Kalon Mitchell sold his company to the post-acute technology organization WellSky in 2018. He then worked for WellSky for five more years, learning the ins and outs of the home health industry in the meantime.

After leaving WellSky, and with some more time on his hands, Mitchell decided to start “Project Sword”, which leverages cost reporting data to analyze the financial position of home health providers at large.

The data shows not an industry enjoying close to 20% margins, but instead one that is in a deeply precarious position moving forward.

The Centers for Medicare & Medicaid Services (CMS) has proposed cuts to home health payments three years in a row. Though its last two final payment rules have not been as harsh as its proposals, they have still come with permanent cuts to payments.

Providers have multiple gripes with these cuts. The first is over the payment methodology that CMS applies, which most providers and advocates strongly disagree with. The second is the rising costs that home health agencies have recently faced. While CMS is cutting home health payment in traditional Medicare, the cost of providing services has skyrocketed – namely due to the cost of labor.

But the final gripe is the one that has turned into a “generational battle” for providers, and that is MA penetration and payment.

Over 50% of Medicare beneficiaries are now under an MA plan, and those plans generally pay far less for home health care than traditional Medicare.

Providers have regularly told Home Health Care News that MA payment for home health services doesn’t cover the cost of delivering care. But providers tend to be mission driven, and also have referral relationships to uphold. Therefore, they continue to take on MA patients, which sinks their overall margins.

Essentially, traditional Medicare subsidizes MA plans in home health care. It’s true that if providers only took traditional Medicare, they would likely enjoy healthy margins. On the other end, though, if they only took MA, they’d likely have inoperable businesses.

While providers have shared these MA payment horror stories anecdotally, it’s been hard to get a good overall picture of what the average home health provider’s margin looks like of late – as both MA penetration and traditional Medicare rate cuts continue unabated.

The whole picture

Whereas traditional Medicare subsidizes MA in home health care, the opposite dynamic exists for hospitals.

MedPAC has repeatedly said that it can only consider Medicare payments when analyzing the home health industry.

“The Commission’s review indicates that FFS Medicare’s payments for home health care are substantially in excess of costs,” MedPAC wrote in its March report. “Home health care can be a high-value benefit when it is appropriately and efficiently delivered, but these excess payments diminish that value.”

At the same time, MedPAC includes all-payer data for hospitals in its reports. For instance, it acknowledged that aggregate hospital margins on traditional Medicare had fallen to -11.6% in 2022, while aggregate “all-payer” margins were at about 2.6%.

But in home health care, the other side of the payment picture is not acknowledged.

“In the MedPAC report, they say one of the supposed foundations of what they’re supposed to do is look at all-payer margins,” Mitchell told HHCN. “And in the chapter on home health, there is no mention of all-payer margins.”

What Mitchell found while working on Project Sword was that MA payments were erasing the healthy margins that could potentially come with a revenue mix dominated by traditional Medicare.

Project Sword and MedPAC’s analyses spit out similar data for Medicare margins, lending credence to Mitchell’s all-payer margin calculations.

When it came to the all-payer outlook, Mitchell found that home health margins sunk below the break-even point.

While 59% of home health agency revenue still comes from traditional Medicare, those beneficiaries now account for only 45% patient censuses.

Cost reporting generally lags, which is why much of the data Mitchell used is from 2022.

But since that point, it’s likely that the situation has exacerbated. MA penetration has continued, while CMS has gone through with another payment cut in traditional Medicare.

“We can see a deteriorating industry, and yet the narrative from CMS and MedPAC is that there’s no better industry to be in than home health care,” Mitchell said. “They have the highest profit margins, and that’s what Congress sees when they look at their report. That’s what they hear when they talk to CMS and MedPAC. But when they talk to agencies and advocates, they hear the opposite.”

Mitchell has been cleaning and trimming the data as much as possible to ensure that his project can turn into a meaningful tool for the industry.

Providers have also told him – and HHCN – that the numbers are on par with what they’re seeing internally.

“We want to take care of everybody, but the reality is that the payments we get from fee-for-service Medicare Advantage don’t typically cover our costs,” Michael Johnson, the chief researcher of home care innovation at Bayada Home Health Care, recently told HHCN. “So, we’ve got to make sure we have the right and best mix. That isn’t any different [than in years past], but we have to take even more clarity and focus on that approach now.”

Bayada has been around for nearly 50 years. It also has hundreds of locations, both in the U.S. and abroad.

While the current payment dynamics are tough, the company has the means to survive. It has the means to find a better payer mix, to become more efficient operationally.

Bayada and other larger home health providers also have a chance to get a better deal with MA plans. That could mean a better per-visit rate or some sort of value-based arrangement.

For smaller providers, that’s not the case.

“We have been very selective on what payers that we work with because of this,” LTM Group CEO David Kerns told Home Health Care News. “But I think especially smaller agencies, they may not have a payer innovation team, for instance. We’re not a huge agency, but we do have some scale. For smaller agencies, it’s hard to get payers to even credential your contract, let alone negotiate a value-based arrangement with you.”

As a result, fewer home health providers exist today than five years ago.

In total, there were 11,353 active home health agencies in 2022, 11,474 in 2021, 11,565 in 2020, and 11,569 in 2019, according to the Research Institute for Home Care (RIHC).

Last month, one of the oldest home-based care providers in the country – VNA Of Greater Philadelphia – closed its doors amid “unsustainable financial losses.”

A home health leader recently told Home Health Care News that one of its MA contracts hadn’t been updated for a decade. When it approached the payer about a rate adjustment, the plan offered a $3 increase.

The Preserving Access to Home Health Act of 2023 included a provision that would have forced MedPAC to consider all-payer margins in home health care, but that did not make it through.

So, with MA reimbursement that sometimes only covers a portion of the cost of care, and CMS reducing traditional Medicare rates, providers are left to their own devices to survive.

A closer look at the data

Mitchell is aware that there are errors in the data used for Project Sword. But those errors aren’t necessarily ones that would change the overall story that the data is telling.

