemented by state and federal programs.

Private duty home care agencies are increasingly in the crosshairs of fraud enforcers if they receive reimbursement from Medicaid and/or Medicaid Waiver Programs. The reason for enhanced scrutiny is that both the federal government, which partially funds state Medicaid and Medicaid Waiver Programs, and state governments that also fund these programs are alarmed about the high costs of them.

Conventional wisdom says that there are big bucks to be saved if fraud and abuse in the Programs are controlled and ultimately eliminated. Conventional wisdom also says that enforcement actions in Medicaid Programs have just scratched the surface. According to this “wisdom,” there are big bucks to be recouped from “low-hanging fruit!”

A recent report from the Office of Inspector General of the U.S. Department of Health and Human Services seems to support this perception regarding private duty home care agencies based on the following:

Between 2014 and 2023, at least 34% of fraud convictions in some years were based on private duty home care services. In some years, this percentage was as high as 48%.
In fiscal year 2023, there were 279 criminal convictions related to private duty home care services compared to 66 for registered nurses and 43 for home health agencies.
Recoveries from private duty home care agencies in 2023 totaled $26.4 million.
The amount of civil recoveries reached a 4-year high in 2023 and the combined criminal and civil recoveries were $1.2 billion, resulting in a return on investment of $3.35 for every $1 spent.

The return on investment of more than three times the amount spent is perhaps the most important figure of all. With a three to one return, regulators will not hesitate to “beef up” enforcement actions.

THE CONSEQUENCES OF FRAUD AND ABUSE ARE SEVERE WHEN SERVICES ARE PAID FOR BY THE MEDICAID AND OTHER STATE AND FEDERAL PROGRAMS!

Personal care private duty agencies, don’t believe the myth that only services paid for by the Medicare Program are subject to fraud and abuse enforcement. The consequences may be devastating, including the loss of businesses. Heads up!

©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.
©2024 This article appeared in The Rowan Report. All rights reserved.

HHAeXchange Makes Leadership Changes

Vendor Watch

by Kristin Rowan | Apr 18, 2024 | Vendor Watch

by Kristin Rowan, Editor

On February 21, 2024, HHAeXchange announced a change in leadership for the homecare management solutions company. Former Chief Revenue Officer Scott Schwartz was named Chief Operating Officer and new hire Lori Harrington came on board as the Senior Vice President of Product. You can read the press release from HHAeXchange here.

HHAeXchange provides management solutions for providers, MCOs, and state Medicaid agencies. The software was designed specifically for home and community-based services (HCBS) and connects state agences, MCOs, providers, and caregivers through its web-based platform. According to HHAeXchange, the personnel changes show the company’s “commitment to providing innovative solutions that some homecare industry challenges.

I had the opportunity to reach out to Scott and Lori to get, in their own words, their visions for the future of HHAeXchange and the industry.

The Rowan Report: Thank you, Scott and Lori for taking some time to talk with The Rowan Report. First, congratulations to you both on your new roles. Can you each share a little about your background and career?

Scott Schwartz: For over 20 years, I’ve focused on system of record, vertical SaaS software and technology, with experience leading sales, marketing, client success and operations. I started my career as a process engineer and have held leadership positions at several SaaS companies, including as the founder and general manager of CampSite. I joined HHAeXchange in 2017 as vice president and have also served as senior vice president and chief revenue officer before stepping into my current role. As chief operating officer, my aim is to galvanize the organization around a shared vision of operational efficiency, innovative service delivery, and customer satisfaction.

Lori Harrington: I have enjoyed a career of over 20 years in healthcare with a background in product strategy and informatics. In my most recent role as vice president of product management at Teledoc, I led product strategy for value-based care initiatives. My passion for digital transformation in B2B2C markets has driven successful healthcare initiatives from ideation to commercialization. I believe that success in healthcare is really understanding your users and building solutions to solve their everyday problems in a seamless, understandable way.

RR: Scott, as part of your new responsibilities at HHAeXchange, how will you ensure effective communication and collaboration between internal departments to better serve customers?

