Home Health Stakeholders Voice Their Concerns To CMS Over Medicare Advantage Program

Home Health Care News | By Joyce Famakinwa
 
Home health stakeholders – and many others – recently had the opportunity to weigh in on the way Medicare Advantage (MA) is currently administered by the U.S. Centers for Medicare & Medicaid Services (CMS).
 
The National Association for Home Care & Hospice (NAHC) and Moving Health Home are among the two groups that answered CMS’ request for information.
 
In July, CMS released that request for information seeking public comment on the MA program. Comments were to be submitted by Aug. 31, 2022.
 
“The significance is that CMS is beginning to evaluate the plans more closely in terms of provider relations and approaches to health care delivery for enrollees and how the plans can improve health care services for these beneficiaries,” Mary Carr, vice president of regulatory affairs at NAHC, told Home Health Care News in an email.
 
Broadly, the comment period gave home health stakeholders the opportunity to affect potential future rulemaking on various aspects of the MA program. This is notable because Medicare Advantage enrollment continues to grow — having more than doubled over the last decade.
 
In fact, Medicare Advantage has 28.4 million beneficiaries, or 45% of the Medicare population. By 2030, Medicare Advantage is expected to have over 52% of total Medicare enrollment, according to data from the research and advocacy organization Better Medicare Alliance.
 
With enrollment on the rise, it’s likely that providers will become even more entangled with health plans offering Medicare Advantage. And as this happens, it’s the responsibility of providers and plans to work together, NAHC President William A. Dombi wrote in the organization’s comments to CMS.
 
“It is imperative that the [MA] plans and the provider community work together to ensure patient-centered, high quality health care is provided to all beneficiaries,” he said.
 
This comment period is also significant because it gives home health stakeholders the floor to share their point of view. In the past, providers have been vocal about the challenges surrounding MA.
 
Specifically, providers have struggled with receiving fair rates for the services they deliver. 

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House Passes Bill to Install Electronic Prior Authorization in Medicare Advantage Plans

Fierce Healthcare | By Robert King

 The House passed key legislation that creates an electronic prior authorization process for Medicare Advantage (MA) plans and other reforms aimed at a major headache for providers. 

The House unanimously passed the Improving Seniors’ Timely Access to Care Act on Wednesday via a voice vote. The legislation, which has new transparency requirements for MA plans, now heads to the Senate.

Lawmakers behind the legislation said in a joint statement the bill will “make it easier for seniors to get the care they need by cutting unnecessary red tape in the healthcare system,” said Reps. Suzan DelBene, D-Washington, Mike Kelly, R-Pennsylvania, Ami Bera, M.D., D-California, and Larry Bucshon, M.D., R-Indiana.

Prior authorization—where providers must first get insurer approval before performing certain services or making prescriptions—has increased in recent years much to the chagrin of providers who charge the process causes a massive administrative burden.

The House bill aims to require the establishment of an electronic prior authorization process for all MA plans to hasten the approval of requests. It would also require the Department of Health and Human Services (HHS) to create a process for faster, “real-time” decisions on the items or services that already get routinely approved.

Another new requirement is that MA plans must report to the federal government on how they use prior authorization, as well as the rate that such requests are approved and denied. The requirement comes as HHS’ watchdog found that MA plans have denied prior authorization claims for services that met Medicare’s coverage requirements.

The overwhelming House vote earned plaudits from several provider groups. 

“At a time when group practices face unprecedented workforce shortage challenges, 89% of [Medical Group Management Association] members report they do not have adequate staff to process the increasing number of prior authorizations from health insurers,” the Medical Group Management Association said in a statement. “By streamlining and standardizing the overly cumbersome and wildly inefficient MA prior authorization process, this legislation will return a focus to the physician-patient relationship.”

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Home Health Referrals Skyrocketed, Patients Became More Complex During Pandemic

Home Health Care News | By Patrick Filbin

As predicted by many at the onset of the pandemic, home health providers gained a larger share of post-acute referrals in recent years than they did prior to COVID-19.

At the same time, data shows that patients coming to post-acute care are sicker and have more complicated care needs than before, all while staffing shortages continue to put a strain on home health agencies.

A new report from the post-acute technology company WellSky shows that by May 2022, home health referrals were at 123% of what they were in 2019.