“There are errors in the data. And I don’t know how many people, as I’ve worked on this project, have said, ‘You can’t use that data. It’s full of errors,’” Mitchell said. “My reply to that is, MedPAC and CMS are using it, and they’re providing a very limited perspective on what they’re doing.”

Mitchell has also shown his work as much as possible, and has included spreadsheets and his methodologies on his website.

But another area where there are definitely errors are the cost reports themselves. And that, too, could be hurting home health providers.

“I’ve never heard of a single agency that is making sure that every single one of their expenses is on these cost reports,” Kerns said. “They don’t have every little thing on there that should be on there. You need to recognize a lot of those expenses, and really work closely with whoever is doing your cost reports to make sure those are accurate.”

If anything, that would mean that margins are worse off than they’re portrayed in the reports.

“This has been haunting us for years,” Robert Markette, an attorney with the law firm Hall, Render, Killian, Heath & Lyman, previously told HHCN. “The numbers are all over the place. The baseline problem is that we don’t report it accurately because we don’t take cost reporting seriously. We give CMS the ammunition they need to make their argument that we’re being paid too much. When in fact, I think we’re severely underpaid.”

As for Mitchell, he plans to get the data in front of as many stakeholders as possible in the near-term future.

The final payment rule is generally released in late October or early November, but CMS also plans to continue cutting payments in the coming years.

The post ‘A Deteriorating Industry’: What Home Health Provider Margins Actually Look Like appeared first on Home Health Care News.

Electronic Visit Verification (EVV) was established as law in 2016 under the 21st Century Cures Act to address fraud and abuse in home-based care delivery. The law provides federal guidelines, but individual states can determine which service codes are included. However, years after nationwide implementation, EVV still remains a burden for home care providers.

Simply put, EVV confirms the details of in-home visits. It holds caregivers accountable for their schedules, ensuring that their work is completed on time and in its entirety. Typically, caregivers work within a mobile app to conduct the EVV process. The app sends the necessary information from their devices to their agency’s home care software.

Six data points are captured at the point of care to verify the facts of a home care visit in real time.

Collecting this basic information in home care settings helps providers and states ensure that authorized care is provided and that caregivers deliver the proper care at the right time. When this verified visit data is collected and analyzed, states can use it to help identify and reduce Medicaid fraud, which drains resources from the system and hinders care delivery to those in need.

There was initial confusion because the act required states to implement EVV for at-home visits conducted by Medicaid personal care providers and home health agencies. However, each group had different go-live dates. Medicaid-funded personal care services were required to comply with EVV statutes by Jan. 1, 2020, and home health agencies by Jan. 1, 2023. However, delays and exemptions made compliance anything but simple.

Further, the federal government has passed legislation regarding EVV, but its implementation varies at the state level. States are categorized as “open” or “closed” models. Home health agencies have the freedom to choose their EVV provider in open states, while in closed states, they must work with a vendor selected by the state.

According to Matt Kroll, practice president of Assistive Care & Assistive Care State Programs at Bayada Home Health Care, despite challenges, Bayada has found that EVV helps prevent false claims.

“It allows us to monitor caregivers in real-time, verify service delivery, and allow for faster issue resolution,” he told Home Health Care News. “For example, if a check-in is late or a caregiver indicates that the client is showing signs of a larger issue, we can see that in real time and detect and prevent adverse events before they lead to a larger medical issue or hospitalization.”

Headquartered in Moorestown, New Jersey, Bayada provides in-home clinical care and support services in 21 states and five countries.

“We believe that we will be able to leverage some care documentation data points to help improve the quality of care we provide our clients and, over time, industry-wide data points may improve the industry as a whole,” Kroll said.

Kroll explained that Bayada supports efforts to prevent fraud, waste and abuse, with the caveat that overregulation can actually hurt the industry in some instances.

“We do feel that overburdensome requirements and unfunded mandates can deter agencies from providing Medicaid-based services, which is detrimental to those populations who already struggle to access the care they need to stay safely at home,” he said.

EVV still a pain point for providers

Because EVV varies by state, its challenges differ by market.

“EVV is still a pain point for providers for various reasons – and they vary by state,” Tim Nyberg, senior vice president of strategy at Sandata, told HHCN. “These can include variance in education from states to providers, the provider’s experience in onboarding and implementing EVV systems, how caregivers are educated on EVV, and whether they understand its purpose and benefits.”

Sandata, based in Port Washington, New York, provides agency management software, systems, and services to optimize billing and claims processing and streamline administrative processes.

“Additionally, some caregivers cite privacy issues in using their personal cell phones to clock in and out of shifts and having their location tracked,” Nyberg said. “Some clients and family members share those same concerns.”

Although all states have worked to implement effective EVV programs, some have needed help with clear and open communication regarding their policies, transparent enforcement timelines and timely responses to questions and concerns from the provider community.

“EVV continues to present challenges for providers primarily due to its complex integration into existing workflows,” John Atkinson, chief technology officer at AxisCare, told HHCN. “The additional effort required is not just about submitting claims, but also ensuring that EVV data is accurately collected and transmitted to the aggregator. This process requires meticulous attention to detail, often adding layers of administrative tasks to an already burdened system. Providers must balance maintaining the quality of care and adapting to new technological requirements, often leading to frustrations. While EVV aims to streamline and enhance transparency, the transition and implementation phase continues to be arduous.”

Founded in 2013, AxisCare is a full-service home care software company based in Waco, Texas.

“Bayada has made every effort to ensure that the transition to EVV compliance is as easy as possible for our caregivers and as least disruptive to client care as possible,” Kroll said. “However, pain points persist. Most notably, cost, lack of standardization across states, technology issues for caregivers and lack of cell service in rural areas.”

Providers who fail to comply with Medicaid rules risk not being paid for their work. Non-compliance with Medicaid rules and policies may also result in the provider’s inability to do business under the Medicaid program.

Apart from the stricter compliance issues, there are also significant downstream impacts. When caregivers fail to clock in at a client’s home, the home care agency cannot verify the services provided, especially in the case of a fall or hospitalization during or after a shift.

