“It’s a distinctive part of the culture of UnitedHealth Group that we continue to strive to deliver on our financial commitments to you through changing environments and unforeseen challenges,” UnitedHealth Group CEO Andrew Witty said during the company’s third-quarter earnings call on Tuesday. “As we look to 2025 … we remain in a dynamic period for the health care sector. Amid this, it’s important that we continue to invest in the durable value creating capabilities of this company that support our 13% to 16% long-term growth objectives.”

Despite this current operating environment, Witty expressed optimism about the company’s ability to grow in the years to come.

The company already owns the home health giant LHC Group, and is in the process of acquiring Amedisys Inc. (Nasdaq: AMED), another one of the largest home health providers in the country.

One of the elements laying the groundwork for growth is UnitedHealth Group’s commitment to the transition of the health system to value-based care, Witty noted.

“At UnitedHealth Group, we’re purposefully organized to support the transition to value-based care,” he said. “It requires deep engagement with patients, setting the foundation to move to more coordinated care, connecting patients to primary care earlier, driving clinically accurate diagnoses more effectively, recognizing and managing chronic conditions and slowing disease progression. We’re seeing the benefits of this work come to fruition.”

Specifically, individuals who receive care services under Optum’s value-based models are more likely to receive cancer screenings. Optum is UnitedHealth Group’s health care services arm.

These individuals are also better positioned to control their diabetes and hypertension, compared to those under fee-for-service Medicare. Plus, they are 10% less likely to visit the emergency room, or be readmitted to hospital.

UnitedHealth Group’s value-based care models incorporate home-based care services, such as house calls, home health care and other in-home visits.

For the third quarter of 2024, UnitedHealth Group brought in revenues of $100.8 billion, a $8.5 billion increase over the prior year period.

Optum’s Q3 revenue was $63.9 billion, a $7.2 billion increase over the prior year.

“This was driven by an increase in both the number and type of care services we offer and the patients we serve, especially in the home and among those with complex needs,” John Rex, president and CFO of UnitedHealth Group, said during the call.

UnitedHealthcare’s Q3 revenue was $74.9 billion, a $5 billion increase over the previous year.

“Indications are tracking favorably as we head into 2025, reflecting continued strong uptake of UnitedHealthcare’s innovative offerings,” Rex said. “Our Medicare Advantage plans, on offer this fall, balance providing as much benefit stability as possible for seniors, while contending with the CMS funding cuts, IRA changes and expected care patterns.”

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This comment was an anomaly, in terms of its brevity. While most respondents expressed similar sentiments, they chose to utilize more words to do so.

Overall, providers went into detail about the specific challenges they are facing in their market, and why the proposed payment rule would impact access to care.

Below are the comments Home Health Care News thought stood out from providers, as they see their margins decrease year over year.

Some comments have been edited for length and clarity.    

***

Within our market, the incidence of home health admissions that include wound care and specifically the types of wounds included within this proposal are increasing. Any decrease to reimbursement for HHAs who are treating these types of wounds would be detrimental to patient care. The cost of supplies continues to increase like everything else in the economy and labor costs to access skilled nurses or therapists who actually have proper wound care treating in these types of cases are also increasing.

In our agency, we recently had to refer a patient who was sent to us to another agency due to the patient’s insurance. The patient developed a pressure wound and the nurse who was sent to treat the patient was not properly trained in wound care. Over the next few weeks, the patient reported that the wound was increasing in severity and he was concerned that the nurse did not seem to know what she was doing. He requested that she get some additional help. The nurse brought her supervisor to observe the wound care provided and ask if it was proper or adequate. The supervisor instructed her that the only thing she could do correctly at that point was call an ambulance for the patient. The patient had developed gangrene in the wound and was transported to a hospital. A few weeks later, the patient’s leg was amputated just below the knee. The result of amputation resulted in significantly higher expense to Medicare than paying for adequate wound care wound cost. Worse, the patient’s quality of life is now irreversibly affected by loss of limb.

I understand the need to try to reduce expenses and cut costs across our federal budget. Home health is a great program that allows for significant improvement in patient outcomes while decreasing hospitalization. I strongly encourage Medicare to consider increasing spending for home health companies to provide quality supplies and hire or train their staff with the necessary certifications and skills needed for advanced care in the home. While the expense for home health may increase, I don’t think it’s a surprise that the rate of hospitalization will decrease and that significantly decreases the overall cost of health care while also improving patient outcomes.

— Primary Home Health LLC

***

I am an administrator of a small independent home health care agency in Calumet City, IL. Every year we are fighting for survival and every year CMS is proposing to cut reimbursement and adding more regulations. Unfortunately, it is the same this year. There has got to be a way that you come up with a plan to stop this madness. It is difficult to pay nurses and have enough people in the office to maintain all of the regulatory requirements. Can you please remove some of the regulations so we can get back to the business of taking care of patients? You just extended RCD 5 additional years. You have extended HHVBP. You have added NOAs but didn’t remove any regulatory burdens nor have you given an increase in reimbursement. The hospital systems are dropping home health agencies like flies in Illinois because it appears we are not valuable. Independent home health agencies are closing because they can’t provide care, pay field staff and keep up with the regulatory burdens put upon us by you. We need a break, please!

