The U.S. Centers for Medicare & Medicaid Services (CMS) took multiple actions on Monday to further support home health providers affected by the COVID-19 pandemic. Most notably, CMS loosened Medicare’s homebound requirement, suspended its pre-claim review demonstration and announced new telehealth flexibilities.
While the “unprecedented” measures are undoubtedly beneficial, the situation on the ground suggests more action will almost certainly be needed — and soon.
Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED) is one of the largest home health providers in the country, but even it has felt the disruption caused by the spread of the novel coronavirus, according to President and CEO Paul Kusserow.
So far, that disruption has largely come in the form of visit cancellations and PPE challenges.
HHCN recently connected with Kusserow to get a better sense of how home health care providers are responding to the ongoing national health emergency. The conversation with Amedisys’s CEO took place on Monday morning, just hours before CMS announced its latest round of home health care support.
Highlights from the interview are below, edited for length and clarity.
HHCN: What kind of impact has COVID-19 had on Amedisys, thus far?
Kusserow: I would first emphasize “thus far.” The situation is still evolving daily.
What are we seeing right now? We have some clinicians who are affected, clinicians who are now in self-quarantine. There’s very few who actually have the virus. And they’re obviously out.
In addition to that, we are — in both home health and hospice — experiencing some decline in volumes due to patients not wanting people in their home. That’s been difficult.
We’re doing all right. But over the past week or so, it’s felt like every time you step out onto this river that it’s completely uncharted water.
What does a typical day look like for you and your leadership team right now?
It starts with a lot of catching up with each other. Chris Gerard, our COO, he’s on operations calls all day. I pop in and out of those calls. Scott Ginn, our CFO, is doing a lot of modeling. David Kemmerly and Scott Levy, who are both on our government affairs team, spend a lot of time trying to understand what the rules of the game are, which is tough because rules are constantly changing.
Meanwhile, our HR people are trying to keep our team members calm and look after our people.
At the end of every day, we all get together and have a call where we go through everything. That includes Saturdays and Sundays. Overall, as a management team, we have to have a very good understanding of what’s occurring on a daily basis.
Personally, I’ve been spending most of my time on the regulatory and legislative front, just to try to make sure that we have a favorable environment to operate in. I believe that’s the best use of my time. There’s also obviously troubleshooting, where we maybe have flareups we need to make decisions on. Ultimately, it’s more or less focusing on communication, following the updates in Washington and hotspot dousing, if you will.
Before we get to regulatory changes, how are you doing on the PPE front?
Better. We’ve found and sourced a lot of equipment, knock on wood. We’ll know by the end of this week if we’re good for the month. We think we’ve at least been able to predict utilization that far out.
We’ve been more open than we normally are when it comes to dealing with people, providers and terms for PPE. We’re dealing with prices that we never would have dealt with before. We’re paying up. The prices have increased considerably. In part, we’re paying up for PPE right now because we hope to, at some point, get reimbursed fairly for it. Today, though, we just need to make sure our patients are safe and our employees are safe. So we’re buying whatever we can.
The CARES Act does a bunch of different things, including paving the way for non-physician certification and press pause on Medicare sequestration. What kind of relief will those measures bring?
The relief from sequestration will be significant. But my understanding is that the suspension doesn’t start until May 1. We’d love it to start April 1, giving us a nice April Fool’s Day gift.
I think flexibilities around our ability to connect telephonically with doctors or to use nurse practitioners more is helpful, though we aren’t a heavy employer of nurse practitioners.
One of the biggest positives so far has been the ability to telephonically connect with physicians. What we’ve seen in some places is that our doctors are just not available. They’re so slammed. It’s hard to even get them to say “yes” on the phone. We’re thankful that a lot of the changes put forth so far have gone through.
But in general, we believe hospitals are starting to rapidly fill up. We believe that within a week or two weeks, they’re going to overflow. Recently, there have been a few articles talking about how the government is putting pressure on hospitals to push out certain types of patients to make way for COVID-19 patients. There’s also talk of building hospital capacity through skilled nursing facilities (SNFs). If that occurs, I imagine we’ll be seeing more referrals from SNFs. I imagine we’ll be seeing more discharges from hospitals.
We’re maybe seeing a bit of a lull in volumes for the time being, but I think we’re going to be slammed in the next couple of weeks. That’s when regulatory flexibility will really help.
What else needs to happen on the regulatory front?
There was a group of us who talked to the CMS administrator two Saturdays ago. We offered three very clear things we needed right now. There were a lot of CEOs from the home health world on that call. I specifically talked about telehealth. We all focused on different areas.
PPE was one clear point of need, but we understand that the administrator can’t just wave a magic wand to solve that challenge. Still, we pushed on that as much as you can do. Currently, the hospitals are getting a lot of the PPE. There’s a real scarcity of PPE for home health providers.
