Covid-19 has exacerbated challenges in the home healthcare subsector, while seemingly putting a target on the backs of home health agencies struggling to deliver high-value care. A combination of technology, policy fixes and investment might be the answer.
Bruce Hornsby’s best known chorus contains the lines “That’s just the way it is. Some things will never change.” It’s a reasonable assessment of how much of healthcare operates and the cost problems that only seem to go one way: up.
In 2016, Medicare paid an $7.7 billion in improper payment for home health services and supplies. The majority ($7.4 billion) of these improper payments for home health services and supplies were due to insufficient documentation, a symptom of a fragmented sub sector of healthcare that’s largely devoid of the type of technology that can enable better care management, coordination and value-driven models of care.
With such staggering figures it’s easy to spot problems and demonize home health agencies for problems related to care and bad practices, but a broader view – one that takes the clinical and operating environment into account – paints a very different picture. A picture that recognizes that patients increasingly want care at home. A picture that recognizes the value that home health can provide, but the operational, clinical and financial challenges they face. A picture that begs for investment, not vilification.
In fact, home health as a post-acute option has been associated with savings of $4,514 per Medicare beneficiary following hospital discharge versus other care settings. Perhaps that is why leading healthcare organizations such as Mayo Clinic are developing “hospital at home” programs, and why Intermountain Health, Ascension, Amazon and others are pushing for policy changes to expand how Medicare reimburses for home care services. And why Medicare Advantage behemoth Humana invested in DispatchHealth, a technology startup providing urgent in-home and hospital-at-home services.
The reality is that there are rare bad actors across sectors of healthcare, which collectively account for 20% of our economy. Home healthcare is certainly not immune to these issues, but cherry picking data and singling out larger organizations isn’t helpful. What would help? Understanding the challenging realities of providing for patients at home, and developing policy and technology interventions to help address these challenges.
The Many Challenges Of Healthcare At Home
Home health agencies face myriad operational, financial, and clinical challenges. From inconsistent and varied inbound referral information to day-to-day care coordination with other providers, from to reimbursement complexities to staffing challenges, and from ineffective benefits design to a broad scope of clinical practice, there are many hurdles to running a safe, effective, and successful home healthcare organization. Covid-19 has only heightened these challenges, with home health leaders expressing concern on issues ranging from staff preparedness to changing market dynamics.
“The concern here is for access to caregivers and the ability of staff to be able to go in and do their job appropriately to make sure that these seniors are not left behind as a result of the ongoing surge that we expect to continue for several months,” said Beau Sorensen, chief operating officer at First Choice Home Health & Hospice, to Home Healthcare News. Most home healthcare recipients in the U.S. are over 65 years old, with ~97% requiring assistance with bathing and 91 percent requiring assistance getting in and out of bed.
Similarly, Peter Miska, president of Phoenix Home Care LLC, told Home Healthcare News that his top concern is how hospital systems and the U.S. Centers for Medicare & Medicaid Services (CMS) want the small home health agencies to close. “This is good for the large providers that have exclusivity and control a majority of the Medicare revenue, but bad for small providers, which are the great majority of agencies in America. We don’t have a seat at the table regardless of cost, quality or patient’s choice.”
Part of the issue lies within the two-party payment system that’s often at play for the majority of patients utilizing home healthcare, where Medicare beneficiaries requiring both skilled healthcare services and assistance with daily living activities (ADLs) often must secure and coordinate providers under both Medicare and either Medicaid or private insurance/pay.
As detailed in a recent Commonwealth Fund study, “These beneficiaries may be at risk for poor outcomes because of lack of coordination between providers,” where home health aide shift changes alone are associated with increased likelihood of hospital readmission within 30 days of initial discharge. Ultimately the study deemed the current Medicare home health benefit design as being unable to sufficiently meet beneficiaries’ needs.
But home health challenges go well beyond Covid-19. Home healthcare delivery is extremely complicated, plagued by logistical challenges, system inefficiencies, payment complexities, and a lack of care coordination, in addition to myriad of other factors, including the following:
Poor discharge planning to home health: “We still have markets around the country where discharge planners are faxing plans to their partners,” said David C. Grabowski, PhD, professor of health care policy at Harvard Medical School, who remains concerned about the lack of data in the home health subsector and post-acute care overall. “We don’t have the data. We’re still uncertain about outcomes. What are we getting for the spend?”
In fact, it wasn’t until the advent of diagnosis related groups (DRGs) in the early 1980s that hospitals needed to think about discharge planning, Grabowski noted. As a result, home health and skilled nursing facilities (SNFs) became the fastest growing cost for Medicare in the 1990s and started to gain more policy attention. But the introduction of DRGs and post-acute benefits was not particularly well-planned or structured. Grabowski notes, “We’d never set it up this way if we were starting over.”
