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At a macro level, home health organizations are struggling with Medicare Advantage (MA) for two main reasons: benefit design and reimbursement.
In order to build stronger relationships with MA plans, agencies are undergoing a strategic shift in their service offerings to meet the unique challenges posed by MA patients.
Those shifts include partnering with other stakeholders to have a clear understanding of what MA plans want.
“Right now, the benefit design of MA plans feels like it’s designed simply to minimize costs,” Michael Johnson, president of home health at BAYADA Home Health Care, told Home Health Care News. “How do we design a benefit that maximizes outcome but takes costs into effect? That’s where we’ve been at odds with each other. They’re trying to control their costs and their assumption is that we’re not interested in costs. The reality is we — home health agencies and MA plans — are interested in both.”
The differences in an MA patient
In 2021, 3 million traditional Medicare recipients received home health care at a cost of $17 billion. It’s unclear how much home health care costs for Medicare Advantage patients, although researchers with the University of Washington (UW) suggest the figure is likely less.
Medicare Advantage plans have claimed an increasing share of Medicare beneficiaries, surpassing the 50% threshold in 2023. This shift means a larger portion of beneficiaries now rely on MA plans rather than traditional Medicare.
While MA plans offer additional benefits, they frequently implement cost-cutting measures such as copays and prior authorization. Medicare pays MA plans a capitated rate per beneficiary to cover enrollee health needs, incentivizing them to coordinate care and minimize expenses, some experts believe.
Working through those cost-cutting tendencies is what Bayada and other home health agencies are grappling with.
At the same time, agencies are finding out that MA patients — generally speaking — are different from traditional Medicare patients in a lot of ways.
That recent study from UW found that home health patients under MA plans have worse functional outcomes compared to traditional Medicare patients, likely as a result of receiving fewer visits.
In the study, MA patients had shorter home health length of stay by 1.62 days and had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively.
The results of the study suggest that MA patients receive shorter and less intensive home health care versus traditional Medicare patients with similar needs.
“Similar to previous research, we found that Medicare Advantage patients receiving home health were younger and more racially and ethnically diverse than traditional Medicare patients,” Rachel Prusynski, a professor at the University of Washington School of Medicine, told HHCN. “But while they were less medically and clinically complicated, they also had fewer social resources.”
Compared to traditional Medicare patients, patients under MA plans were more likely to live alone and live in areas with more poverty, unemployment and less access to transportation, Prusynski added.
Not only were MA patients healthier across the board, the study found that MA patients were less likely to have cognitive impairment, had fewer recent falls, fewer pressure sores, less pain and were taking fewer medications.
With that in mind, it’s up to home health agencies to adapt.
“Broadly speaking, Medicare Advantage patients don’t have as much medical need as the population we typically see,” Johnson said. “The fact that there are fewer visits delivered is not a surprise. Now, we’re forced to think about how those visits are delivered.”
How to adapt
In order to address some of these differences, home health agencies need to form the right relationships.
“The first thing we’re thinking about is, how do we partner with managed care organizations to tap into the extra services they provide around care management?” Johnson said. “If they’re doing some of that work, home health providers shouldn’t feel obligated to do that same work. We could share the load, in theory. It’s easier said than done, but it’s certainly a reasonable goal.”
Using the study’s findings as a research tool, Bayada has started to consider tinkering with its clinical mix based on a patient’s specific needs.
“If you’ve got a limited number of visits, which is generally the case, and there is less clinical need, should we be using more therapy and less nursing?” Johnson said. “We’re digging into that and being more thoughtful about our care plans. We’ve got plenty of clinically complex patients in both MA and traditional Medicare to keep our nurses busy. It’s this other population that we’re trying to tap into.”
The other component is pace.
In other words, if home health agencies have a fixed number of visits set by an MA plan, how are those visits paced in a way where they’re most beneficial for the patient, while also improving outcomes and keeping costs down.
“There’s a difference between delivering eight visits in 30 days and delivering eight visits in 60 days,” Johnson said. “Time does several things. It gives the patient the opportunity to learn and really understand their care plan. I don’t care how good your wound care is, Mother Nature is only going to heal the wound so fast.”
Instead of going to a patient’s home once per week for two months, Bayada may spread those visits out to allow a more measured coaching environment between a nurse or therapist and their patient.
Taking risk
Medicare Advantage plans have historically used a lot of strategies to reduce costs of home health care, Prusynski said.
Things like prior authorization requirements, visit limits and network restrictions are a few examples. One way to avoid some of those cost-cutting strategies for home health agencies is to take on risk of their own.
“If the payer is the only one that has any risk, of course they’re going to manage the costs,” Johnson said. “Things like case rates, which we and a lot of organizations are doing, is one way to take on risk. So rather than paying me for eight individual visits, an MA plan pays me a lump sum and then basically steps away and says, ‘OK, deliver it how you would.’ This gives us the opportunity for more time with an expectation that we’re hitting specific metrics.”
At the end of the day, everyone wins if a patient is able to get better at home on a reasonable amount of visits.
“Much of our outcomes are related to the benefit design that everybody’s dealing with,” Johnson said. “My message to other home health providers, particularly larger ones, is let’s start thinking about who we can partner with to understand our data better and change our behaviors. Then we can go to MA payers and have more meaningful conversations about benefit design.”
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