Scott: We’re focused on enhancing our platform, which connects state agencies, managed care organizations, providers and caregivers, so cross-departmental communication and collaboration are vital. With shared services such as implementation, revenue cycle operations, integrations, technical customer care, training, and customer education under my purview, I plan to streamline communication pathways and ensure all teams are aligned with and working toward our common goals.
We want to leverage our teams’ diverse talents to drive transformation. My approach includes fostering an integrated work environment where interdepartmental meetings, clear information channels, and shared objectives are the norm. Regular check-ins and transparent leadership are key to ensuring every department understands how their work directly benefits our clients, the members they serve, and the company’s broader goals.

RR: And how will you ensure HHAeXchange’s solutions and product enhancements meet the needs of all homecare stakeholders – caregivers, provider agencies, members, and payers?

Scott: Engaging with stakeholders is critical. We involve provider agencies, caregivers, payers and others in our development process to ensure that our platform addresses real-world needs effectively. Our comprehensive engagement strategies support this with initiatives like periodic customer summits, road shows, and information sessions to capture a wide array of insights and feedback.
We monitor industry trends, regulatory changes, and technological advancements, which are factored into planned enhancements and solution updates. And with a team of reputable industry experts, we’re working to ensure that our products exceed the evolving needs of all homecare stakeholders.

Lori: We understand that stakeholders in the homecare space have diverse and critical needs. We keep a pulse on industry trends and challenges such as issues with caregiver turnover, regulatory & compliance changes, increasing volume of live-in caregivers, and an increase in diversification in home care utilization. With these observations, we aim to provide products that support healthcare agencies and caregivers as these trends evolve. Our solutions must be built with a nimbleness that accounts for a continuous change in regulations, EVV compliance requirements, and stakeholder expectations. Frequently engaging with stakeholders, conducting thorough market research, and incorporating feedback loops are integral to our product development processes.

RR: Lori, you mentioned the diverse needs of your stakeholders. What are the greatest problems your clients and prospects say they are looking to solve with improved homecare management software solutions and EVV platforms?

Lori: Our clients are prioritizing caregiver retention and looking for comprehensive solutions to streamline operational processes like billing, HR, and payroll while ensuring regulatory compliance and providing high-quality member care. They need tools to manage the diverse locations of members’ and workers’ schedules, foster strong member-caregiver matches, and enable transparent communications among provider teams.

Taking those challenges into consideration, HHAeXchange aims to equip our solutions with time-saving, stress-reducing features. Operational worklists, for example, alert agencies to important dates and actions their teams need to take regarding caregiver compliance and client authorizations. Our appointment module and case broadcasting feature reduce hassles associated with scheduling visits and quickly filling unexpectedly open shifts.

RR: Two questions, Lori. What trends are you seeing that are transforming homecare delivery models and, in addition to technology, are there any other trends shaping the homecare industry in 2024?

Lori: The ongoing caregiver shortage remains a concern, driving a shift toward more strategic technology investments and training opportunities. Homecare delivery is becoming more person-centered, suggesting the industry has adjusted to EVV and is using the technology to incorporate collaboration with families as caregiver participants. Additionally, there’s a growing emphasis on self-direction, with clients seeking more choice, flexibility and control in their care. Compliance is gaining more attention, with increased scrutiny to ensure standards of care are met across the board. Data and analytics will continue to be a primary enabler for how healthcare is shaped. We account for all of this in our product strategy and development plans.

RR: Final questions for you, Scott. How does HHAeXchange envision the homecare industry evolving in 2024 and, more specifically, how do you see the company’s innovations playing a role in that transformation?

Scott: The homecare industry is at a critical juncture. As Lori said, we’ve noted significant shifts toward value-based care, self-directed care, and person-centered approaches. At the same time, the fundamentals of homecare are as important as ever. HHAeXchange’s role is to stay ahead of trends while improving product offerings and customer experiences. We strive to balance innovative thought leadership with steady progress, continually enhancing the functionality of our foundational platforms to meet clients’ needs.
We’re investing in scalable technology, service improvements, customer education, and strategic integrations to accommodate the industry’s evolution. Our leadership is committed to empowering providers and payers alike with tools to improve caregivers’ efficiency and address fraud, waste and abuse in the industry. Through these efforts and plans, we aim to facilitate a more sustainable, higher-quality, and accessible homecare ecosystem for all involved, ensuring members have the option to receive care and treatment in the comfort of their own homes.