— Deirdre Hezekiah Onwukwe

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I would like to express my concerns regarding the recently released proposed rule for the CY2025 Home Health Prospective Payment System (HH-PPS). As an occupational therapist and a former home health provider, the proposed changes could significantly impact access to quality occupational therapy services for Medicare beneficiaries. Reducing payment for key occupational therapy services raises alarms about the sustainability of these essential services, which play a crucial role in enhancing the well-being and independence of patients in their home environments. It is required to maintain focus on ensuring that Medicare beneficiaries receive the highest quality of care, and adequate compensation for occupational therapy. I urge CMS to reconsider these proposed payment reductions to ensure that patients continue to receive the necessary occupational therapy services for their recovery and overall health.

— Vera Gallagher

***

While we appreciate CMS’ efforts to combat fraud, waste, and abuse, CMS must provide clear guidance to any provider under a PPEO, including the timeline for reviews, the process for any appeals, and the criteria for when sanctions and penalties are imposed.

CMS’ proposed rate reduction does not consider the high costs of inflation, staffing shortages, turnover, and labor stresses that home health providers are facing. Combining those challenges with significant cuts to funding would reduce our patients’ access to life-changing care. This affects the patients who need us the most who may not have the funds and are most vulnerable.

The most vulnerable populations rely on our high-quality care and these cuts will restrict their access to care, particularly in rural and underserved areas.

Changes to the wage index will move some agencies from an urban designation to a rural one, thereby further reducing their reimbursement at a time when rural agencies are facing increased challenges recruiting and retaining employees.

We give excellent care to all who need us and even give charity/indigent care as we can but further cuts to our funding would make it almost prohibited. Our clinicians work very hard and they are not given annual raises, in fact some have not had a raise in almost 3 years. Home health is not an easy job, it is an act of the heart and yet they give everything they have to the patients and community we serve!

— Seaport Scripps Home Health

***

My home health agency serves rural Wyoming. With the high cost of supplies, labor, recruitment and overall cost to service a rural area, the proposed Rule will nearly eliminate our ability to continue to service these areas. We are currently facing high inflationary wages And stiff staff competition with the hospital and other health care providers. A 4% reduction in our reimbursement will only exacerbate the issue.

The 5% wage index cap also prevents our rural communities from obtaining a market rate wage that allows us to hire competitively.

The need for home health in rural communities is only becoming more and more necessary. This rule will prevent all home health agencies from being able to have sustainable reimbursement to service rural communities.

CMS needs to consider the overall stress home health agencies are under with the current economic environment. CMS should consider a reimbursement increase of 5%.

— Symbii Home Health and Hospice Wyoming

***

Compared to CY 2024, CMS estimates a decrease of 1.7% in Medicare payments to HHAs for CY 2025. Henry Ford Health is concerned that the annual update to the home health payment rate has not kept pace with significant increases in the cost of labor, medical supplies and other resources needed to provide high-quality care to our patients.

Much of this cut is attributable to a 4.067 percentage-point decrease that is a result of the behavioral assumption adjustment. CMS’ behavioral assumption adjustments are in direct response to regulatory changes that home health providers are required to follow since implementation of the PDGM on January 1, 2020. These behavioral assumptions are challenging because they are punishing home health providers for decisions brought on by regulatory change. For instance, one reason for lowering payments under the behavioral assumption adjustment was the assertion that there would be an increased volume of “home health periods of care” that would receive a comorbidity adjustment resulting from considering all 24 comorbidities on a claim rather than just five. Specifically, the intent of the PDGM was to rely more heavily on clinical characteristics and other patient information to place home health periods of care into meaningful payment groups, with 432 possible case-mix adjusted payment groups.

As a result of the effects of these changes – as well as to PDGM calculations, low-utilization payment adjustment (LUPA) threshold and outlier reimbursement – HHAs will experience even deeper cuts than the 1.7%. Henry Ford Home Health Care estimates that the reduction is closer to 2.3%.

— Henry Ford Health

***

You continue to cut reimbursement to providers and limit access to services that impact independence, member health, sustainability for providers, and ability for members to remain at home. You cut these services and then blame the providers for poor outcomes. By limiting access to these services, Medicare in the end spends more money to provide services to members in hospitals and skilled nursing facilities. It is time to support members in their home and maintain their health in the first place. It is far less expensive for Medicare to treat people who are healthy enough to recover than to provide services once diseases have progressed and prognosis is far less positive.

— Anonymous

The post ‘We Need A Break, Please!’: Home Health Providers Sound Off On CMS Over Rate Cuts appeared first on Home Health Care News.

WellSky’s latest report pulls data from the company’s network of more than 2,500 hospitals, accountable care organizations (ACOs) and physician practices, as well as 130,000 providers across the country. WellSky is an international software and professional services company.

Overall, the report shows that securing timely post-acute care options for patients is a pain point for hospitals. Even though home health referrals increased by 6%, acceptance rates were only 34.5%.

Tim Ashe, chief clinical officer at WellSky, believes that this is the biggest challenge the health care system is currently facing.

“Demand is increasing, patient acuity continues to expand, and then you layer in the workforce challenges and the supply side constraints that those shortages present, and you have a capacity problem in the post-acute markets, including home health,” he told Home Health Care News. “The 34.5% acceptance rate is really indicative of home health organizations wanting to take those referrals, but in many instances they are constrained either by supply, availability, capacity in general, or the ability to take on particular payers.”

