What I Learned From My Family’s Home Health Experience
Anne Tumlinson | February 15, 2022
COVID-19 has opened the floodgates for health care at home options. Public health emergency waivers are fast-tracking telehealth and hospital at home—which provides hospital-level care in patients’ homes—while infection concerns have driven more patients to home health following a hospitalization. These services and models are part of a growing list of home-based medical care models that also includes in-home primary or palliative care, in-home dialysis, and paramedicine. Some are covered through traditional Medicare, and others are available only through Medicare Advantage plans.
For patients, payers, and health policy professionals like me, the health care at home promise is tantalizing. In its ideal state, it would take fixed capital costs out of health care and redeploy them into person-centered care plans that include the diverse services and supports that individuals with complex care most need. It would also help patients and their families avoid the grueling and sometimes dangerous experience of an institutional setting.
But my recent experience managing home health and hospice for my father has given me insights into the perils that patients and their family caregivers could also face. Before we can migrate more health care into the home, we need to take a hard look at our performance with the current Medicare home-based benefits: home health and hospice. My own experience supporting my 83-year-old father, who is living with two serious illnesses, suggests we have a long way to go before our payment systems and benefit design are seriously up to the task. Below, I share the lessons and insights I gained in that process.
Service Coordination Is Essential To Making Home-Based Health Care Work
One of the benefits of a hospital room is that services and providers can easily visit the patient, meals arrive, nurses check in regularly, the physicians round. It’s an institution and, as such, can be disorganized—no question—but it can also be efficient.
What I realized, in arranging care at home for my father, is that scheduling home visits is a lot of work. And to manage that work, home health agencies commonly ask their clinical staff to “self-schedule,” a practice through which each individual clinical staff person gets in touch with the patient or caregiver directly to set up the visit. It seems practical, but it also leaves the patient or caregiver to serve a centralizing function among many different service providers.
This approach to scheduling created a lot of chaos in our house. Our phone was ringing constantly. We frequently experienced overlapping appointments between nurses and therapists. Often, we received little to no advance notice before a service provider arrived at our door. On at least two occasions, the physical therapist called to say he “was in the area and wanted to stop by in 10 minutes,” during the same window we were expecting a nurse. I had to call each of them separately to work it out.
Throughout, all I could think was—if we “move health care home,” without appropriate solutions (human and digital) for service coordination, we’re going to turn family caregivers and patients into switchboard operators. What if I also had to juggle scheduling aide services, meals, or transportation; services delivered under new models that promise to address social determinants of health? It would be impossible. . .
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Several Government Agencies are Increasingly Targeting Home Care Agencies
Home Health Care News
By Andrew Donlan | February 16, 2022
The next year will be a big one for home care.
There will be increased opportunities for agencies with a larger national spotlight shone on them.
Meanwhile, there are both legal threats and advocacy efforts that should be top of everyone’s mind, Home Care Association of America (HCAOA) CEO Vicki Hoak said during Home Care Pulse’s Growth Summit Monday.
“This is an election year,” Hoak said. “Why is this important? It’s important because this is the time that we, as an industry, need to reach out to our respective lawmakers to talk about home care, to tell the story about home care and its impact on their constituents.”
Lawmakers could make an immediate impact in Washington, D.C, by passing at least a part of the embattled Build Back Better plan – the part that would give $150 billion in funding to home- and community-based services.
But Build Back Better’s path is largely outside of the home care industry’s control. What is more in its power, however, is standardizing the industry.
Right now, regulation and standardization varies greatly from state to state. Hoak has argued in the past that this could take value away from the industry as a whole.
“Our home care industry does not have national standards … and we’re going to have to prove the value of delivering personal care into people’s homes,” Hoak said.
Unionization efforts
California is likely to make it a lot easier for home care workers to unionize in the state with Assembly Bill 2455.
The bill would disclose the personal information – name, address and phone number, for instance – of home care workers. As part of the bill, there’s also a requirement that agencies would need to forward that information to the unions to help them organize.