RR: Thank you both, again, for your time. I wish you both great success in your new roles.

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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

Leadership Changes at HHAeXchange

Partner News

by Rowan Report | Apr 18, 2024 | Partner News

HHAeXchange Names Scott Schwartz as Chief Operating Officer, Announces New Senior Vice President of Product

New appointments highlight the company’s commitment to equipping providers, managed care organizations (MCOs), and state Medicaid agencies with solutions that enable more effective homecare

NEW YORK, Feb. 21, 2024 – HHAeXchange, a leading provider of homecare management solutions for providers, managed care organizations (MCOs), and state Medicaid agencies, today announced that Scott Schwartz, formerly Chief Revenue Officer, has been appointed to Chief Operating Officer, and Lori Harrington has joined the team as Senior Vice President of Product.

After serving as Chief Revenue Officer, Senior Vice President, and Vice President of Sales & Marketing at HHAeXchange for nearly seven years, Scott Schwartz will step into a new role as Chief Operating Officer. In his new position, Schwartz will lead implementation, revenue cycle operations, integrations, technical customer care, training, and customer education. Bringing these functions under Schwartz’s leadership will evolve operations to enable more effective services and solutions.

“Over the past seven years, Scott has been integral in establishing HHAeXchange as the leader in homecare software through helping nearly 10,000 homecare provider agencies leverage technology and spearheading our robust Partner Connect program,” said Paul Joiner, Chief Executive Officer at HHAeXchange. “As we work to expand our platform and create better solutions for homecare providers and payers, Scott’s top priority will be driving operational excellence and delivering an improved end-to-end client experience.”

In addition to the appointment of Schwartz as COO, the company has announced Lori Harrington as the new Senior Vice President of Product. With over twenty years of experience in the industry, Harrington brings an extensive healthcare product strategy and management background to the organization. In her most recent role, Harrington served as Vice President of Product Management for Teladoc, where she led product strategy for value-based care initiatives and was instrumental in developing a client innovation hub for strategic health plan clients, creating a streamlined experience for clients based on their emerging needs.

“Lori’s deep understanding of healthcare and her customer-centric approach will be crucial in advancing our product solutions to serve providers and payers better,” said Tim Brewer, Chief Technology Officer at HHAeXchange. “With her vast experience, Lori will play a pivotal role in driving product evolution and execution, improvements to our current products, and delivering solutions that meet the evolving demands of our customers and the homecare industry to ultimately provide better customer satisfaction.”

As aging populations across the country continue to increase and more members express a preference for homecare, these new appointments will advance HHAeXchange’s commitment to setting new industry standards that enable providers, caregivers, payers, and families to deliver the best care in the home.

For more information about HHAeXchange and its executive team, please visit hhaexchange.com/leadership and follow the company on Twitter, LinkedIn and Facebook.

# # #

About HHAeXchange

Founded in 2008, HHAeXchange is the leading technology platform for homecare and self-direction program management. Developed specifically for Medicaid home and community-based services (HCBS), HHAeXchange connects state agencies, managed care organizations, providers, and caregivers through its intuitive web-based platform, enabling unparalleled communication, transparency, efficiency, and compliance. To learn more information, visit hhaexchange.com or follow the company on Twitter, LinkedIn and Facebook.

SNF Abuses Could be Selling Point for In-Home Care Providers

Clinical

by Tim Rowan | Apr 4, 2024 | Clinical, Editorial

by Tim Rowan, Editor Emeritus

For as long as I can remember, Home Health and Home Care owners and advocates, including their national and state associations, have struggled to develop concrete data to prove what we all know to be true: In-home care is a great deal for payers, both public and private. Underpaying our sector in a misguided attempt to reduce costs results in paying more in the long run. Buying more in-home care translates into lower overall cost.