There is a continued lack of clarity regarding the consequences of non-compliance, according to Kroll.

States and payers each have a compliance threshold that needs to be met, and most – but not all – states have published this information. Non-compliance could result in payment penalties, loss of referrals, audits, and additional penalties and corrective action plans.

The future of EVV

States that have a burdensome EVV system run the risk of losing providers that may be otherwise interested in conducting business there.

“Looking ahead, the future of EVV will be marked by increasingly stringent standards and tighter tolerances,” Atkinson said. “We anticipate a future where the manual entry of EVV data will become largely unacceptable as states demand greater accuracy and efficiency.”

He emphasized the importance of proactively creating a culture of compliance and ensuring that staff are well-prepared to meet changing standards. This includes adopting technology and simplifying processes to enable smooth data transfer to aggregators.

“By staying ahead of these developments, providers can enhance operational efficiency and continue to meet regulatory requirements effectively,” Atkinson said. “Above all, EVV will enhance the accurate delivery of care to seniors, ensuring they receive the attention and services they need when needed.”

The post Years After Implementation, EVV Remains Inconsistent Pain Point For Home Care Providers appeared first on Home Health Care News.

Enhabit Inc. (NYSE: EHAB) has been active in the value-based care space. The company has a small – but growing – number of value-based contracts on the Medicare Advantage (MA) side, as well as Accountable Care Organization (ACO) partnerships.

“Typically these look like upside potential based on quality metrics that both parties agree to, and we try to pick those quality metrics that are going to lower the total cost of care of patients,” Debra Konjanovski, senior vice president of payor innovation at Enhabit, said last month during a panel discussion at Home Health Care News’ FUTURE conference. “If we perform, then we have an opportunity to have some shared savings in that.”

Dallas-based Enhabit has 256 home health locations and 112 hospice locations across 34 states.

For the past few years, payer innovation has been a major component of Enhabit’s overall strategy.

At Bayada Home Health Care, value-based care is another tool that allows the organization to deliver quality care, according to Sue Chapman Moss, managing director of payer and provider contracting and strategy at the company.

“There’s a tendency towards price suppression in our category, and so value-based care is a way to differentiate, and to be able to share the performance that we’re already creating for our patients in their homes,” Moss said during the discussion.

Bayada provides home health, home care and hospice services in 23 states, as well as in Canada, Germany, India, Ireland, New Zealand, South Korea and the U.K.

Currently, Bayada has value-based arrangement partnerships with payers, ACOs and health systems.

“We’re working with partners … that are willing to make an investment in our caregivers,” Moss said. “The contracting structure is probably the least interesting factoid of our value-based care. It’s how we’re spending the dollars, and investing in our workforce, that we’re most pleased with.”

Moss believes that not diving into value-based care would be a missed opportunity for Bayada.

“If you believe in your care model, what you’re doing in the home is creating value,” she said. “If you’re not working with your payers to secure a portion of that value, and you’re just taking fee-for-service rates, all of that value is dropping 100% to the bottom line of the payer, or the risk bearing provider. We view it as part and parcel to securing better value and being able to hire caregivers and invest in great training.”

Key metrics and navigating challenges

Though it varies depending on the payer, there are some key metrics that home-based care providers should be ready to present when trying to establish value-based care arrangements.

“If you’ve met one payer, you’ve met one payer,” Integrated Home Care Services CEO Chris Bradbury said during the discussion. “Even within the payer, depending upon the line of business, whether it’s [MA], managed Medicaid or the commercial line, the ranking of the priorities differ. [However], there are some things that cut across all of them. Timely access to quality of care is super important, no matter who you’re talking to within the payer, whether it’s the network folks, the clinical folks, the finance folks or the line of business leaders for [MA], manage Medicaid or commercial.”

Integrated Home Care Services is a driver of value-based care in the home. The company partners with health plans, providers and other risk-bearing provider organizations.

Bradbury noted that providers should also be prepared to present patient experience metrics.

“With the changes in star ratings, I know our health plan clients that participate in [MA] are far more attuned to the patient experience, and how what you do can either positively or negatively impact their brand,” he said. “It can have a material impact on their financials and their growth.”

Konjanovski pointed out that providers sometimes face the challenge of finding the right person to talk to within the organization that it is trying to establish a value-based arrangement with.

“At times, it’s hard to find the right person in the organization that you need to talk to that can actually make the decision, and then once the decision is done and it’s on paper, actually executing it is a very long process,” she said.

It’s important for providers to recognize when an organization isn’t ready to fully commit to entering a value-based arrangement, according to Moss.

“Not all payers are ready,” she said. “If they’re struggling to pay claims and focused on audits and utilization management, that does not signal an organization that’s ready for your team to invest a lot of time and energy into a value-based arrangement.”

Ultimately, it’s best for providers to enter arrangements with organizations that want to establish a long-term partnership.

“[Find] payers who are willing to make a multi-year commitment,” Moss said. “These are not easy, one-year deals, and so you need to find partners that are willing to put in the time and the energy. Value-based arrangements take some time to get right and to learn together. If you have an adversarial negotiation, sometimes that doesn’t necessarily lend itself to a collaborative relationship at the end, so you always need to keep that in mind as you’re going through the process.”

The post How Enhabit, Bayada Win Home Health Value-Based Care Arrangements appeared first on Home Health Care News.

The home-based care staffing environment will always be a challenge for providers, but things look far better now than they did two years ago in the wake of the pandemic. However, one area that remains a lingering problem for providers is nurses, and specifically nurses who are leveraging a worker shortage to maximize earning power. 

A confluence of factors made recruiting and retaining home-based care workers from 2020 to the beginning of 2023 a major headache.

Increased government aid kept a large amount of workers on the sidelines, for extended periods of time. Meanwhile, many clinical professionals either retired or exited the industry after being burnt out by pandemic-related pressure.

Most of that has abated, but home health providers have told me that one issue definitively remains, and that’s bringing on – and hanging onto – nurses.

