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On Thursday, the Senate approved a bill that will provide $8.3 billion in emergency funds to help mitigate the effects of COVID-19, otherwise known as the coronavirus. Apart from funding, the bill made major changes to telehealth statutes, possibly allowing home-based care providers to both rely heavier on telehealth tools and be properly reimbursed for those services. 

Specifically, Congress is allowing the U.S. Department of Health and Human Services (HHS) to waive certain originating-site constraints, such as the ones that restrict telehealth in nonrural settings. Providers will also be allowed to conduct telehealth instruction over telephones with audio and video capabilities. 

“Because all of the United States is currently under this public health emergency designation, any Medicare beneficiary would now be eligible for care from a provider via a two-way audio-video mechanism, including a smartphone,” legal experts from Alston & Bird wrote in an advisory note. “This applies anywhere in the U.S. for any Medicare-reimbursable telehealth service — not just for treatment of the coronavirus.”

Since the coronavirus began spreading throughout the United States, many home health industry insiders have pushed for greater use of telehealth technology.

Among them is Raj Kaushal, the founder of Senior Healthways Inc. and a former president at LHC Group Inc. (Nasdaq: LHCG).

“We have to look at delivery of care in the case of an outbreak — and how we can shift it,” Kaushal told Home Health Care News. “Can we utilize a triage system? Can we use telehealth? If we’re an agency that doesn’t have telehealth, can we use telephone and text monitoring systems? Video conferencing? We need to find ways to make sure exposure to the patient and the staff is minimal, if it comes to that.”

Despite opening some new doors, there are still certain limitations to the newly relaxed telehealth requirements. Also, for providers that do use smartphones to connect with patients, existing HIPAA standards will still apply.

So far, the coronavirus has impacted more than 108,000 people around the world. As of Monday afternoon, the number of confirmed cases in the United States was approaching 600.

Telehealth becoming vital 

Telehealth has long been considered a big part of the future for health care providers. As providers’ fears worsen, that future could come sooner by necessity. 

The Society for Post-Acute and Long-Term Care Medicine — formerly known as The American Medical Directors Association (AMDA) — represents a community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants and other practitioners working in long-term care settings. Its incoming board president, Dr. David Nace, told HHCN last week that telehealth would play a large role in containing the virus in long-term care settings. 

“I think it has to have a very strong role. Even in the nursing home setting, even in the assisted-living setting, you want to minimize the number of individuals that come in contact with an infected individual,” Nace said. “One of the things that can be quite helpful is the use of telemonitoring and telehealth equipment … . I think that is very appealing in the long-term care setting, and it’s been one of the things that we’ve been thinking a lot about.”

Telehealth tools have their limitations, and they won’t ever be able to replace in-person provider care completely. 

But having the ability to access patients virtually will allow providers to avoid person-to-person contact unless it’s absolutely necessary. 

“I absolutely do believe that [this will speed up the shift to telehealth]. I’m pretty confident, both from the home health organization [perspective] and the potential of CMS opening up different reimbursement models to support this,” Horner said. “I don’t think there’s going to be a choice here.” 

There’s already been examples in areas with a large number of cases — such as Seattle — of both patients and nurses refusing to meet with each other in person. 

Opening doors

Previously, roadblocks for reimbursement prevented providers from committing more to telehealth. Medicare historically has only reimbursed providers for telehealth under special circumstances. 

While policymakers will likely still need to work out details, last week’s language will open more opportunities for providers to be reimbursed for other services in different settings.

In a 2019 study of 159 home health agencies conducted by Definitive Healthcare, roughly 28% of respondents said they had a goal of establishing new telehealth services within the next year or so. 

Definitive Healthcare is a Framingham, Massachusetts-based provider of health care data and analytics. Of the 159 participants, roughly 70% were agency-level providers and 30% corporation-type businesses. 

That has given the agency confidence while bracing for the spread of coronavirus, COO Linda Murphy told HHCN. 

“If you think about the old days when we had a hurricane come through, you’d have everybody on the phone calling patients as well as staff hitting the road to try to talk to patients and get them prepared,” Murphy said. “With technology today, you can be so much more efficient and provide even more detailed information because you can standardize messaging across the whole arena or make it very specialized depending on the type of patient that you’re dealing with.”

Even before last week’s changes to the telehealth reimbursement process, there were perks to using virtual care as a cost-saving tool. That’s especially true under the Patient-Driven Groupings Model (PDGM), which has more agencies strapped for cash. 

“[Telehealth] certainly adds an element of non-reimbursable costs, but it also saves on that visit and it still gives us the potential to achieve the quality outcome that we are looking for,” Sharon Harder, president of C3 Advisors, told HHCN in February. “As we think of home health, generally, all of these innovations are going to help us with our margins when it comes to PDGM.”