Ashe noted that this is a “troubling dynamic” creating a bottleneck across the system.

“Patients need the level of care that home health provides, yet the capacity to care for all of those patients is constrained,” he said.

The report also found that patients discharged to home health care saw a 7% increase in average hospital length of stay.

“While home health agencies want to accept these referrals, they can’t, and so these patients are sitting longer in the hospital,” Ashe said.

Ashe pointed out that these challenges were an opportunity for providers to continue to seek out technology solutions that improve care planning and deployment.

Along these lines, the report also came to the conclusion that generative AI and predictive analytics could be a gamechanger.

“We see the implementation and integration of AI capabilities being a good fit inside of the provider’s workflow,” Ashe said. “It has to be intuitive. And it has to be done in a way that is part and parcel to the clinician, or the provider agency, being effective and efficient in how they’re scheduling, how they’re planning and how they’re deploying care. Ultimately, that leads to them being more enabled to provide higher quality care, and a higher volume of services to more patients.”

Ashe emphasized the importance of using these solutions to automate and eliminate administrative burdens, in order to improve access to care.

The report also highlighted some of the regulatory shifts taking place in the health care market, including the Transforming Episode Accountability Model (TEAM), ACO Primary Care Flex (ACO PC Flex) and the Making Care Primary (MCP).

“All of these regulatory changes and models are shifts and require us to educate ourselves, to prepare and make sure that we’re able to meet the requirements that CMS introduces,” Ashe said. “I see it as a positive and continued movement towards value-based care. At the end of the day, that improves quality. If done right, it reduces cost, which is a critical aspect to making sure that we have a sustainable health care market going forward. Ultimately, it’s the right thing to do for patients.”

The post Home Health Referral Rejection Continues To Create ‘Bottleneck’ Issue For Hospitals appeared first on Home Health Care News.

“To reach this milestone you’ve got to have a number of things,” Pete First, chief development officer of BrightStar Care, told Home Health Care News. “You’ve got to have a really solid system and a solid business case for what you’re doing and processes in place. BrightStar Care has been franchising now for over 20 years. To have that longevity, the history, and the reputation and the brand recognition — all of that feeds into growth. You have to have successful and happy franchisees. That’s one of the big difference makers.”

Chicagoland-based BrightStar Care offers personal home care, home health care and supplemental staffing.

In July, BrightStar Care reported that it signed 15 new franchisees in the first half of 2024. It also signed 24 new franchise agreements and opened 16 new locations during this period.

First noted that BrightStar Care was able to break into new markets, such as New Mexico and Nebraska, for the first time.

The company credits a combination of marketing and operational plans for helping it reach 400 opened locations.

“On the marketing side, we’re very fine tuned with our pay-for-click advertising in markets that we’re trying to get into,” First said. “We’ve got that dialed in with our advertising to look for new candidates. We have existing owners that are really wanting to expand. A number of the new signed agreements were with existing franchisees, so that was a big group that helped us reach that number. Then we’re getting a lot of referrals. Our referrals come from existing franchisees who love the business model, love doing what they’re doing and want to share that.”

However, the road to achieving 400 opened locations wasn’t without its challenges.

“The challenges really are territories,” First said. “Many of our major metro areas are already sold out, but we have markets in smaller suburbs, or different sized territories, that are available. It’s about working with and finding the right people for those territories, and usually it’s somebody that lives there. Let’s say we’re looking at a market that’s maybe 250,000 people, and it’s not in a major metro area, but it’s a great location for a BrightStar Care agency, it’s finding people that are already in that market and who want to make a difference.”

Ultimately, becoming an even larger franchise network will be leveraged to the advantage of BrightStar Care’s franchise owners, First believes.

“With the large footprint that we have, we’re able to negotiate better rates with vendors that the franchisees can use, so it helps to have that scale,” First said. “The big difference is we have a very robust national accounts program, where we have a team internally that provides access to national accounts for all of our franchisees through a central intake system. What that means is, the more coverage that we have across the country, the more opportunities and new national accounts we can open up for franchisees.”

The post How BrightStar Care Got To 400 US Locations, And Where It Plans To Go Next appeared first on Home Health Care News.

The proposal focuses on helping the “sandwich generation,” or adults who are caring for their aging parents while also raising children.

“There are so many people in our country who are right in the middle,” Harris said during her appearance on the show. “They’re taking care of their kids and they’re taking care of their aging parents, and it’s just almost impossible to do it all, especially if they work. We’re finding that so many are then having to leave their job, which means losing a source of income, not to mention the emotional stress.”

About 53 million adults in the U.S. care for a spouse, elderly parent or relative, or a child with special needs. This is an increase from 43.5 million in 2015, according data from a 2023 Guardian Life report.

Broadly, Harris is proposing to allow Medicare to cover home care, which is a proposal that has been raised by industry stakeholders regularly in the past. Currently, Medicare covers home health care – generally delivered after an acute event – but not home care, which is generally a non-medical service.

“They want to stay in their home,” Harris. “They don’t want to go somewhere else. Plus, for the family to send them to a residential care facility, to hire somebody, that is so expensive.”

Katie Smith Sloan, president and CEO of LeadingAge, pointed out that the demand for senior care continues to grow.

