Less than a month before election day, the Democratic and Republican candidates for president are dueling over home-based care plans.

Vice President Kamala Harris announced on “The View” this week a proposal that would allow home care to be administered through traditional Medicare.

On the same day, former President Donald Trump and his campaign released a rebuttal, pointing toward home care-related policy implemented from 2017-2020, plus additional plans for a potential second term.

Harris’ proposal is a more lofty one. It would also – if implemented – create a massive tailwind for home care providers across the country. But, as LeadingAge President and CEO Katie Smith Sloan pointed out after the proposal, “we cannot overstate that without staff, there is no care.”

Trump, meanwhile, pointed to expanded supplemental benefits in Medicare Advantage (MA) as a way for seniors to access more home care-related services. His campaign team also focused on economic points that it believes will make aging in place easier for Americans under his leadership.

In this exclusive, members-only HHCN+ Update, I make the mistake of venturing into the presidential candidates’ plans for home-based care. Specifically, I examine how viable the plans are, and what they could mean for providers, if implemented.

Home-based care takes center stage

Home-based care providers were likely pulling their hair out over the predictable confusion that arose from Harris’ proposal Tuesday.

Home health care is already a robust benefit provided under the Medicare program, and generally includes services delivered to seniors after an acute health event.

Home care is not currently available under traditional Medicare, however, and generally includes non-medical services to help with activities of daily living.

The only place where home care is paid for under Medicare is through MA supplemental benefits, and MA pays for just a sliver of all home care provided currently.

So, yes, Harris’ proposal would be groundbreaking, if implemented. It would completely change the scope of the Medicare program.

As for the companies it would directly impact, pick a notable name in home care.

Currently, home care providers have a large addressable market: seniors with the ability to pay out of pocket for home care services; Medicaid beneficiaries in need of home- and community-based services (HCBS); veterans in need of home care, paid for through Veterans Affairs (VA); and a small portion of MA beneficiaries and long-term care insurance clients.

If home care were paid for by Medicare in the future, that would take the concept of “unlimited demand” to a new level. There are over 30,000 home care agencies in the country, almost all of which would have a new market opportunity if Medicare became another means to pay for home care.

The one potential downfall for providers would be former private-pay home care clients being able to use Medicare to pay for services. Private-pay home care doesn’t come without challenges, but it remains one of the most profitable forms of home-based care business.

Home health providers – which already provide care to Medicare beneficiaries, almost exclusively – would also see a business boon. Many of them already provide home care, and the ability to care for clients through one revenue source in both service lines would be massively beneficial.

After all, home-based care is responsible for one of the only successful Center for Medicare and Medicaid Innovation (CMMI) demonstrations of late. The Home Health Value-Based Purchasing (HHVBP) Model – now implemented nationwide – has already saved Medicare billions, and is likely to save many more billions moving forward.

“We think access to personal care services could at least double from six million customers today. By our estimate, the extra spending would expand the [total addressable market] by ~30% to $110 billion per year,” Macquarie Capital wrote in an analyst note this week. “Since Medicare covers home-based medical services, we expect a wider adoption of the integrated care model following added personal care services coverage. This could also expedite the transition to value-based care. Providers could benefit from aligned incentives, streamlined operations and cost synergies.”

Then comes the question of viability, however.

Harris is not the first person to propose such an idea. Home care stakeholders have suggested it for years, but so have other policymakers.

“When the Affordable Care Act was passed, a component similar to this was included and that ultimately was stripped out,” Tyler Giesting, a director of health care and life sciences at West Monroe, told me this week. “I think we’ve seen it fail in the past for reasons that come down to: can it be economically viable? The challenge would be getting something like this passed, in the way that it has been described so far.”

The Harris campaign has suggested that it would pay for the proposal, in part, by cutting Medicare payments for drugs. It estimated that the proposal would cost around $40 billion per year.

But other estimates suggest that it would cost closer to $400 billion.

Harris sees the proposal as a way to aid the “sandwich generation” – adults that have aging parents to take care of, as well as children. Those responsibilities make it tough to maintain employment.

For Harris, the key would be to convince the right stakeholders of the overall value of home care. It wouldn’t be enough to just prove that more Americans could continue contributing to the economy if they had additional help at home for their older relatives.

Harris’ team would need to instead pitch this as a long-term cost savings project. If more seniors had access to home care, less seniors would be driving up U.S. health care costs in hospitals, emergency rooms and more costly brick-and-mortar facilities.

That is already a battle home care providers face. They are regularly trying to convince payers that more home care equals less overall cost. But a concrete plan, and concrete evidence of those potential savings, would have to be laid out.

“It’s one thing to have this idealistic proposal perspective, and it’s another to actually put it into action with a detailed plan,” Giesting said. “Then, there’s also getting it passed and put into law.”

A detailed plan is key. Even if we accept the idea that more access to home care could ease burden on Americans, while also keeping overall health care costs down, the implementation of the proposal through Medicare would need to be tirelessly thought out.

For instance, New York’s Consumer Directed Personal Assistance Program (CDPAP) – which allows family members to be paid to care for loved ones in need of home care – has been a fiscal disaster for the state.

Self-directed care has potential. It allows unpaid caregivers to be compensated, and for home care recipients to direct their own care. But it’s also hard to oversee.

For what it’s worth, if the proposal did move forward, I think the best way to go about it would be to prioritize care from existing, quality home care agencies. Agencies that train and vet their caregivers, ones that have been providing care professionally for a long time.

Trump proposals

The Trump campaign’s home care proposals are more understated. And, like Harris’ plans, more details would be needed to project true impact – for potential home care beneficiaries and providers.