“If I had 200 nurses show up in my parking lot, I would hire them all without interviewing them,” Bill English, president and CEO of Accurate Home Care, told me in jest at the Continuum conference last year.

English’s joke was layered with some truth, however. Home health providers are desperate for nurses, and affordable ones. Without them, it’s tough to grow – or in some cases, to even survive.

In May of 2023, Adam Holton – then the chief people officer at Amedisys (Nasdaq: AMED) – told me that nurses jumping ship to collect sign-on bonuses was one of the company’s gravest concerns.

He and many other leaders hoped that particular issue would subside as the public health emergency was put further into the rearview, but recent conversations I’ve had suggest that it hasn’t.

In this week’s exclusive, members-only HHCN+ Update, I take a closer look at one of the most pressing issues facing the home health industry, which is a widespread inability to sustainably hang onto a vital workforce.

Home health care’s nursing problem

In May 2023, when I chatted with Holton, Amedisys had some of the best data on home-based care workers in the industry. Its applicant tracking system, specifically, was one of the company tools he was touting.

And that’s also why he was so sure of this problem with home health nurses, or nurses in general.

“When there’s a severe shortage, you expect some of this,” Holton said. “But there’s ample evidence that there is still a contingent of nurses who are really taking advantage of going from one sign-on bonus to another.”

Jeff Knapp, the chief people officer at Bayada, was also a part of that conversation. He agreed, and called Bayada’s nursing woes not a sourcing issue, but a retention issue.

For certain, there are ways to keep the less financially inclined nurses onboard. Those include good company culture, solid training, proper recognition, bonuses and, in general, competitive compensation.

But the average home health provider doesn’t have time to waste and money to blow. And when they are hiring nurses who then turn around and leave in short order, that amounts to a significant financial loss. The recruiting and training costs add up, with little return on investment.

In April 2022, an analysis in Health Affairs showed that the total supply of registered nurses decreased by more than 100,000 from 2020 to 2021, which was the largest decrease in supply in the last 40 years.

Another analysis, published by the Health Resources and Services Administration in November 2022, projected a U.S. shortage of close to 80,000 nurses in 2025, a problem that’s expected to continue – and even exacerbate – throughout the decade.

Specifically within home health care, a study published in the National Library of Medicine in 2021 found over 30% of full-time registered nurses and about 25% of licensed practical nurses left their position in a large home health care agency “over the course of a year.”

To make matters worse, health systems – which compete with home health agencies for nurses – often have more financial resources. At the same time, skilled nursing facilities (SNFs) are soon to be subject to a minimum staffing mandate, which could also increase competition over a small pool of nurses.

And the issue Holton brought to my attention nearly a year and a half ago hasn’t gone away.

For instance, in Care Advantage’s case, nurses are actually declining sign-on bonuses that may tie them to the company for a longer period of time. They’re doing that, in many cases, so they can eventually jump ship for other offers.

“All the big companies are paying high retention bonuses and sign-on bonuses,” Joe Navarro, the chief people officer at Care Advantage, told me this week during Home Health Care News’ Staffing Summit. “It’s to the point that, when I’m interviewing and hiring nurses, when I offer a sign-on bonus, they say they don’t need one. Because they want to be able to jump three months from now, four months from now, for better compensation.”

For large home health providers, that’s an issue. For smaller providers, it’s hard to even enter the competition.

Care Advantage has a large regional presence. Still, nurses jumping ship has become one of its biggest challenges.

“It’s very hard to attract and retain nurses at this point,” Navarro said. “And I think that’s one of the biggest challenges that there is in the industry.”

A costly turnover problem is also magnified in light of the current payment environment in home health care.

It costs far more now to hire and retain a nurse, but all the while, the Centers for Medicare & Medicaid Services (CMS) is reducing home health payment. The agency has cut core payments the past two years, and proposed a third straight cut for 2025.

On the other side of payment, Medicare Advantage (MA) plans are often paying rates for home health care that fall below the cost of care.

Navarro suggested one solution, which was to ensure nurses fall in love with the company culture shortly after joining.

Home health providers could also employ strategies to get a better sense of which nurses are more likely to stay for the long haul.

Having a nurse on staff is better than not having him or her on staff. But if that nurse is set to leave fewer than 90 days in, the economics on that hire could turn upside down.

The post The Home Health Nursing Problem That Isn’t Going Away appeared first on Home Health Care News.

Founded in 1975 and headquartered in Moorestown, New Jersey, Bayada provides in-home clinical care and support services for children and adults, including hospice, behavioral health, and rehabilitation in 21 states and five countries.

Before joining Bayada, Helle stepped away from her position as a CEO to prioritize her family. She said that the decision to leave the C-suite was an easy one, given her desire to put her family first.

“When you align your priorities with your values, what matters most becomes clear,” Helle told Home Health Care News. “The difficulty is navigating the change. It wasn’t a difficult decision in terms of the right thing to do. It was navigating with grace for all involved that I wanted to be thoughtful about.”

Helle said that her colleagues supported her decision, and when it was time for her to re-enter the workforce, she was excited to do so.

“I’ve been in health care for years,” she said. “I love helping people make a difference. My child was in a place where I could come back and put time and attention toward my passion, which is making a difference in communities and doing it through taking care of people.”

Helle re-entered the health care industry in a more functional role than she had previously held, knowing the time and travel required as a CEO. She said her mentors were of great help in navigating back to a C-suite position.

“I was being thoughtful about where I could create value for an organization and how that would intersect with my family’s needs at the time,” she said. “I’ve been fortunate to have amazing mentors. Being able to call on these great humans was helpful as I navigated my journey back and figured out what would be right for me and my family, while still making an impact on patients.”

A call for equity in health care

For women in health care, it’s not always easy to reach the top of the ladder, particularly after a sabbatical.

In 2022, women accounted for approximately 80% of workers in health care occupations, a figure higher than the percentage of women in all other employment sectors, as reported by the Bureau of Labor Statistics. Additionally, women make up 70% of the global health workforce and 90% of frontline health workers.

