Even before entering negotiations with MA plans, providers should have a clear understanding of the challenging reimbursement environment they are walking into, according to Fred Bentley, managing director at the research and advisory firm ATI Advisory.

“Reimbursement rates have really leveled off for Medicare Advantage plans, even as medical expenses have really started to grow,” he said during a panel discussion at Home Health Care News’ FUTURE conference last month. “Whereas plans, in the past, were making, in some cases, double-digit margins, they’re going to pat themselves on the back and give high fives if they hit 3% this year.”

In other words, MA plans aren’t in a generous mood, according to Bentley.

When Elara Caring prepares for MA negotiations, the company remembers to enter with a long-term mindset.

“We have to understand that as much as we want to go in there and just be frustrated with the fact that they aren’t bending to our will, and giving us the rates we want, that we’re going to be dealing with this MA plan down the road,” Brent Nash, chief development officer at Elara Caring, said during the discussion. “They’re going to be our partners in the longer-term, so you need to go in with a positive mentality that you can address a pain point of theirs.”

Dallas-based Elara Caring is a home-based care provider with about 200 locations across 18 states. The company serves more than 60,000 patients.

This focus on addressing the MA plans’ pain points has been a key strategy for the company.

“We’re going into the conversations talking about their issues, and the things that we can do to help,” Nash said. “In the environment that [Fred described], where [plans] are completely getting hammered on from an MLR perspective, if you go in there and you just say, ‘I want more money,’ they’re probably going to just laugh you out of the room. You need to say, ‘I want to help you. What’s your pain point? Are you worried about readmission or ED diversion?’”

Nash noted that providers need to sell their ability to mitigate the cost of the MA plans’ pain points, specifically.

Joe Shannon, vice president of business development at HomeCentris Healthcare, emphasized the importance of providers highlighting their differentiators during these negotiations.

“If you’re talking about some of your data and it’s aligned with all of their other current partners, that might not be enough to move the needle,” he said during the discussion.

HomeCentris Healthcare is a Owings Mills, Maryland-based portfolio of companies that offer a variety of home-based care services, including home health, personal care, therapy services and more.

One of HomeCentris Healthcare’s main MA strategies has been focusing on local and regional plans. This has allowed the company to have more face-to-face contact with decision makers.

“We’re looking for partners that aren’t just interested in membership growth and risk adjustment scores, but really folks that are looking at how we’re taking care of the patients all the way through, and really being able to change the trajectory of what’s going on with their members,” Shannon said. “We’ve had some success with local and regional [plans], having a lot of discussions, soup to nuts, about how we’re able to support their members.”

Similarly, Nash emphasized the importance of getting the right people at the table during these negotiations.

“Bringing the actuaries to the table — that’s going to be really important,” he said. “You need someone who’s got an all encompassing view of the MLR, not just the person who’s focusing on home health or [personal care services].”

Bentley believes it’s important for providers to remember that oftentimes they aren’t the priority of MA plans.

“Home health is not a top concern for Medicare Advantage plans,” he said. “They’re obsessed with hospitalizations. They’re obsessed with specialty drug costs and a few other things. That means the folks you’re negotiating with have a very narrow purview. The art of this is getting the right folks to the table without upsetting the contracting folks.”

In addition to actuaries, it’s important to get chief medical officers to the table.

“The only time we’ve seen success where home health organizations have been able to move into mutually beneficial, innovative contracts … is when you can find a chief medical officer who actually has purview into the business side of plans, or some something equivalent to a CMO who understands the clinical value of home health care,” Bentley said.

Shannon pointed out that in his company’s dealings with regional or local MA plans, there are less siloes between these various departments.

Once a provider is at the table it’s paramount that they come armed with information.

“It’s really understanding, how are those plans doing on their star ratings — that’s publicly available data,” Bentley said. “How are they doing on enrollment — that’s publicly available data. It’s really understanding those specific pain points.”

Home-based care providers are also in a position to tout their access.

“Access is a huge calling card for home health,” Bentley said. “It’s not just access, it is about taking these complex patients that are clogging up the hospital.”

Ultimately, Bentley advises providers to see the bigger picture.

“It’s being myopic around thinking, ‘Well, I’m just here to negotiate on home health, and it’s not having a bigger picture view of your impact on the Medicare Advantage members’ outcomes experience,’” he said. “It’s really understanding your bigger value prop.”

The post For Home Health Providers, Getting The ‘Right Person’ At The Table Is Crucial In Medicare Advantage Negotiations appeared first on Home Health Care News.

That’s one key takeaway from a new data brief from the research and advisory firm ATI Advisory, though MA plans haven’t always been the best administrators of home care. The report examines access to — and enrollment in — MA plans. The report was compiled using data from the Centers for Medicare & Medicaid Services (CMS).

Currently, 14 million adults in the U.S. have LTSS needs. This number will grow as it is projected that more than half of adults who reach the age 65 will develop LTSS needs, according to ATI Advisory.