“President Trump will prioritize home care benefits by shifting resources back to at-home senior care, overturning disincentives that lead to care worker shortages and supporting unpaid family caregivers through tax credits and reduced red tape,” the Trump campaign wrote in a release, in preparation for Harris’ announcement this week.

The campaign also evoked MA supplemental benefits. MA supplemental benefits – through the primarily health related pathway and the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway – were created during Trump’s presidential term.

The benefit that allows for home care services is dubbed In-Home Support Services (IHSS). MA plans have pulled back on offering IHSS in 2024, however.

“The Trump administration provided new Medicare Advantage supplemental benefits that included modifications to help keep seniors safe in their homes, respite care for caregivers, transportation coverage, additional in-home support services and assistance and non-opioid pain management alternatives,” the release continued.

The campaign also pointed out other indirect factors that have led to home care inaccessibility of late, such as inflation, which it believes it can continue to bring down.

Spotlight and policy

Home-based care being in the nationwide spotlight is a good thing for providers and older Americans.

But it’s also worth taking stock of where that spotlight has gotten us before. The Biden-Administration has been laser-focused on home care, but mostly HCBS through Medicaid.

Meanwhile, home health providers have been left behind. Advocates are in the throes of a three-year long fight against continued rate cuts from the Centers for Medicare & Medicaid Services (CMS), as other home-based care proposals are taking shape from both campaigns.

Home health providers are seeing their traditional Medicare payments cut, while also receiving payments from MA plans that often don’t cover the cost of care. All the while, MA penetration continues.

In April of 2023, I wrote about why federal support for home-based care is missing the mark.

While proposals from both campaigns this week contain some good elements, that fact remains true.

As home-based care takes center stage once again, Medicare-certified home health providers are forced to stand behind the curtains, at a time when their margins are evaporating.

“I would also want to remind the Biden, Harris administration that the existing Medicare home health program is under assault currently, and has been since 2020, with billions of dollars in cuts that have diminished access to care, so I think that investment and a stabilization of the existing Medicare home health benefit is something that is also needed,” Partnership for Quality Home Healthcare CEO Joanne Cunningham told HHCN this week. “With this news, I would just offer that recommendation and reminder.”

The post With The Election Nearing, Candidates Battle Over Home-Based Care appeared first on Home Health Care News.

The Transforming Episode Accountability Model (TEAM), which would eventually be mandatory if finalized, would have selected acute care hospitals put under full responsibility for the cost – and quality – of care from surgery up until the first 30 days after hospital discharge.

CMS said that the model would build on the already existing Bundled Payments for Care Improvement Advanced (BPCI-A) and Comprehensive Care for Joint Replacement models.

The proposed model would launch on Jan. 1, 2026, and run for five years, ending at the end of 2030.

“TEAM would be a mandatory episode-based alternative payment model in which selected acute care hospitals would coordinate care for people with Traditional Medicare who undergo one of the surgical procedures included in the model (initiate an episode) and assume responsibility for the cost and quality of care from surgery through the first 30 days after the Medicare beneficiary leaves the hospital,” CMS wrote. “As part of taking responsibility for cost and quality during the episode, hospitals would connect patients to primary care services to help establish accountable care relationships and support optimal, long-term health outcomes.”

Given those all-important 30 days post discharge involved in the TEAM model, home health providers will naturally play a role in helping hospitals achieve high-quality outcomes.

The National Association for Home Care & Hospice (NAHC) is still awaiting further details, but sees home health agencies as squarely involved in the Innovation Center’s proposal.

“Much of the specifics are still to be decided,” NAHC President William A. Dombi told Home Health Care News. “Home health agencies can be expected to be significantly involved with the participating hospitals given the nature of the surgical patients that will be targeted, such as hip fractures and joint replacement patients.”

As part of its strategic direction, CMS wants all Medicare fee-for-service beneficiaries to be in a care relationship with accountability for quality and total cost of care by 2030.

TEAM would be yet another model furthering that goal, if enacted.

Dombi also noted that there could be both upsides and downsides to the incentives tied to the model.

“In many ways the integration of home health agencies will be essential to achieving the price targets that the hospitals will be operating under during an episode of care,” Dombi continued. “The upside is the likelihood that agencies will see increased patient referrals away from what might otherwise be a SNF referral. The downsides include the potential that the hospital will push patients towards the hospital’s outpatient services.”

Home health involvement

The BPCI-A model, which CMS referenced in its TEAM announcement, is a good comparison from the home health perspective.

“They can be involved in formal alignment agreements with participants that could take a variety of forms, and those could be financial, those could be participatory, those could be any number of things,” Michael Wolford, principal at the public accounting firm Forvis, previously told Home Health Care News regarding BPCI-A. “Home health tends to be a lower cost post-discharge setting for Medicare patients. Providers with financial incentives that exist in the BPCI-A model often look for a combination of clinical efficacy, successful patient outcomes and cost-effectiveness of care. Home health tends to rise to the top in those situations.”

Nick Seabrook, the managing principal at the home health consulting and executive search firm SimiTree, sees home health providers playing a similar role in the TEAM model.

“There’s a new CMMI initiative that just came out yesterday, the TEAM model,” Seabrook said at Home Health Care News’ Capital + Strategy event last week. “And basically, what it’s aimed at is better care coordination post-surgery. So, working with home care providers and other post-acute providers to make sure that [beneficiaries] are getting those adequate services that they need after those surgeries.”

CMS mentioned that care for post-surgery beneficiaries can often be fragmented, resulting in poor outcomes.

Health equity would also be a key measure under the TEAM model.