“Our country’s population is aging – and the demand for long-term care and services is growing,” she said in a statement. “Nonprofit providers of aging services have long warned that our current patchwork approach to long-term care delivery and financing is broken. Too many people struggle to access the help that’s needed as we age. Today’s announcement is truly exciting, and unique. Rarely do we see a proposal with this level of specificity included in a Presidential platform. Adding home care to the Medicare program, a much-needed component of a broader long-term care financing reform effort, will offer millions of older adults and families access to services that promote quality of life and safety as people age at home. At the same time, we cannot overstate that without staff, there is no care. Continued attention and investment in the workforce, as noted in the proposal, remains essential.”

Currently, Medicaid is available for low-income seniors that need access to home- and community-based care services (HCBS).

However, long waiting lists have been a persistent issue that limits access to these care services. More recently, MACPAC examined the use of presumptive eligibility and expedited eligibility as a way to speed up the process.

Then again, a small portion of seniors in the U.S. are covered by Medicaid.

Harris explained the reason behind the focus on Medicare for these latest efforts.

“This is about Medicare, because otherwise people have to spend down everything they’ve got to be eligible for the care they need as a Medicaid recipient,” she said.

She also noted that her proposal was about helping individuals get ahead, and not just get by.

Joanne Cunningham, the CEO of the Partnership for Quality Home Healthcare, called the development “important and welcome” news.

“It shows a tremendous understanding of what … the sandwich generation’s needs are, and the needs that many older people have in order to live independently in their homes,” she told Home Health Care News. “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. With this news, I would just offer that recommendation and reminder.”

The National Alliance for Care at Home also applauded Harris for pushing care at home into the spotlight.

“By raising the topic of expanding care at home in such a visible way, in high profile way, this is another acknowledgment that American families really are hoping for stronger access to care at home, that people want to age in place with dignity and independence,” Dr. Steve Landers, CEO of the National Alliance for Care at Home, told HHCN.

The post [Updated] Vice President Kamala Harris Proposes Medicare Home Care Benefit appeared first on Home Health Care News.

“The data suggests that, for the populations that have been studied in multiple different places, it’s a very safe service to be done and with high-quality care, low readmission rates, low escalation rates, low infection rates,” Dr. Adam Groff, co-founder Maribel Health, told Home Health Care News. “The bottom line is people love it, patients love it and it’s a high-quality care experience.”

Maribel Health is a company that helps health systems modernize and deliver advanced home-based care services through technology. This includes services such as, hospital-at-home care, community paramedicine and other high-acute care models.

In 2020, the hospital-at-home model had its breakthrough. Though the model was common internationally, it was considered niche in the U.S. This changed with the introduction of the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care At Home program.

A recent report from CMS found that the program has been largely successful.

Simply put, the CMS waiver created a mechanism for reimbursement for hospital-at-home care. The lack of straightforward reimbursement had been a major roadblock for the model.

Despite the momentum the model has seen in recent years, challenges still exist when it comes to operations and scalability.

Specifically, less than 9% of waiver-approved hospitals accounted for more than 70% of all U.S. admissions, according to data from MedPAC’s June 2024 report to Congress.

“If you add all the admissions together, it’s less than 1/10 of 1% of the Medicare fee-for-service inpatient hospital admissions across all programs,” Ronald Paulus, president and CEO of Maribel Health, told HHCN. “It’s clear that there is an operational challenge that needs to be overcome.”

Additionally, almost two-thirds of hospitals had zero admissions.

Paulus noted that even with these challenges, there have been some examples of success.

“For example, Mass General Brigham in Boston, where our medical director practices, they’ve achieved a census of about 70 from a number of hospitals,” he said. “UMass is not too far away, it has gotten to a census of 20 with just one hospital. Atrium Health has gotten into the upper 40s, low 50s across multiple sites. There are some inklings of success, but the average hospital at home program in the U.S. that had admissions, averaged only two admissions per week, so it’s not achieving what it can.”

For context, among hospital-at-home operators, an average daily census of five is similar to roughly 50 in the hospice space, and around 250 in home health, Groff noted.

“A hospital-at-home program with only five patients doesn’t sound like a lot, but it’s actually a very complex operation,” Groff said. “If you think about what some of these folks are doing — getting to censuses of 50 or plus, that is a very complicated operation. It requires a lot of new knowledge around operations, and then technology to support it.”

In order for hospital-at-home care to continue to see forward movement, there are a number of pillars that Groff and Paulus believe that providers must embrace.

“In some ways it’s simple, in other ways it’s very difficult,” Paulus said. “One is building a high performing team. The second is having a very clear organizational structure. It can’t be a side job. There has to be a clear leader with ongoing P&L responsibility and oversight. Third, there has to be a relentless focus on growth and optimization. You’re reinventing the program at each increment of census. A program of four is totally different from a program of 12, which is totally different from a program of 26, and so forth.”

Another key pillar is having the right tools and analytics that allows providers to orchestrate all of this.

“Those pillars will be very familiar to home health and hospice operators because that’s how they run their businesses,” Groff said. “On the technology and knowledge front, I think this is a challenge for everybody in the home-based care space.”

Currently, hospital-at-home operators are waiting to see if the CMS waiver will continue on. Without an extension, the waiver is set to expire on Dec. 31.

This year, legislation that addresses the model has been introduced. Paulus is optimistic about the future of the model.