However, women are underrepresented in leadership roles, comprising only 25% of health care leadership positions in 2022. Additionally, women of color are significantly underrepresented, making up merely 11% of senior manager positions.

Gender equity is crucial for developing resilient health systems and gender-transformative health and social care policies, according to The World Health Organization.

A common misconception is that the main obstacle to women’s progress is the glass ceiling. Yet, the biggest challenge in reaching top leadership positions is at the first step to becoming a manager, known as the ‘broken rung,’ according to Women in the Workplace, a report from McKinsey in partnership with LeanIn.org.

The report revealed that women encounter the most significant barrier when being promoted to manager from an entry-level position. In 2023, out of every 100 men promoted, only 87 women were promoted to this crucial first step. This imbalance leads to women falling behind and often struggling to catch up.

This disparity is especially important in the home-based care space, where there’s a need to attract staff and where women offer unique contributions, such as empathetic leadership, effective communication and a holistic approach to care.

“A 22% increase in global human capital wealth is estimated, should equal participation of women in health be realized,” a study conducted by researchers at the School of Public Health and Preventative Medicine, Monash University in Melbourne, Australia read. “Increasing the potential of women as leaders is a critical long-term investment for organizational success, improved health policy, and national prosperity and quality of life. More women in leadership increases organizational productivity and maximizes the value of the female workforce.”

Helle finds that being a woman in health care is a rewarding opportunity, and she feels it can only get better as the industry focuses on promoting women to higher positions.

“It’s a great time to be a woman leader in health care, in home health care in particular,” Helle said. “Women can lead differently than men. I think you find a level of compassion, a level of caring, a level of transparency and openness, and that can be a real advantage for a woman. It is getting comfortable with leaning into that and being okay that you don’t have to try to fit a particular mold. Lean into your superpowers and use that to pay it forward, to bring your best to make an organization or a team better and really make a difference.”

The post ‘Lean Into Your Superpowers’: Bayada COO Champions Women In Home Health Leadership  appeared first on Home Health Care News.

Despite variations in service lines, size and operations, the best home-based care organizations all have one thing in common. 

These companies all prioritize the experience — of patients, clients and staff. And while every member of an organization plays a role in shaping the experience, this responsibility largely rests on the shoulders of what is now known as the chief experience officer.

The specific functions of the role, and official title, is dependent on the needs of each individual organization, but broadly, a chief experience officer is focused on implementing strategy that improves customer and employee experience.

At FirstLight Home Care, this person is Kristen Duell, who serves as executive vice president of experience and innovation.

Duell pointed out that most home-based care companies have always centered around experience. But what’s new is the organizations putting a name to this.

“I think about organizations that are really innovating and wanting to put a focus on what that innovation looks like,” she told Home Health Care News. “That can be through new technology, but that can also be through processes and people.”

Cincinnati-based FirstLight Home Care is a provider of non-medical home care that operates 200 independently owned and operated home care locations across the U.S. The company also has a specialized care program aimed at seniors with dementia.

Similarly, Jaya Kumar, who serves as chief digital and experiences officer at Bayada Home Healthcare, believes that the ethos of the role has always been present across home-based care.

“People have been intuitively doing that for the last decade, without calling it experience designer, or experience officer,” he told HHCN. “[It’s about], what can I do to make an interaction simple and elegant? It’s improving the quality and elegance of human interaction.”

Bayada provides home-based care services via its more than 26,000 care professionals. The company has locations in 23 states, as well as in Canada, Germany, India, Ireland, New Zealand, South Korea and the U.K.

In her role as EVP of experience and innovation, many segments fall under Duell’s purview.

“I have marketing that rolls up under me, so that requires everything from the franchisor perspective, but then I also have all new technology that rolls up under my purview,” she said. “When we want to explore a niche new technology, like some chatbots, or anything that rolls out into the patient’s home, those pilots would fall under my purview to explore how that would work.”

Kumar’s role as chief digital and experiences officer centers around “human-centric” design.

“In our solutioning, human-centric design is by far the most important step,” he said. “Now that I’ve understood the burden the person is facing, I am going to look at all the pain points in that transaction. For example, a nurse going to a patient. What are the pain points? Where am I going? What should I do to prepare for this visit? How do I [inform] the patient that I’m on the way? How does the patient [inform] me if there’s a change in his or her desire? Those are all the pain points that are very manually driven. I have to convert each pain point and create a solution that is digital.”

Kumar is focused on understanding the burden felt by the user and converting pain points to bliss points. This process is usually enabled by a technology solution.

Currently, Duell’s biggest goal for FirstLight Home Care is enhancing the company’s foundational processes.

“We’ve been really working on having really clear guidelines on how we’re going to interact and work together as a company and as a network,” she said. “Now that those are in place, we can move a whole lot faster with rolling out new technologies. I think some of the things that we really have focused on are how do we help our franchise owners reduce overhead costs, while being able to increase their revenue streams, so that they can pay their caregivers more, and provide additional benefits that makes them the provider of choice.”

Kumar has set his sights on implementing strategies that will make it easier for Bayada to serve more people at home.

Ultimately, he believes that even though his role is front and center, all members of an organization contribute to the overall experience.

“[It] doesn’t absolve the responsibility of a nurse who interacts with a patient, or a client, of managing that experience,” Kumar said. “That is the most misunderstood thing about this role. I fundamentally believe every interaction, whether you’re a support person, or nurse, or a patient — the person who’s interacting is the owner of that experience. The creation of a chief experience officer is not taking away that important critical accountability.”

The post Turning ‘Pain Points’ Into ‘Bliss Points’: The Chief Experience Officer’s Rise In Home-Based Care appeared first on Home Health Care News.

At 24 Hour Home Care, there has been a move towards funded programs, as that cost of care has continued to increase.

“The cost of labor is through the roof, which means the cost of care is really challenging for us,” Ryan Iwamoto, president and co-founder of 24 Hour Home Care, said during a panel discussion at the Home Care Association of America (HCAOA) national conference on Monday. “As the cost of care has gone up, the cost of alternatives hasn’t gone up to the same clip as private-pay home care. That gap has gotten wider and wider.”

