Home-Based Care Advocates Call for Presumptive Eligibility, Direct Care Workers Fund

Securing direct reimbursement for telehealth visits and a Medicare rate increase are among the top advocacy priorities for home health providers during the coronavirus outbreak. While they share some common goals, home-based care providers that predominantly work under Medicaid have priority lists of their own.

David Totaro is the chief government affairs officer for Moorestown, New Jersey-based Bayada Home Health Care, one of the largest home health providers in the country. In addition to his job at Bayada, Totaro serves as chairman of the Partnership for Medicaid Home-Based Care (PMHC), a Washington, D.C.-based alliance of Medicaid home care providers, managed care companies, technology firms and other stakeholders.

Currently, the major to-dos in the Medicaid space include establishing an emergency fund for supporting direct care workers and securing presumptive eligibility for home- and community-based services.

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Home Health Care News recently connected with Totaro to discuss these and other topics. Highlights from that interview are below, edited for length and clarity.

In addition to his roles at Bayada and PMHC, Totaro also serves as a board member of the Partnership for Quality Home Healthcare (PQHH), the Home Care Association of America (HCAOA) and the Pennsylvania Homecare Association (PHA). He also is a member of the National Association for Home Care & Hospice’s (NAHC) public policy committee.

HHCN: How have your advocacy priorities shifted since the start of 2020?

Totaro: If you look back to just a couple of months ago, I think anybody in almost any industry would say their priorities have changed dramatically. In our case, we’ve gone from “we need higher reimbursement” to “let’s get the equipment we need.” At Bayada, we were specifically asked to put on hold any of our 2020 priorities in our government affairs advocacy program and concentrate totally on helping secure personal protective equipment (PPE).

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That’s saying something. There were so many big 2020 regulatory priorities, including the Patient-Driven Groupings Model (PDGM). But some of those to-dos are now on pause because the industry desperately needs PPE?

That’s exactly correct. And this is not a short-term problem. Even when the pandemic subsides, I think PPE is going to be an increasingly greater part of our cost model, at least over the next several years. That’s something the home health industry has not had to worry about for a long time.

In Illinois, where I am, there’s a policy where you need to wear a face mask or covering in public. As people start to go back to work, companies might adopt similar measures internally. Will that further stress the PPE supply?

We’re competing with everybody now for the same thing. We haven’t hit the peak in demand for our services yet. A lot of the COVID-19 folks are still in hospitals, but we’re preparing for them or caring for a few here and there. The increased cost [of PPE] is about $2 an hour. Providers operate on low margins in the first place, particularly on the home care side.

You’re saying the “increased cost” of PPE is $2 an hour?

On average, the amount of money we’re spending to secure PPE is costing us about $2 an hour more than previously.

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Wow.  But you’re looking at a lot more than PPE at PMHC. Apart from supplies, what have been some of the pain points for providers that deliver care in the home?

We’re in what I would call the “Twilight Zone” right now. We’re preparing for the probability of taking care of more clients and patients than we’ve ever had in the history of home-based care. At the same time, many of our existing clients and patients are declining care. They’re refusing care from even long-term caregivers who they do not want in their homes. It’s this unusual up and down. On one hand, we’re seeing declining revenues. On the other hand, we’re spending more than we’ve ever spent in order to prepare for and survive this pandemic. At Bayada, in one week in March, we spent as much on PPE as we did in the entirety of 2019.

We’re in this very difficult stretch of trying to sustain our long-term business while preparing for what we expect to be a very, very strong period [for volume] toward the end of May, early June and July.

You’re the chairman of the Medicaid Partnership for Home-Based Care. What unique challenges have Medicaid providers struggled with?

Well, we’re not really prioritized yet. Home care isn’t really prioritized yet. Most of the resources and attention is going toward hospitals — and I think we can all understand why. But this is going to change rapidly. We’re concerned that we’re not going to be fully prepared for what the next couple months may bring.

There’s also a significant lack of coordination. We’re sometimes not quite sure where the PPE is and where it’s coming from, how it’s being distributed. Even those who are involved in the distribution process, when you speak to them directly, they’re confused as well and can’t tell you what they’re expecting. We’re in a PPE maze.

Why don’t you think in-home care providers are prioritized when it comes to PPE? Is it a lack of awareness? Is it because the hospitals need PPE more?

I think it’s the latter. Although, I have heard stories about the general lack of awareness. I’m also on the board of The Partnership for Quality Home Healthcare (PQHH). One of our members was in a meeting at the White House prior to a press conference early on. When they were talking about what home care is and what we can do, there was a lack of knowledge in the room. There was a clear lack of awareness of what home care is all about. So I do believe that’s part of the issue. But I just think that there’s a limited supply right now. And it needs to go to hospitals. We were just not prepared as a nation for this pandemic.

