Healthcare at Home: The Rowan Report

by Roger McManus, MBA, and co-author with Tim Rowan of Entrepreneurial Insanity in the Home Care Business (Amazon)

While the grandeur of the Gaylord Resort in Grapevine, Texas may be on the awe-inspiring side of kitsch, attending a trade show there can either be the high point of your business year or an expensive waste of time. While this caveat is certainly true for next week’s annual National Association for Home Care and Hospice Conference and Expo, it applies to every state or national association meeting you attend.

I know what I am talking about. Over the past 30 years, I have attended many dozens of trade shows, personally produced nearly 40 of them, and exhibited at many more. Perhaps the most frustrating thing I have observed, regardless of industry sector, is attendees’ wasting learning opportunities that are laid out before them, especially in the exhibit hall.[McManus provides a good overview about the the wealth of options at typical trade shows that distract attendees from valuable uses of their time. He instead urges attendees/readers to focus on meeting new contacts and notes other essential tasks of attendees/entrepreneurs, such as, finding information to motivate you; finding ideas with which to conduct marketing research; undertaking both pure and accidental education; and, last but not least–enjoy yourself!]

About the Author
Roger McManus is the co-author with Tim Rowan of Entrepreneurial Insanity in the Home Care Business (Amazon) directed at home health and home care agency owners who are trapped as the hub of their business wheel. The book can be ordered at www.RogerMcManus.com. Roger can be contacted at mail@rogermcmanus.com.

©2018 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only.editor@homecaretechreport.com

These are the recently released findings from a study of four years of CMS data analyzed by KPMG, a global audit, tax, and advisory firm, and VieMed (TSX:VMD), a leading provider of post-acute home respiratory services, which commissioned the report.

“The evidence is clear,” said VieMed’s CEO Casey Hoyt. “Using a non-invasive ventilator at home coupled with a high-touch home care model saves lives, saves money, and keeps patients out of the hospital. It is time for both medical practice and health insurers, including Medicare, to catch up with changes in technology. Since the introduction of modern, highly sophisticated home ventilators within the last decade, NIV has become the gold standard for treating patients in the late stages of COPD.”

The KPMG study, “CRF/COPD 4-year CMS Data Comparison of Mortality & Cost, (2013-2016),” examined the costs and benefits of various respiratory assistive devices physicians commonly prescribe for patients suffering from COPD with CRF. A chief finding was that patients using NIV at home with a high-touch care model have the lowest overall costs and hospitalization rates. A high-touch care model includes multiple home visits by a certified respiratory therapist, 24-hour access to medical professionals, and enhanced coordination with physicians and other clinicians.

COPD is a chronic condition that affects as many as 24 million Americans and is the country’s third-leading cause of death, after cancer and congestive heart failure. Treating patients diagnosed with this progressive, chronic condition also costs the country more than $30 billion a year. The KPMG study offers compelling evidence that both outcomes and costs can be improved through home NIV with a high-touch care model.

Outcome and Cost Improvements

Specifically, the study examined results of untreated patients who used no respiratory device at home, patients using a bi-level positive airway pressure device (BPAP), and patients using a NIV. The study looked at mortality, the number of times patients were hospitalized and the total cost of caring for patients in each group.

The analysis found that patients using a BPAP or NIV lived longer than untreated patients. For example, only 22 percent of COPD patients with CRF using NIV died, compared to 38 percent of untreated patients. Although there was little difference in the overall death rates between patients using a BPAP or NIV, there were significant differences in the cost of treating these patients and hospitalization rates.

For example, over a six-month period:

• Patients with no ventilation support cost CMS $41,000
• Patients using a BPAP cost $39,000
• Patients using NIV coupled with a high-touch care model cost $29,000
• 25 percent of untreated patients were admitted to a hospital
• 26 percent of patients using a BPAP were admitted to a hospital
• Less than 20 percent of patients using NIV and receiving high-touch care model were admitted to the hospital

“The KPMG study is one of the most important studies of this issue to date,” said VieMed Chief Medical Officer and pulmonologist William Frazier, MD. “It should help physicians and others make informed decisions about the best approach to treating patients suffering from COPD.”

