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News Roundup: August 14, 2015

ACA's Home Care Pilot Shows Strong Results Out the Gate

Published by California Healthline
By Heather Drost
August 14, 2015

This bipartisan bill will help coordinate care and lower costs for Medicare beneficiaries with multiple debilitating diseases, including Alzheimer's, ALS, congestive heart failure, diabetes and other chronic conditions." -- Rep. Edward Markey (D-Mass.), May 2009.

That bill -- called the Independence at Home Act -- aimed to provide primary care services to Medicare beneficiaries with chronic illnesses in their home setting. At-home care was not a revolutionary idea in 2009, but it had faded into the background in the U.S.

"[Home care] is a 100-year-old or more health care delivery model that grew in this country and then for various reasons became less well known, as things moved to an institution and office-based setting," Gary Swartz, associate executive director at American Academy of Home Care Medicine, said.

Home care advocates have long championed the financial and health benefits of treating elderly patients with chronic illnesses in their homes, rather than having them come to a medical office. The Independence at Home Act was quickly supported by several health care groups -- including AARP, the National Family Caregivers Association and the Visiting Nurse Associations of America -- as a way to reduce health care spending and improve the quality of care.

The bill eventually was added as a provision to the Affordable Care Act legislation and enacted in 2010 by President Obama. In 2012, the Independence at Home Demonstration project launched at 17 medical practices serving more than 8,400 Medicare beneficiaries.

High-Cost Beneficiaries

According to the International Business Times, the demonstration project addresses what some ACA critics have said is a missing component of the law, "an effort to rein in costs."

A USA Today analysis of Medicare data shows more than 94% of the $324 billion spent on traditional Medicare was spent on beneficiaries ages 65 and older with two or more chronic illnesses. The 2012 data show that about 15% of beneficiaries -- more than four million people -- have at least six chronic conditions and account for more than 41% of Medicare spending.

Meanwhile, CMS actuaries expect about 19.1 million additional people to enroll in Medicare over the next 11 years, spurring an increase in health care spending. For example, the latest projections from CMS estimate that health spending growth will rise to an average of 6.2% annually between 2019 and 2024, while Medicare spending is projected to increase to an average of 7.9% over the same period. The report attributes the growth in part to population aging as more baby boomers become eligible for the program.

Further, the health of seniors seems to be worsening over time, according to the USA Today analysis. The number of U.S. counties where 75% of senior Medicare beneficiaries have multiple chronic illnesses has risen by 20% since 2008.

Swartz, whose organization has worked closely with CMS on the demonstration project, said, "House calls will become even more important as the Medicare population is on an accelerated growth curve," and the number of beneficiaries with comorbidities is rising.

How Health Care at Home Can Help

Advocates, including the bill sponsors, have pointed to successful home health care programs across the U.S. that have contributed to reductions in expenditures for high-cost patients, such as those in:

New York;
Richmond, Va.;
San Diego; and
Washington, D.C.

In addition, the pilot project was modeled after the Department of Veterans Affairs' Home-Based Primary Care program, which has been operating since 1972. The program, which provides comprehensive services in the home to veterans with high-cost chronic illnesses, has long been cited as an efficient and effective way to lower costs, reduce hospitalizations and improve care quality. Through the program, care teams -- made up of doctors, nurses, pharmacists, psychologists, rehabilitative therapists and social workers -- coordinate patient treatments, visiting a patient an average of three times per month.

A 2012 analysis by the American Action Forum showed the program resulted in a 24% reduction in health care costs and a 69% reduction in hospital inpatient days. The analysis stated, "Because patients with complex chronic conditions served by Medicare as well as those dually eligible for Medicaid and Medicare have similar care needs to the VA's HBPC enrollees, it raises the possibility that the use of an HBPC-modeled program could similarly reduce hospital and nursing home stays within entitlement programs."

The pilot program is putting that hypothesis under the microscope by testing the effectiveness of providing comprehensive primary care to costly, high-risk seniors who have limited mobility and have been diagnosed with at least two chronic illnesses. The program's 17 participants include several major hospitals, such as:

Boston Medical Center;
Cleveland Clinic Home Care Services;
North Shore Long Island Jewish Health Care System; and
Visiting Physicians Association in Florida, Michigan, Texas and Wisconsin.

