WARNING: Paradigm Shift Ahead

In light of the passage last Thursday by the Senate of S. 2553, the Improving Medicare Post-Acute Care Transformation Act of 2014, I thought I would re-share this post from July. 

If you are responsible for leading a post-acute/long-term care organization, I believe you should take note of two recent regulatory and legislative initiatives that provide a rather clear vision of where the post-acute/long-term care industry is headed – and it’s going to be disruptive to traditional thinking (if you want to survive).

ITEM 1: VBP in Home Healthcare
Earlier this week, CMS issued propose rule,
CMS-1611P, which proposed to update Medicare’s Home Health Prospective Payment System resulting in an over all 2.5% reduction in rates when consideration is given to rebasing adjustments and sequestration. Importantly, included with that rule was a solicitation of comments regarding a home healthcare value-based purchasing (HHVBP) model.

Section 3006(b)(1) of the Affordable Care Act directed the HHS Secretary to develop a plan for implementation of a HHVPB program for home health agencies and to issue an associated report to Congress. Key concepts of that report included building upon existing measurement tools and processes, the alignment with other Medicare programs and tying payment to performance.

As currently contemplated, beginning with CY 2016 in five to eight states participating in an initial demonstration, average Medicare payments would be increased or decreased in a rage of 5% to 8% based on quality performance as measured by both achievement and improvement across multiple quality measures. The belief is these incentives/disincentives would encourage better quality via improved planning, coordination, and management of care.


ITEM 2: Broad Spectrum Reform Targeted
Last week, leaders of the Senate Finance and House Ways and Means committees introduced bipartisan legislation (H.R. 4994, S. 2553) that would have the type of disruptive influence that Clayton Christiansen has researched and explained leads to
disruptive innovation. Being referred to as The Improving Medicare Post-Acute Care Transformation Act of 2014 (or, IMPACT Act of 2014), it would require data gathering and reporting standardization across different types of PA/LTC settings to facilitate better comparisons of quality and resource utilization among those settings and to improve hospital and post-acute care discharge planning.

The data collected and analyses completed would then be used to develop new payment system(s) that could be site-neutral and reflect various forms of bundling and/or at-risk capitation. Anticipated quality measures include functional status, skin integrity, medication reconciliation, major falls and patient preference. If enacted, SNFs, IRFs and LTACs would begin reporting some of these measures as early as October of 2016, with confidential feedback sent the following year and public reporting of the measures occurring in 2018.

Taken together, these two initiatives – even if neither is ultimately implemented – reflect the long anticipated but now swiftly emerging paradigm shift away from fee for service in the PA/LTC industry. They also reflect the migration toward a view of PA/LTC that encompasses the patient’s overall and entire experience after an acute care stay. Owning only a piece of the puzzle, without being able to seamlessly and economically integrate with healthcare providers holding the other pieces, will not represent a sustainable business model.

To reinforce this, simply look at the strategy of Kindred Healthcare. Writing in Forbes Magazine recently, colleague Howard Gleckman noted that,

“as recently as 2010, half of Kindred’s business was generated by its skilled nursing facilities. This year, only one-fifth of its revenues will come from its nursing and rehab centers. In a major strategic shift, Kindred is betting the company on in-home care, hospice, care management, and fully integrated care services.” [my emphasis added]

Ironically, PACE models – whose genesis dates back to the early 70s – are well ahead of the curve in successfully providing comprehensive, integrated services and care, though their positioning platform has primarily been a means of serving low income seniors. That road hasn’t been easy, as development and execution is fraught with financial, operational, clinical and regulatory challenges. But the overall long-term programmatic success demonstrates the value created from integrated care delivery under a fully capitated payment model (as in, see above).

So if you’re one of those individuals I referenced at the top of this post, what I would do if I were you is spend some time understanding the PACE model – and a crash course in organizational change management might not hurt either.