About VieMed Healthcare Inc.

VieMed, through its indirect, wholly-owned subsidiaries Sleep Management, L.L.C., and Home Sleep Delivered, L.L.C., is a home medical equipment supplier that provides post-acute respiratory care services in the United States. Sleep Management, L.L.C. focuses on disease management and improving the quality of life for respiratory patients through clinical excellence, education, and technology. Its service offerings are based on effective home treatment with Respiratory Therapists providing therapy and counseling to patients in their homes using cutting edge technology. Home Sleep Delivered focuses on providing in-home sleep testing for sleep apnea sufferers.
viemed.com and homesleepdelivered.comhomesleepdelivered.com.

©2018 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

Kevin Shaw, Ph.D, showed us a prototype of a wearable monitor that sends a continuous flow of vital signs – including heart rate, respiration, temperature, dressing, eating, ambulating, washing, resting, gait quality issues, falling and stumbling – to a home care office dashboard and to the smart phones of the patient’s family members. What sets the “ADLcare”™ monitor apart is that it is about the size of a half-dollar coin and sticks to the skin with a strip of tape that can only be described as magical. Anyone who has ever ripped off a bandage knows the problem of body hair painfully ripped with it. Dr. Shaw placed one on this reporter’s arm. It held securely until he pulled it off. No pain, no lost hair. AI is based in the Silicon Valley and will soon go into general release. AlgorithmicIntuition.com

FRAX

Bruce Berglind’s New Jersey home care agency achieved stellar patient outcomes after he began to call them regularly on the phone. Soon, nearby agencies asked him to call their patients too. Before he knew it, that business was larger than his home care business. So he sold the home care, moved to the Midwest, and staffed a call center. Today, FRAX serves home care providers from coast to coast, and all of them are seeing patient care improve. fraxoutsourcing.com

True Link Financial

No, these people do not want to loan you money, they want to eliminate the headache of petty cash management, reimbursement forms, and caregiver spending tracking. The True Link Card is a reloadable debit card that can have cash back and ATM withdrawals blocked. Give it to your homemaker care team and let them purchase patient groceries or medications while limiting the stores where the card will work. Dashboard reports show you when and where the card was used, how much was spent, and when funds should be added back to it. Spending can be tracked by caregiver and by patient. truelinkcard.com

Paradigm Claim Services

Maintaining a billing department is right for some agencies and wrong for others. Paradigm is for the latter group. They have relationships with every insurance company and make sure every claim is accurate before submitting it. This reduces the cost of denials and retries. They also have negotiated with most insurance companies to arrange to use one claim form, their own, rather than having to adjust their software to adapt to the uniqueness of each plan’s form. paradigm-claims.com

Homes Renewed

Did you know that there may soon be financial incentives for customizing a home to make it safer and more friendly as the homeowner ages, enabling seniors to remain in their homes longer? There is a lobbying effort in place to get laws passed that would help seniors pay for remodeling updates such as curbless showers, no-step entries, grab bars, better lighting, and much more. Proposals would extend to discounts for home products that have received the “Purple Tag” designation.

Louis Tenenbaum, founder and president of HomesRenewed, told us that builders, remodelers, and product manufacturers have formed a coalition to approach lawmakers. They are looking for more members, “visionaries” they call them, for the “Homes Renewed Coalition.” Current tasks are to support HR1780, a bill for a $30,000 tax credit, and a companion bill in the Senate to create next-generation incentives; to support state and local home update initiatives; to work for private sector incentives from health and long-term care insurers, modeled after reduced insurance premiums for non-smokers and safe drivers; and to champion tax and penalty-free use of retirement savings as incentives for home updates. The coalition’s goals are to make IRA and other retirement savings exempt from early-withdrawal penalties and taxes; reduce insurance premiums; and establish product rebates.

Tanenbaum said, “It is fundamentally unjust to continue medical miracles that add years to our lives without also updating homes to live those lives joyfully and with dignity.” He cited a 2014 study by the Harvard Joint Center for Housing Studies whose authors stated, “The bulk of long term care will occur in single family, owner occupied homes…but the homes are not prepared.” Get more information and join the coalition at: homesrenewed.org

In the Know

Caregiver recruitment and retention are constant battles. The statistics are bleak.