“In our divided world, it seems to be something that has support on both sides of the aisle politically,” he said. “It has a neutral score from the CBO, so that’s very helpful, in terms of a programmatic renewal. We know that patients and consumers have reached out to say that they like this, and they want to have this. If we sit back and think about the demographics of the United States, and how it’s aging, in 2050, the entire [country] is going to look like Florida did in 2020. There aren’t enough buildings to care for all of these people.”

The post Hospital-At-Home Care’s Future Still Hangs In The Balance appeared first on Home Health Care News.

Home-based care providers and Program of All-Inclusive Care for the Elderly (PACE) organizations are in a unique position to strengthen the work one another is doing to care for seniors.

No one understands this better than Alivia Care, a home-based care provider that also has PACE programs under its umbrella. In 2021, Alivia Care opened up Jacksonville, Florida-based The PACE Place.

“We thought No. 1, it related to the type of care that we gave, in terms of chronic elderness, geriatric frailty, many of the things that we see in our hospice patients, so we felt that we had some core competencies there,” Alivia Care CEO Susan Ponder-Stansel told Home Health Care News. “One of the things that we also wanted to do is just practice being responsible for the total cost of care, over a longer period of time.”

Jacksonville, Florida-based Alivia Care provides home health care, hospice care, personal care, palliative care, advanced care planning and PACE services across Northern Florida and Southern Georgia. Currently, The PACE Place serves roughly 150 seniors.

Ponder-Stansel has seen opportunities to bring in its home health resources to benefit the seniors who are receiving care through the company’s PACE program.

“We found that it was actually better to work with our home health agency, especially for things like wound care,” she said. “Home health [clinicians] have certain skill sets that most are very good at, things like wound care or cardiac rehab or diabetic education, some of those things that we would see in our PACE population. Some PACE providers just do it all themselves, so it depends on what works for them, but we felt this was a better way.”

In addition to this, Alivia Care utilizes its personal care staff to offer transportation escorts for medical appointments to seniors receiving PACE services through The PACE Place. These caregivers are also providing support in the home, delivering housekeeping services and help with chores.

On the other end, the company has been able to bring PACE services into the home.

“Not every PACE participant will come into your day center every day,” Ponder-Stansel said. “There are times when people just don’t feel well. We’ve been able to do occupational therapy, physical therapy, and bring that to the home for them. Because PACE is the payer for this, you don’t have to necessarily go through all the hoops of the OASIS. You can just contract with your home health to provide it.”

Referral-based partnerships

One Senior Care is a PACE organization that has formed referral-based partnerships with home-based care providers.

“Oftentimes it’s those home health companies that really know and see the conditions that the patients are living in, and really have a good understanding of the complexity of these patients,” Craig Worland, chief operating officer at One Senior Care, told HHCN. “They’re the ones who realize that the patient may need more, and they actually can be a referral source for us.” 

Erie, Pennsylvania-based One Senior Care is the top PACE provider for rural and Appalachian communities.

Similar to Alivia Care’s The Place Place, One Senior Care also brings its home-based care partners into the home of PACE participants that need additional support.

“There are definitely times where there’s a skilled need that we don’t have at a center within our staff, or there is something that a patient needs just due to how complex they are that we are not equipped to provide,” Worland said. “We work with the home-based care company to provide that.”

The biggest value-add of these partnerships is being able to offer an additional level of care through working with home-based primary care and home health providers, according to Worland.

“That to me is really the sweet spot for these partnerships, it’s allowing us to meet our goal, which is keeping the participant at home, that could be anything from wound care to infusion [services],” he said.

Despite PACE and home-based care providers being natural allies, Worland believes that the latter are sometimes reluctant to collaborate with the former.

“Sometimes home-based care companies view PACE as a competitor, and they almost have an aversion to working together, or an aversion to using PACE as a resource for their really sick patients,” he said. “I think what I’d love to see is just more of that collaboration.”

For Alivia Care, the internal partnership between its home-based care arm and its PACE program has meant leaning into each segment’s strengths, as opposed to taking everything on.

This doesn’t mean the collaboration is completely free from challenges.

“Coordination and communication is something that is sometimes challenging, and you have to build in mechanisms for hearing from those who are providing the care in the home, and then having them coordinate with your interdisciplinary care team to manage that care and make sure you’re responding to anything that’s going on, and planning adequately,” Ponder-Stansel said. “There’s a higher degree of communication than you would normally see with a Medicare patient.”

Worland also stressed the importance of strong communication within these partnerships.

Ultimately, he wants home-based care providers to understand the mutual benefits that come from teaming up.

“The onus is on the PACE plan to explain that and spell that out, but as patients continue to get sicker, get more complex and their care needs become more challenging, I really want these home care companies to be thinking about PACE as a partner,” Worland said.

The post PACE Programs Emerge As ‘Natural Allies’ To Home-Based Care Providers appeared first on Home Health Care News.

Having a unique business model is a strength, but it also means dedicating time to explain how the company operates and its overall value add. It’s a position Klein has often found himself in.

“I used to have a boss that referred to that as an ‘evangelical sale,’ because you actually have to evangelize what you’re doing,” he told Home Health Care News on the latest episode of the Disrupt podcast. “People don’t know what it is at first.”