What else can Congress do to support, in particular, Medicaid home-based care providers? For example, in a letter PMHC sent to Congressional leaders, you called for the creation of a dedicated fund for direct care workers.

We’re faced with various challenges. We have workers who are declining to go into their patients’ homes because they’re either fearful of contracting the virus and bringing it home, or because they have children at home. Schools have been canceled through most of the school year. On top of that, there’s also the opportunity for many of them to collect unemployment under recently implemented policies that are almost better or similar to working.

A direct care workers fund — the idea we’ve proposed — would actually reward and incentivize the direct care workers who do work during the coronavirus. We’ve proposed that those who work through the pandemic get 1.5 times their average rate during this period of time. We’ve proposed that those who are actually caring for COVID-19 patients get a 2-times better rate. We’re also proposing that they be covered for emergency sick leave as well. 

Incentivizing workers to keep working is critical. In one case I’m aware of, one of our member agencies saw a 400% increase in unemployment claims in a week.

Is that doable — a dedicated fund to help providers better support direct care workers?

It’s already happening in some places, to an extent. There are some states that have enacted increases for home- and community-based service workers. Massachusetts has increased their rates by 10% through the pandemic. In North Carolina, we got a 5% rate increase for Medicaid. Arkansas has also increased their rates. In New York, Gov. Andrew Cuomo said he believes that there should be hazard pay for all front-line health workers, which include home- and community-based care workers.

Another solution PMHC has suggested is a post-discharge care kit that follows the patient. When a COVID-19 patient goes to the hospital and is discharged to home-based care, A PPE kit follows them back into the home. Could you talk a little bit about how that might help?

Well, it’s not an idea that we’ve gotten great traction on yet because of the limited supply of PPE and the needs hospitals have. However, we’ve initiated — and, in this case, I’m talking about Bayada — conversations with the New Jersey Hospital Association. Yesterday, I spoke directly with the Maryland Hospital Association. We’re trying to get our hospital associations to not only embrace this concept, but to work with us in helping source supply. The last thing they want is to send a patient home — and then there’s no equipment or limited equipment to be able to care for that patient during the recovery process. If that happens, they possibly end up back in the hospital, where there’s limited capacity.

We’ve gotten a good response. They think it’s an interesting idea that they’d like to continue to discuss. We’ve been asking for a one-day supply, up to a week’s supply, just to make sure that home-based care clients and patients are covered.

That seems like a good lesson for other providers: If you’re struggling with PPE, maybe try your hospital partners and see how they can help.

I’ve also noticed that you have to ask in almost every situation you’re in. It’s essential to make sure that others are aware of the new needs that you have.

Home care providers traditionally have not had their caregivers go into a home with gowns, gloves, masks or goggles. I was invited to be on a call in New Jersey about two weeks ago with the Senate president, who was hosting industry leaders within the state. There was one individual representing a variety of industries. I represented home care. There was someone from transportation, the restaurant industry, hospitals, etc. I mentioned the fact that our No. 1 priority was securing PPE and I went into reasons.

Well, on that call was the head of UPS for the state of New Jersey. He called me immediately afterward and said he was getting 60,000 masks that day. He said he was giving us 2,000 masks. It’s amazing to me how everybody wants to help. They all know that there’s a dire situation, but they don’t know where it is sometimes. You just have to let them know.

What else is important to touch on?

I do want to mention one other thing. Also included in the proposal that PMHC submitted to Congress was the call for “presumptive eligibility.” That’s something we have been seeking for years — getting Medicaid home-based care presumed eligible immediately from discharge at the hospitals. Right now, it’s only if you go into a nursing home that you are presumed eligible for Medicaid immediately. However, for home care, you have to go through a process. We’re asking that, during this pandemic, we presume all COVID-19 patients immediately eligible for Medicaid home-based care. I think we’re hopeful that [policymakers] are going to do that, because no one wants to send a patient who is recovering from the coronavirus to a nursing home at this stage.

Right now, without that, you either have to go to a nursing home for care, or you go home without care and you wait for approval.

What long-term impacts do you think home-based care providers are going to see from the coronavirus?

This is putting pressure on every agency to shine. This is our opportunity to show what we can do. Those who can deliver quality care at the least expensive costs will succeed. I don’t see reimbursement increasing over the short term, because state budgets have been drained. So providers who can both deliver quality care and lower costs are really going to stand out.

Do you think home-base care providers might see a shift toward delivering more acute care on a regular basis in the future?

Yes. One of the premises we have always had is that people prefer to be cared for at home. I think that’s going to be increasingly true. And I think that our health care workers — whether they’re physicians, nurses or others — are going to want to see their patients being cared for primarily at home. I think that provides us with a significant opportunity, both in the short term and definitely in the long term.

Besides PPE, are there any other challenges from a supplies or equipment perspective?

I was on a call recently about PPE. We talked about something that no one is discussing. In New Jersey, we have an urgent need now for oxygen. This has never been raised in any of our other states.

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