• Average turnover is 66% and rising
• 81% of caregivers with no training quit within the first 90 days of employment
• Only 16% of caregivers say they feel “connected and engaged” by their employers

“In the Know Caregiver Training” says it is one of your available weapons for this battle. With the motto “Train, Engage, Retain” the online education company offers a 10-point checklist you can use to choose your training company.

1. Does the catalog include a wide range of relevant topics?
2. Is a “blended learning” plan available?
3. Does the price reflect the quality?
4. Are topics developed by industry experts?
5. Are the courses presented in an engaging manner?
6. Do topics satisfy state and federal requirements?
7. Are topics kept up to date?
8. Does the company have a singular focus — with caregiver education as the only priority?
9. Are extra value add-ons available, relevant, and useful?
10. Can the provider promise excellent, ongoing customer care, even after the contract is signed?

Of course, In the Know asserts that they can answer ‘yes’ to all of these. Still, they recommend using this checklist with any training company you use. knowingmore.com

Retinent

Speaking of recruiting and retaining, perhaps the most innovative companies we discovered is one that helps you automate your incentive program. When one employee recruits a colleague to take a position with your company, you may want to offer the first person a reward. Keeping track of this program does not have to be resource intensive. Retinent software automatically adds your spiff, let’s say an extra .25 per hour, to the wages of the referring employee. If employee #2 recruits someone, you can set the software to add .25 to his hourly wage and perhaps .05 to the wage of employee #1, and so it goes. One early adopter found that his private duty agency retention rate increased from 47% to 72%. retinent.com

©2018 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

New York, NY — Medicare Fall Open Enrollment occurs from October 15 to December 7 of every year and is the time of year when people with Medicare can make unrestricted changes to their coverage options. To assist the press in their Medicare coverage, the Medicare Rights Center has developed Medicare Fall Open Enrollment: A Resource for Journalists, Fall 2018, which includes a list of upcoming changes, expert advice, and related issues of interest to people with Medicare. Also included are consumer-friendly resources that can be shared with readers.

The Medicare Rights Center, a national nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities, expects that journalists will find the resource helpful as they prepare coverage for this year’s Medicare enrollment season.[Included in this news release are a few notable updates for 2019, such as: 1.  Part B Premium remains  unchanged in 2019;  2) Part D  Medicare costs in 2019 will vary as follows:In 2019, Medicare beneficiaries will have a 75% discount on the cost of their brand name drugs during the coverage gap (also known as the doughnut hole). The discount for generics during the doughnut hole will increase from 56% to 63%. 3) The New Medicare Advantage (MA) Open Enrollment and Disenrollment Period begins in 2019 , while the Medicare Advantage Disenrollment Period (MADP) will be replaced with a MA open enrollment and disenrollment period that lasts from January 1 through March 31 each year. [A handful of other updates are also noted in this news release.  It is also noted that Part B premiums remain unchanged; Part D costs in 2019 will remain relatively stable; andBeginning in 2019, the Medicare Advantage Disenrollment Period (MADP) will be replaced with a MA open enrollment and disenrollment period that lasts from January 1 through March 31 each year.]

A few notable updates for 2019 include the following:

• Part B Premium Remains Unchanged
  Medicare Trustees predict that in 2019, the standard Medicare Part B premium will not increase and thus will remain at $134 per month.

• Part D Costs in 2019 The average Medicare prescription drug plan premium is projected to remain stable in 2019 at about $32.50 per month, down from $33.50 in 2018. In 2019, Medicare beneficiaries will have a 75% discount on the cost of their brand name drugs during the coverage gap (also known as the doughnut hole). The discount for generics during the doughnut hole will increase from 56% to 63%.
• The New Medicare Advantage (MA) Open Enrollment and Disenrollment Period
  Beginning in 2019, the Medicare Advantage Disenrollment Period (MADP) will be replaced with a MA open enrollment and disenrollment period that lasts from January 1 through March 31 each year.
• Specific notes are made about MA changes needed to be made by certain “special” enrollees during 2019 and it is advised that the complete Medicare Fall Open Enrollment: A Resource for Journalists be consulted which is s available on the Medicare Rights Center’s website at: https://www.medicarerights.org/pdf/fall-open-enrollment-resource-for-journalists.pdf.]

