NAHC’s Bill Dombi: Horizontal Integration, Workforce Innovation to Accelerate in 2022

The end of 2021 brought a handful of key home health policy issues to a temporary conclusion, including the congressionally secured delay to Medicare sequestration. But the industry still has a long list of other priorities that it’s hoping to carry out in Washington, D.C. – starting with Choose Home.

“Potential cost-saving is what is attracting bipartisan support for this legislation,” Bill Dombi, president of the National Association for Home Care & Hospice (NAHC), told Home Health Care News during a recent HHCN+ TALKS episode. “And if there’s a big deal, it’s the fact that we have members in leadership and on committees of jurisdiction in both parties in both houses of Congress.”

HHCN is pleased to share the recording and transcript of our HHCN+ TALKS conversation with Dombi, recorded in late December. Read on to learn more about:

— The major policy and regulatory issues impacting home health and home care in 2022

— How NAHC views the in-home care workforce situation

— Dombi’s predictions on what “the next evolution” of home health care will look like

The below has been edited for length and clarity.

[00:00:05] Bob Holly: Good afternoon, everyone. Welcome to another episode of HHCN+ TALKS. I’m Bob Holly with Home Health Care News. Today, I’m joined by Bill Dombi, president of the National Association for Home Care & Hospice (NAHC). Bill, it’s always great speaking with you. Thanks for being here today.

[00:00:21] Bill Dombi: I appreciate the opportunity. Looking forward to our discussion, Bob.

[00:00:25] Holly: For those tuning in, if you haven’t joined us for a TALKS conversation before, we do welcome questions from the audience.

All right. Bill, I think we’re going to be focusing most of this conversation on 2022. But I thought we could start by looking back on a couple of key developments toward the end of 2021. One of the most recent ones is Medicare sequestration. The House and Senate came together, passed some legislation to kick the can down the road a little bit on that. Given that action, in your view, how is that going to be helpful to the home health community? Because it’s again, delaying that 2% Medicare sequestration cut, but also PAYGO requirements as well.

[00:01:27] Dombi: Exactly. The sum total would’ve been a cliff of 6% come Jan. 1. If I put myself in the chair as, say, somebody heading up a home health agency, that’s a great sigh of relief.

The specifics are such that the 2% sequestration is in a moratorium for the first three months of the year. It then goes to a 1% cut for reimbursement for the next three months, then to a 2% full sequestration amount in July. The PAYGO, which was a 4% cut, gets kicked into 2023 scoring, as they call it, for purposes of determining what it has to be paid for.

We fully expect that in the first three months of 2022, this will be on the agenda as well for Congress once again. The short-term change on sequestration is predominantly due to how they could find a way to pay for it. We were there in 2020. We’re here in 2021 with the same thing happening for next year. On sequestration, they kicked it into 2031. Once they get into next year, they can kick it into 2032 as well, with a 10-year budget cycle.

But I tell you, there was that universal sigh of relief when this was signed into law.

[00:03:16] Holly: Yes. I wanted to start with Medicare sequestration because it does have this nice ending to it, at least for now. Something that is still open and on the advocacy agenda is Choose Home. That’s been circulating in the Senate since July, and, I think, in the House since October. We’re getting around the holiday times now – should home health agencies be miraculously expecting to have a Choose Home Christmas present sitting underneath their Christmas tree in a week?

[00:03:51] Dombi: Well, there are miracles that happen this time of year, but it won’t be Choose Home, unfortunately.

According to the “Bill Dombi Schedule of Desired Outcomes,” we should have been talking in 2020 that Congress had passed the Choose Home proposal because it’s such a good idea. Congress has other priorities that are just sucking the air. In fact, they sucked the air out of Washington just recently with Senator Manchin saying he was not going to support the social infrastructure bill as it’s written, pushing that into 2022 for discussions.

What we’re looking at for Choose Home at this point is the calendar of mid-February of next year, because the government’s funded through a continuing resolution through that point, and Congress will then have a potential vehicle that we could attach it to. The key factor is – and this is true not only for legislation we’re advancing, but all kinds of legislation – we need to get an analysis done by the Congressional Budget Office (CBO). When I say “we” I mean the congressional sponsors need to get it. Without a CBO score for whether it costs money or saves money, it doesn’t go anywhere.

We have great allies in Congress now helping us get that CBO score. With CBO, it’s always an issue of demand and supply – how much supply of resources they have to do the analysis and what are the priorities of demand. The current biggest priority continues to be the Build Back Better Act, and that will continue through the end of this year and into early next year as they reopen discussions. We want to see if we can slide ours in there somewhere, however.