Cheers – and Happy Independence Day!!
  ~ Sparky



Healthcare Reform Depends on Home Healthcare

As shared in this space last week, the Council of State Home Care Associations recently completed a five-month project that was designed to gain a better understanding of how well home healthcare and hospice agencies are prepared for Healthcare Reform.  Artower Advisory Services published the summary findings and observations of that report hereNote that throughout this post I refer to, “home healthcare” without intending to be ignorant regarding the variation in terminology and services and care provided by agencies of different types (e.g., home care, skilled home health, private duty, hospice, etc.).

Now that the survey is over and results published, I wanted to take a moment and share some background behind my passion for working with and supporting the Council’s efforts and, more generally, the home healthcare industry.  In a nutshell, I believe that if the goals of Healthcare Reform are to be achieved, there are two areas where success will be most important: Wellness and Prevention – and Home & Community-Based Services.

The former because finite resources simply cannot afford to save people from themselves forever, and the latter because the age wave will require a more efficient and effective consolidation of services and care in non-institutional settings.  And, promisingly, I believe there are great opportunities where home and community-based services can be effective in promoting and facilitating wellness and prevention – across all age cohorts.

Shortly after the March 2010 passage of the Affordable Care Act I created a reference document that summarized and organized the various programmatic funding opportunities available to organizations both directly and indirectly involved with healthcare delivery.  What struck me at the time – and does to this day – was the number of instances where home healthcare was specifically identified as a potential recipient of funding pursuant to its role in helping to facilitate the intended benefit of such initiatives.

And what also struck me at the time was the hugely important role that home healthcare must play in the evolution of care delivery models under Healthcare Reform.  There are several compelling reasons in support of this belief.  There are also significant obstacles in the way of realizing the potential of these opportunities.  I will discuss each, in turn, below.

Compelling Reasons Underscoring the Importance of Home Healthcare

Policy Advancements
First, and perhaps most important, is the continued public policy advancement that is moving US healthcare delivery away from institutional settings to individuals’ homes.  Driven by a confluence of consumer preferences (i.e., especially of the Baby Boomer Generation), desire to reduce unsustainable capital costs and recognition of the
health benefits home-based care can offer, policy initiatives at both the state and federal levels have steadily been moving toward a redistribution of public funding toward home-based care, and this is certainly reinforced in the Affordable Care Act.

Valuable Positioning
Second is the existing knowledgebase that home healthcare providers possess.  They already have established business models, market intelligence, operational capabilities and the clinical acumen necessary to identify, plan and implement integrated care delivery models that bring services and care into the home.  This “ahead-of-the-curve” positioning can offer substantial advantages to home healthcare agencies as they seek to become  a valuable conduit between acute care providers and patients as part of integrated care delivery models.

Alignment with Community-Based Solutions
Third, they are quite naturally already community-based.  One of the most highly attractive programs thus far in the implementation of the Affordable Care Act has been the Community-Based Care Transitions Program.  While other healthcare provider types are in the community, home healthcare agencies very much are the community.  They are ideally situated to leverage the knowledge and awareness gained from caring for individuals in the very homes that are the foundational elements of those communities.

Ability to Transcend Care Delivery
Finally, taken together, private duty, home care, skilled home healthcare and hospice agencies represent a wider transcendence of individual service and care than any other provider type.  From providing the occasional, and as-needed, personal care services (i.e., assistance with various activities of daily living) to intensive, ‘round-the-clock medical care, home healthcare agencies are excellently positioned to facilitate holistic and integrated care delivery.

Industry Challenges

But as the ORASI© survey identified, there are substantial challenges that must be overcome if home healthcare agencies are to successfully take advantage of the opportunities presented.  Some of these challenges are within the purview of organizations to develop strategies for overcoming, while others represent exogenous considerations beyond their direct control.  Thus, to a significant degree, the latter represent important future public policy considerations that must be addressed if the desired benefits from home healthcare are to be realized.