Los Angeles-based 24 Hour Home Care offers home care and intellectual and developmental disability (IDD) services across California and Arizona.

Iwamoto noted that 24 Hour Home Care still operates under a private-pay structure, but that working with other programs, like Medicaid-funded home- and community-based services, allowed the company to make more of an impact.

“By adding more breadth to our services, we can impact more lives, and not just for people that can afford it, but for people that may need it even more so,” he said.

For home care providers looking to scale, it’s important to make strategic trade-offs, according to Iwamoto.

“If you try to do everything, you’re not going to be able to do anything,” he said. “For us, it is [about] finding the things that worked well, the bright spots, and putting time and energy towards those bright spots,” he said.

Matt Kroll — president of personal care services at Bayada Home Health Care — believes that scaling private pay now is all about nailing the “business rhythms.”

“Specifically, understanding what our pricing strategy is, understanding what are the KPIs that matter,” he said during the panel discussion. “We still see huge demand. We just don’t want all of it. We realize that we’re much better at taking cases where they need 40 hours a week plus.”

Moorestown, New Jersey-based Bayada is a provider of home health, hospice and home care services. It has over 360 locations across 23 states and six other countries.

Bayada is looking to plant its flag in five new markets annually, but the company has perfected its strategy for growth expansion, according to Kroll.

“We’re not very good at planting new flags in the states,” he said. “What we’re good at is, if we’re in Chicago, we could probably divide Chicago in different parts, and location matters. We think about how we can divide up the markets we’re in and get hyper-local, so we can continue to scale our business.”

On its end, Family Tree Private Care discovered that the best way to enter new markets was through M&A expansion. This also means retaining or hiring staff that is familiar with that market.

“If you can’t entrust other people to grow and develop, it’s just really difficult,” Daniel Gottschalk, president of Family Tree Private Care, said during the discussion.

As a company, Family Tree offers concierge-level caregiving, private nursing and care management services in Texas and Colorado.

Iwamoto also believes in the importance of having the right people in place. In fact, he has taken the Trader Joe’s model, and ran with it, at 24 Hour Home Care.

“It’s hard to find someone that does not like Trader Joe’s, and their secret sauce is competitive prices and quality goods, but I think how they win is through their people,” he said. “We win, not just by our caregivers, but the people behind the caregivers. They’re a little bit more engaged, better trained and better paid than our competition. I believe that is the reason why we’re here today.”

The post The ‘Strategic Trade-Offs’ Private-Pay Home Care Providers Are Making To Grow appeared first on Home Health Care News.

The comments were critical of the proposed rule itself. They were also critical of the process CMS took to get there.

“UnitedHealth Group has grave concerns that the 5.653% proposed permanent adjustment (cumulative 10% adjustment) will significantly impact the ability of the home health community to ensure beneficiary access to home health services,” Keith Myers, the CEO Emeritus and Chairman of LHC Group and a senior advisor at Optum, wrote in a public comment. “Home health agencies are experiencing challenges meeting beneficiaries’ home health needs due to the implementation of the PDGM payment system and the permanent payment adjustment imposed in CY 2023.”

Optum is the health care services arm of UnitedHealth Group (NYSE: UNH). Its capabilities are vast, and include home-based primary care, home health and hospice. It officially acquired LHC Group – one of the largest home health and hospice providers in the country – earlier this year. It’s in the process of acquiring Amedisys Inc. (Nasdaq: AMED) as well.

Overall, it has 135,000 team members and provides care to more than 100 million Americans.

Last year, CMS implemented a -3.925% permanent rate adjustment.

The continued cuts from CMS would force beneficiaries to look for care from more expensive settings, or forgo care altogether, which do serious damage to overall health outcomes across the care continuum, Myers wrote.

“Reducing home health reimbursement levels in 2024 as the agency is proposing will only exacerbate this decline in access to home health care,” he continued.

Several home health leaders also pointed out that CMS is not required to make these payment reductions. The Social Security Act authorizes CMS to institute permanent and temporary adjustments “at a time and in a manner determined appropriate.”

“For 2024, CMS could use this authority to delay any application of the permanent adjustment until the home health community stabilizes and beneficiaries’ access to vital home health services is restored,” Myers wrote.

Other home health leaders, meanwhile, pointed out that the Biden Administration has been touting home-based care and vowing not to cut Medicare. All the while, it’s cutting reimbursement for home health agencies.

Andrew Baird, VP of government affairs and policy counsel for Enhabit Inc. (NYSE: EHAB), wrote that the recent proposal from CMS is an “intentional policy approach that threatens to erode Medicare beneficiaries’ access to high-quality home health services.”

“Given the discretion that CMS has in the application of any permanent adjustments, the agency’s decision to apply these direct cuts to the Medicare home health benefit flies in the face of the current Administration’s public commitment not to cut the Medicare program for the growing number of America’s seniors,” Baird wrote in Enhabit’s comment.

The Dallas-based Enhabit is one of the largest independent providers of home health and hospice care in the country. Its footprint includes 255 home health locations and 108 hospice locations across 34 states.

Leaders criticized the agency’s “how,” pointing to the lack of research shown in the rulemaking process.

“Nowhere in the proposed rule does CMS indicate that it has conducted any rigorous analysis to measure access to home health services,” Baird wrote. “And we dispute the reliance on the Medicare Payment Advisory Commission’s (MedPAC) opaque and overly simplistic measurement of access to home health on account of the likelihood that it is inaccurate.”

CMS relies on, to an extent, information that is collected by MedPAC. MedPAC is an independent group that advises the U.S. Congress on issues related to the Medicare program.

Home health leaders have often criticized MedPAC’s influence on CMS’ decisions, and are now taking issue with the group’s access adequacy analysis, which – as Baird pointed out – consists of one metric: whether a particular county is served by at least two home health agencies.