“People with Traditional Medicare undergoing a surgical procedure either in the hospital or as an outpatient may experience fragmented care that can lead to complications in recovery, avoidable hospitalization, and other high costs,” CMS wrote. “This is because in a fee-for-service (FFS) payment system, providers and suppliers are paid separately for each service and procedure, potentially resulting in fragmented care, duplicative use of resources, and avoidable utilization.”

The post CMMI’s Proposed TEAM Model Offers Another Risk-Based Opportunity For Home Health Providers appeared first on Home Health Care News.

The Home Health Value-Based Purchasing (HHVBP) Model is one of the Center for Medicare and Medicaid Innovation’s (CMMI) only cost-saving successes, which is why it was expanded nationwide on Jan. 1, 2023.

Just six of 49 CMMI payment demonstrations have produced savings, with HHVBP standing out in a major way. HHVBP is expected to save hundreds of millions of Medicare dollars on a yearly basis moving forward.

The HHVBP demonstration alone saved the Centers for Medicare & Medicaid Services (CMS) $1.38 billion. Some home health providers believe those savings – as well as future savings in the expanded model – should be shared with them.

That doesn’t seem to be in the cards. But quality home health agencies do stand to benefit, at least to a certain extent. Those performing above the 50th percentile under the model get positive payment adjustments up to 5%. Those performing below that threshold see a negative payment adjustment, however, of up to 5%. The first performance year was 2023.

All the while, CMS continues to change the HHVBP model, implementing tweaks yearly that raise provider eyebrows.

“The one [change] that’s scary is the OASIS-based discharge function score; it’s a brand new measure,” Healing Hands Healthcare CEO Summer Napier told me in November. “You’re looking at what you expect that patient’s discharge function to be when you submit that score. But a lot of what happens from the time a patient comes on service until they’re discharged is out of our control, right? One of the things that we get held accountable a lot for in home health is everything else that the care team does that’s outside of home health.”

Other parties have their eyes on the model – and CMS’ changes to it – as well.

Recently, a technical expert panel (TEP) dove into HHVBP, and provided subsequent thoughts on its measures’ strengths and weaknesses. The panel’s latest findings and meeting summaries were released in December.

Some of those findings were refreshingly new, while others backed up home health provider gripes.

We dive into those findings in this week’s exclusive, members-only HHCN+ Update.

Reviewing HHVBP adjustments

The TEP is made up of health care experts with diverse backgrounds that catapulted them to “expert” status. There were professors, researchers, front-line workers and business owners on the panel. Many of them had direct experience in home health care.

The panel’s goal was to provide input and advice to CMS on the measures it was considering putting forth in the expanded HHVBP model, viewing things from a provider perspective – and health equity perspective – as well.

The TEP will continue to meet in the future to discuss refinements to the HHVBP model, and it will meet in person once per year and virtually four times per year moving forward.

There were many suggestions from the TEP that seemed worthwhile to share with home health stakeholders, beginning with those tied to health equity.

When the model was expanded, nonprofit home health agencies were immediately concerned. Specifically, they were concerned that they would ultimately be penalized for taking care of sicker, more complex patients. Providing care in underserved and socioeconomically challenged areas could mean less patient improvement during an episode of care, resulting in negative payment adjustments for those agencies.

The TEP warned CMS about the possibility of agencies prioritizing certain patients under the HHVBP model to achieve better scores.

One suggestion was to consider a Health Equity Adjustment (HEA) similar to the one being implemented for skilled nursing facilities in 2027. Under that adjustment, providers could receive “bonus points” added to the total performance score (TPS) depending on their “performance level and share of dually eligible beneficiaries.”

But there was concern from the TEP that would actually exacerbate disparities in the home health setting.

Ultimately, the TEP urged CMS to focus on certain factors with health equity in HHVBP in mind: “The TEP reiterated that caregiver availability, payer source, and history of missed visits are key drivers of patient success in home health and encouraged CMS to consider developing measures related to these factors.”

CMS already adjusted the measures that matter most for HHVBP in the CY 2024 final home health payment rule.

One HHVBP measure CMS plans to introduce – “improvement in dyspnea” – got a reaction from the TEP. Panelists expressed concern that this would be an area difficult for home health agencies to improve on, while also cautioning that improvement could lead to bad motivators.

“The concerns expressed by the TEP about the Improvement in Dyspnea measure did not lead them to support dropping the measure from the expanded HHVBP Model,” the TEP summary read. “Rather, several TEP members stated that they felt the measure of the weight of the measure should be decreased (with a corresponding increase in the weight of the claims and HHCAHPS survey-based measures). They suggested that CMS continue to monitor HHA performance on this measure to ensure that the benchmarks and achievement thresholds are consistent with clinical expectations about how well HHAs can perform on this measure.”

The TEP noted that an “improvement in the management of oral medications” is difficult, too, because it would not apply to all home health patients. Several panelists also recommended reducing the weight of that measure.

The panelists also suggested that HHCAHPS survey-based measures reword questions to ensure that respondents understood they were rating their experience with the home health agency they interacted with.

In terms of the discharge function score touched on above by Napier, panelists were generally supportive of the measure. They did provide caveats, however.

“Several TEP members agreed that it is good that the measure is not focused on improvement, which reduces concern about upcoding,” the TEP summary read. “One TEP member noted that it is important to recognize that not all patients have the same potential to improve, which means that, for some patients, slowing decline or stabilizing is a positive outcome.”

Several panelists also were concerned that the discharge function measure does not include all the activities of daily living elements, such as bathing and dressing, which have been a major focus for home health agencies in the past.

Positive overview

Providers often find that regulators are out of touch with the ins and outs of home health care delivery. Simple adjustments to scoring in HHVBP can both be nonsensical and extremely damaging to a home health business’ bottom line.

