Improved interoperability around patient data. Policy action around immigration to bolster the home-based care workforce in the near term. The continued evolution of hospital-at-home programs.
These are just a few of the many topics that National Association for Home Care & Hospice (NAHC) President William A. Dombi is focused on while advocating on behalf of home health, home care and hospice organizations in Washington, D.C., and across the U.S.
In This Future in Focus interview, Home Health Care News sits down with Dombi to discuss that advocacy and where home-based care is headed in the not-so-distant future. In addition to the previously mentioned topics, Dombi offers his views on the discrepancies between fee-for-service Medicare and Medicare Advantage, plus the rulemaking going on within the U.S. Centers for Medicare & Medicaid Services (CMS).
HHCN: To start, I’ll ask you to look back over the past few years to the very beginning of 2020. From then until now, how would you describe the overall progress home-based care has seen in the U.S. – and what are some of the best examples of that advancement?
Dombi: My best description is that the continuum of care, based on settings, has taken major steps towards disappearing.
What I mean by that is, in years past, people would describe the continuum of care as a step-down based on settings – hospital being the highest level of care, then stepping down, ultimately, to home care and self-care, if that works for the individual. Since 2020, what we’ve seen from a programmatic/operations perspective, as well as policy perspective, is that breakdown.
The best example is the expansion of the hospital-at-home program, which is now closing in on 400 sites. That’s a program that, pre-pandemic, barely had a heartbeat.
What do you think is the single-most important thing that needs to happen in order to further accelerate home-based care here in the U.S.?
Much of home-based care is financed through various government programs like Medicare, Medicaid and VA services. What really needs to happen is those programs need to catch up with the time to modernize and offer real programs rather than just demonstration programs.
In your view, what are the top 2-3 ways that technology specifically has advanced home-based care in recent years?
There has been an absolute mind-boggling expansion of technology in home- and community-based care, particularly around remote patient monitoring and virtual visits. The population of patients has been accepting of it – and we’ll continue to see greater and greater acceptance of it, which really helps maximize resources to patients in the home setting. It also expands the scope of the services that they could get.
The technological connection has really expanded the ability to take on a patient that requires a higher level of care. It’s got a ways to go, but it’s absolutely a tool that’s indispensable in the expansion of home- and community-based care.
What emerging technology trend do you see disrupting home-based care most over the next 5 years, and why?
Two things come to mind, and they’re really at opposite ends of the technological spectrum.
I think we will see advancements in patient-data interoperability, which are way overdue. That can make home care a very viable approach because you could be in someone’s home and access everything there is to know about the patient (when that interoperability exists). I think we can see that push the envelope over the next three to five years because it’s been in play for a much longer period of time without bearing full fruit so far.
The other is self-care technologies. Patients and their family members provide a lot of the care themselves when someone is in a home care setting. When a home health agency, a hospice or hospital-at-home program discharges the patient from their care to self care, those technologies will help the transition to be a safe and effective one.
They can also help continue to monitor a patient’s vital signs, which could lead to an early reporting system and avoid any kind of an acute exacerbation or emergency from coming about.
The other side of this self-care-technology conversation includes the possibility of bringing some very powerful, large international companies into the mix. Some that we’ve already seen show interest: Apple, Amazon, Best Buy.
When we think about advancing home-based care, we can talk about moving the needle with a variety of key decision-makers and gatekeepers. Looking exclusively at the policy space, what are some home-based care advancements you’d like to see turn into reality?
One thing that comes to mind is caregiver compensation, and in particular, direct care workers who provide support with activities of daily living (ADLs). The population which has the greatest need for home- and community-based services are those who have advanced age with multiple comorbidities – and that means ADL deficits.
How are those deficits going to be met? Generally, in person – at least until technology advances to the point of androids and robotics, which probably won’t happen in my lifetime. So, where do we find that workforce? That’s a major question of today, and we know that compensation is absolutely connected to that.
There are efforts coming out of the current White House as well as in Congress to try to improve it. States are doing a good bit on this in their Medicaid programs as well. It’s hard to ignore that aspect of health care at home, that personal care support, when we start talking about all these great advances in technologies, but it’s real.
Then there’s also advancing home-based care and advocating on behalf of providers in the context of payers, including managed care. What degree of progress has the home-based care field made in communicating their value to payers, in your view?
The greatest measure of progress is actually at the beginning of a process. We’re at the beginning of that process of evidencing the value proposition of care in the home to the payers.
It took a long time for them – for the payers, like managed care – to get their heads out of the silo of just looking at discounted payment rates, instead listening to discussions of dynamic values, supported by hard evidence. We’re just now seeing the beginnings of that happening among some of the larger payers.
We’re also seeing one other thing, which is quite hard to ignore, and that is that home health agencies and hospices are being acquired by these payers. Obviously, UnitedHealth Group and Optum have jumped in full force into it, along with Humana. That’s sending messages to other payers.
It may not mean they need to acquire one to be what we now label a “payvider,” but it is starting to open the minds of people. I still think we’ve got a long way to go because the predominant reimbursement approach, for home health services in particular, is a discount off of a purchase and payment rate. That’s a long way from recognizing value.
Generally, as we conduct this interview in mid-2023, do you believe payers currently recognize the value of home-based care services? If they don’t, or if there’s still understanding that needs to happen, how are you and your organization contributing to those efforts?
I don’t think that they are appreciating the value sufficiently at this point. How are we trying to change that element within the process overall? We’re actually starting with our own membership, getting them to understand the importance of having reliable, validated data to demonstrate value.