This is one part of the story, and we continually search for the proof our sector so desperately needs. But there is another aspect to the Home Health, Home Care advantage that must not be overlooked as we focus on payer finances.

Patient care and safety

One need look no further than our post-acute care neighbor, Skilled Nursing Facilities, to understand how much better off elderly citizens are when in-home caregivers and clinicians enabled them to stay in their own homes and avoid institutionalized care. A new, peer-reviewed study titles “Profits Over Patients” was published in the online collective The Conversation. If unfamiliar, think of it as The Huffington Post for scholars and researchers.

In the exposé, investigators Sean Campbell and Charlene Harrington reveal that for-profit organizations have been infiltrated by Wall Street investors and other venture capitalists, seeking quick turnarounds and handsome profits. Founders and other SNF owners gladly accept generous offers to be acquired or partner with investors who immediately begin to impose cost-cutting measures and maximize profits. The probe, which paired an academic expert with an investigative reporter, discovered a number of startling findings:

“The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under weak and poorly enforced regulations with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health.”

Campbell and Harrington also looked at the ineffectiveness of state inspectors, who have limited ability to impose meaningful fines for violations. One startling example in the report is that of a Louisville SNF. The care was found to be “abysmal” when Kentucky inspectors filed their survey report.

“Residents wandered the halls in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate with a stick, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead gash. That person was allowed to roam and enter the beds of other residents. In another ase, there was sexual touching in the dayroom between residents, according to the [surveyor’s] report.

“Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors.

“Overall, there was a critical lack of training, lack of staff, and lack of supervision.”

The report said state inspectors found 29 deficiencies, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The fine imposed was $319,000 — more than 29 times the average for a nursing home. Payments from Medicare and Medicaid were suspended. The investors and owners chalked the fine up to a normal cost of doing business and, five months later, inspectors found six additional deficiencies “of immediate jeopardy,” the highest level.

The parent company of the Kentucky SNF, Infinity Healthcare Management, owns 58 facilities across five states. Since 2021, Infinity has been hit with nearly $10 million in fines, more than 4.5 times the national average.

Cut staff, save money, hide money

The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, endangering patient health. “Meanwhile,” the authors assert, “owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporation

s. Federal regulators have neglected the problem as each year likely billions of dollars are funneled out of nursing homes through related parties and into owners’ pockets.”

The report points out that problems of this magnitude are found far less often in small, single-location facilities and in national chains and franchises. The sweet sport for abuse seems to be in the mid-range, for-profit organizations that have been taken over by far-away investors. Sadly, 72 percent of the SNF’s in this category are for-profit. “While such chains account for about 39 percent of all facilities, they operate 11 of the 15 most-fined facilities.

Relevance

A frequent message at Home Healthcare conferences in recent years has been the renewed interest in our sector from big money investors. While quick profits and the enticement of early retirement might bring Home Health and Home Care owners to the negotiating table, this exposé may be a reason to take a breath and think it through. Most of you who nurtured your company from startup to attractive acquisition target did so as much out of compassion as entrepreneurship. Would you not wonder, from your perch on the sun deck of a cruise ship, whether your legacy is being dragged in the mud and your patients and employees reduced to a Wall Street cost column?

Read the entire report here.

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

Little Clinical, Cost Benefit to Diabetes Tech

Admin

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

CONTACT: Shannon Bishop-Green, SBishopGreen@MessagePartnersPR.com, (860) 305-3197

NEW REPORT FINDS THAT DIGITAL DIABETES MANAGEMENT TOOLS FAIL TO DELIVER MEANINGFUL HEALTH BENEFITS TO PATIENTS WHILE INCREASING SPENDING

Independent evaluation from Peterson Health Technology Institute recommends new directions for digital diabetes solutions

NEW YORK — Peterson Health Technology Institute (PHTI), an independent organization that evaluates healthcare technologies to improve health and lower costs, today released a new evaluation of digital diabetes management tools. These solutions are used by millions of Americans and have been funded by $58 billion of investment and mergers and acquisitions, yet the evidence shows that the technologies do not deliver meaningful clinical benefits, and result in increased healthcare spending.