While industry stakeholders may believe that their concerns fall on deaf ears at CMS from time to time, it should be reassuring that there are examinations, like the above, being sent directly to the agency.

The post Certain HHVBP Measures Remain Disconnected From On-The-Ground Home Health Care Delivery appeared first on Home Health Care News.

In a Health Affairs article published Thursday, top CMS officials at CMS — including Administrator Chiquita Brooks-LaSure — looked back at a decade of alternative payment models launched through the Center for Medicare and Medicaid Innovation (CMMI). In addition to Brooks-LaSure, authors of the piece included CMMI Director Elizabeth Fowler as well as Meena Seshamani and Daniel Tsai, who oversee Medicare and Medicaid, respectively.

CMMI was created through the Affordable Care Act in 2010. Its goal: to move toward a more value-based system in order to curb costs and improve the quality of care.

Since its 2010 launch, CMMI has rolled out more than 50 alternative payment models that compensate health care providers for delivering high-quality care while lowering costs. Of these, CMS officials have singled out HHVBP as one of the six that have accomplished CMMI’s mission.

Specifically, the model has resulted in an average annual savings of $141 million to Medicare since its 2016 implementation, according to CMS. It is also one of four models that met the requirements to be expanded in duration and scope.

Broadly, HHVBP is a Medicare demonstration that aims to tie reimbursement to quality of care. Under the model, home health providers are paid based on how well they keep their patients healthy and out of the hospital.

Currently, Medicare-certified home health agencies in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee participate in the HHVBP demo. CMS is proposing to expand HHVBP nationwide next year.

The Visiting Nurse Service of New York (VNSNY) is among the home health providers supportive of the move.

“Well, frankly, we do support the home health VBP, even though New York was not part of the demo,” VNSNY CEO Dan Savitt said during a recent HHCN+ TALKS appearance. “We’ve embraced VBP as a company. I’ve been saying for years to the payer community, ‘Let us take the risk, and we’ll show you what we can deliver in terms of value to the patient and the payer.’”

New York-based VNSNY is one of the largest not-for-profit home- and community-based health care organizations in the U.S. Its offerings include home health, hospice and palliative care services, in addition to mental health support and more. The organization cares for more than 44,000 patients per day.

While HHVBP has received industry support, VNSNY and other providers are pushing CMS to build in more upside opportunities as part of the expansion.

“We know that the VBP program and the demo saved $141 million in one year in just those nine states,” Savitt said. “If you think about that, that should be in the pie to share. In a true value-based agreement — and in our value-based arrangements — we’re sharing.”

Over the course of the next 10 years, one of CMMI’s key areas of focus is to re-evaluate how it designs financial incentives for its various models. In doing so, CMS is hoping to encourage substantial provider participation.

“While voluntary models can demonstrate a proof of concept, they limit the potential savings and full ability to test an intervention, because participants opt-in when they believe they will benefit financially, and opt-out, or never join, when they believe they are at risk for losses,” the CMS officials wrote in the Health Affairs piece.

In addition to the recent piece from the four CMS officials, Health Affair also published an article highlighting strategies for integrating more patient-centered elements into alternative payment models. One of the key strategies included increasing access to home- and community-based services to meet patients where they are.

“Policymakers and providers should use [alternative payment models] that provide population-based or capitated payments to support the flexible delivery of care where patients may need it most,” the piece noted.

Doing so would allow patients to utilize appropriate home-based services. This could mean home-based primary care, hospital-at-home, or a number of home- and community-based services.

Another strategy is addressing the social determinants of health (SDoH). This requires clinical and community service providers to form relationships and the right payment mechanisms.

“Population-based or capitated payments can better support providers to make meaningful connections between patients and non-health-related service needs,” the piece explained. “[Alternative payment models] could also account for SDoH in risk-adjustment methodologies or provide a small payment to providers that serve high proportions of beneficiaries with social needs.” 

The post CMS Officials Reflect on the Home Health Value-Based Purchasing Model’s Success appeared first on Home Health Care News.

Liz Fowler, the new head of the Center for Medicare and Medicaid Innovation (CMMI), has been thinking about this value-based care “crossroads” since joining the agency not quite two months ago.

“We want the CMS Innovation Center model tests to work, to lower costs, improve quality of patient care and better align payment systems to promote patient-centered practices,” Fowler said Tuesday during a National Association of ACOs (NAACOS) virtual event. “But we also need to be honest about the nature of innovation, that not everything is going to be a home run. Some things will work, others won’t.”

NAACOS is a Washington, D.C.-based advocacy group that represents hundreds of accountable care organizations (ACOs) across the country.

Since its formation following the Affordable Care Act’s passage, CMMI has developed more than four dozen alternative payment models, with only four becoming a permanent part of Medicare. The mandatory nine-state Home Health Value-Based Purchasing (HHVBP) Model is one of the innovation hub’s most successful demonstrations, government data suggests.

CMMI has rolled out a handful of its alternative payment models over the past couple of years alone. Prominent examples include its somewhat controversial direct-contracting initiative, which currently features the “Global” and “Professional” options with different degrees of risk for participants.

Another direct-contracting concept known as the “Geographic Direct Contracting Model” was originally scheduled to begin on Jan. 1 of next year, but the new Biden administration CMMI has opted to put it under review for an undefined period of the time.

NAACOS is among the groups to raise concerns about direct contracting.

“In my view, we’re at a really critical juncture in the path toward value-based care,” Fowler said. “And this is my perspective, having worked on these issues for a while. I feel like over the last 10 years since the center was established, we’ve lost some consensus in the stakeholder community about what we’re trying to achieve.”

Fowler isn’t the only health care expert to critically question the CMS Innovation Center’s ongoing projects. The Medicare Payment Advisory Commission (MedPAC), for instance, has discussed how CMMI needs a more harmonized portfolio of alternative payment models with fewer, more strategic designs.