Bill Miller, CEO of WellSky (one of the country’s largest post-acute technology companies), echoes Grabowski’s sentiments on the lack of data in the discharge planning and transitions of care process, noting that historically, discharges and care transitions have been based on geography, convenience and history, not science.
“There are two reasons to apply science to a discharge,” says Miller: the first is doing right by the patient, in terms of right site of care, right provider, and doing right by coordinating information flow; the second is the economics of it. “Through intelligent care technology, providers can deliver better outcomes and lower our total spend on healthcare.”
Information Asymmetry And Complexity Home Care: Most clinicians and patients want their care to be delivered at home. “From human, clinical and financial perspective, there are no positives in having patients readmitted soon after being discharged from hospitals,” said John Loghnane, MD, a board certified family
medicine physician in palliative care and hospice medicine who continues to practice as a hospitalist as part of CCA’s Complex Care Service at Boston Medical Center. “Stabilizing patients’ acute and chronic issues safely and effectively in the home setting just makes good sense and good medicine.”
It also can be hard.
“Home health is a challenging environment with a really wide scope of practice,” says Loughnane, though he notes it can be done well.
Home health agencies must develop comprehensive care plans, but per the above, frequently rely on sparse information contained in a fax.
The wide scope of clinical practice also makes it difficult for any agency to optimize clinical practice or operations for any managing any specific condition.
In addition, administrators themselves are in a position of running a healthcare delivery organization, but without the ability to see their patients or much ability to track their clinical progress. Rather, they rely on high skilled clinical staff to go into the field, care for patients, and document progress. This can be a challenge for administrators due to high staff turnover rates (an issue also impacting nursing homes) and natural differences in how staff have been educated, trained, and variations as simple how they measure wounds (for instance, head to toe vs length x width). Issues relating to patient scheduling, logistics, and dealing with staff no-shows or sick days (especially during Covid-19) further complicate things.
Resources are stretched thin: Home health agencies are responsible for developing care plans that frequently require physical and occupational therapists, nurses with varying scope of practice, and more. While home health aides do not provide physical and occupational therapy or skilled nursing care, they are responsible for observing and overseeing patients’ physical and mental health and coordinating with other providers.
Clinical staff may only see a handful of patients each day, but they see patients who have additional chronic conditions to manage (in addition to post-acute needs), live in different settings (a one bedroom apartment in a four story walk up is different than a single family home in the suburbs), with different support structures and caregivers with whom to interact (a man in his 90s living alone likely has different needs from a late-60s woman who lives with her children). Developing relationships with each one and meeting the needs of each one while trying to beat traffic to the next appointment can be a difficult balancing act.
Coordinating care plans and staffing is further complicated amid Covid-19, when traditional morning “care team huddles” to discuss plans for the day cannot be conducted reliably in person.
Complex and conflicting reimbursement frameworks: Payment structure challenges often leave home health agencies between a rock and a hard place. The majority of a home health agency’s post-acute patients are Medicare beneficiaries. Traditional Medicare recently changed its reimbursement scheme to pay for 60 days of care in two phases (early and late periods) based on the clinical condition of a patient; this encourages agencies to figure out how to efficiently allocate its clinical resources to deliver the appropriate care over the time period. On the other hand, Medicare Advantage plans and commercial plans often have different payment models (some paying on a per visit basis, some setting a number of visits allowed), creating different incentives for agencies to carefully manage.
That’s all just for post-acute care. But for longer term services, home health agencies often deal with payment from individuals themselves or private insurance plans that have different eligibility and care requirements.
All of these leaves agencies in a place in which they not only deal with multiple different payers (bringing its own administrative complexity that is known to contribute to physician burnout), but different reimbursement models that require them to juggle different care models and operating models.
Solving for the above challenges at scale is not trivial. Health information technology and digital health tools may provide a pathway.
Fueling A Data-Driven Intervention
With Covid-19 as a catalyst, the need for and reliance on healthcare technology has become apparent, but the degree to which digital health solutions are being leveraged varies greatly from home health agency to agency.
“We need communications tools and secure data exchange capabilities to port information from the home health agency to a personal care agent and back. And then have the complementary data tools to track outcomes,” said WellSky’s Miller.
“At Optum, for instance, the insights we had for acute providers were powerful and predictive,” said Miller, who is also the former CEO of Optum Insights, adding that in the post-acute space, “it’s comparatively been a desert.” Optum is the health services platform of UnitedHealth Group, which provides data analytics, technology and clinical insights for health plans and providers.