HCAOA filed litigation over that stipulation, but failed. Still, workers are free to opt out and not have their personal information shared.
“The good news is that workers can opt out,” Hoak said. “But they need to understand that they do have that ability to opt out, meaning that they can say, ‘I don’t want my private information shared.’”
Moving forward, there is some concern among industry advocates that this type of legislation could take on a nationwide scale. While not enough momentum has been generated there yet, Hoak urged operators to remain “vigilant.”
Legal threats
The U.S. Department of Justice (DOJ) announced last month that four home care operators in Portland, Maine, were indicted on counts of wage fixing and labor market allocation charges.
But what was more noteworthy about the announcement was the color that came with it.
“This indictment is the first in this ongoing investigation into wage fixing and worker allocation schemes in the [personal care services] industry,” the release read.
The DOJ, the Federal Trade Commission (FTC) and the U.S. Department of Labor have all increased their targeting of the home care industry, Angelo Spinola, the co-chair of the home health and home care industry group at the law firm Polsinelli, also said at the Growth Summit.
“We’ve seen the FTC and the DOJ kind of pair together,” Spinola said. “There’s a focus right now on restraint of trade, effectively – holding down caregiver wages and caregiver movement. There’s a focus on non-competes and any kind of collaboration between agencies saying, ‘Hey, you don’t hire my employees, I won’t hire yours’ or agreeing to keep pay rates the same.”
On the DOL side, enforcement against home care agencies has been ratcheted up by the new administration.
Part of the reason for that could be due to the appointment of David Weil, the administrator of the wage and hour division of the DOL during the Obama years and the Biden administration’s appointee. Weil has not been confirmed yet, however.
“I think that was a little bit of a surprise for some, he’s a very controversial nominee because of some of his positions – particularly around joint employment and independent contracting,” Spinola said. “So I think that’s if he does become affirmed, it will be a significant issue for the franchise systems on the joint employment front, and certainly the consumer-directed models on the independent-contracting front.” |
Self-Determined Hospice CAP Overpayments
The Health Group, Hospice Alert Volume 22.02
According to MedPAC, almost 20% of all hospice providers are now exceeding the Medicare aggregate payment limitation (“CAP”). Many hospices will have a CAP liability when they file their self-determined CAP liability report on or before February 28, 2022. Many more hospices will not have a CAP liability at the time of filing the self-determined CAP liability, but will incur a CAP liability as time passes and the CAP liability calculations are reviewed by the hospice’s respective Medicare Administrative Contractor (“MAC”).
Every year, we receive numerous inquiries from our clients, other hospices, and consultants regarding when the liability should be paid, as well as filing for an Extended Repayment Schedule (“ERS”) to liquidate the reported CAP liability. Unfortunately, the hospice’s approach to liquidating the CAP liability is dependent on the respective MAC and, potentially, other factors.
The following instructions are provided on the respective MAC’s website.
PALMETTO GBA
“Repaying an Overpayment (if applicable)
If the cap computation indicates an amount due the Medicare Program, please submit a check made payable to Palmetto GBA for the full amount (or the first month payment if requesting an ERS) and mail the check. The payment can also be submitted using eCheck. eCheck is a feature of the eServices portal, where registered providers can submit payments electronically. To register and utilize this feature, access our website, and select the eServices link.
Requesting an Extended Repayment Schedule
If you are unable to repay the cap overpayment in full, you may submit documentation supporting a request for extended repayment. This documentation must be sent at the time of the submission of your cap computation to avoid withholding of your payments.”
NGS
“If the self-reported cap calculation indicates an amount due to Medicare, please wait to receive a demand letter before making a check payable to National Government Services.
If a provider is unable to repay the self-determined overpayment within 15 days, they can submit a request for an ERS.”
CGS
“Any overpayment amount calculated as a result of the self-determined cap should be sent, along with a cover letter that explains what the payment is for.
Checks must be made payable to CGS. If the overpayment is not submitted at the same time as the self-determined aggregate cap, CGS shall demand the overpayment reported on the self-determined aggregate cap.”