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By Alex Spanko | January 26, 2020

The new fee-for-service Medicare model absorbed much of the oxygen around nursing home payment reform in 2019, but 2020 — as well as the years beyond — will bring a slew of alternate payment pressure to the post-acute sector.

Over the next two years alone, 95% of post-acute operators will find themselves in new payment models, according to a January report on 2020 health care trends from consulting firm Avalere Health — while Medicare Advantage will continue to expand its footprint into an array of new covered services.

“Medicare is reorienting payment around patient needs rather than resource utilization, while MA plans and accountable care organizations are encouraging patient care in the lowest-cost, clinically appropriate care settings,” the Washington, D.C.-based Avalere noted.

The Patient-Driven Payment Model (PDPM), which became the standard fee-for-service reimbursement system for nursing homes last October 1, represented a step in that direction, shifting incentives away from therapy volume and toward resident need. Though the early returns have been positive — with multiple sources reporting widespread payment boosts in PDPM’s first months — experts have warned that downward adjustments could be coming if the federal government determines that the model strays too far from its revenue-neutral goal.

But PDPM only represents one front in the changing payment landscape. Medicare Advantage plans have rapidly expanded their offerings for the 2020 plan year, with more than 59% covering telehealth services — a move that some operators in the space have eyed as a key opportunity, particularly in the wake of a 2019 federal rule making it easier for MA plans to pay for telehealth interventions.

“The breadth of MA benefits continues to expand and evolve to meet patient needs,” Avalere managing director Fred Bentley said in the report. “Plans have more flexibility to offer benefits targeting specific populations, creating opportunities for new partnerships.”

On top of Medicare Advantage, Avalere estimated that 95% of all post-acute providers will find themselves in some kind of alternative payment model in 2020 and 2021, prompting the consulting firm to advise operators to consider diversification to weather the changes — while also exploring the increasingly popular Institutional Special Needs Plans (I-SNPs), special Medicare Advantage plans for long-term care residents.

“Post-acute care providers will increasingly need to demonstrate their unique value relative to other care settings and evaluate opportunities to diversify into home health,” Avalere observed. “Some providers may choose to become payers themselves, launching Special Needs Plans to secure their foothold in the changing market.”

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Alex Kacik

Home health providers will look to significantly expand their telehealth offerings as they curtail their therapy services, according to a new survey.

The number of home health agencies that use telehealth services like remote patient monitoring, virtual consultations and medication management technology will double over the next two years, according to Definitive Healthcare’s home health study that polled 159 providers in October. More than 53% of respondents indicated that they will use telehealth services within the next two years, up from around 21% currently.

Notably, no home health agencies said they would be expanding their occupational, physical and speech therapy, which more than 85% of the organizations currently provide.

“There’s no doubt the healthcare industry is facing a massive shift that will affect all sectors,” said Curtis Gattis, CEO of the health-tech company LeadingReach, citing the aging population and prevalence of chronic conditions. “Our need for physicians in every specialty is only going to increase. Expanding and growing telehealth offerings in home health and across the entire healthcare industry will help meet this need.”

But virtual care will require better care coordination and communication between providers as the industry adapts to the burgeoning technology, Gattis added.

The home health sector has been preparing for the implementation of the new Patient-Driven Groupings Model, which will no longer base pay on therapy hours and will reimburse 30-day periods of care instead of 60-day stints come Jan. 1. The new pay model is meant to shift the focus from the volume of services provided to one that relies on patient characteristics. Home health agencies that have focused on therapy almost exclusively could see significant revenue declines, according to a recent report from Trella Health.

A similar model was implemented for skilled-nursing facilities on Oct. 1, which prompted a massive workforce restructuring. Occupational therapists, physical therapists and speech-language pathologists who work in home health have reached out to Modern Healthcare, saying they have been laid off or experienced significant pay cuts. Many are concerned that patient care will be diminished as a result.

The CMS said that it will “continue to monitor the amount of therapy provided via the different modes and we will consider revising the policy and enforcement efforts as necessary.”

A recent survey by the National Association for Home Care & Hospice found that 48% of 685 home health providers polled indicated that they plan to decrease therapy utilization by at least 10% in 2020.

While therapy services are poised to decline, home health providers are looking to grow their specialized care offerings. Palliative care, veteran-specific care and mental health services are projected to grow the most over the next two years, according to Definitive’s report. Less than 41% of the home health agencies surveyed currently offer those services; the most common specialty services are wound care, cardiac diseases, COPD, diabetes, joint replacement and degenerative diseases.