New York-based Vesta Healthcare is a specialized medical group for individuals receiving home-based care services. The company oversees, coordinates and supervises care in the home. It recently raised $65 million in a Series C funding round.

At the center of all of this is the belief that caregivers are an integral part of health care. HHCN recently caught up with Klein, who went into detail on this topic. During the conversation, Klein also talked about where sees home-based care business opportunities and how the company has been able to expand so rapidly.

Below is that conversation, edited for length and clarity.

Subscript to Disrupt to be notified when new episodes are released. Listen today on Apple Podcasts or SoundCloud.

HHCN: For the listeners that are unfamiliar with Vesta Healthcare, can you go into detail about your company’s business model and how it works with home care providers?

Klein: We are a specialized medical group for people with long-term home care. We have a highly-integrated network of non-medical providers, particularly personal care agencies, but other provider types as well. We get referred patients from the community and other providers the way that anybody would get referred, and then we work with the agencies that are servicing those folks to integrate the [people] who are providing that care, and their service coordinators and what have you, into the care that’s actually being delivered.

It’s a unique model that allows us to take the insights and access that people in the home have and convert it into actionable events for medical care delivery, in a way that the medical side of the house can reimburse for. I think it’s very effective in engaging the home in terms of improving quality of care.

Let’s take a step back, can you share with listeners what your health care background is, particularly on the home-based care side?

I grew up in a home care family. My dad worked for a health plan. My mom is a social worker. My grandparents worked in health care as well. Health care is kind of in the blood.

I ended up starting my health care career working for a company in New York called Visiting Nurse Service of New York (reporters note: The company is now VNS Health). It’s one of the oldest and largest nonprofit home care companies around.

I had the very weird entry point of implementing an episodic reimbursement program for home care, Medicare, PPS — that I’m sure many people here know. I really started my health care career from the standpoint of value-based home care. Over the past 20 years, I’ve had the ability to work on this from a variety of perspectives. I’ve been an operator of a plan. I’ve been a vendor that’s focused on in-home assessments and care management. I’ve done episodes of care payments, but all of it has been really around this idea that the home is a very important, overlooked and disconnected setting of care. If you can engage the people that are there, as part of the delivery system, you can actually create better outcomes, as well as reduce cost and improve satisfaction.

I’ll give you one quick anecdote. When I was working at VNS, I was on a project for one of their executives. I had the ability to actually go out and do a whole bunch of home care visits studying what happened in the home. I remember being absolutely blown away by what these nurses and aides were doing. I came back, a naive 20 something, talking to my boss about how great all this stuff was, and what a difference it must have made. His comment was something to the effect of, ‘wouldn’t it be great if?’

What came from that was the idea that, ‘Oh, wait a second, this part of the system actually isn’t being used properly.’ Later on, I had another person there refer to home care as the caboose of health care. That’s been one of the things that I’ve spent a lot of time thinking about and working on ever since.

Caregivers — whether informal family caregivers or ones with agencies — are such big pieces of Vesta Healthcare’s puzzle. Why is that so?

They’re the ones that have the most access and positions of trust. We got into this with the idea of making health care better, and there’s been a tremendous amount of investment and innovation in the system.

This caboose part of it — if you look from a dollar spend perspective and a population spend perspective, it’s actually a very large caboose. It’s kind of gigantic. It makes up a huge percentage of state Medicaid budgets. If you look at people who are older adults with functional limitations, the likelihood that you end up on Medicaid. You look at the size of the workforce, you’re talking about millions of paid aides, tens of millions of caregivers, it dwarfs almost anything else, but it really doesn’t get a lot of focus. We built a company, and a program, around the idea that the enormous resource — which I’ve come to call the dark matter of the health care system — we can do good things if we engage it. That’s why it’s the center.

Your company recently raised $65 million in funding. Can you walk listeners through Vesta Healthcare’s funding history, and what this latest round of funding will enable the company to accomplish?

Vesta Healthcare was founded in 2019 and we were founded out of a prior company.

What we did was we raised our initial round of capital from some of the original investors. That would be what you would consider round A. That was really designed to get us proof of concept. Can we demonstrate that we have a business that folks are interested in working with? We did that, and then shortly thereafter, we ended up doing our B round. That was really designed to help us scale, because we had some demonstration that what we were doing was working. The B round was designed to get us to a point where we had essentially unit economics. We knew that our business was working, economically, so it would be viable in the long term.

We hit some pretty rough market conditions over the past few years. The health care innovation landscape has been a very tough place to actually access capital in, and I’m really fortunate to have great investors and partners that have helped us along this journey, and we were able to grow and scale during that time. Then earlier this year, we were able to raise our C round, which is a growth round that’s designed to help us digest all the opportunities that we’ve been developing over these past few years, so we’ve been growing very rapidly. You may have seen that we were on the Inc. 5000 for the fastest growing companies, almost 1,000% growth over the past three years. We have more than that lined up over the next few years.

Growth is expensive. You have to hire, you have to invest. We’ve expanded our footprint geographically. We’ve expanded the programming that we can support. In addition to our present models, there’s a new one called GUIDE coming out that we’re going to participate in. There’s other value-based, aligned programs that we participate in. All that requires investment.

What this round of investment is going to do is twofold. We use debt to help finance some acquisitions that helped us catalyze our growth, so it retires that older debt. The equity portion of it is primary equity that we’re using to grow the company to the next stage.