From a broader sense, we have committed significant resources to a major project by ATI Advisory, looking at the comparison of Medicare Advantage with Medicare fee-for-service home health services, in terms of patient outcomes and financial outcomes. We’re still not finished with that, but it is providing us with some illumination around value that will provide information to both the plans but also to the providers of services.
Some early information is that the home health agencies are essentially treating the Medicare Advantage patients in an almost identical way to the way they treat the traditional Medicare patients, which means the patients are getting similar outcomes with some exceptions. Obviously, we’re looking at the hospitalization and the urgent care side of it, but if the home health agencies are losing money on those patients, and invariably they are losing a lot, the ability to sustain those losses is being reduced as traditional Medicare starts cutting payment rates as they did for 2023.
A goal is having the providers arm themselves with data to say, “Look, we delivered you a great service. Maybe we can’t continue to do it unless you provide us with some more support. And we’re willing to talk about a risk-sharing or value-based kind of approach to reimbursement.”
We’re really trying to arm them with global kind of data that could be used with the plans as well as their own operations. Just getting them to be aware of what they are dealing with.
One key fact we’ve been conveying to people is that the Medicare margin that they get on traditional Medicare is being used to subsidize the plans — generally in an average area of about 15 points of subsidization. If you continue to see, which we all expect to, that the proportion of Medicare Advantage patients grows, then the ability to subsidize decreases. So we’re trying to get the providers to understand that, and I think we’re succeeding. At this point, it is not a good business practice to rely upon a margin from another payer to subsidize a growing payer, such as Medicare Advantage.
It may come down to it that the wherewithal that we’re giving to the providers of services puts them in a position to say to the plans, “Sorry, we can’t do business with you unless you come to the table with more viable reimbursement.”
Not to play hardball with them necessarily, but the facts simply say: If we keep doing this, we’re not going to be around for you or anybody else.
Looking ahead again, what’s on your advocacy to-do list for the rest of 2023?
On the home health side, it’s the proposed rule and the reimbursement rate for 2024. We’ve got a risk of a serious rate cut, with continued discussions around permanent adjustments combined with the temporary adjustments. We don’t foresee that happening in the 2024 rulemaking.
Even a four-point cut, our calculations and the evaluation we’ve done, that would put half the providers of services with a margin of zero or below. That’s not a place anyone wants to be.
On the hospice side, it really is all about the intensity of oversight and the infiltration of fraud, as well as schemes that could corrupt not just the image of the hospice program and the benefit under Medicare, but corrupt the benefit itself overall.
We’ve got great allies and CMS and in Congress to try to deal with that. I think we got people to recognize that this is not systemic to hospice providers, but it’s something that can be targeted. But we went through this in home health back in the 1990s, and it was a very, very difficult time for home health when people were, on the policy side of it or the regulatory side of it, shooting from the hip and taking a broad, shotgun approach to things, which created a difficulty for home health agencies that often led to their closures.
When it comes down to Medicaid home- and community-based services, everybody always looks at Medicaid in a different way than they look at Medicare. They need to look at Washington. It’s a $100 billion-plus program, HCBS, and way bigger than anything Medicare does – and it is at a crossroads right now. Everybody sees the need to expand it to take care of waitlists, and take care of caregivers and their compensation. But the administration put out a proposed rule that will not work: requiring 80% of the payment rate to be used as compensation to the workforce — a valued intention that we can support, but the approach to it … you’ve got such variation from one state to the next. Is it 80% of $15 an hour, or 80% of $35 an hour? That’s a big difference when you’re trying to meet your administrative costs.
Last but not least, we’re focused on workforce availability – something that impacts all areas of home-based care. It’s not all about compensation. In many ways, it’s about human supply. We don’t have the people in the country who are going to nursing schools or willing to be a home care aide. We are looking at the very sensitive area of immigration for a potential near-term solution on this. Nothing’s going to solve it all, but we’ve got to start with the most immediate solutions available and work our way up to some long-term solutions.
What trends, challenges or opportunities do you see helping – or hindering – the advancement of home-based care over the next 12 months?
I think the trend that jumps out to me on the positive side is the expanding scope of what’s being done at home, and we talked about that relative to hospital at home, but it goes beyond that. You’re seeing many more disciplines of caregivers, from physicians on through, and the technology aspects of all of that is very, very heartening. I’m looking to see, does that also move outside of the world of the elderly and the disabled into normal health care areas? For age groups from zero on through their whole life? That would be a major advancement, if home care became part of that health care realm.
Because when you look at who’s receiving home care, they’re generally highly disabled — they may be pediatric or they may be in their 80s and 90s, but they’re highly disabled or they’re very elderly and have a lot of needs for activities of daily living support. But there are people today who are going in at age 25 for an appendectomy, who were in for day surgery and coming home with limited or no support. Home care can be part of that.
There are emergency room services that are being provided today that could be provided in the home setting, with the technologies that we have. In the near-term future, we could probably have a nurse come to your home faster than it would take for you to wait in an ER waiting room.
These are the kinds of opportunities that we see going forward. The greatest hindrance is the medical industrial complex getting out of its own way. People still need to recognize the value and that there are no sacred cows of hospitals and physicians.
It’s all about getting health care to people – and the setting should not be the driver. The care needs should be the driver, and if people can get out of that out-of-date and anachronistic view that health care is supposed to be in bricks and mortar, then that benefits the patient.