How Value-Based Care Could Change a Hospice Organization’s Culture

Hospice News | By Jim Parker

A transition to value-based reimbursement would fundamentally change the traditional hospice business model. It could also wield a powerful influence on an organization’s culture.

Hospices are inching ever closer to the value-based arena. To date, much of this has centered around diversified programs like palliative care, PACE and other services.

However, the ongoing value-based insurance design model (VBID) demonstration and some Accountable Care Organization (ACO) relationships are giving providers a taste of how at-risk reimbursement may affect their core hospice business.

But the impact on culture will largely depend on the providers’ leadership, according to Dr. Sachin Jain, CEO of SCAN Group.

“There are some really positive changes that are attached to a value-based care organizational model,” Jain told Hospice News. “There are also some potential negative changes that can take place, and that’s where I think leadership ends up being really important because you can take the same set of facts and interpret it really differently.”

The SCAN Group is the parent company of SCAN Health Plan, a $4.3 billion nonprofit Medicare Advantage (MA) organization that covers more than 285,000 members across California, Arizona, Nevada and Texas.

‘Capitation is freedom’

To create a positive culture in a value-based environment, corporate leaders need to keep their eyes on the long-term, big picture while making “doing the right thing for patients” their top priority and guiding principle, Jain said.

If leaders maintain this kind of mindset, a capitated payment model can create opportunities to do more to preserve patients’ health or improve their quality of life, he indicated. For example, a provider or health plan could purchase a refrigerator for a patient to store their insulin, which would fall outside the scope of a traditional fee-for-service model.

 “Capitation is freedom. It’s the freedom to do the things to really keep patients healthy over the long haul. Without the right leadership, it can become an invitation to cut corners,” Jain said. “Value-based care is neither good nor bad. It is a way of paying for things, and then it is up to enlightened leaders to make it good — leaders who think long term and who choose as much as possible to be pro-patient and not necessarily pro-profit.” 

A vast range of payment and care delivery systems can fall under the designation “value-based care.” For many hospices, the best pathways to those payment models are through additional upstream services.

Inroads to value-based reimbursement

Thus far, the biggest step into value-based care has come with VBID. Through a component of this model, the U.S. Center for Medicare & Medicaid Innovation is currently testing coverage of hospice care through Medicare Advantage. 

Often called the Medicare Advantage hospice carve-in, CMS recently extended the payment demonstration through 2030, with plans to allow some types of concurrent curative care during its later years. Participating providers must also offer palliative care to remain in the program.

Though it remains to be seen whether the VBID model will become permanent in the long run, hospices can expect value-based payment systems to become more prevalent as time goes on.

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The Current State of the Caregiver Crisis

McKnights Home Care | By Lance A. Slatton

As caregiving providers and stakeholders, we are well aware of the increasing challenges we face due to the ongoing caregiver crisis. Following the pandemic, we’ve witnessed a sharp increase in terms of the need for care and a decrease in the number of caregivers available. Whether that be due to financial strain, a struggling economy, or otherwise, one thing is for sure: the crisis isn’t going anywhere anytime soon.   

Looking ahead, the caregiver crisis is likely to intensify unless significant measures are taken to address the root causes. Currently, nearly 1 in every 5 Americans who provide care are going unpaid. With inflation on the rise, even those that are fortunate enough to be able to take on unpaid care positions may not be able to do so for much longer.

What we know for sure is that increased demand is to be expected. The aging population will continue to grow, resulting in an even higher demand for caregiving services. It is essential to prepare for this surge in demand by developing innovative solutions to bridge the gap between available resources and the needs of the elderly.

We might also anticipate an impact on the quality of care being provided. With the ongoing caregiver shortages and increased workload for those that are employed, there is an inherent risk of compromised quality of care. Overworked caregivers may find it challenging to provide personalized attention to each individual, which in turn can affect those receiving this vital care.

We’re also likely to witness an unprecedented strain on the healthcare system. The caregiver crisis is gearing up to have ripple effects on the broader healthcare system. Overwhelmed caregiving companies may struggle to collaborate effectively with healthcare institutions, leading to disruptions in patient care and potential strain on hospital resources.

What does the data show?

• A recent survey from Survival Coalition found that 62% of people needing care are concerned that they won’t be able to stay in their own homes or live independently. People around the country are feeling the anxiety and fear that comes along with this crisis.
• Research conducted by BCG shows that the United States could face a potential GDP loss of $290 billion in the year 2030 and beyond in the care economy if no improvements are made. This impact is sure to be felt by not only those in the caregiving space but the loved ones around them and future generations as well.
• The number of unfilled care jobs is sitting at 1.8 million, with numbers expected to rise rapidly.

Financial implications for caregiving companies

The caregiver crisis not only affects the well-being of individuals in need of care but also poses financial challenges for caregiving companies.

The constant need to recruit and train new caregivers due to high turnover rates can be financially burdensome for caregiving providers. These costs can significantly impact the company’s bottom line.