“Home health agencies are tailoring their care to specific disease states or conditions, which seems to be more common than it had been,” said Matt Valley, a senior healthcare analyst at Definitive.

But finding and hiring quality staff seems to stand in their way, with 61.6% conveying that as being their greatest challenge. The home healthcare industry is projected to grow 36% by 2028, estimated to add over 1 million jobs in the process, according to the Bureau of Labor Statistics.

The next biggest obstacles were profitability, the uncertain regulatory landscape and payer coverage, particularly when it comes to telehealth.

“Finding qualified staff isn’t just an issue for home health agencies,” Valley said. “But it could be magnified in an expanding sector.”

As home health providers look to mitigate staffing shortages through new technology that aims to automate data entry, improve communication and streamline payment, the CMS has been seemingly supportive of home-based care.

Beyond its Medicare demonstration pilots, the agency loosened restrictions this year in Medicare Advantage that facilitated in-home aid with bathing, dressing, cooking and other tasks. It also allowed plans to pay for palliative care in the home.

In 2020, the agency will reimburse Medicare Advantage plans that expand their in-home coverage of patients with chronic conditions. A home infusion therapy benefit, which will cover professional services, patient education and monitoring for in-home medication delivery, will kick in in 2021.

“This could open the door for massive growth in home healthcare,” Valley said.

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Author: Linda Wilson

Dive Brief:

• Home health agencies are growing their businesses, with 43% of them planning to expand or add services in the next two years, according to a survey of the companies from Definitive Healthcare, which sells data on healthcare providers.
• Telehealth will see a jump as almost 28% of agencies plan to launch those services. Nearly 21% already offer them, according to the report released Tuesday.
• Chronic care is another prominent area for the 159 home health agencies in the study. Nearly 70% now offer specialized services geared toward people with chronic illnesses, treating an average of nine diseases. Other common offerings are therapy services (85.5%) and homemaker services (50.9%), according to the study, which Definitive conducted in October.

Dive Insight:

The home health industry is poised for explosive growth, fueled by an aging population of baby boomers.

CMS also is enabling the industry’s growth and diversity of service offerings. For example, the agency began allowing Medicare Advantage plans to offer non-skilled, in-home support to their chronically ill beneficiaries this year.

As baby boomers become seniors, they “fall within the very age demographic most frequently suffering from chronic disease states and conditions, like Alzheimer’s, cardiac diseases, COPD, and diabetes,” Jason Krantz, CEO of Definitive Healthcare, said in a statement.

Home health agencies are responding to this demand with a variety of telehealth services, the study found. Nearly 73% offer remote patient monitoring with clinical grade devices and nearly 42% plan to add or expand this service in the next two years.

The majority (66.7%) offer remote monitoring with consumer devices, while nearly 35% plan to launch or expand this service in the next two years. Half of the home health agencies surveyed offer two-way video or webcam services and about a third plan to add or expand the service.

Other technology services home health agencies offer include: email (42.4%), medication management technology (42.4%), image sharing technology (36.4%), mobile apps for e-visits (33.3%), group video conferencing (33.3%) and population health tools such as texting (27.3%).

They’re planning to add or expand in a variety of areas including palliative care, veteran-specific care and mental health services.

When asked about the top challenges they face, hiring qualified staff ranked the highest among the survey respondents at home health agencies (61.6%), followed by profitability (42%), and an uncertain regulatory climate (34%).

Home health agencies are not the only ones in the industry expanding their services. Health systems also are moving into home care. The idea is to move patients who do not require continuous monitoring out of costly hospital settings sooner.

For example, Nashville-based Contessa Health, a provider of at-home care for patients recovering from non-life-threatening conditions, has inked contracts with Ascension, CommonSpirit Health, and Highmark Health.

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The Centers for Medicare & Medicaid Services (CMS) on Thursday finalized the Patient-Driven Groupings Model (PDGM) for 2020, in addition to its plan to phase out home health pre-payments and introduce a new home infusion therapy benefit.

But perhaps the biggest news for U.S. home health providers is a major update to PDGM’s widely opposed and controversial behavioral adjustment.

Broadly, the assumption-based behavioral adjustment is built on CMS’s belief that agencies will automatically change their coding and visit behavior in order to maximize reimbursement under the looming payment overhaul.

In its proposed payment rule dropped in July, the PDGM behavioral adjustment stood at 8.01%. In Thursday’s final rule for calendar year 2020, that adjustment decreased to 4.36%, a figure that’s likely still higher than the industry would like — but a significant drop nonetheless.