Keith Lind, a senior strategic policy adviser at AARP's Public Policy Institute, noted that qualifying providers already have established house call delivery programs. The demonstration project requires them to perform home visits and report on quality metrics and patient satisfaction, and they receive no federal grants upfront. Those who meet certain quality standards and savings receive a share of government savings.

Under the program, practices must meet minimum savings requirements, which are calculated based on practice size, to be eligible to share in the savings. The first 5% of savings are allocated to Medicare and the remainder are shared with CMS based on quality performance. The percentage of savings the provider would receive as an incentive payment is determined by the number of quality measures it achieves.

The Independence at Home demonstration project by design is all risk to the practices and zero risk to Medicare and taxpayers, which is great for country, Swartz said. He noted that the 5% savings requirement for CMS "is unique among the ACA Innovation Center programs."

Preliminary Results Are In

After three years, CMS released the first round of data from the demonstration program, revealing total savings of more than $25 million in the first performance year, with CMS receiving $13.3 million and practices receiving $11.7 million.

CMS said the project saved an average of $3,070 per beneficiary. Of the 17 programs, 12 generated savings and nine met first-year spending targets, which made them eligible to receive bonus payments. The payments ranged from about $275,000 to about $2.9 million.

Data from the American Academy of Home Care Medicine show that 1.5 million Americans would be eligible for the program if it were implemented at the national level, generating $4.5 billion in savings annually.

Future Expansions?

The promising start prompted Congress to approve (SB 971) a two-year extension of the project, which Obama signed into law July 30.
Swartz said his organization is pushing to expand the program to become a permanent Medicare benefit. He said, "We learned you can build it, staff it, organize it and deliver care in this model. It is doable and replicable" at the national level.

Lind also praised the initial results and favors expanding the program. However, he noted that the sustainability of the program will be clearer after the results for year two and three are released.

However, he expressed some reservations about the program's restrictive criteria, noting, "[The participating practices] could be doing a lot more for people and have a bigger impact" if they didn't have to meet the program's strict savings targets.

Reinventing Home Health

Published by Health Affairs Blog
By John Marchica
August 14, 2015

Accountable care is finally coming to home health.

The Centers for Medicare and Medicaid Services (CMS) is launching a value-based reimbursement (VBR) pilot program for Medicare home health care agencies. The model is part of the 2016 Home Health Prospective Payment System proposed rule, which was published in the Federal Register on July 10.

In the current reality of home health care, if you are a home health provider and not part of a hospital or health system, your world looks something like this:

A hospital discharge planner (your customer) chooses which agency will care for the homebound patient (also your customer).
CMS (another customer) dictates how much you get paid and has recently decided to pay you less every year.
You itemize every last thing you do and spend hours learning coding techniques to maximize how much you get reimbursed.
And by the way, you have a hard time finding people to work for you at a wage where you can be profitable.
Home health care sounds like a miserable business to be in. And if there ever was a golden age for home care, it certainly became a more challenging endeavor after CMS set its sights on value-based payments. Everything about the home health business is fee-for-service, which is bad news if CMS is writing the checks.

Through accountable care organizations (ACOs) and other Innovation Center initiatives, CMS’s goal is to transition from fee-for-service to performance-based compensation, and eventually, to full capitation like Medicare Advantage. Administrators and policymakers see the aging baby boomer population and want certainty about their ballooning budgets.

Yet CMS didn’t go out of its way to include home health in its immediate plans for health reform (other than to slash reimbursement rates). Why? I believe that by cutting rates and moving to value-based reimbursement, CMS is signaling to the market that the agency wants the “mom and pop” providers out of the business.

I also believe that CMS is telling the industry: innovate or die. Figure out a way to change how you do business that fulfills the Triple Aim.

How Value-Based Reimbursement Works
For the recently announced VBR initiative, CMS will increase or decrease the amount reimbursed for services depending on quality performance. Payment adjustments will start at 5 percent and increase to 8 percent in later years. According to the proposed rule, the goals of the incentive program are to improve the patient experience and quality of care and to weed out poorly performing home health agencies.

Medicare-certified home health agencies are already required by CMS to have an outside firm survey the patients they care for through the Home Health Care Consumer Assessment (HHCCA) and to submit other quality data through the Outcome and Assessment Information Set (OASIS). In the proposed rule, CMS suggests 25 quality measures for performance assessment, all of which are currently reported to CMS. The agency has also suggested four new metrics, which include reporting adverse drug events, whether the patient has been vaccinated for shingles (herpes zoster), whether the patient has an advanced care plan or has named a surrogate decision maker, and whether home health care workers have had a flu vaccine.