OUR EXPERIENCE
The following is a quick overview of certain key items based on our experience:
- NGS, unlike other MACs, asks hospices to wait to make repayment until they receive communication from them (see instructions above). NGS may update the hospice’s calculation based on more current PS&R data.
- All MACs issue demand letters for reported, or updated CAP liabilities. Palmetto GBA issues a demand letter quickly in response to the self-filing if payment was not made at the time of filing. Historically, we have recommended that hospices wait until they receive notification from the MAC regarding the CAP obligation in case the MAC modifies, for any reason, the amount of the obligation. However, hospices dealing with Palmetto may want to liquidate the liability at the time of filing or begin the ERS process at the time of filing. Caution – we have seen instances when the liability was paid but payments were withheld due to a communication issue at the MAC.
- These letters typically provide for repayment of the liability or the submission of an ERS within 15 days to avoid withholdings against remittances.
- Hospices should be on alert for the receipt of a demand for repayment (hospices with multiple operating locations must ensure that communications from the MAC will be received timely by those responsible for any repayment).
- Hospices should ensure their CAP files are complete including all self-filings, all notices received relating to each respective CAP Year, and documentation supporting all CAP liability repayments, including ERS filings, approvals, and payments made.
Regardless of the action you take, hospices should be keenly aware of CAP liabilities and the resolution of those liabilities. |
Shock and Awe at Homecare 100
Tim Rowan, Editor
The Rowan Report
Home Care industry leaders are typically guarded with their opinions and careful with their words when speaking from a stage in front of 475 colleagues and a video camera. Whether out of an accumulation of frustration or simply having been away from live audiences for so long, this year's expert panelists at Home Care 100 were anything but typical. More than once, whispers were heard across the Scottsdale Phoenician ballroom, "Did he actually say that?"
Getting Tough with Medicare Advantage
It started with a discussion among executives from our industry's largest providers. Moderator Tim Craig, Home Care 100's Chief Content Director, shot pointed questions and received frank answers from LHC Group's Chief Strategy and Innovation Officer Bruce Greenstein, Bayada Home Health's CEO David Baiada, Amedisys Home Health's COO Chris Gerard, and Kindred's CEO David Causby.
Inevitably, the conversation under the title "The Future of Home Care Post-Covid" turned to the expansion of Medicare Advantage, currently up to 43 percent of Medicare beneficiaries and expected to reach 50 percent within two years. Panelists spoke their minds about the rise, calling it a crisis.
Mr. Greenstein opened the door:
"We are all complicit and we are losing. This is a serious moment in time, and we have been glossing over it for far too long. MA imposes reimbursement averaging two-thirds of Medicare rates. We are getting our clocks cleaned. We could not be more frustrated by what is happening.
"We have become commoditized 'price-takers,' essentially providing staffing for managed care companies. Here we are with our incredible skill set. We evaluate a patient, create a comprehensive plan of care, and we get asked to do three or four visits. Our data gets co-opted, and we get paid maybe two percent over our costs.
"Some plans are better than others, but there has been little or no recognition of the value of Home Health by Medicare Advantage plans, and there is little we can do about it.
"As MA grows, even if you put all of us at this table together, we don’t have enough leverage to dictate terms of the relationships. They have been infected with the 'elixir of power,' and they cannot resist its allure. They will continue to dictate the terms unless we all work together – legally, of course, under the agreement at this gathering and not discussing rates – otherwise, we will not get anywhere.
"Every year, you negotiate MA contract rates, and give in to losing money on every MA patient just to please referrers so they will give you the patients on original Medicare who pay the bills. We have ignored this for far too long. It is a crisis.
"We here in this room are the Home Care 100, but there is a Home Care 1000 out there that will continue to give in to this abuse, and we can’t stop them.
"Value-Based-Pay is nice, but Medicare Advantage insurance companies will still dictate our number of visits, our quality of care, and our price." . . .
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