Let’s talk a little bit about Vesta Healthcare’s expansion. In 2021, the company was in five states, and now it’s in 21 states. How have you expanded so rapidly, and where do you want to go next?

We’re seeing patients in 12 states, and we have 21 we can see patients in. What we’re doing is basically following our referral patterns. We don’t ever enter a state without there being someone that’s bringing us into the state.

The nature of our business is that you’ve got imperfect overlap between payers and providers. We work with home care agencies that cover multiple states. We start with them in one state, and they want to expand with us. We go to the next state with them. When we get to the next state with them, we have to get to scale, so we apply for network participation. I’m really proud that we’re in network with over 100 health plans at this point in time. Then we use the ability to be in that state with a partner as a catalyst to recruit other partners to work with us, which then does the same thing again. It brings us into new geographies, and we repeat it all over. We’re just following where the growth is taking us, and that’s been the reason why it’s happening so quickly.

What are some of the growth barriers that you’re seeing in the market? More importantly, how is Vesta Healthcare navigating these challenges?

First and foremost, for a company like ours, the biggest barrier to growth is understanding what we are. If you go and talk to most participants in the system, they probably say, ‘Hey, we already do care management in some form or another,’ and they do. There’s lots of care management out there. If we’re a different form of current care management, or we’re not care management at all, then what are we?

One of the things we’ve had to learn how to do over the past few years is tell our story, which is why I told it the way I did. We’re a specialized medical group for people with long-term home care. We oversee and coordinate and supervise care in the home, and we engage the aides and caregivers as part of that. When you start to frame it in that sense, many payers will recognize that they don’t have a provider or network that’s doing this. Many providers will recognize that they would benefit from this. This is something that could help them improve their own businesses and improve their own quality. That’s the first part, I used to have a boss that referred to that as an ‘evangelical sale’ because you actually have to evangelize what you’re doing. People don’t know what it is at first.

The second part of it is just the inertia of the delivery system. If you’ve ever tried to get a contract with a payer, get in network, get anything through that stuff, it just takes a long time. We come in through the front door in most places. There’s nothing fast about it. We have to get in network. We have to get credentialed. You have to recruit credentialed providers. You have to get to scale. All of that takes a long time and a lot of resources. Which comes back to having great partners. But once it’s in, it also tends to be pretty durable.

Where are you seeing key home-based care business opportunities right now?

I think that the future of care in the home is in the earliest innings right now. The ability for technology to rapidly upskill and scale what can happen, the ability of better information flow will enable much more personalized approaches that do a much better job of using the home setting as an actual setting of care. Payment models have to continue to innovate to support that.

If I were looking at ways to continue to expand what folks do, I would be looking at how to get skilled agencies to the top of their license, how to move end-of-life care into the home on a greater basis, how to upskill the non-skilled, to get them to the top of their ability levels. I would be looking at virtual models that can augment home-based models, so you can get greater scale out of them. I would be looking at personalized approaches for management of medications. I would be looking at ways to really simplify getting things like DME into the home.

I think there’s so many different places here where, in the home, you can do things that will ultimately be higher quality and lower cost. Behind that, I think there’s also a ton of back-end stuff right now. There is a lot of administrative burden that happens around home-based care. As the system gets smarter on this and understands what it’s doing, it will be able to eliminate a lot of the paperwork and back and forth that, frankly, exists because of the complexity of the system, but doesn’t add any value.

As CEO, what goals do you have for the near-term future?

I want us to clearly demonstrate the value that integrated care in the home creates.

There’s still too much evangelizing happening around this. I’ve met some folks who are innovating around similar models, and I cheer for them. We have to get to a place where the notion that care in the home that’s not integrated is an anathema. That you would always expect that care in the home is going to be part of just care in general.

Secondly, to make sure that the business that we’re running is sustainable. I run a business. I have to make sure that what I’m doing works economically. I have to be really careful as we grow, that we don’t take on too much. I have to be really careful that we continue to perform well. The second part, as a CEO, is to run a great company. I would say the third part of it is to make sure that I am a very valuable partner.

If I’m not a valuable partner, I’m going to lose my partners. I need to make sure that the folks that I’m working with on the provider and the payer side are experiencing the value that we set out to create for them, and in my mind, that does extend all the way to the caregivers. Whether you’re a family member, or an aide in this system, I believe there should be a material difference to being supported by someone like us, where you feel greater access, greater support, greater control, greater participation.

The post How Vesta Healthcare Raised Over $60M To ‘Integrate’ Personal Home Care appeared first on Home Health Care News.

The collaboration between BrightStar Care and Medically Home is one example of this.

“More care is moving into the home, and higher acuity care is moving into the home,” Shelly Sun Berkowitz, founder and executive chairwoman of BrightStar Care, said during a panel discussion at Home Health Care News’ FUTURE conference in August. “I think that’s exciting, but home care providers that have been more on the non-medical side need to start thinking about how they transform and move into higher levels of acuity. I think that’s where a lot of the opportunity is going to be.”

Chicagoland-based BrightStar Care offers personal home care, as well as supplemental staffing and home health care. It has over 400 franchise locations across the U.S.

On its end, Boston-based Medically Home partners with organizations to help them deliver hospital-at-home services, as well as emergency department services in the home. The company coordinates in-home visits, sets up the proper technology and equipment, and pulls together all of the necessary resources.