To meet the increasing demands, caregivers are regularly required to work overtime, leading to additional costs for companies. Furthermore, the risk of caregiver burnout can increase the likelihood of sick leaves and decreased productivity. This vicious cycle can cause an end result of turnover as well.

Finally, the inability to maintain a consistent and skilled caregiving staff can lead to a decline in client satisfaction and revenue. Reputation and trust are vital in the caregiving industry, and these frustrating caregiver shortages can severely impact a company’s reputation.

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OSHA Finalizes Injury and Illness Log Submission Requirements

NAHC

The Occupational Safety and Health Administration (OSHA) issued a final rule that amends its occupational injury and illness recordkeeping regulation to require certain employers to electronically submit injury and illness information to OSHA that employers are already required to keep under the recordkeeping regulation.

Specifically, OSHA finalized the requirement for establishments with 100 or more employees in certain designated industries to electronically submit information from their OSHA Forms 300, 301, and 300A to OSHA once a year. Establishments with 20 or more employees in certain industries would continue to be required to electronically submit information from their OSHA Form 300A annual summary to OSHA once a year.

OSHA proposed to remove the requirement for establishments with 250 or more employees, not in a designated industry, to electronically submit information from their Form 300A to OSHA on an annual basis. However, based on public comments expressing concern over the proposal, OSHA is retaining the requirement for establishments with 250 or more employees to also submit the Form 300A -Summary of Work-Related Injuries and Illnesses, electronically to OSHA once a year.

OSHA finalized its intent to post the data from the annual electronic submission requirement on a public website after identifying and removing information that reasonably identifies individuals directly.

OSHA has developed a list (Appendix A) of Industries that will be required to continue to electronically submit Form 300A annually if they have 20 or more employees. The second, new, list (Appendix B) includes the industries that OSHA requires submission of Forms 300, 301, and 300A annually if they have 100 or more employees.

Neither home health nor hospice agencies are on the lists and therefore are not included in the OSHA form submission requirements for establishments with less than 250 employees. Because OSHA finalized that all establishments with 250 or more employees must electronically submit Form 300A, large home health and hospice organizations will be required to comply with this requirement.

This final rule becomes effective on January 1, 2024.

Judge Orders State to Provide Private Duty Nursing Care

Shared with permission from Elizabeth E. Hogue, Esq.

July 14, 2023, a Judge issued an opinion and order, in which he said that the State of Florida must provide services, including private duty nursing care, to medically fragile children who are living in nursing homes or threatened with institutionalization so that they can live at home [United States of America v. State of Florida, Case No. 12-cv-60460-MIDDLEBROOKS/Hunt, (U.S. District Court for the Southern District of Florida, July 14, 2023)]. This court decision is based on violations of the Americans with Disabilities Act (ADA) and Olmstead v. A.C. ex rel. Zimring [527 U.S. 581 (1999)], a decision of the U.S. Supreme Court. This decision is important for home care providers because, as a result, a significant number of additional children may receive private duty nursing care at home. Similar cases are pending in other states.

The children at issue in this case are under twenty-one years old and have disabilities resulting in their need for services on a daily basis. The children frequently qualify for Medicaid and require help with activities of daily living. Necessary services often include the use of technology or equipment for communication, mobility, breathing, eating, and other tasks along with the use and maintenance of feeding tubes, breathing tubes, ventilators, and wheelchairs.

Children who are institutionalized spend months and sometimes years isolated from family and the outside world. In this case, one hundred forty children were living in nursing homes already and approximately one thousand eight hundred children were threatened with institutionalization.

The Court said:

“They don’t need to be there. I am convinced of this after listening to the evidence, hearing from the experts and touring one of these facilities myself. If provided adequate services, most of these children could thrive in their own homes, nurtured by their own families.”

Then the Court said:

“Several Medicaid services were put at issue, but there is little question that the shortfalls in meeting the need for private duty nursing (or “PDN”) was at the heart of this case – the subject was addressed by nearly every witness who took the stand. The lack of access to PDN was by far the most glaring and critical problem facing families with medically complex children. Most families are receiving nowhere near the number of hours they require…By the close of the evidence, I was convinced that the deficit of PDN in Florida is causing systemic institutionalization.”

The Court then acknowledged that the problem of the lack of adequate PDN services is likely based on staffing shortages. However, the Court refused to accept lack of staffing as a reason to not provide the services children need. The Court noted that many private duty staff members are paid $14.00 per hour on average nationally. The Court observed that increasing wages may result in appropriate availability of staff members. Regardless of the cause, however, the Court was clear that the Medicaid Program must meet the needs of children for private duty care at home in order to prevent unnecessary or threatened institutionalization.

Courts in other states are likely to issue decisions similar to this one. This means that private duty agencies must prepare for an influx of clients/patients. In fact, private duty agencies should take the initiative to partner with state Medicaid Programs to meet the needs of an increasing number of children for private duty services at home. 

The Judge quoted Nelson Mandela in the Conclusion of his opinion:

“There can be no keener revelation of a society’s soul than the way in which it treats its children.”

We can only say, “Amen!”