Even though Medicaid is the most common way people access LTSS, it’s not available to individuals who do not meet the correct income threshold..

With this in mind, MA is set up to fill some of those gaps. Home care providers recognize this, but their patient is wearing thin when it comes to working with MA plans on supplemental benefits.

“Medicare Advantage plans can use supplemental benefit authorities to help fill this LTSS access gap among Medicare beneficiaries and support their nonmedical and health-related social needs,” ATI Advisory wrote in the report. “MA plans can offer LTSS-like supplemental benefits through multiple pathways such as Expanded Primarily Health-Related Benefits (EPHRB) and Special Supplemental Benefits for the Chronically Ill (SSBCI). Plans participating in Value-Based Insurance Design (VBID) can offer both EPHRB and SSBCI benefits using VBID authority.”

EPHRB and SSBCI benefits both include some form of home care, as well as caregiver support and home modification services.

ATI Advisory found that 82% of Medicare-only beneficiaries have access to a plan with at least one LTSS-related supplemental benefit.

“Through a series of important policy changes in recent years, Medicare Advantage plans became able to offer a more holistic set of services to plan enrollees,” Johanna Barraza-Cannon, director in ATI Advisory’s state program and policy practice, told Home Health Care News in an email. “The 82% statistic demonstrates the continued market uptake of non-medical benefits. Medicare Advantage plans are growing increasingly comfortable providing a broader set of services.”

However, only 9% of Medicare-only MA beneficiaries are enrolled in an MA plan with at least one LTSS-related supplemental benefit.

“Supplemental benefits are only one part of a person’s decision-making process to enroll in a particular MA plan,” Barraza-Cannon said. “Within supplemental benefits, there is a broad spectrum of benefits across dental, vision, hearing, LTSS-like benefits, and social benefits like food supports that might influence a person’s decision, based on what their needs are. More research is needed to understand factors related to the decision making process related to an individual’s selection of an MA plan.”

The report also looked at access to MA plans across numerous demographics.

ATI Advisory found that Medicare-only beneficiaries who live in urban areas have a greater likelihood of accessing LTSS-related supplemental benefits, compared to their counterparts who live in rural areas. ​​

Access to LTSS-related supplemental benefits is most prevalent among Black and Hispanic Medicare-only beneficiaries.

On the flip side, access to LTSS-related supplemental benefits is least common among American Indian and Alaska Native Medicare-only beneficiaries.

Ultimately, Barraza-Cannon believes that home-based care providers have a role to play in the solution, as the number of people who have LTSS needs continues to increase.

“The market continues to demand more whole-person solutions, and this will only increase as our nation’s population ages,” she said. “Home-based care providers can play an important role in these whole-person solutions, often as the eyes and ears into what a person needs outside the traditional medical setting.”

The post As Need For LTSS In US Grows, MA Plans Still Have The Chance To Fill The Gap appeared first on Home Health Care News.

Otherwise, patients are likely receiving – unbeknownst to them – subpar care that isn’t guaranteed to keep them out of more costly settings.

That’s part of the thesis behind the company Careforth, which is a family caregiver support platform.

A recent analysis conducted by the research and advisory firm ATI Advisory, on behalf of Careforth, found that the company was able to lower adverse health event occurrences and keep seniors out of costlier settings. By keeping them at home, Careforth says it saves approximately $60,000 per person. That’s, of course, through its family caregiver guidance. 

“From helping caregivers navigate the health care system, to providing them the tools they need to advocate for themselves and the person they care for, to coordinating referrals for necessities like lift beds or ramps, our wraparound support makes it more possible for care to happen safely at home,” Katie Tardiff, Careforth’s SVP of clinical programs and services, told Home Health Care News in an email. “We empower caregivers and provide the tools they need to ensure their loved one’s safety, reduce ED visits and remain in their homes and community – where they most want to be.”

Based in Boston and founded in 2000, Careforth provides care teams for family caregivers. Those care teams connect caregivers with local resources and provide education for dementia care, behavioral health care and other conditions. They do so via in-person at-home visits, as well as virtually.

The ATI analysis also found that there was a 46% lower probability of at least one injurious fall for Careforth’s patients compared to other dual-eligible individuals.

“After an initial evaluation and assessment, we match each caregiver with a coach and co-create a customized care plan unique to their circumstances and needs,” Tardiff said. “We educate caregivers and provide resources to create awareness, build knowledge and increase confidence so they are prepared to identify changes in condition of their loved one, and intervene to prevent outcomes like falls or emergency department visits. Equipping family caregivers is central to care plan development.”

Furthermore, Careforth helps reduce emergency department visits. There was a 21% lower probability of at least one ED visit in a year under its watch, according to the analysis.

Due to that nationwide caregiver shortage, and the millions of Americans that care for family members, self-directed or consumer-directed payment models have become more common.