We also said some onerous elements of the homebound requirement need to be waived.
Additionally, we said we need telehealth support — and we need that pretty dramatically. Telehealth will do two things. No. 1, it’ll allow us to provide care to people who are reluctant to have people come in from the outside, even if they’re licensed caregivers. No. 2 is telehealth allows us to preserve PPE. So, if we can utilize telehealth and have that included as part of an episode, that would be beneficial for us.
And another point related to telehealth: We do have some [staff members] in quarantine because they’ve been exposed to people who have had COVID-19. These folks are fine. And they want to do some work for home. We think this might provide an opportunity for them to do that in some instances.
What do you think about CMS’s move on Saturday to expand the accelerated payment program?
I think it will delay some of the effects of the Patient-Driven Groupings Model (PDGM). When PDGM started to kick in, we saw probably 50 places reach out to us to talk about absorbing them or buying them. That has stopped. People might just be busy now. They maybe don’t know what to do. Or if these agencies can get paid 100% or more for care, maybe they’re going to provide that care and then be able to live another day.
I recently heard somebody say, “Take everything you thought you knew about PDGM, take all the projections you had and toss them out the window.” Do you agree with that to any extent?
It all depends. There are some potential positives with all the regulatory changes related to COVID-19, but the devil is in the details. Everything depends on how these things get instituted and what the final rules are. There have been some broad brush, very nice things that have come out. Again, suspending the 2% sequestration, for example. That changes things. The accelerated payments change things. PDGM’s cuts — the 4.36% adjustment — are still in existence, as far as we know. So we’ll see where all this comes out.
But let me take a step back. If CMS waives the 2% sequestration, if they give us fair payment and if they allow telehealth and alternative ways of providing care in the home, then I think we as an industry have a fighting chance. The big companies, I’m sure, have a very good chance of coming through this. It’s still going to be bumpy, though. And again, my guess is that in two, three, maybe four weeks we’re all probably going to see increased utilization in some way, shape or form.
It sounds like we’re not yet at the critical moment in the COVID-19 pandemic for home health providers.
The idea is that this thing is going to crash around Easter. If that’s the case, there’s going to be significant cases out there. There won’t be enough ICU beds. There won’t be enough hospital beds. I don’t know about SNFs as much, but there are still going to be people leaving SNFs and assisted living facilities. We’ve seen more people getting referred into long-term care hospitals. I don’t know when, but at some point people will not be able to stay in makeshift institutions or other settings. They’ll eventually have to come to the home.
One of our former mayors here in Chicago had a saying about how every crisis is an opportunity. I think that phrase is relevant to this conversation. Do you think Amedisys comes out stronger as a company after the dust settles on the coronavirus emergency?
I think the phrase is along the lines of “never waste a good crisis.” There is that view. Absolutely. I think clearly we’re going to come out culturally stronger. We’ll have a stronger relationship with our employees. As an industry, we’re going to come out stronger if we’re doing the right thing with our policies and procedures. And we’re starting to develop innovative tools. We’re pushing forward.
I also think this is an opportunity for us to show CMS that we don’t need traditional face-to-face, that we can use creative methods to get people taken care of faster. I think that’s going to be a benefit to us.
Another way we’ve adapted: At Amedisys, we’re building what we’re calling virtual care centers. A lot of the meetings that we used to have — patient meetings that we used to have — are now occurring virtually. Creating these virtual care centers will help with care delivery, but they’ll also lessen our physical footprint and our need for real estate — offices and things like that. And we’re learning a lot about how to effectively get people educated and trained in the field during an emergency. From a technology perspective, a best practices perspective, a policies perspective and a communications perspective, we’ve learned a lot.
This definitely isn’t a lot of fun — that’s for sure. But I think we’ve learned a lot. And I think we, as a management team, get better. Amedisys will come through this fine. It’ll be a little rocky at times, but we’ll get through this. It’ll give us a good buffeting so that when things get back to normal, we’ll be a lot stronger as a company and as a provider.
What else is important to talk about?
I just want to underscore how important it is for CMS to move forward quickly on the relaxation of the rules, particularly with telemedicine and some of the traditional requirements we’re used to. They need to provide more flexibility. If not, it could get very bad, very quickly. My hope is that we’re going to see something today, tomorrow or this week at the latest.
And if we do get that flexibility, then what happens when all this goes away? When this dissipates, are policymakers going to sit down together and say, “Oh my god! What have we done? We’ve opened up the floodgates!” My hope is that policymakers are smart about it and instead realize opening up the floodgates in some areas has been very beneficial.
Hopefully, they want to leave them open.