Post-acute care is the process of enabling functional recovery, following an acute or inpatient admission. Many settings can be used to support post-acute care, including skilled nursing and rehabilitation facilities, but often, the most preferred setting for care is the home.
Older Americans, with Original Medicare and increasingly Medicare Advantage health insurance coverage, represent the lion’s share of patients seeking post-acute care. While their preferences for recovery at home are clear, there are barriers to fully enabling the home, despite data that suggests the home can be a more efficient and higher quality site of care for recovery that also improves total cost of care, including costly re-admissions and inappropriate emergency room utilization.
At ViVE 2024, Panelists Share Prior Authorization Progress and Frustration in Payer Insights Program
At the Payer Insights sessions on Day 1 of ViVE 2024, a panel on prior authorization offered compelling insights from speakers who shared the positive developments in this area after years of mounting frustration. Speakers also shared challenges as they work with providers to figure out how policy developments and technology will work in practice.
So why then, has post-acute care, particularly the use of skilled home health, lagged consumer preferences, especially the wishes of senior Americans? The answer is complex, but there are several factors working against this goal.
Though skilled home health has been around for decades, labor pressures, especially following the pandemic, continue to rise, and nursing shortages remain at an all-time high. Quite simply put, there is not enough skilled labor to support the demand for home health. Because many home health agencies are understaffed, they are unable to take on as many patient referrals. This leads to longer wait times for placements, leaving the discharging care providers to conduct multiple referrals until they can find an agency that can take a patient.
For Medicare Advantage members, access is even more complicated by reimbursement issues. Today, Traditional Medicare is generally a better payer for skilled home health services compared to Medicare Advantage plans, which are private plans offered by health insurance companies as an alternative to Traditional Medicare. Medicare Advantage plans often include low-cost to no-cost premiums, with additional supplemental benefits such as vision, dental and health care allowances. These disparities in reimbursement are a conundrum the industry must solve, as Medicare Advantage enrollment and market penetration is at an all-time high of 48% and expected to go as high as 60% by 2032. The industry must do better to ensure that these Americans do not slip through the cracks and can be offered similar level of access and service as traditional Medicare beneficiaries.
The accelerated expansion of value-based reimbursement solutions to post-acute care is a significant opportunity to reduce disparities in payment between Traditional Medicare and Medicare Advantage members and offer more meaningful solutions for increasing MA access to home health care. By rewarding providers for reducing total cost of care and sharing savings from lower readmissions and inappropriate ER utilization, the industry can take meaningful strides to not only drive better alignment for performance but reduce disparities in access to home health for Medicare Advantage members.
When Investment Rhymes with Canada
Canada has a proud history of achievement in the areas of science and technology, and the field of biomanufacturing and life sciences is no exception.
The path to get there, however, will take work as the home health care provider landscape is fragmented. While several large national home health agencies exist to help serve certain markets, an enormous amount of regional and local agencies are also required, making the process of building value-based networks laborious.
The evolution of new tools and technology to better support how we deliver home health care and support agency success in value-based arrangements will also be important. Enabling home health care providers, particularly given the labor pressures they face will be paramount, and tools that help refine our understanding of patient needs, simplify documentation, and reduce administrative paperwork will be key. For example, two patients with similar home health needs, but with different comorbidities, caregiver, or socioeconomic needs, may require a different number of home health care visits and extra care coordination support to ensure they recover successfully in the home, such as assistance with appointment setting to ensure they have a ride back to their provider’s office for a follow-up visit.
The ability to predict a patient’s potential for an adverse outcome and to monitor their risk and health needs throughout their home health care episode, and in the period immediately following the conclusion of their home health episode, is also essential. Data collected from discharge notes, start of care assessments, progress notes, along with remote monitoring devices and historical patient health data can all be harnessed more effectively to help us better understand member needs, treatment plans and risks.
Advancements in AI will also significantly boost stakeholders’ efforts across the industry and improve the way post-acute care is delivered. Imagine a world where large amounts of data can be summarized in near real-time to derive insights that could influence and inform more personalized treatment plans and recommendations for patients, such as referrals to hospice and palliative care, or to care coordinators to help patients obtain nutritious meals needed to bolster their recovery. Improving our understanding of a patient’s needs not only offers opportunity to improve care, outcomes, and patient satisfaction, but also allows the industry to better staff and plan for the care that is needed, ensuring that precious resources are optimized and deployed in the most effective manner.
While all these challenges may feel insurmountable, there is tremendous momentum already underway in the industry to tackle many of these problems. Collaboration across key stakeholders, including home health agencies, providers, patients, health plans, and post-acute care solution providers will be critical to fully enabling the home as a preferred place of care, and for ensuring that all seniors, including Medicare Advantage beneficiaries, can utilize home for their recovery and health care.
Photo: Dusan Stankovic, Getty Images
Brian Lobley brings over 20 years of experience leading healthcare businesses, operations, and strategy. Prior to joining tango, he served as the executive vice president, chief operating officer, and president of Health Markets at Independence Health Group, the parent company of Independence Blue Cross, LLC. He was responsible for leading Commercial, Consumer, and Medicare lines of business and the company’s group pharmacy business and Operations, Business Technology Services, Informatics, and Innovation departments. He provided oversight for the company’s subsidiaries: AmeriHealth New Jersey, and AmeriHealth Administrators.
This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.