It has been assigned to analysts at CBO – that much we know, but that doesn’t tell us whether we’re No. 1 in the queue or No. 101. We still think we’ve got a solid chance of ultimately getting across this finish line in the near term, but it won’t be 2021, unfortunately.

[00:05:54] Holly: I think it was last week or the week before where I noticed Senator Manchin had actually signed on as one of the co-sponsors of Choose Home. That seems like a big deal to me. Am I reading too much into that?

[00:06:19] Dombi: Potential cost-saving is what is attracting bipartisan support for this legislation, and if there’s a big deal, it’s the fact that we have members in leadership and on committees of jurisdiction in both parties in both houses of Congress. Senator Manchin obviously is a nice person to have in the middle of all of this, being the moderate he is.

[00:07:05] Holly: Of course, the other big regulatory/policy item on the radar is the vaccine requirements, vaccine mandates. There are a couple of big national ones, but there’s also state-level mandates. If you’re a home health provider right now, how is your head not spinning?

[00:07:34] Dombi: Well, I know my head’s certainly been spinning because of it. There are so many different aspects of this to explore relative to mandates alone as it relates to the vaccine. We recommended when the first court actions were taken that providers of services continue moving forward to, at least from a process standpoint, bring themselves toward compliance in anticipation of potential court reversal.

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*Editor’s note (Jan. 14, 2022): The U.S. Supreme Court released its opinions on the U.S. Centers for Medicare & Medicaid Services (CMS) and Occupational Safety and Health Administration (OSHA) mandates on Jan. 13, after this TALKS episode with NAHC’s Bill Dombi was recorded.

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[00:10:35] Holly: Is there anything from 2021 that you want to wrap up?

[00:10:49] Dombi: I think one of the big areas that people are still wondering about is the future of the public health emergency declaration. Along with that comes the flexibilities that CMS put into the Conditions of Participation (CoPs) and other rules – telehealth being there for a number of the important aspects of it like the face-to-face encounter.

Then probably in second place is the Provider Relief Fund. Some monies were delved out just recently in a distribution to rural providers as well as a fourth general distribution based upon documented need, but there are still billions of dollars left. We’re facing another surge in COVID-19 infections and hospitalizations, plus other health care demands.

[00:12:00] Holly: Yes. On the Provider Relief Fund point, originally assisted living providers weren’t included in that. Eventually, they were. Is there any chance for something similar to happen with some home-based care providers that haven’t been included thus far?

[00:12:17] Dombi: I can tell you one thing: I haven’t given up. Just last week, I sent another message over to a different official at HHS. She’s the acting director of HRSA, where the monies are being managed at HHS. Then just today, it was announced that the director of HRSA was finally appointed by the White House. Coming over from the White House, actually. I’ll be reaching out to her as well.

This is one of those very unfair circumstances. If the company had even one Medicare patient – and they had 99% of their patients otherwise in private-pay personal care, non-medical services – they would’ve qualified for an earlier distribution. But if they have no Medicare or Medicaid patients, they don’t qualify. It makes no sense. The last administration expressed that, “Well, we need the Medicare/Medicaid connection in order to manage that.”

You mentioned assisted living facilities. They don’t have a Medicare/Medicaid connection, and behavioral health doesn’t have the same kind of connections that physical health might have. And dentists and such, they found specific ways to make it work. We’re telling HHS, “We can use these same approaches, the same processes for the non-medical home care companies, which everybody has recognized as essential.” They need the support as much as anybody else.

[00:13:58] Holly: Looking ahead toward 2022, whether it’s a very specific thing or maybe something that’s more on a macro-level, what are the key forces that you see shaping home health care? For example, I wrote a piece a couple of weeks ago and mentioned value-based care being a key force shaping home health, then obviously COVID-19 and staffing pressures as well.

[00:14:27] Dombi: If there’s a macro-element, it’s workforce. It’s not just the shortage that’s there – and the shortage that might persist going forward – but it’s also the nature of the workforce and scope of practice that they may have as well. Then an element of that which ties to the workforce is technology. The technology is absolutely moving in favor of expanded supports in home- and community-based care. You put the two together, there is a great symmetry between the two. But you’ve got to solve the workforce problem to make it the brightest future possible in home care.

You’re not going to solve it just with technology. I may be a sci-fi fan and enjoy the Terminator movies, but we don’t have robotics that close at hand in order to replace humans in the workforce – whether we’d even want them to do so. But there are a bunch of other issues that are going to shape the future.

You mentioned value-based purchasing. I may not be seeing that as much of an impact as some others might see, just because home health care has been really focused on quality outcomes for a long time already.