The downfall, of course, is when there are either families taking advantage of the payment mechanism or there are underqualified workers trying to manage a loved one’s care.

Careforth’s goal is to negate some of those concerns, so that the seniors and the health care system are actually benefiting from the care being provided.

The care teams regularly connect family caregivers, too, with other home-based care providers.

“Careforth is always collaborating with home health, hospice and other community-based providers to ensure comprehensive care in the home,” Tardiff said. “When we identify needs or gaps in resources, we work with home-based care providers and community partners to fill those needs. It’s well known that home-based care requires a multitude of supports to be successful. It’s our mission to surround caregivers with connectedness so they can confidently care for their loved ones at home.”

The company believes that caregivers are most able to influence a senior’s health, which means empowering those caregivers will lead to better outcomes.

“It was important that Careforth undertake this third-party analysis of our Structured Family Caregiving program for a number of reasons,” Careforth President and CEO Matt Marek said in a statement. “First, the data helps us demonstrate the strength of our programs for policy makers as they seek approaches that support aging in place. Second, the findings help us shine a spotlight on family caregivers as a possible solution in addressing direct care worker shortages. And finally, and fundamentally importantly to Careforth, the data provides us insights so that we can meet our mission to continually improve our support to family caregivers.”

The post How The Home-Focused Careforth Reduces ED Visits, Falls Through Family Caregiver Support appeared first on Home Health Care News.

In 2023, PACE enrollment exceeded 70,000 participants and has seen an over 40% growth in enrollment since 2019.

Many home-based care providers have already gotten into PACE. The Jacksonville-based Alivia Care – a home health and hospice provider – has even become a PACE administrator itself.

But, in order for providers to become PACE partners or participants, they have to be as prepared as possible prior to the enrollment process.

“We have really seen increasing competition for RFPs in recent years, which has required organizations to really think ahead and prepare ahead of an RFP release,” Tina Hansen Pickett, managing director of ATI Advisory’s Medicare innovation practice, said during a webinar Tuesday.

Generally, PACE participants live in their respective communities prior to enrollment, but are patents who would qualify for nursing home placement based upon their level of impairment and care needs.

PACE providers offer medical, physical, emotional and social need solutions — much of which is centered around a PACE center. A PACE center is a physical facility in which the program offers an adult day center, a medical clinic, dental and other services.

A PACE provider — like InnovAge, for example, one of the largest PACE providers — will enroll those participants and receive capitated payments from Medicare and Medicaid.

PACE organizations or agencies — including health care providers, insurers or community organizations — may issue an RFP to solicit proposals from potential partners interested in participating in or providing services for the PACE program.

These proposals outline how an organization intends to meet the requirements and objectives outlined in the RFP. The applications include details on the services they will provide, their qualifications and experience, their proposed budget and any other relevant information.

One of the strategies ATI Advisory experts recommend is being enthusiastic about each answer and doing the homework beforehand.

“You have to nail absolutely everything,” Jade Gong, senior advisor with ATI Advisory, said during the webinar. “It’s still very surprising when you look through the applications of those that did win and didn’t win, just the small differences in the applications.”

A provider’s bandwidth and capabilities is another key part of the equation.

“Especially if you’re new to PACE,” Gong said. “It’s very possible that PACE is feasible in your market but not feasible for you. This requires careful consideration. There are many unknowns in this process and there will be many unknowns as you construct your RFP. Especially if you’re new to this, you have to make sure you’re committed and have the appetite for the amount of risk that you’ll be taking on.”

Gong recommended organizations do their own internal pressure test. What would this mean for leadership? What is your risk tolerance as a company?

As PACE expands into more states, there isn’t a lot of concrete evidence that can ensure providers will get a certain reimbursement rate in any given state.

Certain capabilities vary from state to state as well.

“You’re going to have to bring in PACE operational knowledge if you don’t already have it in your organization,” Gong said. “All of the states require various month-by-month startup plans with a lot of detail. When it comes to the provision of services, they’re going to ask you how you would operationalize certain components like network development, transportation and other aspects of the program.”

After becoming an expert in these RFPs, Gong reiterated that the process will force organizations to truly understand their own strengths and — maybe more importantly — their weaknesses.

The post As PACE Grows, Here’s What Providers Need To Know About Getting Involved In The Model appeared first on Home Health Care News.

Around 2019, Medicare Advantage (MA) was all the rave among home care providers.

That’s because, in 2018 and 2019, two pathways opened for MA plans to provide more benefits to beneficiaries: the primarily health-related benefit pathway and the Special Supplemental Benefits for the Chronically Ill (SSBCI) pathway.

Included in those were plenty of areas of opportunity for personal home care providers to step in and become more involved with the Medicare dollar. In-home support services (IHSS), namely, were a popular benefit that providers theoretically stood to benefit from.

But, since 2019, that optimism around MA has waned for most. The return on the investment has largely not been there.