The COVID-19 emergency added value to, and demand for, home-based care delivery. The industry should expect that demand to stick.

“As you start to bring to bear science on the discharge dynamic, you will continue to see a growing number of patients moving into home-based care settings,” Tim Ashe, chief clinical officer at WellSky, told Home Health Care News. “Complex care plans can be safely delivered effectively and efficiently at home.”

Referrals staying near 123% of 2019 might not be a realistic expectation, Ashe said. But now that the industry is removed from the worst of the pandemic, there is still plenty of room for growth.

“I don’t know what the growth rates are going to be, but I personally anticipate continued growth,” Ashe said. “That’s going to take some investments in the infrastructure across the home health industry. How do we make sure the tide is rising so that all providers can provide care at scale to complex patients?”

One of those solutions could be the Choose Home Care Act of 2021, a piece of legislation that — among other things — supports in-home care alternatives to skilled nursing facilities (SNFs).

The bipartisan bill is currently in limbo in Washington D.C., but would be a vehicle of relief for SNFs and a boon for home health agencies.

That’s particularly relevant given the WellSky report also found that during the first quarter of 2022, referral rate rejection among home health referrals climbed to 71% due to a lack of staff.

“That’s a direct result of staff capacity,” Ashe said. “Those rejection rates are concerning. It goes back to enabling the industry to scale and incent professional and paraprofessional care providers to come into the industry because it is a really attractive space. We just need to solve some of those economic and potential safety issues that I think were highlighted during the pandemic.”

Even if home-based care demand rises, without the corresponding staff capacity, that demand could be all for naught.

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Given Regulatory Uncertainty, Hospital-At-Home Models Are Losing Momentum

Home Health Care News | By Andrew Donlan
 
The Centers for Medicare & Medicaid Services (CMS) gave health systems and providers the ability to take hospital at home as a concept and run with it during the public health emergency (PHE).
 
Those providers did so, and now they’re wondering what comes next. With regulatory uncertainty moving forward, the hospital-at-home momentum has been put on pause – but not because of patient preference or provider enthusiasm.
 
“There is over 250 hospitals and 100 health systems across 30-plus states that have now been granted CMS waivers,” Biofourmis CMO and co-founder Maulik Majmudar said on a Moving Health Home webinar Tuesday. “However, it is also clear that a sizable part of the country does not have any offerings today. And more importantly, the number of CMS waivers granted in the last few months has been on a decline.”
 
The Boston-based Biofourmis is a tech-enabled at-home care enabler. The startup recently reached unicorn status.
 
Indeed, there are plenty of hospitals that have been approved to provide hospital-level care in the home under the CMS waiver. But many have not begun to do so given the regulatory cliff they face. The Acute Hospital Care at Home waiver is tied to the PHE, which could be ending by the end of this year.
 
Some health systems have found other mechanisms to provide hospital-at-home care independent from the waiver. There is also introduced legislation that would extend the Acute Hospital Care at Home waiver by two years past the PHE. But nothing yet has been set in stone.
 
And thus leads to the halted momentum: only two hospitals in the country have treated more than 2,000 patients under the hospital-at-home waiver, according to Majmudar.
 
“The key point is that there’s a lot of opportunity and room for technology to drive both safe and effective deployment of these programs, but especially in a way that allows us to achieve scale,” he said.
 
The resulting hesitation from the regulatory holdup has spurned innovation, and also providers’ ability to learn from their mistakes on the fly as they scale.
 
At the same time, there are health systems – like Advocate Aurora Health, for example – that love the opportunity to provide this care in the home, but not exactly as its allowed right now under the waiver.
 
“We certainly support the continuation of the waiver,” Dawn Doe, the VP of value-based programs and continuing health at Advocate Aurora Health, also said on the webinar. “But we ask for more flexibility on the structure, and the entities that can provide the program, for us as an integrated health system.”
 
For instance, as currently constituted, the waiver makes it so Advocate Aurora Health is forced to have its 27 hospitals all have different hospital-at-home programs.
 
That, Doe said, just doesn’t make sense for Advocate Aurora based on how it’s structured.
 
“We would like to see reimbursement models that really provide patients the ability to stay in their home while avoiding expensive institutional care,” Doe said. “And that the waivers for telehealth and remote monitoring reimbursement be made permanent. This not only improves patient outcomes, but will also address the strain on staffing resources.”

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