The ‘Toxic Positivity’ Around Bringing More Care Into The Home

Dr. Sachin Jain – the CEO of SCAN Health Plan – is a provocateur on the topic of home-based care.

I’ve talked to him in the past about his concerns with value-based care, for instance, at a time when value-based care is almost ubiquitously championed.

In a closed-door discussion on Thursday, Jain offered more of these thought-provoking insights. He was joined in the discussion by Dr. Sandhya Rao, the chief medical officer of Blue Cross Blue Shield of Massachusetts; Phyllis Yale, an advisory partner in the health care practice of Bain & Company; and George Barrett, the former CEO of Cardinal Health (NYSE: CAH), who moderated the discussion.

The conversation was centered around the shift to value in home-based care. What it ended up being was much more than that.

Each participant offered up thoughts on the challenges and opportunities of more care shifting into the home.

Among the topics discussed were what will change in home-based care delivery over the next five years and where the U.S. may be getting it wrong when it comes to care in the home.

“I would say my perspective on this topic has shifted over the last couple of years as I’ve watched my own parents age, and we’ve tried to deliver care for my parents in the home,” Jain said. “I’ve realized how challenging, how difficult and how complicated it is. And how much toxic positivity there is around moving care to the home, and the obligation for all of us to try to make it as easy as possible for people to get care in the home, recognizing that there’s just so many unstated barriers.”

In this week’s members-only, exclusive HHCN+ Update, I draw takeaways from this conversation and try to make sense of them.

Pushback against talking points

In addition to his concerns about the pursuit of value-based care, Jain has also taken a stand against another popular home-based care talking point: the idea of everyone practicing “at the top of their licenses.”

He first explained that to Hospice News last month.

“The worst kinds of clinical organizations treat people like they’re interchangeable parts – as if expertise, experience and training don’t matter,” Jain said then. “And I think the people who suffer the most from this are the patients, because they’re looking for people who are skilled at taking care of a wide range of problems and situations. And what they’re instead getting is a level of experience that doesn’t necessarily match what they need.”

Jain brought this idea up again Thursday when presented with the idea that team-based care would be the way forward in the home.

Sometimes, team-based care really means team-based care. And other times, it’s a “fancy word for labor arbitrage,” he said.

“The top-of-the-license language that has started to purvey in our industry, I think, is oftentimes driven by financial forces that are trying to shift things that ordinarily existed with physicians to nurse practitioners, taking things that were for nurse practitioners to RNs, things that used to be with RNs to community health workers, and things that used to be with community health workers to people’s families,” Jain said. “I think we have this extra obligation that I want to call out, to really ensure that there’s the right level of supervision.”

Jain described current supervision in home-based care as “chart audits.”

One of the most important questions to ask moving forward, he said, was whether the supervision model is sufficient in home-based care.

“The supervision, … it’s some version of like reviewing documentation, which is a really thin model of quality control and performance management,” Jain said. “There’s just important questions to ask around this notion of team-based care and ensuring that the right level of professional truly is weighing in on the care of patients.”

Of course, home-based care providers encourage workers to be practicing at the top of their licenses for a couple of reasons, each of which have merit.

The first is for retention. Home-based care workers that are allowed to do more, and feel as if they are performing the care their training allows, tend to be more satisfied in the workplace.

Secondly, the staffing shortage is such an issue across all positions in home-based care that having everyone practice at the top of their licenses becomes a necessity for some of these providers’ care plans to be viable.

Jain also pushed back on something else that I personally have written a lot about over the last two years, and that’s MA plans’ ability to offer Special Supplemental Benefits for the Chronically Ill (SSBCI).

In fact, I wrote about home-focused MA benefits last week as plans began to tout their benefits for the new year. The feeling generally has been that plans were using these primarily and non-primarily health-related MA benefits to offer more in-home care – often via home-based care providers – as a way to differentiate themselves.

But Jain isn’t so sure that’s working.

“I’m not sure that those benefits sell, to be super honest,” Jain said. “I just spent the last week with our brokers, talking to them about whether our products excite them or not, and our products have a lot of SSBCIs. … I think the conversations that happen at conferences and forums like these is really different than the conversations that are happening with brokers.”

That may be true. But it is also indisputable that plans have taken advantage of the in-home support services (IHSS) offerings – both through the SSBCI and primarily health-related pathways – more and more each year.

And as for more of the “toxic positivity” around home-based care, some have also have questions on the “why” that’s driving the shift to home.

Is it mostly because the home can provide the best environment for whole-person, higher-quality care? Or are health systems and payers just looking to save money by shifting care into lower-cost settings?

Finding home-based patients

Though treating patients in the home – both in a pre-acute and post-acute fashion – has been rising in popularity over the last decade, there are still ways to make the process even more seamless.

That starts with health plans and health systems, who aren’t always great at finding out early who could be treated in the home.

“As for engaging in home-based solutions, it’s still sort of based on judgment,” Rao said. “I would love to be in a position where there’s a bar. [For instance], for this member, it is clear that in addition to prescribing Metformin, we should be enabling them with these components in the home.”

New standards of care need to be taught and implemented from the ground-up, Rao suggests. Physicians and others should be trained to recognize when and if a patient could benefit from home-based care.

The landscape and the relationships between providers and plans will likely look a lot different five years from now.

Ideally, that should benefit home-based care providers.

“I believe that these home-based solutions will become increasingly embedded in at-risk providers, that it’s the providers that need to do the integration rather than having payers layer on solutions to the providers,” Yale said. “And I think we’re finally seeing [value-based care] take off. I do think, five years from now, we’ll be in a very, very different spot.”