The analysis, conducted by a team of health technology assessment experts and informed by clinical advisors, evaluated eight widely used digital tools that people with Type 2 diabetes use to track and manage blood glucose using a noncontinuous glucometer.

The report found that people who use these tools achieve only small reductions in hemoglobin A1c (HbA1c) compared to those who do not, and these reductions are not sufficient or sustained enough to change the trajectory of their health, care, or long-term prognosis, including cardiovascular risks. The solutions also result in increased overall healthcare costs. One promising solution, Virta, supports nutritional ketosis to achieve diabetes remission in patients who follow the rigorous diet modifications.

“When these digital diabetes management tools launched more than a decade ago, they promised to improve health outcomes for people with diabetes and deliver savings to payers. Based on the scientific evidence, these solutions have fallen short, and it is time to move toward the next generation of innovation,” said Caroline Pearson, executive director of PHTI. “Patients with diabetes invest time, energy, and resources in these tools, and they deserve to experience meaningful, positive benefits for their health. The healthcare sector as a whole needs transparent, accurate information about the clinical and economic impact of these digital tools that are taking up precious healthcare dollars.”

PHTI’s rigorous analysis incorporated an evidence-based assessment framework and review of more than 1,100 articles, including 120 submitted to PHTI by companies evaluated in the report. PHTI’s ratings are at the category level, including remote patient monitoring solutions that support providers, and behavior and lifestyle modification solutions that engage users to improve their diet, exercise, and self-management.

HbA1c is the standard form of measurement of glycemic control in diabetics. The studies show that these digital tools deliver small reductions in HbA1c of 0.23 to 0.60 percentage points compared to usual care. These results are generally below industry standards for Minimal Clinically Important Difference (MCID) of 0.50 percentage points. Further, the evidence indicates that this small improvement is not durable because the reduction is not sustained over time.

Additionally, PHTI’s analysis did not find evidence to demonstrate that digital diabetes management tools improve other health factors, including weight loss, body mass index, blood pressure, cholesterol, or other common conditions impacting people with diabetes. The analysis also concluded that, despite the disproportionate impact of diabetes on low-income and racially and ethnically diverse communities, these tools are not currently being deployed in ways that improve health equity.

PHTI’s evaluation further determined that these tools increase net healthcare spending. This is due to the fact that price for the solutions exceeds the associated healthcare cost savings, because the minimal clinical benefit does not enable the patient to avoid other care or treatments. For patients using tools in the remote patient monitoring category, annual spending is projected to increase by $2,002 for commercial insurance patients, by $1,011 for Medicare patients, and by $723 for Medicaid patients, as a result of higher provider payments. For patients using tools in the behavior and lifestyle modification category, annual spending is estimated to increase by $484 for commercial insurance patients, by $513 for Medicare patients, and by $574 for Medicaid patients. For all payers, the increased spending associated with virtual diabetes solutions has a significant impact on total spending given how many people are eligible to use the solutions, including 4.3% of those with commercial insurance, 17.0% of those with Medicare, and 4.8% of those with Medicaid.

In addition to its scientific literature review, PHTI proactively engaged the companies included in the report and provided an opportunity for them to share data and product information. Companies in PHTI’s evaluation include DarioHealth, Glooko, Omada, Perry Health, Teladoc (Livongo), Verily (Onduo), Vida, and Virta. The evaluation considered evidence about which populations stand to benefit the most from using the technology, as well as the durability of clinical impacts given the importance of sustained glucose control to achieve health benefits. The economic analysis modeled expected healthcare savings resulting from improved glycemic control for patients using digital diabetes management solutions who are enrolled in Medicare, Medicaid, and commercial insurance.

PHTI identified two potential bright spots for digital diabetes management tools. Initial data showed that Virta users are much more likely to achieve clinically meaningful benefits in glycemic control, including diabetes remission and the ability to reduce or eliminate their diabetes medications, if they can maintain the rigorous dietary requirements of the intervention. The other area of greater potential is among patients with higher starting HbA1c levels who are newly starting insulin. By engaging these patients at an early critical transition point in their care, digital solutions could have more impact by helping establish good self-management habits among these higher-risk patients.