For one, providers that generally dealt with private-pay clients were met with less favorable rates in MA, plus less reliable scheduling for their caregivers. Then, particularly recently, the growth in plans’ adoption of SSBCI and primarily-health related benefits has slowed.

This year, for instance, 867 plans are offering IHSS as a supplemental benefit, according to the research and advisory firm ATI Advisory. That’s a significant drop off from 2023, when 1,308 plans were offering the benefit.

Lingering optimism

By 2022, providers were already backing off the idea that significant MA investments were worth their time.

“We’re sitting on the sidelines and watching,” Right at Home CEO Margaret Haynes told Home Health Care News in late 2022. “We certainly are dabbling in a couple areas where it makes sense, but it really does come down to the reimbursement rate.”

Many of the larger home care companies were beginning to feel that way, and have since become more entrenched in that thinking.

But BrightStar Care – and its CEO, Shelly Sun – were going the opposite way. Sun felt that digging into MA was more than worth it, given how many seniors would be enrolled in a plan in the next few years. It was a way, from Sun’s perspective, to diversify revenue while also planning for the future.

Also in late 2022, Sun told HHCN that BrightStar was converting 5% to 10% of its MA clients to private-pay clients down the line.

In early 2024, she remains optimistic, albeit with some caveats.

“I still am very bullish on Medicare Advantage, because the mission for BrightStar has always been taking care of moms and dads, grandmas and grandpas,” Sun recently told HHCN. “And if 50% of those seniors are likely to have Medicare Advantage, not being there to help them use a government benefit to make their dollars work further to help keep them at home, that would be contrary to our mission.”

The Chicago-based BrightStar Care has more than 380 home care locations nationwide. It also has a senior living portfolio and provides supplemental staffing. Overall, the company has 15,000 caregivers and 5,700 registered nurses on staff.

Because it is a franchise, the entrance into MA business required convincing. After all, the margins that come with MA beneficiary hours are much more slim than the traditional private-pay hours franchisees are used to servicing.

To combat that issue, BrightStar has also increased its company-owned footprint, which allows it to test out the best way to handle MA cases, alternative models and new technologies.

Sun also does not think that the fewer plans offering personal care benefits will negatively impact business for her company, however.

“Not every Medicare Advantage plan offers supplemental benefits,” she said. “And not every set of supplemental benefits offers personal care, but I believe we should be able to take it when they do. And I think there’s a similar number of hours that will be covered in 2024 compared to 2023, even though fewer plans are offering them. The ones that offer them are increasing their volume.”

For the ones pulling away, Sun believes that’s due to the difficulty that came with managing networks of home care providers in given markets.

The ones that still offer the benefits may face similar struggles, but Sun believes the data is showing those plans that offering personal care is extremely beneficial to their members.

“It improves their loss ratios because home care is the lowest cost of care, and it helps avoid some hospitalizations that are more expensive,” Sun said.

If anything has tapered Sun’s bullishness on MA, however, it’s how plans are handling the benefits.

“In 2024, most of [the plans] will have moved to conveners,” she said. “I think that’s dangerous, because unless they have SLAs in place, from our experience, conveners are not making sure that the customers that had benefits last year – and had a specific caregiver last year – that they end up with the same agency the next year.”

Sun has been reaching out to health plans directly to make sure they’re aware of that problem, which she believes is a big one given the amount of weight “customer satisfaction” will hold on STAR ratings for MA plans.

That is where there needs to be a “wake up call” for plans, according to Sun.

Still, she is sticking with the strategy. Not only does she believe her initial thesis will be proven correct, but also, she believes that the seniors underneath MA plans are in need of this type of care.

“Obviously, it’s not about profitability in the short term. The plans don’t pay well,” Sun said. “But it’s the right thing to do. And it’s going to be a horrific experience for these seniors, which is what I’m trying to get with the plans on to avoid.”

Working through it

FirstLight Home Care, like most home care providers, is also focused on expanding further into alternative payer sources. That effort has mostly included Medicaid and the VA, but it also still does include MA.

The company’s CEO, Glee McAnanly, also recently expressed some concerns to HHCN over how the plans were administering benefits.

“We’re struggling with some of the payer groups with reimbursement rates,” McAnanly said. “We’re working through that to see what happens. I am concerned with margin compression. And we’re going to have to figure out how to make things work [with those plans].”

Despite frustrations, home care provider leaders aren’t blind to the trends.

Yes, MA plans’ investment in personal care may be waning slightly in the short term, but more than 50% of seniors covered by Medicare are now under a MA plan.

That, plus billing rates skyrocketing in private-pay home care over the last three years, is enough for providers like BrightStar and FirstLight to keep trying to make things work.

“We can say all we want, but the margins are always going to be tight,” Kristen Duell, the VP of experience and innovation at FirstLight, told HHCN. “We have to execute around how we’re able to reduce the costs in other areas from an operational perspective.”