Former Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma has similarly talked about a need for recalibration.

“The center stands in need of a course correction in model design and portfolio selection, if value-based care is to advance,” Verma said in October.

CMMI and CMS haven’t just pumped the brakes on the Geographic Direct Contracting Model. Earlier in April, policymakers announced they were shutting down a second round of applications for the Global and Professional options.

So far, 53 organizations have been approved to take part in Year 1 of the two directing-contracting options. Of those, 39 are participating in the Global option and 14 in the Professional option.

In March, CMS also revealed plans to delay implementation of the Primary Care First Serious Illness Population payment model, with no new start date in sight.

On her end, Fowler took a “two steps forward, one step back” stance on those moves.

“Innovation and health system transformation is not easy, and it is an iterative process,” she said at the NAACOS event. “At CMMI, we want our alternative care models to position participants for success. Sometimes that means speeding up when there’s an opportunity, and sometimes it means taking a beat to ensure that a forthcoming model can realistically deliver on what’s intended — and that it’s the strongest option based on our evidence and data.”

Prior to her post at CMMI, Fowler was executive vice president of programs at The Commonwealth Fund and vice president for global health policy at Johnson & Johnson. She was chief health counsel to Sen. Max Baucus (D-Mont.), chair of the Senate Finance Committee, from 2008 to 2010, playing a critical role in developing the Senate’s version of the Affordable Care Act.

While CMMI is carefully evaluating all of the new alternative payment models emerging, the agency is not any less dedicated to advancing its value-based care mission, Fowler emphasized.

“We’re taking a look at the portfolio,” she said. “In the words of a previous CMMI leader, it’s really like looking at your retirement portfolio and, every once in a while, [realizing] it needs to be rebalanced.”

The post New CMMI Director Liz Fowler: US at ‘Really Critical Juncture’ on Path to Value-Based Care appeared first on Home Health Care News.

Despite backing from most of the home health industry, the HHVBP Model — first implemented in 2016 — had seemingly hit a speedbump in recent years. Apart from a handful of minor modifications, the model only remained active in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee.

With more than one-quarter of its home health agencies currently located in HHVBP states, the Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED) has been among the biggest supporters of value-based purchasing. The company has persistently urged the Center for Medicare & Medicaid Innovation (CMMI) to expand the model for over a year.

“There’s still a perception out there that there is a high level of fraud in home health care — and that’s simply not true,” Amedisys CEO and President Paul Kusserow told Home Health Care News. “I think having to prove ourselves on the quality front and being willing to take risk on quality is absolutely the right thing for us.”

So far, even just the limited HHVBP Model has been able to achieve overwhelmingly positive results.

Since its implementation, the model has contributed to a 4.6% improvement in home health agencies’ quality scores, in addition to average annual Medicare savings of $141 million, federal statistics show. On top of those points, agencies in HHVBP states have been able to significantly lower the costly utilization of hospitals and skilled nursing facilities (SNFs).

“This has been extremely good,” Kusserow said.

As part of its push for an expanded HHVBP Model, Amedisys brought in Washington, D.C.-based research and consulting firm The Moran Company. The home health giant asked Moran to dig deeper into past results and explore what a nationwide rollout would eventually look like.

After cranking the numbers, the research firm estimated that a 50-state HHVBP Model would result in about $6.3 billion in savings over a 10-year period, using Congressional Budget Office (CBO) scoring methodology.

“We engaged in a very long dialogue [with CMMI] and exchanged a lot of data to push this forward,” Kusserow added.

Inside the advocacy process

Besides the whopping $6.3 billion in savings, Moran also determined that a nationwide rollout of the Home Health Value-Based Purchasing Model would lead to better post-acute care outcomes for Medicare beneficiaries and more ways for the U.S. Centers for Medicare & Medicaid Services (CMS) to identify high- and low-quality providers.

In many ways, the advocacy efforts around HHVBP were so effective because they were driven by “the power of a good idea,” according to David Kemmerly, the chief legal and government affairs officer at Amedisys. Instead of having to artfully persuade CMS and CMMI to expand the model, his team’s job was more about giving policymakers the objective information they otherwise lacked.

“They have to go make their case with the actuaries before they can expand something,” Kemmerly told HHCN. “So we helped arm CMS with the data and information they needed.”

It took more than facts and figures, however.

To help advance HHVBP, Kusserow communicated regularly with CMMI Director Brad Smith, the former CEO of home-based palliative care provider Aspire Health who joined the CMS Innovation Center in early 2020. Kusserow and Smith had already “known each other a long time,” thanks to their shared experiences in Nashville, Tennessee, and standing as Rhodes scholars.

“When [Smith] went to Washington, he called me up and said, ‘What should I be thinking about?’” Kusserow said. “Obviously, he was asking a lot of people that. I said, ‘I really think there’s something to value-based purchasing in home health. I’d really like you to look at it.’”

At first, CMMI decision-makers were concerned about home health provider buy-in.

While Amedisys and others sought to advance HHVBP, others were slightly skeptical, especially early on. More than a few home health operators believed HHVBP was just another piece of government regulation, with others too preoccupied with the Patient-Driven Groupings Model (PDGM) to worry about alternative payment mechanisms.

On its end, Amedisys worked hard to boost the industry’s understanding and acceptance of HHVBP, Kemmerly said.

“There’s a bit of politics involved,” he noted. “[Smith] asked us early on, ‘Where is the industry on this? And can you bring the industry to the table?’”

Unanswered questions

CMMI and CMS are committed to expanding the Home Health Value-Based Purchasing Model, but there are plenty of questions left to answer — and improvements that can be made.