Category-level ratings are available here.

In the United States, about one in seven adults—more than 38 million living in the U.S.—has Type 2 diabetes, which is the eighth leading cause of death. At over $400 billion of total healthcare spending annually, diabetes is the most expensive chronic condition to treat and manage. Given the critical role of patient self-management, investment in digital health tools has surged in recent years.

Throughout the assessment process, PHTI worked with a range of independent evaluation partners, clinical advisors, patients with Type 2 diabetes, and other stakeholders. Report contributors and reviewers included:

Curta: assessed the clinical and economic impact of these technologies using the published ICER-PHTI Assessment Framework for Digital Health Technologies, including the systematic literature review and budget impact assessment
Charm Economics: identified what technologies cost to deliver, how they work, and their impact on patients and purchasers
Institute for Clinical and Economic Review (ICER): co-developed the ICER-PHTI Assessment Framework for Digital Health Technologies, and was consulted to review its implementation in this report
Ami Bhatt, MD, chief innovation officer of the American College of Cardiology
Richard Milani, MD, chief clinical innovation officer, Sutter Health; former innovation lead at Ochner Health System
Karen Rheuban, MD, co-founder and director of the University of Virginia Center for Telehealth

“Managing diabetes is complex and essential to future cardiovascular health. Patients will gain agency and drive better clinical benefit if they direct their time and effort towards effective interventions rather than tools that provide marginal or no benefit,” said report contributor Ami Bhatt, MD, chief innovation officer of the American College of Cardiology.

“New diabetes technologies need to be easier to use, by the people who need them most, at lower cost than standard care, and provide real health benefits,” said report contributor Richard Milani, MD, chief clinical innovation officer at Sutter Health. “This evaluation suggests there is room for new innovations that deliver for patients and address worrying increases in healthcare spending.”

The PHTI report provides recommendations and best practices for innovators, providers, and payers. The next generation of diabetes management solutions should aim for clinically meaningful improvements in glycemic control, potentially integrating continuous glucose monitors and new GLP-1 obesity medications. Solutions should also generate sufficient evidence to support broader adoption, and they should prioritize access for populations who need them most. Providers of diabetes care should have clarity about the performance of these digital solutions when recommending them to their patients. Payers, including health plans and employers, should adapt their contracting approach to require transparency about the solution’s usage and benefits within their covered population and to include financial performance guarantees tied to clinical outcomes.

“PHTI is filling an important role in delivering actionable and market-facing information to digital health purchasers about what solutions will make a meaningful impact on health outcomes for members, making them worth investment,” said Peter Long, PhD, executive vice president, Strategy and Health Solutions at Blue Shield of California and a PHTI Advisory Board member. “Having an organization like PHTI cut through the noise of digital health options helps payers make faster and more effective decisions for members so that we can focus on the big work of transforming the healthcare system.”

PHTI has announced that future assessment areas include virtual physical therapy, blood pressure monitoring, and mental health tools.

# # #

About the Peterson Health Technology Institute

The Peterson Health Technology Institute (PHTI) provides independent evaluations of innovative healthcare technologies to improve health and lower costs. Through its rigorous, evidence-based research, PHTI analyzes the clinical benefits and economic impact of digital health solutions, as well as their effects on health equity, privacy, and security. These evaluations inform decisions for providers, patients, payers, and investors, accelerating the adoption of high-value technology in healthcare. PHTI was founded in 2023 by the Peterson Center on Healthcare. For more information, please visit PHTI.com.

Meet the Remarkable Women of the International Home Care Nurses Organization

Admin

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

By Kristin Rowan, Editor

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

Meet the Team

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

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

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

History of IHCNO

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

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

The Conversation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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©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

CMMI Terminates Hospice Carve-In Demonstration

Regulatory

by Rowan Report | Mar 6, 2024 | Regulatory

From the NAHC News Desk,

Late on Monday, March 4, the Center for Medicare and Medicaid Innovation (CMMI) announced it plans to formally end the Value-Based Insurance Design (VBID) Medicare Advantage hospice “carve-in” demonstration on December 31, 2024, and that it will not accept applications to the previously released CY 2025 Request for Applications (RFA) for the hospice component of the Model. In its announcement, CMMI stated that it made the decision to terminate the demo “after carefully considering recent feedback about the increasing operational challenges of the Hospice Benefit Component and limited and decreasing participation among MAOs that may impact a thorough evaluation”. CMMI recently solicited input on the carve-in via a public request for information (RFI).