But what I think comes from value-based purchasing that’s going to shape the future was the expansion of the Home Health Value-Based Purchasing (HHVBP) Model nationwide into the Medicare home health benefit. That is an absolute validation of home health care’s long-standing view that it brings dynamic value in health care, meaning it’s not just less expensive than an alternative service in a different setting but that it saves money. In addition to that, the HHVBP demonstration program showed how much could be saved just in reduced hospitalizations via home health care.

That will shape the future a lot for home health care because it puts in the minds of all regulators, all payers, Medicare Advantage included, “I should take a deeper look at this.” They can see, “This is not just 2% of my budget. This could affect 20% of my budget from a financial standpoint, or from a patient standpoint.” Reduced hospitalizations means greater chance of rehabilitation, restoration, maintenance of the patient’s condition and avoidance of fatalities. That will shape the future, I believe, in so, so many ways.

When we’re looking at the matters that are out there, we’ve got the routine stuff, the Patient-Driven Groupings Model (PDGM) stuff. We’ve got the threats coming from the Medicare Payment Advisory Commission (MedPAC) on payment-rate cuts. We’ve got one other thing, I believe, that’s out there: alternative levels of care directly provided in the home setting, from a SNF level (like Choose Home) to hospital at home.

There’s no longer a continuum of care from a step-down setting to another setting. There’s a continuum of care in terms of need. But the settings now are a spectrum of settings that become available for a wide range of continuum of care needs out there. We really, I think, have moved into a whole new generation of health care services at home. Just within the last 12 months, it all came together.

[00:18:24] Holly: You mentioned MedPAC, and this wasn’t on the agenda originally, but something that we just covered that I found really interesting was MedPAC questioning home health access data. Do you think that’s something we need to look into more?

[00:19:27] Dombi: I think we need to. I think that MedPAC’s model for evaluating access and payment rates is way too antiquated. It doesn’t fit anymore. When you look at just the numbers, it’s almost as if MedPAC sometimes backs into a predetermined finding that access is adequate enough out there by choosing data points.

History is very important. You learn a lot from history. In the last five to 10 years, we have seen a loss of over 1,000 home health agencies and a reduction in the number of Medicare beneficiaries utilizing services.

We’ve said to MedPAC, “How is it that you could say everything’s okay when we have less home health agencies, less users of services, and those people getting less service?” Those aren’t the ingredients for “everything’s OK” in my mind.

[00:22:15] Holly: We talked a little bit about the factors shaping home health care in 2022. Are those factors different in any way as far as home care? And when I say “home care,” I’m thinking more of the private-pay, non-medical model?

[00:22:37] Dombi: Well, I think there are similarities – and there are differences. The workforce issue for home health is actually not just shared on the non-medical home care side, but it’s greater.

And If it’s the private-pay side we’re talking about, it’s not highly regulated. As much as non-medical home care likes to be not so overly regulated, there are some questions that come about regarding quality of care because of the lack of standardization, the lack of any kind of guardrails for those businesses, other than those that they’ve put in place themselves.

When looking at the non-medical home care workforce, No. 1 to them is quality from top to bottom. That’s important.

[00:24:02] Holly: A fun question that I thought that I could throw out there since we’re looking ahead to 2022: Is there one contrarian or alternative prediction you might have about either home health or home care? Something where the entire industry is saying we’re going to zag, and you think the industry is actually going to zig?

[00:24:23] Dombi: I think the concept of this intense consolidation of the industry that puts the little guy out of business, I’ve never bought into that. There is consolidation. There will continue to be consolidation in the industry, but there will continue to be opportunities for new players, too – small, medium and large-sized providers.

The common view is that the industry is going to consolidate into some handful of very, very large companies. We have some very, very large companies today – and some are getting larger still. But we still have a very vibrant universe of small providers of services delivering high-quality care efficiently, able to make quick changes when the demands are there for doing so. I’m not one who believes that the industry ends up consolidated to the extent that some people might be predicting, which doesn’t mean the big guys don’t have big opportunities. They still will have that.

The ability to have new entrants is a positive force. That brings innovation. It brings energy and competition, which often makes us better, too. That’s the one area where I would be zigging when others are zagging, perhaps.

[00:25:54] Holly: This was an interesting conversation that we had at an event a couple of weeks ago. Somebody made a comment to me about how the market is looking more and more like an upside-down bell curve, where you still have a lot of really small scale, mom-and-pop businesses, then you’re starting to see more and more large home care providers.

[00:26:59] Dombi: When you look at the deals, so many of them are a big company taking on another big company, or a fairly big company. It’s rarely, in comparison, trying to merge the culture of 25 different small operators into your culture. Again, I do see the opportunity out there.

One person some years back gave me one of the maxims in home care: He who has the workforce survives or prevails. Right now, that is clearly a big key.