Challenge: Fraud & Abuse
The home healthcare industry has been its own worst enemy for nearly a generation now.  The inability to self police perceptually damaging fraud and abuse has resulted in a giant target on the industry’s back that has been manifested in burdensome regulations, which have often appeared to be throwing the baby out with the bathwater.  Although widely accepted that the isolated actions of a few have resulted in broad brush castigation, perception is reality: and the reality is this is a daunting challenge the industry must address square on before it can hope to be strong participants in integrated care delivery models.

Challenge: Producing the Necessary Labor force
Home healthcare is quite obviously a very labor-intensive business.  Unfortunately, the dichotomy of projected future demand for caregivers and cost constraints holding down the ability to gain a competitive advantage through wage differential is likely to get worse before it gets better.  This phenomenon will likely be the greatest driver of industry consolidation in the near future.  Organizations that are better able to recruit, train and educate and then retain the highest quality caregiving staff will ultimately have success over competitors.

Challenge: Over Reliance on Technology
Not unique to home healthcare is the belief (hope) that technology – both care-oriented (e.g. supportive, remote monitoring,  tele-health) and information (e.g., electronic medical records, communication, operational functionality) will provide great opportunities to increase productivity and efficiency.  This is a belief that I fear will end up costing a lot of agencies their businesses.  While technology certainly offers great promise, successful agencies will recognize it for what it is: an enabler of people and processes.  If the requisite investments are not made in the latter two, expenditures on technology will only hasten the burden of financial unsustainability under Healthcare Reform.

Challenge: Non Home Healthcare Provider Acceptance
In order for home healthcare agencies to be effective participants in a world of integrated care delivery they must be able to partner with other healthcare providers in ways that add value to both those organizations – and, more importantly, their patients.  Healthcare in the US for far too long has been dominated by silos of care segmentation.  Getting different provider types to work together and across disciplines is going to require a tremendous amount of personal discomfort on the part of healthcare providers – and it is going to require a major leap of trust, particularly in the sharing of patient information.  For better or worse, the burden of building that trust rests largely on the home healthcare industry.

Policy Considerations

The home healthcare stands at the precipice of a tremendous opportunity to be the primary facilitator of innovation and the catalyst of sustainable change in how healthcare is delivered in the United States.  It is strategically better positioned than any other care provider type to embrace the underlying concepts of Healthcare Reform embodied in the Affordable Care Act.  It is also functionally and pragmatically better positioned than any other provider type to implement the several programmatic integrated care delivery initiatives of the Act.

But as identified above, the industry faces substantial challenges.  Without being able to make the requisite investments in infrastructure, knowledgebase, technology and – most importantly – caregivers, the industry will not be equipped to fulfill these expectations.  Thus, it is vital that future public policy recognize the importance of providing adequate funding necessary to develop the industry into the national care delivery network required for success.  Not only does the home healthcare industry’s success depend upon it – but the successful implementation of Healthcare Reform under the Affordable Care Act depends upon it.

  ~ Sparky


Pub Chat # 3 ~ Marcia Tetterton

This edition of Pub Chat coincides with the release of a new report published by Artower Advisory Services, which summarizes findings and observations from the recently completed Organizational Readiness Assessment Survey Instrument (ORASI©).  For more information, please click on the links below: 

   ORASI© Press Release         2012 ORASI© Summary Report

With the recent decision handed down by the Supreme Court regarding the constitutionality of the Patient Protection and Affordable Care Act, the probability has increased substantially that healthcare providers will have to implement significant changes in the way they do business. To assist providers of home healthcare and hospice in determining their organizational readiness for Healthcare Reform, the Council of State Home Care Associations commissioned the adaptation of an organizational readiness self-assessment survey developed by Artower Advisory Services for use by member agencies.

Over 940 participants from member agencies of 26 state associations took part in the survey during the period April 3, 2012 through July 3, 2012. The primary purpose of this effort was to help those agencies and the state associations to which they belong better understand the areas where attention, focus and training are necessary to help prepare home healthcare and hospice agencies be successful under Healthcare Reform.

You can listen to my interview with Marcia by clicking on Larry’s microphone, below:

~ Sparky



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