NAHC was pleased to be able to provide detailed comments to the RFI highlighting our members’ ongoing concerns and frustrations with the demonstration and registering our deep skepticism that the model was necessary or appropriate for hospice patients and families. We are pleased to see CMMI has decided to end this particular demo, and we look forward to continuing to work with them to advance innovation in care delivery and payment models for people with serious illness.

Since the carve-in was first announced, NAHC has maintained our strong opposition to the premise that incorporating hospice into the Medicare Advantage was necessary or would lead to positive outcomes. In 2019, NAHC emphasized our “unqualified opposition” to the program when it was first unveiled, and after more details were released in the model’s first request for applications (RFA); We have continued to stress our concerns since model implementation began, working with our hospice members to solicit feedback and translate those experiences into direct advocacy with CMS, CMMI, and members of Congress. As early evaluation data and inputs highlight, the model has been extremely burdensome for both hospices and participating plans, and has had no measurable positive impact on beneficiary or family outcomes, care experiences, or Medicare spending.

In the announcement about the model’s termination at the end of 2024, CMMI stated that the decision is not a result of the demo “not meeting its goals”, and that the agency will continue its evaluations of the hospice component to assess its overall impact. Over the course of the three years of the model, it was clear to NAHC that the demo was not meeting CMMI’s stated goals to drive greater care continuity and higher quality hospice care for beneficiaries and families. We also questioned the premise that a carve-in would save the Medicare program money in the long run. Contrary to what the VBID evaluators found, the seminal 2023 NORC research demonstrated that hospice utilization in the traditional Medicare program saves billions of dollars a year while delivering high-quality care.

CMS also indicated in their notification that later this year, they will issue additional guidance to ensure that “all obligations of any impacted organization may be met in a timely and reasonable manner so that hospice beneficiaries in the Hospice Benefit Component maintain a coordinated, seamless care experience.” NAHC will be following up directly with CMMI to better understand what may be included in this guidance and when it may be released.

Increasing access to hospice care remains NAHC’s primary policy goal. We are committed to working to improve more timely connection to hospice, reducing the percentage of very short stays that make it difficult to benefit fully from the hospice model, and ensuring every provider is capable of delivering high-quality, person-and-family-centered services. We appreciate our engagement with CMMI on the carve-in over the years, and we welcome the opportunity to collaborate with them on new ways to support seriously and terminally-ill people and their families.

CMS Announces Multi-Pronged Effort to Strengthen Direct Care Workforce

Admin

by Elizabeth E. Hogue, Esq. | Mar 6, 2024 | Admin, CMS, Regulatory

by Elizabeth E. Hogue, Esq.,

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

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

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

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

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

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

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

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

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

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

Cyberattack Interrupts Pharmacy Operations

Admin

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

By Kristin Rowan, Editor

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

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

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

February 28, 2024

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

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

Source of the Attack

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

Implications

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

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

Point of View

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

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editor@homecaretechreport.com

Sources:

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

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

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

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

Acute Hospital Care at Home

Clinical

by Kristin Rowan | Feb 21, 2024 | Clinical, Regulatory

By Kristin Rowan, Editor

Federal Waiver Program

In 2020, CMS launched a hospital care at home program to help increase patient capacity during the height of the Covid-19 pandemic. The study included 300 hospitals and thousands of patients receiving care in their home using a hospital at home waiver. Outcomes of the study showed that patients had greater ability to stand up and move around at home than would have had in a hospital and that in-home caregivers were better able to educate patients on home to care for themselves once they were able to see the social determinants of care in the home. CMS also reports only 7.2% of patients were required to be transferred to a hospital.

