In The News

Provider Groups, Lawmakers Weigh in on MA Plan Proposed Rule

McKnight’s Home Care | By Eastabrook

Provider groups and lawmakers have flooded the Federal Register with comments about the Centers for Medicare & Medicaid Services’ proposed Medicare Advantage and Medicare Part D rule released in December. Among other provisions, the rule would crack down on MA marketing practices and create requirements to increase access to behavioral health and culturally competent care. 
LeadingAge urged CMS to ensure that MA enrollees have proper protections and access to services as the penetration rate of those private plans nears 50%.
“We want to ensure MA enrollees’ access includes up to 100 days of skilled nursing care (when medically necessary) and coverage for all medically necessary, 30-day home health episodes, as is permitted under traditional Medicare,” Nicole Fallon, LeadingAge vice president of health policy and integrated services, penned in a letter to CMS Administrator Chiquita Brooks-LaSure. 
The Partnership for Quality Home Healthcare urged CMS to ensure continuity of care across all Medicare plans to prevent MA beneficiaries from being denied services covered under Medicare.
“We urge CMS to clarify that a home health plan of care, ordered by a physician or allowed practitioner, which would be covered under traditional Medicare as a home health episode, should be considered a “course of treatment” for which prior authorizations must be valid for the duration of the entire plan of care,” Partnership CEO Joanne Cunningham wrote in her letter to CMS.”
Senate Finance Committee Chairman Sen. Ron Wyden (D-OR), who released a report last year on deceptive advertising and marketing used by MA plans, urged CMS to crack down on MA plan fraud.
“It has become clear that not all enrollees are seeing that value or being put first,” Wyden said in his comments to CMS. “I strongly support the proposed rule as it seeks to restore important protections against deceptive and fraudulent marketing tactics, expands access to non-physician behavioral health providers, and promotes health equity for historically underserved communities.”
MA plans, which are less expensive than traditional Medicare fee-for-service plans, have been coming under increased scrutiny. Last year, the Office of Inspector General accused MA plans of denying or delaying services to beneficiaries covered under Medicare. A recent study by Kaiser Family Foundation found MA plans denied 6% (35 million) prior authorization requests for medical services in 2022.

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More Payers Leaning Into High-Acuity, At-Home Care Could Be ‘Game Changer’

Home Health Care News | By Andrew Donlan 

Hospital-at-home care had a breakthrough moment in the U.S. after the onset of COVID-19.

At the end of 2022, the $1.66 trillion omnibus spending bill made sure that the financial setup that helped get hospital-at-home programs off the the ground during the pandemic would not go away once the public health emergency ended.

But the Centers for Medicare & Medicaid Services’ (CMS) Acute Hospital Care at Home waiver is now just one part of the larger shift to high-acuity home-based care. While that funding mechanism remains, organizations are also finding new ways to fund hospital at home – and new models to bring into the home.

Medically Home – one of the early adopters of a business model tailored around enabling hospital-level care in the home – recently unveiled its “ED in Home” model, which is meant to bring emergency department care into a patient’s home.

“Our primary focus is to build the core chassis to decentralize care,” Medically Home CEO Rami Karjian told Home Health Care News. “So, what you’re seeing here with ED in Home is a natural extension of that primary focus to decentralized care to another use case.”

The Boston-based Medically Home partners with health plans, health systems and other providers to enable hospital-level care in the home, namely through coordinating in-home clinician visits and supplying the necessary technology, medication and equipment.

Its financial backers include the Mayo Clinic, Kaiser Permanente, Baxter International Inc. (NYSE: BAX), Global Medical Response and Cardinal Health Inc. (NYSE: CAH).

The ED in Home program was officially announced in January, though thousands of patients had already been cared for underneath it at that point. While it’s live in Massachusetts, Medically Home is actively working on bringing it to other states across the country, though Karjian declined to name specific ones at this point.

“Adding ED at Home is another use case, and it’s particularly powerful today, because of the access challenges that COVID exposed,” Karjian said. “Patients don’t want to go to the hospital, they don’t want to be in the hospital, they’re finding it harder and harder to get to a hospital. This brings the hospital front door to them in a way that inpatient care alone couldn’t.”

More payers getting involved

CMS and the Acute Hospital Care at Home waiver were the primary drivers of health systems delving into hospital at home in 2020 and 2021. But the model is no longer a niche service offering.

Because of home-based care’s ability to drive down costs, there’s an increasing amount of payers and providers willing to engage.

“The commercial payers are really starting to accelerate the rollout and adoption of this,” Karjian said. “We’ve had a number of the commercial payers in a number of states come to us and just say, ‘How can we work together, along with the health systems, to accelerate this and maybe even provide some of the funding that would allow this to progress?’ So, that’s very exciting.”