During this time, people with MA may make the following changes one time:

• Switch between MA plans
• Or, switch to Original Medicare with or without Part D

A change made during the MA open enrollment and disenrollment period is effective on the first of the following month.

• Changes to the Special Enrollment Period for People with Extra Help
  In 2019, individuals enrolled in the Low Income Subsidy (LIS), also known as Extra Help, are limited to changing their Part D plan once per calendar quarter in the first three quarters of each year.

  Any changes made during this special enrollment period are effective on the first of the following month. People with LIS may use the Fall Open Enrollment period during fourth quarter to make changes to their coverage, with changes effective January 1.

The complete Medicare Fall Open Enrollment: A Resource for Journalists is available on the Medicare Rights Center’s website at: https://www.medicarerights.org/pdf/fall-open-enrollment-resource-for-journalists.pdf.

A consumer version of this resource is also available on Medicare Interactive. Developed by the Medicare Rights Center, Medicare Interactive (MI) is a free and independent online reference tool thoughtfully designed to help older adults and people with disabilities navigate the complex world of health insurance.

©2018 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only.editor@homecaretechreport.com

At this week’s Annual Leadership Conference of the Home Care Association of America, the usual lineup of keynote addresses and breakout sessions filled a packed, two-day schedule, followed by an assault on Capitol Hill on day three. What conference organizers will remember most is that they did not schedule a classroom large enough for a breakout titled, “The New Medicare Advantage Benefits: What it Could Mean for your Agency.”[Rowan details the  lack of room space to accommodate all conference attendees to this breakout session. Instead. 2 conference attendees  –consultants Anne Tomlinson and Ginny Kenyon–gave the overflow crowd of Private Duty Home Care executives a thorough background and history of the federal Medicare Advantage program and followed with detail about what they can expect over the next two years. Though their briefing was based on what limited information CMS has released so far, the session gave the audience some valuable marching orders. Here are some areas covered by the consultants: 1. A provision in the Bipartisan Budget Act of 2018  that was changed by Congress opened the door for insurers who participate in Medicare Advantage to cover certain non-medical services for their members. Effects that are expected to be embraced by insurers of MA participants are noted in this article. 2)Rowan noted that, while many operating in healthcare at home look forward with great anticipation to MA opening the doors for insurers to cover clients with non-medical needs, he indicates  that some in the industry are moving with caution as they raise questions about who and what exactly will be covered.  3)  Rowan offers tips on Where To Begin? A good deal of the questions at the break-out session concerned providers as well as clients, taking in questions they raised, such as “How much benefit should we provide?” and “How do we describe and market our less familiar services, such as adult day care?” The consultants suggested forming partnerships with physician groups and setting up and undertaking meetings with CFOs of MA groups.]

Changed by Congress

A provision in the Bipartisan Budget Act of 2018 opened the door for insurers who participate in Medicare Advantage to cover certain non-medical services for their members. Approximately one-third of Medicare beneficiaries have opted for Medicare Advantage over straight Medicare or Medicare with a commercial supplement so far.

Final rules will be published in December but only minor changes are expected for calendar year 2019 with full implementation to arrive in 2020. According to Ginny Kenyon:

• Where existing rules require so-called “Supplemental Benefits” to be health related, the new rule will allow MA plans to reimburse for many quasi-medical services commonly provided by private duty agencies. Examples include medication management, disease prevention measures, and treatment of common illnesses. What is not included are “comfort” or “social” services such as companionship, shopping, house cleaning, etc.
• Under the “benefit uniformity rule,” MA plans are required to offer the same benefits to all plan members. The new rule allows plans to target benefits to groups of enrollees who have certain clinical diagnoses.

Less Than Universal Glee

While most non-medical providers cannot wait for the MA doors to open next year, there are a few observers and agency owners approaching the new rule with caution. We spoke with Bob Roth, founder and Managing Partner of Cypress Home Care in Phoenix. “I’m feeling positive about offering these services to our clients and patients who are enrolled in Medicare Advantage,” he told us, “but I’m waiting to see what hoops CMS might be requiring us to jump through. What certifications will they want? What kinds of claims? Will our software have to undergo major changes?”

