August
4, 2019 ferarcosn/Pixabay | CC0
The new Medicare Advantage opportunity for
home care providers will break out in 2020 and boom in 2021. But while providers are
already building the infrastructure and the partnerships necessary to
capitalize on this enormous play, three major red flags remain.
For Medicare Advantage (MA) to fully benefit
from the power of home care, these three problems will need to be addressed.
1. The payer
partnership problem
Home Health Care News recently outlined the six steps home care providers must take to succeed in
Medicare Advantage. One of those six was the need to educate payers
on the basic differences between home care and home health, an issue indicative
of the larger problem: navigating an entirely new partnership.
“[Payers view home care] as a red-headed step
child, as a variant of the home health world,” Jeff Bevis, CEO of
Cincinnati-based franchiser FirstLight Home Care, told HHCN. “They place us far
down the food chain — that’s maybe the way to put it. Not really acknowledging
the value that we can provide them as a payer, and certainly as a service to
their policyholder.”
For the home care-MA plan partnership to work,
each side is going to have to adjust how it does business.
Home care providers will have to build new
technological infrastructure and, potentially, new organizational
infrastructure, such as 24-hour capabilities. They will have to learn how to
work with insurance companies, including new challenges in billing, coding and
data collection, as they move away from private pay on a client-by-client
basis. They will have to learn how to work within national ecosystems with
organizations powered by massive bureaucracies.
Payers, meanwhile, will have to learn the
differences between home care and home health. They’ll have to learn how to
measure success in home care. They’ll generally have to learn how home care can
deliver the outcomes they want for their members.
“I think there is going to be a really steep
and fast learning curve for the Medicare Advantage plans themselves between now
and 2022,” Medicare Advantage expert Anne Tumlinson, founder of Washington,
D.C.-based research and advisory services firm Anne Tumlinson Innovations, told
HHCN. “They’re trying to understand a variety of different things around not
just home care benefits but all of the things they can offer under the
supplemental benefit flexibility.”
2. The reimbursement
problem
Between the timing of the MA expansion
announcements, the lack of historical data showing the value of non-medical
services on a senior’s health and the getting-to-know-you relationship that is
building between major insurers and home care providers, the non-medical
supplemental benefits packages have been slow to reach the market.
But there is another element that is slowing
down the rollout from the provider’s perspective that also explains the
as-of-now low expectations from providers on revenue opportunities: the
reimbursement rates.
“We were looking at these benefits — Anthem,
for example — and saying, ‘This doesn’t work for us,’” Doug Robertson — health
care regulation and compliance manager at Omaha, Nebraska-based Right at Home —
told HHCN.
What he saw was a benefit from Anthem that
reimbursed a home care session of up to four hours for $40. If the home care
session lasts just an hour, and the home care agency bills $30 an hour, that’s
a $10 reimbursement, he noted.
But if the session lasts all four hours of the
benefit, the agency has charged the client $120 and only received $40 from the
insurance company. And because MA prohibits value-based care plans from using
“balance billing” — where the client pays out of pocket for however much of the
service is not reimbursed — there is no financial incentive for the home care
provider to participate if the reimbursements are too low.
“Because the home care benefit in MA is so
new, payers are still exploring what a reasonable reimbursement could be,”
Right at Home Vice President of Business Development Kerin Zuger told HHCN. “We
have learned of reimbursements that range from $10 an hour to $22 an hour, so
it is going to take a few Medicare plan cycles for payers to determine the
right reimbursement based on supply and demand.”
3. The unchecked
creativity problem
The CMS rule expansion in 2019 for the 2020 plan year was
monumental, giving MA plans a level of flexibility and creativity that is
basically unchecked. For example, the final call letter for MA plan year 2020
notes that “MA organizations have broad discretion” in determining what’s
called the “Special Supplemental Benefits for the Chronically Ill,” and
includes “pest control” as a possible benefit.
But unchecked creativity brings its own
problems. Take home modifications, for example.
While there has been some buzz around home modifications in
the new MA landscape, the reality reveals the inherent challenge at the heart
of MA’s home care expansion: the double-edged sword of creativity.
The value of home modifications within MA is
simple to understand: It’s an aging-in-place play. The problem is that the MA
expansion is for people with chronic conditions, and home modifications — such
as grab bars in the bathroom, non-glare lighting in the home or wider entry
doors — are best done proactively, before a person could definitively say they
are chronically ill.
So aging-in-place modifications have a much
stronger value proposition when done proactively, and yet proactive work is a
harder sell to MA plans. Instead, home modifications are more common after a
person falls and returns from the hospital, and by then it’s too late.
“That’s a bad time to do it,” Louis Tenenbaum,
a former home modifications contractor who now runs the home mods policy and
advocacy organization HomesRenewed, told HHCN. “It’s not easy to do it as a
contractor when the family’s in turmoil. And it doesn’t have the prevention
aspect to it if you wait until after an event.”
That’s one major roadblock. Another is that
unlike other MA benefits, a home modification is a capital improvement to a
person’s home, meaning they then own the benefit.
Let’s say a senior is choosing between two
insurers — MA Plan A and MA Plan B. MA Plan A buys into the notion that home
modifications improve a member’s social determinants of health, and that these
modifications must be done proactively.
In the first year with MA Plan A, the senior
builds the modifications. But because this is a proactive measure, the
financial benefits to MA Plan A might not be realized until the second, third
or fourth year that the senior is in that plan.
Yet because the senior now owns the home
modification forever, there is nothing that would prevent that person from
changing after a year to MA Plan B, which does not offer home modifications but
offers other benefits that MA Plan A does not.
Despite those challenges, as well as the lack
of definitive, outcome-based data showing the value of home modifications,
Tenenbaum is hopeful that this new landscape of creativity from CMS will lead
to an uptick in home modifications done early, and done correctly.
“I think we’re on the cusp of recognizing the
value of home modifications,” he said, “and making it something that people can
take advantage of.”
This article draws from HHCN’s new report,
“The New Medicare Advantage Opportunity in Home Care.”
Click here to access the complete report,
which includes a guide to the five key challenges home care providers will face
in MA as well as a comprehensive five-step process for finding MA plans that
offer specific supplemental benefits related to home care, including
instructions for combing CMS.gov.
Companies featured in this article: Anne Tumlinson Innovations, FirstLight Home Care, HomesRenewed, Right at Home
When not covering senior news, Jack
Silverstein is a sports historian and staff writer for SB Nation's Windy City
Gridiron, making regular guest spots on WGN and 670-AM, The Score. His work has
appeared in Chicago Tribune, RedEye Chicago, ChicagoNow, Chicago Daily Law
Bulletin, Chicago Magazine, and others.
https://homehealthcarenews.com/2019/08/3-red-flags-for-home-care-providers-entering-medicare-advantage/
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