The post For Home Care Providers Still Invested In Medicare Advantage Business, Patience Is Wearing Thin appeared first on Home Health Care News.

In 2024, however, providers can win with the correct focuses in mind.

“You don’t want a managed care strategy; you want a value-based care strategy,” Anne Tumlinson, founder and CEO of ATI Advisory, said during Aging Media Network’s Continuum conference. “Managed care is just a financial tool — much like how population-based health demonstration programs like ACOs are financial tools.”

The Washington, D.C.-based ATI Advisory is a health care research and advisory services firm.

Changing the way a home health agency operates is no easy task. In fact, it’s a huge operational shift that Tumlinson has seen firsthand.

“To move from delivering units of service to delivering value is really, really difficult,” she said. “Changing what it is that you sell and how you get paid to do it is a huge undertaking.”

That’s a road Devin Woodley, the VP of managed care contracting with VNS Health, is very familiar with.

New York-based VNS Health is one of the largest nonprofit home-based care organizations in the U.S. It offers home health, hospice, palliative care and mental health support services, among others. It also has its own health plan.

At VNS Health, as the market has changed, Woodley and his staff have focused on marrying what capabilities the agency has to market opportunities.

It also helps that VNS Health is a “payvider.”

“Working with our health plan, we understand how to take on risk from a large health plan perspective and what health plans’ pain points are,” Woodley said. “From the provider side, we also have a deep understanding of how to take on risk. Now we’re able to bundle that together on the payvider model and figure out where the synergies are between the two sides.”

For agencies who might not be as adept at working with a health plan, Tumlinson said there are a few key points to focus on.

The first is to make sure the clinical model is built for value.

“Do you have a clinical model that can actually deliver outcomes as opposed to just units of service?” she said. “Do you have some kind of a mechanism for aligning payment for those clinical services in a way that rewards you for that value? Whether it’s an ACO contract or a managed care contract, or contract with somebody who’s doing that.”

The second key ingredient is the room for scale.

“Even if you’re not a real estate-based provider like senior living, and you’re an operator that delivers more of a continuum of care in the community, there are lots of ways in which you can attach yourself to scale,” Tumlinson said. “Partnering with senior living is one of them. So you have to have those three pieces: a clinical model, the financial alignment through contracts and the scale.”

Self-awareness plays a key role in surviving and thriving in today’s market as well.

For VNS Health, there’s an obvious benefit of having its own health plan, but understanding the ins and outs of the health plan helps Woodley and his staff make the most of its partnerships and opportunities.

“We intimately understand — in owning our own health plan — what those silos are that health plans have,” Woodley said. “There’s a lot of grain that falls between those silos and there’s a lot of good eating we can get out of that grain that’s falling between them. Being able to leverage that understanding with our capabilities, matching that up, that’s how we’ve been able to unlock some really good value.”

The post ‘You Want A Value-Based Care Strategy’: Tips For Home Health Providers In A Managed Care World appeared first on Home Health Care News.

ATI Advisory found that these disparities exist by examining race, gender and geography. The report was sponsored by Robert Wood Johnson Foundation, and analyzes data from the University of Michigan’s health and retirement study. ATI Advisory analyzed data from 6,232 respondents.

“Our report found that people who needed assistance, like the home care industry provides, were more racially and ethnically diverse, and more often resided in rural areas,” Nils Franco, senior analyst at ATI Advisory, told Home Health Care News. “We found resource differences, and disparities that may constrain access to home care provided by the industry, as well as an important role for Medicaid in potentially expanding access to LTSS for individuals who lack private financial resources.”

Broadly, LTSS are the care services that people need when they begin to have trouble managing their activities of daily living, selfcare and diseases.

In 2020, roughly 7.7 million individuals used LTSS, and Medicaid is the most common source of coverage for these services.

Overall, Black individuals experienced LTSS needs 114% more often than white individuals, and Hispanic individuals 72% more often than white individuals, according to the report.

“The services provided by the home care industry are needed by a particularly racially and ethnically diverse population, but access to these services, using private resources, is constrained for many and especially among black or Hispanic individuals,” Franco said. “Our finding of the inequitable distribution of LTSS needs is part of a broader conversation about inequities in health care, overall, throughout the lifespan.”

Franco noted that ATI Advisory’s study underscored the importance of further research to investigate the causes behind these disparities.

In addition to disparities across race and ethnicity, the report found that individuals living in rural communities experienced LTSS needs 23% more often than individuals in urban areas.

“In rural areas, one concern is the distances providers have to travel for a connection to care among individuals who have LTSS needs,” Franco said. “To find out that LTSS needs are more common in rural counties, highlights a potential area of concern around care access for those individuals.”

The report also found that Black and Hispanic individuals, women and individuals living in rural counties had fewer private financial resources.

Black and Latino individuals were also less likely to have health insurance coverage, compared to white individuals.