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Despite Hardball Tactics With Home Health Providers, MA Plans Have High Gross Margins

Home Health Care News / By Patrick Filbin
Insurers are reporting much higher gross margins per enrollee in the Medicare Advantage (MA) market than in other health insurance markets, according to a new Kaiser Family Foundation analysis.
At the same time, many Medicare Advantage plans continue to play hardball with home health providers by rationing utilization and offering low rates.
The KFF analysis took a look at financial data in four insurer markets: Medicare Advantage, Medicaid managed care, individual (non-group) and fully insured group.
In 2021, MA insurers reported gross margins averaging $1,730 per enrollee. That was at least double the margins reported by insurers in the individual/non-group market ($745), the fully insured group/employer market ($689) and the Medicaid managed care market ($768). Source: KFF
There is still some margin pressure for MA plans, as the Centers for Medicare & Medicaid Services (CMS) is looking to increase oversight of them and claw back overpayments in the near-term future.
While MA pays almost the same as traditional Medicare in a hospital setting, for instance, skilled nursing facilities and home health agencies are often paid far less by MA for services.
“Medicare Advantage plans have both higher average costs and higher premiums (largely paid by the federal government) because Medicare covers an older, sicker population,” KFF reported. “While Medicare Advantage insurers spend a similar share of their premiums on benefits as other insurers in other markets, the gross margins — which include profits and administrative costs — of Medicare Advantage plans tend to be higher.”

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Enhabit CEO's Advice to Providers: Learn to Work with Conveners

McKnight’s Home Care / By Diane Eastabrook
Conveners can be an important ally for home health firms as they negotiate contracts with Medicare Advantage plans, according to Enhabit Home Care & Hospice CEO Barb Jacobsmeyer. 
Jacobsmeyer told investors during a conference in New York Wednesday that conveners, who work as intermediaries negotiating rates and services between payers and providers, are gaining a better understanding of home health’s value.
“They are taking that full-picture approach that they are going to be responsible for the cost of care, so we actually think engaging more proactively with conveners and getting into more agreements with them is probably the way we need to go because they do get it,” Jacobsmeyer explained. 
Still, the Enhabit executive admitted to the audience at Citi’s 2023 Healthcare Services, Metech, Tools and HCIT Conference that her attitude about conveners is an about-face from what it was roughly a year ago. At that time, she shared the view of some providers that conveners can make it difficult to negotiate lucrative rates and contracts with payers. Jacobsmeyer said Enhabit’s payer innovation team, which negotiated 18 contracts with Medicare Advantage plans late last year, helped change her attitude about conveners. 
Jacobsmeyer said the payer innovation team has become especially integral to the company as the payer mix shifts more from traditional fee-for-service Medicare plans to MA plans. She said in the past year the company has seen a 4% decline in fee-for-service plans and an 11% increase in MA plans. 
Jacobsmeyer told the conference negotiating payer contracts at lucrative rates is becoming especially important in home health given ongoing uncertainty surrounding Medicare rates. For 2023, the Centers for Medicare & Medicaid Services increased the Medicare reimbursement rate a skimpy 0.7% and instituted a 3.925% behavioral rate cut totaling $635 million. The second half of the behavioral health cut could go into effect next year, as well as a temporary clawback of overpayments related to the Patient-Driven Groups Model (PDGM) in excess of $2 billion.
“Certainly you could anticipate that we will get the other half of the behavioral adjustment, but with a market basket that will offset that,” Jacobsmeyer speculated. “But, I think the big topic is going to be the clawback. Right now the $2 billion number is out there.”

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What Does a Funeral Do?

By Barbara Karnes

I've been thinking about funerals. Doesn’t everyone? Maybe not. What does a funeral do? It honors the person that has died and brings support and comfort for the living. Funerals are about people coming together, a “send off” kind of gathering and sharing support for the beginning of our grieving journey. 

We used to lay the body out in the living room. Family and friends came to our home, paid their respects to the one that died and gathered around the grieving. Sometimes church and clergy were involved but often not.

Gradually, as we became more "civilized," our end of life rituals became more varied and elaborate. Visitations were held in funeral homes, and funerals were conducted in a church for the grieving before the gathering at the cemetery.

Today, we are looking, thinking, re-evaluating the comfort found in end of life rituals and services. 

We are considering Life Celebrations before we actually die so we can enjoy the party. I’m not sure there is much support for the grievers there, but there is lots of love and affirmations for the person facing the end of their life.

We are having in-home gatherings, going back to having the body in the "parlor".

Memorial services with the body not present are popular, generally with a nice portrait picture in place of the body. It tends to deflect the pain, or so people say. I’m not so sure about that.

When planning your burial in your Advance Directive, here are some things to think about:

Funerals are for the living. They are to bring comfort. Recognizing the life lived by the person that died is comfort to the living.

Funerals in churches are tradition. They tend to be attended because that is what we do when a life ends. Funeral services are about listening. Listening to others share kind words, listening to clergy saying redeeming words, singing praising songs. If you are not “churchy” then you can skip a church funeral. Have a service of sharing, of pictures; a gathering of friends and acquaintances in the funeral home with the body present. (There is something reflective about seeing the body laid out. Yes, my special person is dead).

Visitations, I’m sad to say, are becoming less and less a part of the end of life traditions. Why sad? Because visitations are about visiting, about sharing, about interacting, all of which is support for the griever. A visitation is a community experience at a time when support is the most comforting. A time where words have less meaning than a hug, an embrace, or a presence just sitting quietly.

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