“If a county has two or more HHAs, MedPAC deems access adequate for the entire county’s population,” Baird wrote. “MedPAC’s access adequacy analysis uses 2021 provider enrollment and utilization data, meaning that the data that CMS relies on to assess access in 2024 will be three years old before the drastic CY2023 or proposed CY2024 cuts had occurred. Additionally, significant changes in HHAs’ locations and areas of service will very likely have occurred between 2021 and 2024.”

AccentCare leaders also took issue with CMS’ methodologies.

“CMS should conduct an independent analysis of the budget neutrality methodology that was developed by the agency and its contractor to ensure that it is consistent with Congressional intent,” Stacey Smith, VP of public affairs at AccentCare, wrote. “The agency’s current approach to budget neutrality overcorrects home health payments and is destined to negatively impact Medicare beneficiaries — particularly those residing in medically underserved areas and patients with complex medical conditions. The analysis should also examine the payment system to ensure continued access to quality services.”

The Dallas-based AccentCare provides home health, hospice, palliative care and care management services across 31 states.

AccentCare — like many other providers — believes CMS is operating under a “fundamentally flawed” premise.

“To our knowledge, CMS has not undertaken any impact analysis of these significant home health payment reductions, instead relying on MedPAC’s flawed measure of access using the number of beneficiaries that lived in a zip code where a Medicare HHA operated,” Smith wrote. “Measuring access by simply looking at zip code data fails to examine the volume of individuals being cared for by an agency or the patients’ specific needs and resources necessary to improve function and live with greater independence.”

The overarching theme in many of the comments submitted was that the cuts are too much, too soon.

Between rising referral rejection rates, higher staffing costs and macroeconomic trends, further cuts could be detrimental to the industry and to the patients it serves.

“This combination of simultaneous payment reductions and cost increases has already resulted in reduced services, increased open shifts, and patient denials that have reached unprecedented levels,” David Totaro, chief government affairs officer with Bayada Home Health Care, wrote. “This situation will continue to worsen and aggravate already-fraught access-to-care issues for Medicare-eligible Americans who prefer care at home. Without adequate funding, providers will not be able to recruit and retain enough home health care workers and staff the growing number of cases of individuals who wish to receive care at home.”

The Moorestown, New Jersey-based Bayada is also one of the largest home health providers in the country. It has over 360 locations across 23 states and six other countries.

In the company’s letter, Totaro reported Bayada has been forced to deny, on average, 64% of patients referred to home health care in the last year due to the inability to provide services.

Continued cuts to reimbursement will limit access to care even more, Totaro said.

“The agencies that can adjust will be forced to make cuts in critical areas when they should be making investments, resulting in a reduction of health equity for those that rely on care at home,” Totaro wrote. “There will be agencies that are unable to maintain operations under weakened balance sheets and consolidation pressure and will be in jeopardy of closing their doors entirely.”

The post ‘Exacerbating Decline In Access’: LHC Group, Enhabit, Bayada Sound Off On CMS’ Proposed Rate Cuts appeared first on Home Health Care News.

With referral rejection rates skyrocketing to new highs in recent years, home health providers have to be more intentional about maintaining strong relationships with referral sources.

In 2022, the industry saw a 76% referral rejection rate, compared to 54% in 2019, according to WellSky data.

With this in mind, providers are employing a number of strategies to sustain positive relationships with key referral sources.

Relationship upkeep

Last year, American Advantage Home Care saw its referral rejection rate reach roughly 56%.

American Advantage Home Care provides skilled nursing, rehab and specialty care services. Currently, the company serves seven counties in the Southeast Michigan area and has a census of 200 patients.

The company’s referral rejection rate was partly driven by an influx of patients with higher acuity levels, according to President and CEO Cleamon Moorer Jr.

“Higher-acuity patients decrease our overall bandwidth because they require higher frequencies and more disciplines,” he told Home Health Care News.

For American Advantage Home Care, staying in consistent communication with referral sources has become vital.

The company also provides monthly and quarterly updates to its referral network to maintain good rapport.

“We like to send out information about programs, whether that be a CHF program, a diabetes management program, or even updates about some of our personnel,” Moorer said. “If we have personnel that recently received training, or a certification in wound care management, we try to let our referral contacts know that.”

Large provider strategies

AccentCare chooses to enter every referral they receive. Tad Kendall, the company’s chief growth officer, pointed out that this isn’t industry standard.

AccentCare itself only began doing this a few years ago.

“We want to see what our true conversion rates or selection rates are, and so we’ve made a choice to do that,” Kendall told HHCN.

Dallas-based AccentCare delivers home health, hospice, palliative care and care management services. As part of its network, the company has 30,000 employees that deliver care in more than 250 locations across 30 states and the District of Columbia.

The company found that it had an acceptance rate that is in between 30% and 40%.

Clinical capacity is one of the biggest contributors to that. Medicare Advantage (MA) is another driving factor, according to Kendall.

“[MA] plans have significantly underfunded home health in the market, which creates a real challenge to service all of the patients coming out of the referral sources that we have,” he said. “The economics just don’t pencil out. The lack of funding really hampers the ability to then have the investment available to hire really quality clinicians, as well as build the capacity.”

Given these realities, there’s been a concerted effort to maintain strong relationships with referral sources.

“We invest heavily in our client-facing teams, so our sales teams,” Kendall said. “We have clinical liaisons that are in a number of the facilities that we work with. We have what we call patient care navigators that basically helps a patient be brought on to our services. We’re really investing in what is our front door. The client-facing team is a critical part of it.”

Another strategy AccentCare employs is targeting key referral sources. In order to pull this off, the company partners with Trella Health.

“Even though we’re probably going to a fewer set of individual referral sources, it allows us to go deeper and build more meaningful, long-term relationships with those referral sources,” Kendall said.

On its end, Bayada Home Health Care has seen a consistent uptick in referrals since 2020.

“[That year] was probably the biggest catalyst for it — clients that are looking to … go directly home for care, and not always appropriately,” Kaitlyn Catenacci, a regional sales director at Bayada, told HHCN. “I would say that is another challenge, right? You have high-acuity patients who are looking for home health services, straight from the hospital discharge. It puts a lot of pressure on agencies to increase capacity to serve those clients.”