Ultimately, the report made a number suggestions including endorsing policies that reduce disparities in financial resources, limiting barriers to Medicaid LTSS insurance coverage and designing programs aimed at delivering care for individuals without in-home support.

“We’re really trying to highlight the need for these public programs to think about some of the disparities we’re seeing,” Johanna Barraza-Cannon, director of ATI’s state program and policy practice, told HHCN. “Our continued research wants to be able to narrow and tighten some of these recommendations to be actionable. There’s a lot of room for these programs to look at these findings, and think about how they can better tailor their programs to meet these needs.”

The post Report: Disparities Emerge In Those Seeking LTSS As They Age appeared first on Home Health Care News.

That’s one takeaway from a recent Kaiser Family Foundation (KFF) webinar.

Seniors that aren’t getting financial support or assistance from Medicaid are either paying out of pocket or relying on support from informal or family caregivers, according to Anne Tumlinson, founder and CEO of the research and advisory firm ATI Advisory.

“Of that remaining two thirds, half of them live under 200% of poverty,” Tumlinson said during the webinar presentation. “We have a lot of older adults living in the community today, without any kind of Medicaid assistance, who can not afford home care, assisted living, who do not have long-term care insurance policies. Those people are 100% reliant on family caregivers, if they even have them. If they don’t, it’s a very dire situation. Those are often the people most at risk of spinning down into a Medicaid nursing home.”

These facts underscore how underfunded long-term care services and supports are in the U.S., Tumlinson noted.

“We don’t have enough money flowing into the system to attach to all of the people who have these needs,” she said. “If it’s a system where every single family is developing their own solution, one family at a time, one household at a time, of course we don’t have an infrastructure.”

A recent analysis found that while the majority of seniors will need some sort of in-home care support, the vast majority of them cannot afford that care.

Tumlinson doesn’t believe that this is an issue that the private market can solve on its own.

“This is just not an insurable risk that is possible to address through a private market,” she said. “This is not car insurance. This is not even health insurance.”

Instead, Tumlinson called for government solutions, specifically putting a new public program in place created from tax dollars.

In the meantime, there are various programs in place across different states. For example, Washington funds public insurance for its residents based on tax dollars.

States like California and Minnesota are considering similar programs, Tumlinson noted.

“We’ve seen states and state legislatures really sitting up and realizing the federal government is not going to solve this problem,” she said. “Medicaid is a liability on their books, and they need to start looking at other options for paying for it.”

States such as Vermont, Wyoming and Washington are also working to address these issues through Medicaid demonstration programs.

Ultimately, Tumlinson believes that collective action will be key to activating change.

“As families, we can not solve this problem by ourselves,” she said. “We are going to have to collectively solve it. States are going to be part of the solution. Hospitals and health systems are going to be part of the solution. CMS is going to be behind the scenes helping to facilitate all of those solutions, while we wait for Congress, hopefully, to act on something more universal and national.”

The post Seniors Aren’t Getting Enough Financial Support To Afford Home-Based Care appeared first on Home Health Care News.

Funding for fee-for-service home health care and home- and community-based services ebbs and flows. But the payer source most likely to dictate the future of home-based care providers – across the board – is Medicare Advantage (MA).

MA plans aren’t immune to tough rate environments, either. In fact, they’re in one right now. That’s one of the reasons why in-home supplemental benefit offerings will take a dip for the first time in 2024.

In-home support services (IHSS), which offer an MA entry point for home care providers, will take a major hit. IHSS grew rapidly from 2020-2023, with the amount of plans offering them growing from 283 to 1,308. In 2024, though, only 867 plans will be offering IHSS, according to the research and advisory firm ATI Advisory.

That has caught the eye of providers and health care analysts.

“Given the tougher MA reimbursement backdrop for 2024, plans are prioritizing certain supplemental benefits, driving a more dichotomous path related to year-over-year supplemental benefits penetration vs. 2023, which generally exhibited increased supplemental benefits penetration across the board,” Scott Fidel, managing director at the investment banking company Stephens, wrote in a note shared with Home Health Care News.

The reduction of supplemental benefit offerings – both of the Expanded Primarily Health-Related Benefits (EPHRB) and Special Supplemental Benefits for the Chronically Ill (SSBCI) variety – is discouraging, particularly for home care providers that have invested a lot in catering to MA business.

It’s my feeling that this is a blip, however, and that MA plans will continue to find ways to work with home-based care providers to reduce member hospitalizations in the future. To make sure of that, I chatted with Terri Swanson, the president of Medicare at CVS Health’s (NYSE: CVS) Aetna.

This week’s exclusive, members-only HHCN+ Update dives into where MA plans, including Aetna’s, are headed from a home-based care standpoint in the next year and beyond. I also share a couple of other recent MA developments that providers should know about.

Bucking a trend

The drop in IHSS offerings is not just because of higher regulatory scrutiny above MA plans’ heads, Bill Winfrey, the director of Medicare innovation at ATI Advisory, recently told HHCN.