Nine states were randomly selected to be part of the pilot program; the proposed states are Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, and Washington. CMS is receiving comments on the proposed rule until September 4, 2015.

The Future Of Home Health: Bleak Or Bright?
Industry insiders knew that VBR payment reform was coming, as the Affordable Care Act directs CMS to develop a plan to implement value-based purchasing. I’ve also been encouraging home health agencies for some time to partner with ACOs and become part of the value stream. Yet beyond dabbling in a handful of bundled payment experiments, few home health care companies have made an effort to be part of the discussion about value-based care. Not a single one has taken the lead.

One reason for their reticence is an issue of comfort: like most other established businesses, they resist change. Another, perhaps less emotional reason, is the way that CMS issued its final rule on ACOs. Home health providers can be part of a Medicare ACO at its inception as long as a physician group or hospital is the primary owner. Beyond that, any other arrangement by another Medicare provider or supplier must be approved at the discretion of the Secretary.

Further, since agreements and contracts must be executed before an ACO submits its application, it isn’t clear whether that new agreement would be allowed at the beginning of a new performance period.

What the VBR initiative means for home health agencies is clear and is part of CMS’ stated objectives: weaker providers without the technology and other means to keep costs in line and quality under control will go out of business. There are more than 12,000 Medicare-certified home health agencies today. Perhaps less than half will survive in the form we know it by 2018, with the fastest decline in pilot states.

Innovations In Home Care
Some providers are looking beyond traditional service models and expanding their services to enhance the patient experience, improve the quality of care, and lower costs.

Hospice of Michigan last year expanded its At Home Support program to partner with Ohio-based Western Reserve, after a pilot showed a 34 percent cost reduction—about $3,400/month—by reducing hospitalization, re-hospitalizations, and emergency room (ER) utilization.
Moorestown, New Jersey-based BAYADA Home Health Care has launched a physician house call service that it expects will enhance the continuum of care offerings the company already provides. The company made news with a substantial technology investment in April 2013, when it equipped 4,000 caregivers with Samsung Galaxy tablets. BAYADA says it improved patient care, allowed for faster reimbursement, and reduced after-hours paperwork.
CMS recently announced results from the first performance year of its Independence at Home project, calling the demonstration “positive and promising.” Evaluators found that participants saved over $25 million — on average, about $3,070 per beneficiary. CMS said all 17 participating practices improved quality in at least three of six quality measures and four practices improved quality on all six. One of the program participants, the Visiting Physicians Association, netted $7.8 million in practice incentive payments out of the $11.7 million bonus that CMS paid out.
Reinventing Home Health Care
As an industry, I used to think that home health care needed to rebrand itself. It could sure use a fresh coat of paint, I would say. It needed a new marketing strategy, one that went beyond having armies of fresh college grads make sales calls to doctors and discharge planners.

I was wrong. Home health care doesn’t need rebranding. A fresh logo and an awareness campaign won’t solve the problem that all home care companies face: how care will be delivered and paid for in the future is completely at odds with how they do business today. Home health isn’t the only health care sector with this problem right now, but it may have the most to lose. The industry needs a turnaround, a reinvention of what its role is to be in a post-ACA environment.

In my view, the successful home health enterprise of the future will resemble companies like the Visiting Physicians Association, but will offer much more. They will employ primary care physicians and nurse practitioners that make house calls, as well as licensed in-home caregivers, from skilled nursing to Private Duty care. They will offer full-service coordination of post-acute care and will manage challenging populations with chronic, co-morbid conditions. They will integrate telemedicine by caring for patients in novel ways. They will deploy preventive technologies that keep patients safe and out of the hospital. They may even provide ancillary services like in-home diagnostic testing, prescription management, and clinical lab services.

A thriving home health provider will align with ACOs, hospitals, and health systems for bundled services and risk-based contracts based on patient type. And they will be fully accountable for the quality of care delivered and will put their payment at risk if quality suffers.

There is no “best way” to solve the difficult business problems that home health is facing. The mid-tier and large home health companies are all very different in the services they offer, strengths and weaknesses, leadership, vision, and culture.