The Moorestown, New Jersey-based Bayada – like AccentCare – is one of the largest home health providers in the country. It has over 360 locations across 23 states and six other countries.

Though Bayada couldn’t quantify its rejection rates, Catenacci noted that with the increased demand the company is seeing, staffing has been challenging and conversion rates have dropped.

This has forced Bayada to get really creative and very flexible with referral partners, especially when it comes to being able to triage patients.

“For example, we may not have a nurse in this particular geography, but we might have a therapist that can start services,” Catenacci said. “It’s really important to not only maintain a positive referral relationship, but also to work with them to make sure that we can get creative around providing care for those clients coming home.”

In the end, all of the aforementioned leaders agreed that it is imperative in this day and age for home health providers to not bite off more than they can chew when it comes to accepting patient referrals.

Editor’s Note: A previous version of this story suggested that a 76% referral rejection rate meant that 76% of patients were unable to receive home health services. That is inaccurate. The data suggests that 76% of referrals are being rejected, but generally, patients are eventually able to find a care provider.

The post How Home Health Providers Are Maintaining Positive Referral Relationships Amid Historically High Rejection Rates appeared first on Home Health Care News.

The odds are stacked against home health providers.

Even while more care is heading to the home, providers have three fundamental problems. The first is that there is an insufficient workforce to meet demand. The second and third are both rate-related.

The Centers for Medicare & Medicaid Services (CMS) is actively reducing home health reimbursement in Medicare fee for service. Other than advocacy efforts, there’s not much providers can do about that. At the end of the day, CMS – generally – has the final say.

Meanwhile, Medicare Advantage (MA) plans don’t even pay as well as CMS under traditional Medicare. And, unfortunately, there are more Medicare Advantage (MA) beneficiaries today than ever before. Tomorrow, there will be more than there was today.

CMS’ finalized and proposed rate cuts both threaten the industry. But even if it may not feel like it, providers do have some control over the two other factors.

They can get better at recruiting and retaining talent, and they can prove their value to MA plans and demand a better payment set-up.

It’s not easy. But providers are finding ways – because they have to.

In this week’s exclusive, HHCN+ Update, I take stock of home health providers’ recent successes in MA and staffing.

Staffing wins

One of the biggest drags on home health providers’ finances over the last few years has been contracted labor.

In late 2021 and early 2022, for example, contracted labor was costing large home health providers millions. Even if only 4% of a company’s labor was acquired through those means, it was a significant tailwind.

On a second-quarter earnings call Thursday, Enhabit Inc. (NYSE: EHAB) leaders suggested it may be possible to completely eliminate contract labor by the end of the third quarter.

Geoff Abraskin – the president of hospice for Amedisys Inc. (Nasdaq: AMED) – shared similar optimism with me regarding contract labor last month.

“We’re seeing some green shoots from people applying for jobs,” he said. “We actually just had our best two months in terms of fills. We’re seeing contractor costs coming down, so that’s a big positive for us.”

Enhabit, meanwhile, had its best quarter for net nursing hires since it began tracking the metric. In total, it had 203 net new full-time nursing hires in the second quarter.

Addus HomeCare Corporation (Nasdaq: ADUS) averaged 81 new hires per business day in the second quarter, which is contextually a very strong number.

The caveat for Addus is that hiring has been much more seamless in personal care. Still, clinical hiring has also seen “modest” improvements.

“We have seen modest improvements compared to this time in 2022,” Addus CEO Dirk Allison said. “Hiring in our clinical segment continues to improve overall, but there are certain markets that have been more difficult, and that has impacted our growth in those markets.”

Addus chalked part of that success up to its new candidate management system, which has shortened the time between application and hire by as much as 10 days.

Part of Amedisys’ staffing success has also come from a new candidate tracking system, according to its Chief People Officer Adam Holton.

“This year, we put in a new applicant tracking system,” Holton told me in May. “And I think for the first time in my career, I’ve seen the difference between an average applicant tracking system and a world-class one. And – legitimately, with nothing else being different – what that actually can do for you. In an increasingly digital world, you can get to many more candidates.”

While competitive hiring is – to some extent – dependent on rates, there is evidence to suggest that the best home health providers are continuing to find better ways to hire and hold onto talent.

MA negotiations

Avoiding MA’s penetration and emergence is no longer an option for most home health providers.

But there are two issues they’ve run into when trying to engage with the MA plans that will – in part – dictate their futures.

The first is point people. Despite the need for home health care, many health plans don’t have a specific individual that is in charge of the administration of home health services. If they did, at the very least, conversations could be had.

But even if the plan does sit down with home health providers, sometimes they aren’t ready or willing to go at risk with them. While home health providers are sometimes considered the archaic ones, many are finding it’s the plans who aren’t ready to pay based on value.

Enhabit CEO Barb Jacobsmeyer first brought up that conundrum in June. But her company has also agreed to dozens of new contracts with MA plans this year.

Things are slowly changing.

“I think there’s been light years of progress,” Bayada CEO David Baiada told HHCN, referring to discussions with health plans. “Bayada has been one of the largest providers of home-based care to the managed care industry for over 25 years. And in the last five years, we’ve seen a significant acceleration in our engagement and strategic dialogue with the payer community.”

In Pennsylvania, Abraskin noted that Amedisys had completed successful pilots with MA plans. Specifically, in a partnership with Aetna, Amedisys was able to reduce hospitalization rates by 3.5%.

Enhabit, Amedisys and Addus have provided regular updates on their MA battle because they’re public companies.

But smaller companies are making strides, too, even if those strides come while they grit their teeth through frustration. They’re finding out what the plan needs, looking into the right numbers, and, ultimately, building the case that they should be paid more, or at least differently.

“We’ll be able to take data [on] how we reduce the cost of care — especially around emergency room visits and rehospitalizations — and take that to Medicare Advantage payers,” Allison said in May.

The post Controlling The Controllables: Home Health Giants Improving MA Contracts, Staffing Amid Rate Cuts appeared first on Home Health Care News.