“We suspect the main reason behind the decrease is that IHSS is a more administratively complex benefit to offer, especially compared to something like a grocery card,” Winfrey said. “To offer the benefit, plans must identify providers in a crowded marketplace, build a provider network to ensure market coverage and manage increasing labor costs that are driving up the cost of the benefit itself.”

The complexity behind offering such a benefit is why companies like The Helper Bees exist in the first place. The Helper Bees builds out a network of home care providers on behalf of the MA plans to make delivering on the promise of home care services easier.

The Centers for Medicare & Medicaid Services (CMS) also announced earlier this week that it would be paying closer attention to supplemental benefits, ensuring that members are both aware of the benefits and using them if needed. This is partly because, in CMS’ view, plans are largely using supplemental benefits as a marketing scheme rather than a service benefiting members’ health.

“Plans have reported that enrollee utilization of many of these benefits is low,” CMS wrote in fact sheet. “To ensure the large federal investment of taxpayer dollars in these benefits is actually making its way to beneficiaries and are not primarily used as a marketing ploy, the proposed rule requires Medicare Advantage plans to engage in minimum outreach efforts so that enrollees are aware of the supplemental benefits available to them.”

Higher utilization of the benefits would be good news for providers that have committed to taking on MA members as clients.

But, in theory, higher utilization should be good for plans as well. If the benefits are utilized correctly and address social determinants of health, through home care and other means, that would be of benefit to members’ overall health.

On Aetna’s end, it believes that a home-based care approach begets more home-based care usage. Through Signify Health – which is also a part of CVS Health – Aetna offers all MA members an annual “healthy home” visit.

Healthy home visits are a way for Aetna to screen patients and their homes for health concerns or other needs. It’s a type of care that has become more popular in MA over the past five years.

“They evaluate the home environment to see if that member has things in their environment that could be improved, or whether there are things that could lead to a fall risk,” Swanson told me. “We just think it’s a really wonderful service, … especially because four out of five people surveyed say they want to receive care in their homes.”

The healthy home visit from Aetna also allows the insurer to connect members to the supplemental benefits it does offer, including IHSS.

Aetna does offer IHSS across the country, but the benefit is still utilized on a smaller scale than the healthy home visit, Swanson said.

“[The IHSS] are gaining in popularity, particularly for people who have mobility issues or trouble with transportation,” she said.

There are different “flavors” to IHSS benefits under Aetna, Swanson explained.

The first is a benefit where there’s a set number of hours of personal care services – provided by a home care provider – that a member can use in whatever way they feel best. Those don’t need to be ordered by a doctor, either, and can be used at the discretion of the member.

Then, in some plans, there are hours of personal care set aside for members during the 30 days following a discharge from an inpatient facility. That’s much more geared for those undergoing a recovery process, which home care providers are used to handling.

Aetna sees considerable value in these home-based care services, and Swanson said that it is evaluating how the above benefits are utilized when considering “future expansion.”

“We want to be proactive; our goal is to get in front of a situation that would develop the need for hospitalization or some other kind of significant health event,” she said. “We want to get in front of that, and help the member enjoy their life. That is why we offer these types of services.”

Despite the rate environment, Aetna has been able to “maintain and even invest further in” supplemental benefits. Swanson credited that, plus the fact that 87% of Aetna’s MA members are under plans rated four stars or higher, as reasons to be bullish on enrollment moving forward.

Alongside Blue Cross Blue Shield, Humana and UnitedHealthcare, Aetna is one of the largest MA insurers in the country. Its commitment to home-based care is necessary context in the overall story that is being told, which is that home-based care benefits are down.

They may be down, but the actual amount of opportunity shouldn’t fall too much for home-based care providers. The plans that have committed to actually offering those benefits to members, like Aetna, are not pulling out.

In case you missed it

There have been several interesting Medicare Advantage developments over the past few weeks. While not all related to home-based care, they’re interesting nonetheless.

These developments include:

– On Thursday, progressive members of Congress hosted a press conference “on the shortcomings of Medicare Advantage.” The conference, which shows continued scrutiny of MA, was held at the halfway point of Medicare open enrollment.

– On Monday, CMS announced it was also taking steps to improve access to behavioral health care services for MA plan enrollees by proposing updates to network adequacy standards.

– A report from Reuters suggested that Cigna could sell its Medicare Advantage business for “several billion dollars.”
– A study released at the start of November found that Medicare Advantage has 70% fewer readmissions than fee-for-service Medicare, with 24% fewer preventable hospitalizations.

The post Aetna Bucks Medicare Advantage Trend, Continues To Invest In Home-Based Care Benefits appeared first on Home Health Care News.

Diving into value-based arrangements with payers always sounds good, in theory, for home health providers.

But it is easier said than done. Providers have to commit to value-based care, but even before that, they need to do their homework to be successful over the long haul.