On a basic level, it’s still unclear whether policymakers will try to expand HHVBP through a standalone proposal or through the annual rulemaking cycle. Additionally, it’s not yet known whether that future expansion will be national or more incremental, possibly adding another dozen or so states to the current nine-state mix.

Scott Levy, the senior vice president of government affairs at Amedisys, was in the trenches for most of Amedisys’ advocacy battle on HHVBP. In all likelihood, CMS will pursue a 50-state expansion and implementation through the annual rulemaking cycle, Levy speculated.

“I’m just merely reading between the lines, but our discussions [with CMS] and our data presented to them was all based on the idea of a nationwide expansion,” he told HHCN.

Along with answers to those questions, Amedisys is also pushing for improvements to the HHVBP Model itself.

In 2020, home health providers were exposed to 6% upside and downside risk, depending on their quality performance. That figure increases to 7% and 8% in 2021 and 2022, respectively.

But it’s almost impossible to come close to that full upside or downside as the model is currently structured.

“The upside has been good for us. It’s generally quite positive,” Kusserow said. “But we feel the curve is too clustered toward the center. It is very hard to get the full rewards or to get the full penalties.”

In 2018, the payment adjustment in HHVBP ranged from a 1.5% penalty for providers in the lowest-10th percentile to a 1.5% bonus for providers in the highest-10th percentile, according to an investment note from Bank of America. CMS previously stated that the average adjustment was a 0.85% bump in 2018.

“Companies out there with good technology, good tracking systems, good checklists, good verification processes and very good clinical operations are the ones that are going to continue to do well and thrive under this, for sure,” Kusserow said.

A possible complication to HHVBP expansion plans could have been the transition to a new Biden administration, which is guaranteed to bring changes to CMMI, CMS and throughout the U.S. Department of Health and Human Services (HHS).

Yet the team at Amedisys doesn’t see that as an issue, considering the model’s origins.

“[HHVBP] was actually rolled out by the Obama administration,” Levy said. “It was proposed during the fall of 2015 for a January 2016 implementation.”

The post National Expansion of Home Health Value-Based Purchasing Model Estimated to Create $6.3B in Savings appeared first on Home Health Care News.

The goal of that model — which has 51 entities already signed up — was to bring a private-sector approach to risk-sharing arrangements in traditional Medicare.

The U.S. Centers for Medicare & Medicaid Services (CMS) — along with the Center for Medicare & Medicaid Innovation (CMMI) — is now adding to its direct-contracting portfolio while also shining a light on home care.

CMS announced on Thursday that it’s launching the “Geographic Direct-Contracting Model,” another new, voluntary direct-contracting pathway designed to pay health care providers for the quality of their care and ability to cut costs.

The launch shouldn’t come as a surprise to those who have been listening to CMS Administrator Seema Verma or CMMI Director Brad Smith over the past couple of months. Even with immediate coronavirus-related challenges within the health care system, both underscored the government’s commitment to value-based care during an October virtual presentation. 

“The Geographic Direct-Contracting Model is part of the Innovation Center’s suite of Direct-Contracting models and is one of the Center’s largest bets to date on value-based care,” Smith said in a statement from Thursday’s announcement. “The model offers participants enhanced flexibilities and tools to improve care for Medicare beneficiaries across an entire region while giving beneficiaries enhanced benefits and the possibility of lower out-of-pocket costs.”

By initially testing the new direct-contracting model in a small number of geographies, CMS and CMMI will be able to thoughtfully learn how emerging flexibilities are able to impact quality and costs, he added.

Under the model, participants will take upside and downside responsibility for Medicare beneficiaries’ health outcomes, giving them a direct incentive to improve care in their given markets.

Within each geographic region, participants with experience in risk-sharing arrangements and population health will partner with health care providers and community organizations to better coordinate care.

“The need to strengthen the Medicare program by moving to a system that aligns financial incentives to pay for keeping people healthy has long been a priority,” Verma said in a statement. “This model allows participating entities to build integrated relationships with health care providers and invest in population health in a region to better coordinate care, improve quality and lower the cost of care for Medicare beneficiaries in a community.”

Medicare beneficiaries in the model will remain in traditional Medicare, maintaining all of their benefits and coverage rights.

Organizations that participate in the new Geographic Direct-Contracting Model may create “a network of preferred providers, armed with the model’s enhanced flexibilities to provide the right care for beneficiaries at a lower cost,” according to CMS. That will certainly include home-based care businesses, many of which go by the mantra of delivering “the right level of care at the right time.”

Additionally, participants and preferred providers may choose to enter into alternative payment arrangements, including prospective capitation and other value-based arrangements.

In other words, home-based care providers may have a new runway to take off into value-based care.

“Beneficiaries may also receive enhanced benefits, including additional telehealth services, easier access to home care, access to skilled nursing care without having to stay in a hospital for three days, and concurrent hospice and curative care,” CMS noted in its announcement.

The Geographic Direct Contracting Model will have two three-year performance periods.

The first performance period will take applications in 2021 and have a performance period from Jan. 1, 2022, through Dec. 31, 2024. The second performance period will take applications in 2024 and have a performance period from Jan. 1, 2025, through December 31, 2027.

CMMI expects to release a request for applications for the first performance period in January.

The agency has already identified 15 “candidate regions” for the new model, each of which contains between roughly 150,000 to 700,00 Medicare beneficiaries. Those regions include major metropolitan such as Philadelphia and Pittsburgh in the eastern to U.S., to San Diego and Los Angeles in the West.

More information on the new model is available here.

The post CMS Announces New Direct-Contracting Model to Promote ‘Easier Access to Home Care’ appeared first on Home Health Care News.