Coming from a data-first organization like Optum Insights, Miller has prioritized data access and information exchange capabilities at WellSky, shifting from the typical post-acute data desert to a lush and vibrant data rainforest. “We invest a lot of time and effort into interoperability that helps improve data visibility with analytics layered on top to deliver additional insights that inform smarter, better care,” he said.
In the absence of data, delivering high-quality care in a home health setting becomes incredibly challenging, if not impossible. As Harvard’s Grabowski noted, “There’s a lot of low-value care in these settings. There’s also a lot of high-value care. We just don’t have a good sense of which happens where yet.”
It’s without question that technology adoption, data access and information exchange can help the home health sector in many ways, and for many constituents; for example, giving nurses the tools they need to better capture and track clinical details, run diagnostics, and ensure they can better communicate with providers. Similarly, remote patient monitoring (RPM) tools can be used in tandem with patients to help providers better track and deliver care while enabling patients to better care for themselves.
Like WellSky, home health agencies are already seeing the benefits from tech and the added transparency it brings. As Dan Dietz, president and CEO of CommonSpirit Health at Home, recently shared, “We will continue leveraging our technology-based solutions such as remote patient monitoring, virtual visits and medication management delivery to enhance our care plans while supporting infection control measures and social distancing to minimize risk for our caregivers.” He also spoke to the companies continued use of analytics to help make data-driven decisions during the pandemic. “We have focused equal effort into providing tools and resources to our front-line caregivers to ensure they are safe, engaged, supported and have what it takes to be resilient in hard times.”
What’s Next? Policy Levers And Technology Can Usher In Change
From Miller’s perspective, there are many steps that agencies can take that will make a big difference to caregivers in home health settings, all of which the company is spearheading through its software:
- Support staff retention and satisfaction by equipping their clinicians with easy-to-use technology that connects them to expert resources when needed and delivers insights at their fingertips.
- Leverage powerful point-of-care software to empower agencies to optimize care delivery, reduce paperwork, and eliminate duplicative data entry.
- Reduce complexity and enhance team morale with technology that supports caregiver success.
Then there are the policy levers related to technology adoption that could, and likely should, be pulled in the home health setting, just as they were for electronic health records (EHRs) in the acute care setting over a decade ago.
In a recent JAMA article Julie Adler-Milstein, PhD, suggests a number of steps the Biden administration can take, including replicating the EHR Incentive Program for post-acute organizations that have to date been ineligible for financial incentives in order to drive digital transformation. She notes that post-acute care organizations (including home health) “are essential to high-quality care delivery for vulnerable populations. While digitizing acute care hospitals and ambulatory practices was expected to help these organizations digitize, this largely has not occurred.”
When it comes to an economic stimulus package focused on post-acute care facilities, Miller of WellSky agrees with Adler-Milstein. “As we’ve seen happen in acute care, incentives would certainly speed up EHR adoption in post-acute,” said Miller. “We’ve known for a long time that adopting EHR technology across post-acute care is the first step toward unlocking better outcomes for more people.”
However, while EHRs are vital, Miller notes that they’re only part of the equation. “Policymakers also have the power to advance other legislative priorities that further support post-acute providers, such as reimbursing for telehealth services and embracing innovative care models like hospital-at-home,” he says.
In addition to incentive packages and expanding legislation to support health at home, Loughnane is bullish on the number of organizations developing solutions and platforms focused on integrating social determinants of health (SDoH) and public health with clinical care delivery, which is of great benefit to home healthcare recipients, providers and caregivers alike.
“I’m excited about the startup focused on providing high quality care in the home,” said Loughnane. “When a patient comes into my office, except for rare circumstances, that’s for my convenience, not theirs,” he said, referring to the attractiveness of (and demand for) offering primary care health services at home, instead of making patients come into the office.
For example, Cityblock Health, NowPow and Unite Us are three technology firms helping to address social determinants of health by facilitating closed loop referrals and care coordination with community and public health services. “All the organizations providing care didn’t know about other service providers,” said Taylor Justice, CEO of Unite Us told Forbes previously. “There was this lack of connectivity and communication between all of these different sectors and all of these different industries. So we started Unite Us to fill that void.”
Don’t You Believe That’s Just The Way It Is
No sector of healthcare is without its faults and (hopefully rare) bad actors, but providing healthcare at home has clear value to patients and payers: it’s where people are most comfortable, and it is a lower cost setting than inpatient or other institutional settings. Increasingly, policymakers and industry leaders are turning to home health as a potential solution for rising costs and issues of accessibility. But it’s a challenging business to be in: for healthcare providers seeking to meet patients where they are, there are a series of hills to climb every day.
Rather than demonize an industry or accept that “That’s just the way it is,” perhaps the best rejoinder is “Ah, but don’t you believe them.”
With policy support, public investment, and technology firms bringing new capabilities to bear, there is promise on the horizon.