“Based on the comments received and reconsideration as to frequency of the assumed behaviors during the first year of the transition to a new unit of payment and case-mix adjustment methodology, we are finalizing a -4.36% behavior change assumptions adjustment in order to calculate the 30-day payment rate in a budget-neutral manner for CY 2020,” CMS wrote in its final rule.

National Association for Home Care & Hospice (NAHC) President William A. Dombi said his organization was “greatly heartened” by the move and that it represents a “much more realistic view” of the PDGM-transition process.

NAHC didn’t back off its opposition to assumption-based behavioral adjustments all together, though.

“The Bipartisan Budget Act of 2018 requires that the home health payment model reform be budget neutral,” Dombi said in a statement to Home Health Care News. “While it permits behavioral adjustment to payment rates, NAHC believes that assumption-based rate calculation should not occur because of the high risks of error and the creation of an incentive to change behavior solely to maintain Medicare revenues. Instead, NAHC supports adjustments only after actual behavioral changes have occurred.”

CMS’s move to somewhat lessen its assumption-based adjustment isn’t just in response to industry feedback: It’s also due to Congressional attention. Dozens of U.S. senators and more than 100 House lawmakers have signed on to legislation targeting PDGM’s behavioral adjustment.

“While the PDGM payment model reforms include sensible changes, the behavioral adjustment remains a concern, albeit to a reduced level,” Dombi said. “There is bipartisan, bicameral legislation pending, S. 433 and H.R. 2573, that can help resolve these concerns fully.”

Overall, CMS’s final rule for 2020 increases Medicare payments by an estimated 1.3% — or about $250 million. The increase reflects a 1.5% update required by the Bipartisan Budget Act of 2018, plus a mandated 0.2% decrease to rural add-on payments.

While the behavioral adjustment has risen to priority No. 1 for home health providers, CMS’s proposed plan to phase out pre-payments — or Requests for Anticipated Payments (RAPs) — had also been a point of focus.

CMS is officially moving forward with its plan, which some industry experts say will create insurmountable cash-flow problems for small and mid-sized providers. Currently, RAPs provide up to 60% of an episode’s anticipated payment at the beginning of care.

CMS will begin phasing out pre-payment for home health services over the next year and eliminate them entirely in 2021.

The agency is killing the RAP, it says, largely due to ongoing fraud concerns.

“CMS has seen a marked increase in … fraud schemes perpetrated by existing [agencies] that receive significant upfront payments, then never submit final claims and close for business, making Medicare recoupment efforts impossible,” agency officials wrote. “CMS believes that eliminating RAP payments over the next two years would serve to mitigate potential fraud schemes while minimally impacting [home health agencies] due to implementation of the PDGM, which increases the frequency of payments for services to [agencies].”

Instead of a RAP, CMS is finalizing a requirement for a one-time submission of a Notice of Admission (NOA) beginning in 2022. Home health agencies will be required to submit an NOA within give calendar days of the home health start of care — or be subject to a financial penalty for each late day.

In addition to all those changes, CMS is also finalizing its plan allowing therapist assistants — rather than only therapists — to perform maintenance therapy under the Medicare home health benefit, in accordance with individual state practice requirements.

Broadly, the change allows therapist assistants to use all of the skills under their license and gives home health agencies more flexibility when it comes to maintenance therapy, which some see as under-utilized, according to CMS.

While CMS is bullish on the change, some industry leaders see it as too little too late.

“The potential issue is that maintenance therapy visits tend to occur at a lower frequency,” Anthony D’Alonzo, director of clinical strategy and innovation for Bayada Home Health Care, told HHCN in July. “And CMS isn’t easing up on the [therapy] reassessment rule, which requires PTs, OTs or speech therapists to reassess the patient every 30 days.”

Despite the change, therapist assistants still won’t be able to make changes to a patient’s plan of care.

Home infusion therapy hasn’t been an area of focus for many home health providers, but that may change moving forward thanks to CMS’s final payment rule for 2020.

Specifically, Thursday’s final rule provides a permanent home infusion therapy benefit to be implemented beginning in 2021, as required by the 21st Century Cures Act. Home infusion therapy is the administration of certain types of medication, through durable medical equipment (DME) pumps, in the patient’s home.

Apart from advocacy organizations, home health technology partners have also started to weigh in on Thursday’s final rule. The list includes Texas-based software and technology company Axxess.

“After a year-long industry-advocacy drumbeat, we are encouraged that CMS listened … and reduced the onerous behavioral adjustment,” Deborah Hoyt, senior vice president of public policy for Axxess, told HHCN in an email. “While this impact was tempered, several of the other elements in the rule remain quite concerning to home health providers.”

Axxess will continue to work with home health stakeholders and members of Congress in the coming months to further refine PDGM, Hoyt said.

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