And part of that may include a national expansion of the Home Health Value-Based Purchasing Model.

Created under the Affordable Care Act, CMMI — also known as the CMS Innovation Center — supports the development and testing of innovative health care payment models. Since its formation, CMMI has developed at least 54 payment models, including the Home Health Value-Based Purchasing Model.

As U.S. health care costs continue to rise, CMMI’s work has grown increasingly important, especially around value-based care, according to Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma. National health care spending is expected to grow at an average annual rate of 5.4% from 2019 to 2028, outpacing the gross domestic product’s average annual growth rate of 4.3%.

But of those 54 payment models, only a handful appear to be working.

In fact, just five have shown statistically significant savings.

“In 2019 alone, over 450,000 providers participated [in those models], serving over 26 million patients,” Verma noted. “But more recently, the evaluation data for the early models have been completed. And unfortunately, the results are deeply concerning.”

Verma addressed CMMI’s progress and the future of value-based care on Tuesday during a virtual event hosted by CMS’s Health Care Payment Learning & Action Network (LAN). Verma was joined by Brad Smith, who co-founded and served as CEO of home-based palliative care provider Aspire Health before being named CMMI’s director in January.

“The Center stands in need of a course correction in model design and portfolio selection, if value-based care is to advance,” Verma said.

Providers ‘must have skin in the game’

Shifting the U.S. health care system toward value-based care is one of CMS’s many priorities, Verma remarked during the virtual event. In addition to payment, value-based care also means providing pricing transparency, strengthening interoperability and minimizing paperwork burden for providers.

When it comes to establishing more successful value-based payment models, CMMI needs to prioritize two pillars, Verma said.

First, it must step back from voluntary models “designed with an abundance of financial carrots to attract participation.”

“Models must incorporate design elements that require participants to have skin in the game,” Verma said. “Models where providers have downside risks have actually performed better.”

Secondly, CMMI needs to do a better job of developing effective, meaningful benchmarks to measure the success of value-based payment models.

Smith echoed that idea, pointing out that CMS and CMMI have been too generous or lenient in judging how new payment mechanisms are performing.

“CMMI has learned a tremendous amount over the past 10 years about value-based care arrangements, and we are grateful for the tremendous participation we have had to date in our models,” Smith said at the LAN event. “As we move into the next phase of the Innovation Center, we believe we must push even harder to move more providers into value-based care payment arrangements.”

Expanding the Value-Based Purchasing Model

While most of Tuesday’s remarks took a hard look at what CMMI has accomplished thus far, both Verma and Smith did point out several positives.

Smith, for instance, called out the Home Health Value-Based Purchasing Model as one of the Innovation Center’s most successful efforts.

Implemented in 2016, the Value-Based Purchasing Model was designed to pay home health providers in nine states based on outcomes and the value of services delivered. This year was the sixth year of CMMI testing out the model, exposing home health providers to 6% upside or downside risk based on their performance.

Home health providers in participating states have mostly supported the value-base model, with many calling for a national expansion beyond the current states of Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee and Washington.

CMMI hasn’t hinted it has any plans to do so — until now.

“As we look at our portfolio, we have other models that we believe may be able to expand in the coming years,” Smith said. “For example, our Home Health Value-Based Purchasing Model has shown significant cost savings and improvement on key quality metrics. It’s one of the examples of the models that we’re looking at to think about if we could expand it nationally in the next year or so.”

Besides the Value-Based Purchasing Model, Verma and Smith likewise pointed to the relatively new Primary Cares Initiative and the related direct-contracting model as impactful value-based care efforts.

“Last year, we announced the CMS Primary Cares Initiative, featuring the direct contracting model, which has the potential to drive quality and value across the entire system in a way that we’ve never seen before,” Verma said. “Going forward, we believe direct contracting can take an exciting new step with a geographic option, in which a set of entities would take on full risk for all eligible Medicare beneficiaries in a certain region.”

The post Home Health Value-Based Purchasing Model Set for Nationwide Expansion in ‘Next Year or So’ appeared first on Home Health Care News.

The bill, dubbed the “Strengthening Innovation in Medicare and Medicaid Act,” could handcuff CMMI and reduce its output — forcing the innovation center to instead abide by further reporting requirements.

The lawmakers’ worry is that CMMI, which was founded under the Affordable Care Act, has too much free rein. Even if its efforts are well-intentioned, the concern is that patient care could be compromised without additional standards and transparency requirements.

Moreover, lawmakers worry that — if left unchecked — CMMI may only add fuel to the health care spending fire. Currently, nearly one-fifth of U.S. GDP is tied to the health care sector.

U.S. Reps. Terri Sewell (D-Ala.), Adrian Smith (R-Neb.), Tony Cárdenas (D-Calif.) and John Shimkus (R-Ill.) introduced the bill. Rep. Sewell — a co-sponsor of the Home Health Payment Innovation Act — has been a particularly active lawmaker over the past several months when it comes to new health care bills.

The newly introduced bill comes just a few weeks after CMMI appointed a new director, Brad Smith, who formerly co-founded and worked as the CEO of the home-based palliative care provider Aspire Health before it was sold to national insurance giant Anthem in May 2018. Smith most recently served as the COO of Anthem’s diversified business group, which Aspire became a part of.

The former director of CMMI, Adam Boehler, left the position in July when he was selected to lead the International Development Finance Corp. (DFC). Boehler emphasized in-home as well as value-based care to reduce spending, which is the agency’s main priority.

With Smith at the helm, home-based care agencies expected the innovation to continue, Bruce Greenstein, the chief strategy and innovation officer at LHC Group Inc. (Nasdaq: LHCG), said at Home Care 100 in January.

