This article is a part of your HHCN+ Membership
Two weeks ago, Home Health Care News hosted our flagship FUTURE Conference in downtown Chicago. Since then, I’ve been reflecting on the event’s panels as well as my on-background conversations to get a better feel for where the health care world — and home-based care, in particular — is headed.
Value-based care and the shift away from fee-for-service Medicare was predictably a major discussion point, as was the evolution of acute care at home models and what the U.S. Centers for Medicare & Medicaid Services (CMS) plans to do with its COVID-19 hospital-at-home waiver. Consolidation among providers and payers was also a big conversation point.
FUTURE 2021 was one of my first in-person events since the pandemic began, so it felt great reconnecting with all of our favorite sources and readers. I know many of you still aren’t traveling or just couldn’t make it this year, though. With that in mind, I wanted to bring a little bit of FUTURE directly to your inbox.
In this week’s exclusive, members-only HHCN+ Update, I highlight five of the most thought-provoking comments from the event, accompanied by my personal take on the statements.
“So much of what we’re doing is tied up in ‘the old way of getting paid.’ But let’s undo this notion where we say Medicare fee for service is one way and the relationships that we have with managed care plans is somehow enlightened. It’s actually the other way around.”
– Bruce Greenstein, chief strategy and innovation officer, LHC Group Inc. (Nasdaq: LHCG)
For years, Medicare Advantage (MA) and managed care have been seen as the places where payment innovation happens. Increasingly, though, policymakers are starting to test out new models within the “traditional” Medicare landscape.
One of the biggest examples of that is the Home Health Value-Based Purchasing (HHVBP) Model, which CMS hopes to expand nationwide starting in 2022. The CMS Innovation Center has actually cited HHVBP as one of the most successful alternative payment models ever due to its ability to improve quality and curb spending.
What surprised me the most about Greenstein’s comment, however, was his different way of looking at the everyday Home Health Benefit.
“We’re capitated,” he continued. “In Medicare fee for service, we get an episode, then we use our clinical judgment and our operational efficiency to bring the care to the patient’s home that’s needed. And we do a great job at that.”
In comparison, managed care is often exclusively focused on “how many visits we’re going to pay for,” Greenstein added.
“There’s community identification, or advanced care, versus our CMS waiver program, which identifies [patients] in the hospital. Okay, so here’s the biggest difference: One works, one doesn’t. The waiver program, while well intended, is tough.”
– Christi McCarren, senior vice president of retail health and community-based care, MultiCare Health System
This was one of the most interesting comments from all of FUTURE, in my opinion.
Since CMS unveiled it last November, the hospital-at-home waiver has universally been described as a blockbuster hit. The waiver started with just a handful of participants, but it has swelled to more than 77 approved health systems and 177 hospitals as of Oct. 5.
The temporary initiative has been so popular, in fact, that many of the participants and their home-based care enablers have urged CMS to make the waiver permanent. But McCarren was one of the first to point out a pretty important imperfection, one that I wholeheartedly agree with.
As it’s currently designed, the CMS waiver helps health systems and hospitals shift patients into the home after they’ve already gone to the acute setting. In many ways, the initiative is reactionary, limiting its ability to improve outcomes and lower costs.
Instead of thinking about acute care at home in the sense of “hospital to home,” CMS should consider models that identify acute patients in the community right off the bat. That’s effectively what MultiCare is doing with DispatchHealth, McCarren explained.
“What’s flawed about the CMS waiver program is how we identify the patients and actually bring them into the program,” she said at FUTURE. “You have to get by that patient perception. You are also counting on ER doctors that are busy to identify the patients as they come in the door – is that going to happen at every institution? It doesn’t happen in mine.”
“The goal is to have an integrated ecosystem. The goal is for the member or the patient to have one point of contact that takes care of everything you need, right? Whether it’s pre-acute care, post-acute care, acute care, advanced care, primary care, specialty care. That’s the vision that we’re trying to [achieve].”