Hospital Study

Mass General Brigham conducted its own study alongside CMS and analyzing outcomes of diverse patients, including socially vulnerable and medically complex patients. The findings of their national analysis showed that within 30 days of discharge, 2.6% of patients used a SNF, 3.2% died, and 15.6% were readmitted. Findings were consistent among all groups, including those who generally have worse outcomes: patients of Black and Latine race and ethnicity, dual-eligible patients, and patients with disabilities.

Health System Study

In April of 2020, Kaiser Permanente conducted an 18-month study on the scalability of “Advanced Care at Home” (ACAH). The patients all required hospital-level care and were first admitted to the program through the emergency department. Some were admitted to the hospital, and some were instead admitted to the Kaiser ACAH program, where a team of nurses, physicians, nurse practitioners, and a pharmacist developed a care plan.

This study increased its daily census from 7.2 per day to 12.7 per day at the end of study. The average episode of care decreased from 7.43 days to 5.46 days and readmission rates dropped from 11.52 percent to 9.24 percent. These patients were less likely to experience delirium than patients admitted to traditional hospital settings. The researchers noted the limitation of the study as being too small to develop precise comparisons.

Limitations of Acute Hospital Care at Home

Currently, the only patients eligible for AHCaH are those who have been evaluated in a hospital or emergency department. Kaiser has extended this to patients seen in their own urgent care offices in areas where they don’t own a hospital. Kaiser has served a few thousand patients through this program, but they estimate there are more than 1.1 million eligible patients. Rural patients who don’t live near a hospital or emergency department have the same trouble accessing AHCaH that they do accessing hospital and physician care now.

The CMS waiver for AHCaH has been extended through December 2024. Beyond that, it is unclear how hospital care at home will be reimbursed. Some providers have offered hospital care at home to risk-based patients in a VBC model. Not all eligible patients will qualify for the waiver or VBC reimbursement. Without specific provisions from CMS to reimburse hospital care at home for all Medicare and Medicaid patients and coverage from private insurance, the hospital at home program will remain limited.

The current model for AHCaH includes technology support for the patient using a tablet, smartphone, or other device. This requires that the patient have a broadband internet connection in the home, which eliminates eligibility for rural patients who are already underserved.

Final Thoughts

There is a lot of support for Hospital Care at Home among providers, health systems, and consumer insurance companies. Support for home health, hospice, palliative care, and supportive home care has not been as strong. As these larger players start to see the cost and outcome benefits of care in the home, a few things may happen.

First, hospitals, payers, and physician groups may start to recognize the value of care at home and be more open to creating referral partnerships with care at home agencies. Home care is a small percentage of total care reimbursed by Medicare and Medicaid and we could see that increase.

Conversely, these providers may realize that care at home is lucrative and will extend their own AHCaH models to include post-acute and hospice care, cutting out home care agencies altogether. Care teams are constructed around a Hospital Care at Home patient. Including a post-acute nurse who is familiar with the patient history would provide additional continuity of care.

Either way, I see the support for the Hospital Care at Home program as beneficial to home health. Branches of health care that were previously averse to extending patient care into the home are now supporting it. Increased adoption of telehealth and other technology platforms increase the possibilities for integrating with home health and hospice providers. Interoperability between Hospital Care at Home and Post-Acute Care at Home may finally become a reality.

We will continue to report on the AHCaH waiver as the deadline to renew comes closer.

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Sources:

CMS (2024) Acute Hospital Care at Home Data Release Fact Sheet. Retrieved from: https://www.cms.gov/newsroom/fact-sheets/acute-hospital-care-home-data-release-fact-sheet#:~:text=In%20response%20to%20challenges%20faced,inpatient%2Dlevel%20care%20at%20home.

Mass General Brigham (2024) Study of National Data Demonstrates the Value of Acute Hospital Care at Home. Retrieved from: https://www.massgeneralbrigham.org/en/about/newsroom/press-releases/study-of-national-data-demonstrates-the-value-of-acute-hospital-care-at-home#:~:text=In%20addition%2C%20within%2030%20days,and%20have%20fewer%20adverse%20events.%E2%80%9D

mHealth Intelligence (2023) Kaiser Permanente Study Shows Scalability of Hospital-at-Home model

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