“If you think that over the last few years the [CMMI] has been producing too much for you to keep up with, keep your seatbelt buckled,” Greenstein said in January. “There will be a lot more coming.”

It’s possible that the new bill could jeopardize that. It would require HHS to implement a plan to monitor the effects of models on patients and seek to “mitigate any adverse impact, including reductions in care or reduced access to care … .”

Although the bill could create new burdens for CMMI, Greenstein is more bullish on its premise. Additionally, he thinks that Congress paying close attention to things like CMMI at all is a good thing.

“[Congress] has been seemingly divisive over health care issues for a really long time,” Greenstein, the former chief technology officer of HHS, told Home Health Care News. “There are things that they do come together on. I think about the 21st Century Cures Act — that was an incredibly bipartisan bill, and it really addressed part of our health care system that really needed help.”

The bill could lead to more disapprovals, but if CMMI isn’t thrown off its groove of producing creative solutions to reduced spending, perhaps more oversight from Congress and more feedback incorporated from providers could improve the agency’s efforts.

I think it’s always positive when we have an organ of government that has the responsibility of innovating in our health care system, and they’re doing that,” Greenstein said. “And I think it’s very positive when Congress is paying close attention to it.”

The post Federal Lawmakers Look to Handcuff CMMI appeared first on Home Health Care News.

That’s according to LHC Group Inc. (Nasdaq: LHCG) Chief Strategy and Innovation Officer Bruce Greenstein, who discussed the future of health care and embracing risk last week at the Home Care 100 conference in Aventura, Florida.

“If you think that over the last few years the Centers for Medicare & Medicaid Services (CMMI) has been producing too much for you to keep up with, keep your seatbelt buckled,” Greenstein told Home Care 100 attendees. “There will be a lot more coming.”

Specifically, Greenstein’s comments on CMMI and what providers should expect were prompted by a question related to Brad Smith, who officially became Adam Boehler’s replacement for running CMS’s innovation arm earlier in January. Prior to joining CMMI, Smith co-founded and served as CEO of home-based palliative care provider Aspire Health before it was acquired by Anthem Inc. (NYSE: ANTM) in 2018.

Boehler was widely known as a supporter of value-based payment models and in-home care. Smith will likely bring more of the same, according to Greenstein. The LHC Group executive is a former Washington veteran himself, having previously served as chief technology officer for the U.S. Department of Health and Human Services (HHS).

Although he doesn’t know Smith directly, early signs point to lots of activity from CMMI’s new leader, Greenstein said.

“I was texting with a pal that came from the government world not long ago,” he said. “I asked, ‘What’s the early word on Brad?’ The word was the guy has definitely hit the ground running. He’s going like crazy, and [CMMI] is trying to provide him with a good understanding of how the bureaucracy works so he can create more models like Adam Boehler had the chance to do.”

In the early going, Smith is tasked with building out CMMI’s Primary Care Initiative, unveiled in April. On a high level, the Primary Care Initiative creates five new, risk-based payment models through two main pathways: Primary Care First and Direct Contracting.

While the details of each new payment model are still being rolled out, they’ll likely create ample opportunities for all types of home-based care providers, Greenstein said. That’s especially true for those who provide palliative care under the new Seriously Ill Population (SIP) payment option. 

Today, palliative care is often paid for by MA, private insurance or on a private-pay basis.

“Primary Care First really should involve quite a bit of activity from care-in-the-home providers,” he said. “We’d probably offer [palliative care] a whole lot more if we can get paid for it without losing money. We’re just able to pay the bill [at this point].”

On its end, the Lafayette, Louisiana-based LHC Group has already signed up for being a provider in the Primary Care First program. Its participation in the new value-based payment models adds to the company’s already extensive history in risk-sharing and value-based arrangements.

LHC Group’s organizational risk profile, for example, includes participation in the Medicare Shared Savings Program (MSSP) and Next Generation accountable care organization (ACO) models. Its profile also includes risk-based MA contracts and participation in the Home Health Value-Based Purchasing (HHVBP) model.

On top of those efforts, the company also is active in Model 3 of the Bundled Payments for Care Improvement initiative (BPCI), in addition to BPCI Advanced and hospital-at-home demonstrations.

With those and other value-based payment structures emerging, providers can no longer afford to sit on the sidelines and exclusively focus on fee-for-service Medicare, Greenstein cautioned. That doesn’t mean giving up all fee-for-service business in the present, but there’s inherent danger in neglecting the fact that the home-based care market is in the middle of rapid, sweeping changes.

“Work hard to understand what the opportunities are because you don’t want to be passed up or commoditized in the process,” he said.

Understandably, many providers are somewhat reluctant to move away from a predominately fee-for-service reimbursement mix.

In 2018, the average home health fee-for-service Medicare margin checked in at 18%, according to the Medicare Payment Advisory Commission (MedPAC). For 2020, MedPAC estimates that margins will hover around 21%.

Meanwhile, all-payer margins — including MA — are about 4.3%.

Looking at the home health industry as a whole, the typical agency gets about 55% of its funding from Medicare, with Medicare Advantage making less than one-fifth of the representative agency’s reimbursement stream, according to MedPAC.

“Don’t give up any fee-for-service business because you’re so excited about MA,” Greenstein said. “But don’t lose sight that the market is definitely changing every single day. My one prediction is — especially with somebody like Brad, regardless of what you think about the Medicare program and different administrations — that we’ll continue on a fairly predictable path.”

“Within 10 years, it’ll be the end of fee-for-service as we know it,” he added.

The post LHC Group’s Innovation Head: ‘Within 10 Years, We’ll See the End of Fee-for-Service as We Know It’ appeared first on Home Health Care News.