– Dr. Amal Agarwal, vice president of home solutions, Humana Inc. (NYSE: HUM)
HHCN has reported a ton on what Humana Inc. is trying to build in the home-based care space. At FUTURE, one of the company’s chief home care architects suggested the insurer is far from finished.
In addition to the home health capabilities Humana has through Kindred at Home and other parts of its business, including strategic partnerships, the company is looking at emergency room-level care in the home. Agarwal, an ER physician by training, is especially bullish on ER-at-home opportunities.
“Let’s say, you know, maybe 60% of what I see probably doesn’t need the emergency room, right?” he said at FUTURE. “I also don’t know where else [patients] would go. But some of that could be done in the home, and so I want to make sure that we do that.”
I wouldn’t expect Humana to make any splashy moves related to ER-level care in the home just yet, as it is still working on the integration of Kindred at Home — its largest acquisition ever. Making sure Kindred’s operations continue to run smoothly and that it’s 40,000-plus associates feel comfortable with the transition is priority No. 1, Agarwal explained.
“We have a network of about 1,000 providers. That’s home health, home infusion, home [durable medical equipment]. we’re expanding to include nurse practitioners. We’re expanding to include home health aides and personal care assistants as well into that network, so it will continue to grow. But there will be consolidation. We heard it this morning in a number of cases. Networks are going to narrow, and some organizations are going to survive — and some are not. Today, a lot of health plans that we speak with use CMS star ratings as the criterion. They used to do that on the skilled nursing facility side, and we work with health plans that have cut 60% of their skilled nursing facilities out of their network. I don’t think they’ll ever be able to do that on the home health side, but home health agencies are going to have to differentiate themselves.”
– Steve Wogen, chief growth officer, CareCentrix
As I was getting ready to send this HHCN+ Update, CareCentrix announced it received a majority investment from Walgreens Boots Alliance (Nasdaq: WBA). The investment will advance Walgreens’ capabilities in post-acute and home care, while likewise helping CareCentrix scale its model.
After seeing this news, I had to include the above comment from CareCentrix’s Wogen.
Beyond his remarks about consolidation, I found Wogen’s thoughts on the narrowing of networks incredibly insightful. To avoid being on the outside of narrow networks, he specifically said home health agencies need to demonstrate outcomes and prove how they help lower total cost of care.
Within the next two years, I believe “total cost of care” will replace readmission rates and similar statistics as the most important thing home health operators need to quantify.
“We are still very excited about direct contracting. I think the reason why, and I think the reason everyone should be excited, is it’s going to … unleash some of the innovation that you see happening in the Medicare Advantage space. The challenge that we had in it, well, there are three things actually. One was that it’s still Medicare fee for service, and it’s built on a fee-for-service chassis.”
– Chris Johnson, vice president of corporate development, Landmark Health
Landmark Health, now part of Optum, is one of a few dozen approved direct-contracting entities (DCEs). And the organization has been a vocal supporter of CMS’ portfolio of direct-contracting models since the start.
“We, as an organization, have been interested in a model like this for traditional Medicare beneficiaries for a long time,” Johnson previously told HHCN in December 2020.
Among its reasons, Landmark was excited about the direct-contracting opportunity as a way to expand beyond the MA environment. Speaking at FUTURE, Johnson said he’s still excited, but now Landmark is starting to get a feel for certain roadblocks to true payment innovation.
One roadblock, for example, has been the fact that direct contracting is essentially an evolution of original Medicare, meaning DCEs need to be able to navigate the process of submitting fee-for-service claims. That’s not something Landmark has ever had to do before, Johnson pointed out.
Another challenge for Landmark centers on how it actually finds patients it can manage under direct contracting.
“Today, we are a direct caregiver to patients, but we contract through either provider groups or managed care organizations that are able to give us patient lists and say, ‘Here are these patients who need your services, please go find them.’” Johnson said. “We were unsuccessful in working with CMS and with the Innovation Center to be able to get that type of a relationship, and that would require us to actually build a direct-to-consumer capability. And that’s expensive and takes a long time.”
Companies featured in this article:
CareCentrix, Humana, Landmark Health, LHC Group, MultiCare Health System