Moving away from fee-for-service and moving toward risk through value-based arrangements takes a tremendous amount of research, operational awareness and financial investment.

It also requires legwork before, during and after negotiations with payers.

“In my experience, what happens so often is that providers get brought into these conversations without doing their homework first,” Fred Bentley, managing director at ATI Advisory, told Home Health Care News. “All of a sudden, they’re at the table and they think, ‘Let’s wing it.’ Or they will let the payer dictate the conversation, and the provider is just in reaction mode.”

What providers can do

Before sitting down at the table with payers, providers should clearly understand their goals. It may seem like a no-brainer, Bentley said, but it’s often an overlooked aspect of the process.

“It sounds so obvious, but ask yourself, ‘As a home health provider, what are we trying to achieve here?’” Bentley said. “There are different objectives. It can split into two paths: are you looking to grow your core business and are you using value-based care as a tool to be a more preferred critical partner in the eyes of the payer? And, it’s not mutually exclusive, but on the flip side, do you see real revenue upside?”

It’s quantitative versus qualitative, Nick Seabrook, managing principal at SimiTree, told HHCN.

“What do you want to get out of this?” Seabrook said. “You can get into it from a dollar and cents standpoint — prioritizing revenue. Or you can get into it with almost a marketing approach and say, ‘We have this relationship with a certain payer because we’re succeeding in this,’ and that could open the door to other referral sources.”

Also in order: a brutally honest look at what a provider’s value proposition is.

One of the challenges home health faces in particular, Bentley said, is that they are late to the game.

“They’re not out of the picture, but it’s not uncommon for payers to say, ‘We empower the primary care doctors and shift the risk to them — what can home health bring to the table?’” Bentley said. “That’s when you find your value prop — providers should have a painfully honest discussion about what they could bring to a Humana, for instance. What is it that you bring to the table, and how do you convince them that you’re ready for this?”

Payers have to be able to trust that a provider can live up to its promises, too.

A provider needs to prove it can manage the finances behind a total cost-of-care arrangement and clarify its internal strategic goals. That’s Phase One.

Phase Two is finding out how it can help payers win.

“The first two questions I would ask as a provider are, ‘Would you be open to some kind of value-based arrangement?’ and ‘What matters most to you?’” Seabrook said. “Any kind of insurance company that’s going to be in some kind of a risk-sharing, value-based arrangement is ultimately looking to cut costs. They’re looking at overall patient spend and where can they best do that while maintaining quality care for the patients.”

Other questions providers should ask payers, Seabrook said, should be centered around specific patient characteristics that matter more to one payer than others.

If there’s a certain population above a specific age, with a certain disease type, that may be a way into these relationships.

Lastly, providers should know how exactly they’ll be getting paid if a deal gets done.

“What I think is the No. 1 question when it comes to these relationships is, ‘How does the payment work?” Seabrook said. “That’s probably the biggest question a lot of these agencies have because they may not even know where to start when it comes to how you actually get paid for this. What kind of reimbursement structure would the payer be open to? Is it a risk-share model? A full-risk structure? Is it a metric-based system where if you hit a metric you get paid based on certain milestones? Those are questions I’d ask.”

The right strategy

When thinking about the discussions at the negotiation table with payers and health systems, Frontpoint Health CEO Brent Korte goes back to the two “S’s”: scale and STARS.

“If you come to a health system with those two, then you can generally help solve their problems,” Korte told HHCN. “You have to find a way to make their difficult jobs easier.”

Based in Dallas, Frontpoint is a home health and hospice company that specifically tailors its business model to take on Medicare Advantage (MA) patients.

Frontpoint’s strategy in value-based arrangements is saying yes to things when others say no.

“We believe that value to our referral sources is providing scale — the ability to take a lot of patients — and STARS, which is obviously high-quality care,” Korte said. “But it’s also access, meaning we say yes when others say no, and that is deeply meaningful to someone that’s trying to discharge 50 patients in a day. Especially when, statistically, 26 of those 50 patients are Medicare Advantage.”

Knute Nelson Home Care and Hospice, on the other hand, is still in the early stages of its value-based care journey. For now, it’s focused on finding the right payer partner.

“We’re researching into it,” Rebekah Mattocks, director of quality and education at Knute Nelson Home Care and Hospice, told HHCN. “With value-based purchasing coming up, we’re looking into getting in some of those relationships with some of those payers. We’re trying to find the right partner and make sure we get that set up in a smart way.”

Knute Nelson provides home health, senior housing and assisted living, among other services, in 43 counties in Minnesota and North Dakota.

For a provider dipping their toes into these waters, things can be complicated, but they can be simplified, too.

“How does the payer define value?” Korte said. “And how do you solve for that?”

The post ‘Do The Homework’: What Home Health Providers Need To Know Before Sitting Down With Payers appeared first on Home Health Care News.