Roth’s concerns were echoed by the software vendors we spoke with at the HCAOA conference. Friendly competitors Geoff Nudd, CEO of ClearCare, and Todd Allen, CEO of AxisCare, said they are ready to begin to work on adding MA claims capability to their products but cannot begin until specific guidance is released by CMS. Even after that guidance appears, however, these MA plans are still private insurance companies that can create their own forms and set their own claims procedures. There is no requirement on the horizon that will demand uniformity among them.

That concern led us to another HCAOA exhibitor that might be effective in the middle, between providers and MA plans. Paradigm Claim Services takes over the tedious paperwork for home care agencies, often acting as their entire billing department. Chief Customer Officer John Corrigan told us about one of the advantages of using his service. “In addition to reducing denials by making sure claims are clean and accurate before being submitted, we have gained some clout with payers,” Corrigan said. “We convinced their legal teams to allow us to submit claims on our forms instead of having to adapt to every insurer’s unique form. They wouldn’t do that for any one individual provider. And we think we will be able to get the same concession from MA plans when the time comes.”

CMS has concerns as well, Ann Tomlinson told the gathering. When the Act was signed into law, regulators queried Congress about limited Medicare dollars being diverted to cover increased spending by MA plans. This arises, she explained, from the way MA plans are funded. “Each plan bids for business, every year, based on a benchmark monthly premium specific to each county. But those benchmarks are then risk-adjusted. So they may only be paid 70 percent of the benchmark for their healthy 65-year old members but as much as 2.8 times the benchmark for an 89-year old with several co-morbidities.”

Where to Begin?

Questions from the packed room revealed provider concerns as well. “How do we figure out who is eligible?” “How much benefit should we provide?” “How do we describe and market our less familiar services, such as adult day care?”

The two consultants did offer some recommendations to home care providers, keeping in mind that MA plans care first about their enrollment numbers and only secondarily about actual healthcare spending.

• Form partnerships with physician groups and other providers. Approach MA plans with those partners to demonstrate you belong to an effective care network.
• Insurers are looking for operationalized programs, not ideas for possible futures. Talk with them about your patient outcomes and your operations.
• If you are small, use your size to your advantage. Don’t try to “beat” the national franchisor, offer to be the backup for their overflow.
  • (This point was confirmed by John Aurelio, president of Kindred at Home’s south central region. “You are exactly right,” he offered, raising his hand from the back of the room. “Even with our tight relationship with Humana, we can’t handle every patient.”)
• Demonstrate your ability to support good relationships between insurers and enrollees; maybe your selling point is that you can help them retain enrollees, their primary concern.
• Bring peer-reviewed studies to the MA conversation; they will be skeptical of your own data but will believe peer reviewed literature on programs like yours. Cite the studies that indicate the need for long-term supplemental services is associated with a high rate of hospital admissions.
• Yes, getting a meeting with an MA CFO — the one who will resonate with your claim that you can save them money by keeping their members out of the hospital — is not an easy task. So start with those where you may already have a Medicaid contract.
• Walk in to the meeting with a one-page data sheet that show how you could work with them to decrease their costs and improve their outcomes and generate higher client satisfaction.
• Prepare for the fact that you may be informing this MA CFO for the first time of the new law. Even the ones who are aware of the law often say it is too late to make changes for 2019.
• Know which diagnoses cost them the most and what each hospitalization costs them. (You may first need to get this information from the plan’s CFO.)
• Remember, you are a partner, not a vendor. You are there to help make it all work for your shared patients. You can increase their star rating, which may increase their CMS payment.
• If they offer you a reimbursement rate lower than your costs, be prepared to walk away. You cannot make it up in volume.
• Start to prepare now but be patient. The full benefit of this new law will not be seen until January of 2020.
• Once you have a contract, train your home care aides to recognize problems and get in the habit of reporting them. Be sure to track changes in readmission rates before and after you enter the partnership. Use that data to continue to market your services.

©2018 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reprouction by permission only. editor@homecaretechreport.com