It particularly is important relative to this aspect of consolidation. The large companies are large by having a lot of locations, but the sites themselves are not necessarily large. Those sites are competing with a small operator who’s in just one locale for that workforce – and that small operator may be the winner in getting that workforce. That’s the strategy people have to be thinking about, “How do I get and keep that workforce?”

[00:28:09] Holly: You talk to your home health members regularly on the workforce point. Do people expect the situation to improve, worsen or kind of stay the same?

[00:28:32] Dombi: I think it depends a lot on who you’re talking to. On one side, people will say, “With the increased attraction that care in the home is bringing, perhaps we can recruit some staff from other care settings, be it nursing homes or hospitals or physician’s offices.” The flexibility, the independence, the much-improved image of health care providers in the home setting could attract some people. That’s taking from one segment of health care and moving it into your segment. That only has limited value in the end.

Others are saying, “How do I compete with the hospitals who are paying big bonuses and big hourly wages to these workers, who, more importantly, are not even out there?” These workers aren’t even out there to recruit away. Reports are coming out every week about another group of health care providers – the most recent one I read was on physicians and nurses – who plan on retiring in 2022. I think you’re going to have both sides’ views relative to improvement, but nobody that I’m talking to believes we’re going to see some sort of exponential increase in staff availability in 2022.

There might be some improvements around the edges perhaps, but a lot more work around retention needs to be done to keep the current workers compared to recruiting additional ones.

[00:30:16] Holly: It really seems like this is going to be a prevalent issue until we as a nation figure out how to increase that pipeline of people going into direct care or going into nursing. Then if they go to nursing school, figuring out how you educate them about the opportunities in home-based care early on.

[00:30:38] Dombi: On that nursing side, home care is going to have to deal with the fact that they had the luxury in the past of going only after workers who are highly experienced. That was true because putting them in an independent care position – in the home setting – often required somebody with experience under pressure. We’re going to have to grapple with the scope of practice aspects. What could be put into the hands of other individuals so that everybody’s operating at the top of their profession? What could go on there? I think there’s a lot of room for some further investigation.

[00:31:27] Holly: Well, I promised I’d only take up 30 minutes or so of your time, and we’re getting to that point. To start wrapping the conversation up, a theme of this year has been the evolution of the home health space. You mentioned the different types of care, from SNF at home to hospital at home or whatever you want to call it. In your view, what’s next for home-based care? What’s the next generation, so to speak? Then, lastly, just what’s next for the National Association for Home Care & Hospice?

[00:31:59] Dombi: Well, I think what’s next for home health care and home-based care is probably an acceleration of what I’ll call horizontal integration, meaning that when the home care company is offering a range of health care services at home in contrast with specializing in home health or non-medical. You can do that with a virtual integration or an actual integration, but people are looking for efficiencies. And they’re also recognizing that when a patient starts in, say, home health care, they’re likely to need other health care services at home, either at the same time or as the level of need for that individual changes.

I think one of the other things that we can expect in the future is a better seat at the table with such parties as Medicare Advantage plans or ACOs, because the respect meter has been steadily going up for health care services at home. In-home care providers have been demonstrating they need not just a seat at the table, but they need a microphone at that seat. They need people listening to them.

What’s in the future for NAHC? We think NAHC is already pretty well positioned on the horizontal integration side with the nature of what we do overall, but we’re looking at a tremendous amount of opportunity out there. There’s the Choose Home program, whether that gets done in 12 months or 24 months or 60 months – it’s still a great idea. We’re going to be continuing to move towards that. We hope to see the Build Back Better Act passed by Congress and signed into law with the significant increase of support from Medicaid home- and community-based services (HCBS).

We know what January at least brings to NAHC is continued advocacy around that important piece of legislation. We were disappointed that in the Build Back Better Act, the tax credit for private-pay services was not maintained. We think we’ve got a lot of strong allies on that out there, particularly AARP. That’ll be on the agenda from an advocacy perspective as well.

We hope that the dust starts to settle around telehealth services, so that we don’t get ourselves burdened by the abusive activities that occurred outside of our own sector that are haunting us at this point in time.

The last two things I’d probably mention would be an effort focused on Medicare Advantage. We are crafting a very deep-dive research analysis with the intention of demonstrating value to the Medicare Advantage plans. MA enrollment continues to grow, and it’s forecast to find itself in the 50% to 60% range in the not-too-distant future, which means we can no longer depend upon Medicare fee-for-service to be there to support shortcomings of MA. We’ve got to solve the Medicare Advantage issue and make them the strong partners that they should have been for a long time.

Last but not least, we have a whole platform related to the workforce issue, to try to improve the workforce situation. It ranges from educational supports to immigration changes – and simply just helping to find people who can be there, people who see the value of having a career in home- and community-based services. Workforce is going to be a significant priority of ours in 2022.