Medically Home and BrightStar Care have been partners since 2018. At the time, the former was in “startup mode” and was attracted to BrightStar Care’s approach.

“BrightStar came in with this entrepreneurial approach to our work together,” Dr. Pippa Shulman, chief medical officer at Medically Home, said during the discussion. “It was immediately, ‘How can we solve the problem that you have, and not be constrained by our idea of what home care medicine looks like?’ It was really future thinking. Now, we’ve both grown. We’re both different organizations, and we’ve really committed to partner together, and when we need new nursing services, BrightStar is our primary partner going forward.”

Shulman is a hospital-at-home pioneer, and previously told HHCN that “the tipping point is coming” in relation to that type of care in the U.S.

In 2023, BrightStar Care expanded its higher-acuity care services by rolling out primary in-home clinician and transport services in Arizona.

“We’re a franchise organization, so we went and bought back several of our franchisees, made a multi-million dollar investment in Arizona to own the territory, control the territory,” Sun said. “We believed hospital at home would be so important for the growth of our brand and the transformation of health care in our country. We wanted to make sure we could spend the money, get the vehicles right, meet all the expectations of a great partner, but we felt like that’d be difficult to do, if we were relying just on a franchisee.”

Sun noted that this strategy allowed the company to work out the kinks before pulling in franchise owners.

“It’s a great way for us to be able to take a company-owned marketplace, spend our capital – not a franchisee’s capital – and figure it out, get the bumps out, and then once it’s ready, roll it out to our network,” she said. “I think we learned a lot together, built a great program there … and continue to make lots of impact for our franchisees across the country. As a good franchisor, I don’t want the franchisees having to spend their hard earned capital figuring it out. I have a much greater capacity to do that as a franchisor.”

Since then, BrightStar Care — in partnership with Medically Home — has expanded this effort.

In April, the company rolled out these services in California and New Jersey, and they’re offering this care in six states.

Ultimately, Shulman believes that the home should be the center of health care in the future.

“I’m not saying we don’t need hospitals,” she said. “We do, but we need ICUs, and surgery centers and a place for traumas [patients] to go. Almost everything else we can do at home.”

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“We are excited to have the opportunity to serve CDPAP consumers and personal assistants,” Maria Perrin, chief growth and strategy officer at PPL, told Home Health Care News. “Consumer direction programs are all we do as a business. For years, we’ve not only been operating throughout several states, but we’ve made it our purpose and mission to advance access to consumer direction and make these programs stronger, sustainable and more culturally competent. This is a great opportunity for us, and we are really excited to be partnering with our [fiscal intermediary] partners.”

Through CDPAP, a Medicaid-funded home care program, people seeking care are allowed to hire a caregiver of their own choosing. This often means informal caregivers, which are paid for their services through the program.

Roughly 700 businesses currently serve as fiscal intermediaries, many of which are home care providers themselves. The state is looking to save $1 billion annually by appointing one administrator.

As part of the agreement, PPL must work with four local organizations, and a network of 30 home care agencies.

“Our approach to this was to make sure that we put together a partnership with existing CDPAP fiscal intermediaries and with the independent living centers,” Perrin said. “That would make sure there’s ample capacity from a volume standpoint and from a linguistic standpoint, making sure that people who are not english speakers continue to be served. That people who have disabilities, or cultural or religious considerations, would continue to be served. At this point, we have over 30 existing CDPAP fiscal intermediary partners that we’ve identified, in addition to the 11 independent living centers, who will continue their work.”

Perrin noted that with state approval, PPL is open to identifying and partnering with even more organizations.

PPL will also relocate its headquarters to New York. The move will create over 1,200 jobs, according to a press statement.

Additionally, The Chinese American Planning Council will aid in managing the program in Long Island, Westchester County and New York City.

Uncertainties around CDPAP

With these changes to CDPAP, Emina Poricanin, founder and managing attorney of the New York-based Poricanin Law, believes that many providers will be weighing their options.

“As far as the providers are concerned, this is just additional uncertainty about their future as a business,” she told HHCN. “A number of them are, even more expeditiously, exploring other lines of personal care services that they can offer in New York State because they have no choice but to pivot from this program.”

For some, this means transitioning patient care hours into a traditional licensed home care services setting and out of CDPAP, Poricanin noted.

In addition to fiscal intermediary restructuring, Poricanin pointed to the significant decrease in reimbursement rates as another area of concern for providers.

“[It] takes out, largely, any incentive for a provider to be in this program,” she said. “Irrespective of what happens with PPL, or any single statewide fiscal intermediary, there’s simply very little money in this program. Therefore providers, regardless of what happens with the single statewide [fiscal intermediary] restructuring, should and are looking long term into what they can do with this line of business.”

Poricanin also believes that the state may see additional lawsuits, specifically ones that challenge if the appointment was a true competitive bidding process.

“The number has not been released, but based on my own knowledge of the market, I assume there were at least 200 applications that were submitted to New York State, and yet they were able to turn those around from mid-August and send out rejection letters yesterday,” she said. “How did they get through all of those applications that quickly, if they were actually reviewing the applications and giving each applicant a fair opportunity to apply? That is probably going to be the subject of some litigation — that the process was not conducted fairly.”

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