Serving the home health, home care and hospice industry since 1999.

by Tim Rowan, Editor

DATELINE ORLANDO — A welcome new format by Lincoln Healthcare Leadership treated this year's Homecare 100 participants to a series of expert panels focused on the issues of greatest concern to Healthcare at Home providers and the vendors that service them. In the past, inspirational, day-long experiences led by authors of books about how to be a champion business leader were fun and appreciated but this year's focus on immediately usable information, coupled with scheduling the event on a non-Superbowl weekend for the first time, fused the meeting with a gravity that matched the national atmosphere in our sector.

Out of the gate, friendly competitors Bill Dombi of NAHC and Edo Banach of NHPCO took the stage to compare notes on the regulatory environment that will dominate 2018. Moderated by Sheri Dodd of Medtronic Care Management Services, with just enough humor to keep the entire conversation from growing too dark, the association presidents parsed the short- and long-term significance of new home health regulations, Conditions of Participation, relationships with lawmakers, and what hospice can learn from it all about what to expect in coming years.

The most important lesson learned last year, according to NAHC president Dombi, is that the defeat of HHGM — the radically different home health payment system that he has previously described as "worse than IPS" — demonstrates the power we have in DC. "2,500 comments came in to CMS in a matter of hours," he reported. "We would have liked to have seen ten times that but we realize that previous open comment periods, even concerning major regulatory changes, only saw one-tenth as many.

"We dodged a bullet," Dombi asserted. "It would have been a 15% rate cut. But we still need to learn from this experience what we need to do to win next time. HHGM was not literally defeated, only delayed. Elimination of therapy as a payment driver is our next hurdle. We can show them it is in their best interest to keep paying for therapy because it has saved Medicare billions of dollars over the years. It takes people who are dependent and makes them independent. Home health therapy costs a fraction of skilled nursing facility therapy."

One of the red flags to watch for, Dombi added, is that this time CMS did not control the decision about budget neutrality. "The Office of Management and Budget got their hand in the mix. It seems they want to be in more control going forward."

Dismantling silos
NHPCO president Edo Banach kept coming back to the problem of healthcare sector silos. "Always keep in mind the value of diversification," he urged the audience of home health and hospice executives. "CMS pushes us into silos but we should be spending our efforts on breaking them down." As a strategy, he recommended expanding service lines. "If there is a threat to home health this year, there are opportunities in personal care or hospice."

Critiquing MedPAC
Asked by Ms. Dodd which voices are most and least heard, Dombi jumped in with the most candid comment ever heard from a NAHC president. "MedPAC recommendations are frequently ignored and they publicly wonder why their analyses, calculations and advice to Congress so rarely become law. Well, I tell them, it's because you don't do a good job!" NAHC calculations and forecasts, especially about profit margins and beneficiary access to care, are more accurate, he declared. "Beneficiaries are concerned about access to care, not payment rates."

Banach agreed. "It is important to organize our voices," he responded, joking about two supposed competitors appearing on the same stage and agreeing on the basics. "Our two communities have differences but are more powerful when we put those voices together. It is the consumer's voice that is missing. They are dissatisfied with the way things tend to unravel at the end of life and we should be too."

Critiquing our critics
"There is certainly some small amount of fraud in our sector," Banach acknowledged. "But there are also a lot of simple math errors, or other honest mistakes, such as a physician neglecting to add "M.D." to his signature, resulting in a two year-old claim being denied. Providers are running scared because auditors do not care about the difference between honest mistakes and criminal intent. The result is that providers come right up to the legal line. That can reduce access to care, forcing patients go back to the hospital when they should stay at home."

About those COPs
"Remember that these new conditions were more than 20 years in the making," Dombi commented. "and we still do not even have the final Interpretive Guidelines." He contends that several COP provisions will not work and gave one example. "A new requirement is that home health aides must practice on real patients; they cannot use medical dolls or so-called pseudo patients. There could not be a clearer example that CMS does not understand our business. Try to imagine which one of your patients would be happy to volunteer to be practiced on by a student."

What happened to VBP?
Both association presidents agreed that we need a definition of "value" before we are able to pay for it. "We believe in Value Based Purchasing because we have seen it change your behavior," Dombi declared. "But we must actively resist the move to base value assessments on spending per beneficiary. It's not about spending. If they do that, I'm moving to France!" He added that even Medicare Advantage leadership is starting to understand value instead of just unit price. "It’s taken a long time to get there, but it’s starting."

They also noted that there seems to be a slowdown in implementing Value Based Purchasing. It is likely due to the change in administrations in Washington. The strategy, they say, has to include flooding CMS with the data we have but the the challenge is in getting them to look at it. "Obama was moving full speed ahead with Value Based Care," Dombi added. "This new administration is more focused on experiments, waiting to see how the demonstrations pan out, saying they do not know yet what direction to go. For example, we demonstrated that savings from VBP in the first nine states, if extrapolated to all states, could save Medicare $4 billion over 10 years. We had no takers, no interest at CMS."

NHPCO is working with CMS to update their old data to help them make better decisions. "It is incumbent on us to say, 'That's a good first step. Now, before we rush to step two, let’s talk about some data.' Make them look at merely the quality of hospice services when assessing value. Hospice offers grief counseling to family and, after a natural disaster, sometimes to entire communities. There is a lot of value in that that does not appear in patient outcomes."

He continued, "When the government comes to hospice and says, '‘we should get into non-medical services,’ we remind them, 'that's hospice; that's what we've been doing for 35 years, what with spiritual counseling, music therapy and the like. First we need to establish the foundation of who we are, what is hospice and what is palliative care, then we must make clear that more folks need person-centered, interdisciplinary care well before the end of life.

What do we do now?
Sheri Dodd asked them for some concrete recommendations. Bill Dombi said providers should be investing half their resources in preparing for the future but reserve the other half to protect themselves today against payment denials and other accusations from MACs, ZPICs, UPICs, RACs and the like.

"Get your story together," Edo Banach said. "Use data analytics to tell prospective ACO partners and the government who you are and what you are able to accomplish in terms of quality outcomes and cost savings. I know it is hard to do at a time when we are trying to play defense against fraud accusations but data is your strongest tool."


©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. One copy may be printed for personal use; further reproduction by permission only.