But the one common problem—how to operate in a VBR environment—is something all home health care agencies should address right away. Industry executives must develop a sense of urgency to find the opportunities that drive their enterprises forward, and not remain stuck in the past.

Telehealth Technology Trending in Alternate Settings

Published by mHealth Intelligence
By Vera Gruessner
August 14, 2015

Telehealth technology adoption is experiencing a surge across the healthcare industry as more states continue to develop regulations that would provide coverage for doctors participating in telemedicine. In fact, telehealth technology can be utilized in a variety of fields from psychiatric care and cardiology to pediatrics or primary care.

As previously reported by, children with special needs could greatly benefit from the increased use of telehealth technology. With access to certain specialists lacking in rural areas and some parents unable to provide sufficient transportation for their children, it proves more necessary to incorporate telehealth technology in efforts to improve pediatric care.

Telehealth Technology Adoption
James Marcin, MD, MPH, Medical Director of Pediatric Telemedicine at UC Davis Children’s Hospital, spoke with to offer his perspective on telemedicine in the pediatric field. “In what ways do you see telehealth technology benefiting the pediatric field in particular?”

James Marcin: “Telehealth is a way to address access barriers currently that are primarily related to patients living in underserved and rural communities. First of all, there’s lots of ways it can be used in pediatric healthcare. The biggest use of it is allowing kids that need to see otherwise regionalized specialists that are typically located in urban hubs gain access to those specialists much more easily in their own communities.”

“It also can be used in acute care settings where a child might be in an emergency department and needs pediatric specialists at her or his bedside. It can be used in hospitals and from a child’s home such as kids with special healthcare needs.”

“Those that are fragile and connected to medical technology such as ventilators, telehealth allows providers to see them while they’re at home, which is a huge advantage to the child and to the family. In a lot of ways, it can help bring providers to the patient as opposed to the other way around, which is often a barrier for kids with special healthcare needs.” “What are some of the biggest trends you’ve seen in telemedicine and other technologies used for pediatric care?”

James Marcin: “The most common use has been for outpatient specialty access. That’s still the bread-and-butter of pediatric telemedicine. In terms of more recent trends of the past few years, getting access to pediatric specialists, allied health professionals, and therapists in alternate settings – in schools, in day cares, or even when the patient is at home.”

“Those are more recent trends. It’s not only true for kids with special healthcare needs, but other children, adults, and the elderly as well. The idea of being able to provide this service to the patient in a more convenient location is an emerging trend.” “Have you noticed an increase in family use of mobile apps and smartphones for monitoring their children’s health? What are some of the most popular apps?”

James Marcin: “Patient and family use of mobile applications or video-conferencing like Skype are definitely increasing. Oftentimes they can be disease-specific. Children with diabetes, for example, are networking among each other – even on Facebook. There are disease-specific apps and forums for kids with similar conditions to meet with other kids. Certainly, there is a rise.”

“I won’t comment on the most common apps because I think there are different ones based on age groups. For babies, it’s not the patient participating but their mothers and fathers. They use a variety of technologies to be able to connect such as blogging. I think it’s definitely increasing. The demand for direct-to-patient applications is increasing so that patients and families are able to access their regular healthcare provider on the computer or an iPad.” “What advice would you offer to a healthcare provider who’s having difficulty adopting and implementing telehealth technology?”

James Marcin: “Telehealth is increasing and a lot of it is being driven by consumer demand or patient demand. For the providers who are skeptics, they need to realize that patients and consumers are more demanding so it’s incumbent on them to listen to their patients’ concerns and desires.”

“In addition to that advice, these technologies can be implemented or leveraged in good ways that are beneficial for patient care – especially those that pediatricians refer to as the medical home concept. I think that we can use these technologies to maintain and even enhance the medical home if primary care providers are kept in the loop and there is well-coordinated care.”

“But the technologies can also be disruptive to that model of care. If a patient goes into a WalMart kiosk, swipes their credit card, and talks to a provider on MDLive in an emergency. Then these remote technologies are disrupting the medical home.”

“Not only do the providers need to realize that consumers are wanting this type of service and are willing to pay for it, but if it’s not done in a smart way, it can be counterproductive such as when patients are calling on different web-based applications and getting different uncoordinated treatments from different doctors. This is actually harmful for patient care.”