The NAHC Strategic Planning Congress: Setting an Agenda for Action
By Lisa Yarkony
“We’re all a product of decisions we make in our life,” NAHC President Val J. Halamandaris recently told attendees at the NAHC Strategic Planning Congress. “The fact that you have taken the time away from your business to be here says it all. You’re making an investment in the future. You’re making an investment in NAHC and all your patients, especially the 78 million baby boomers who are going to need home care and hospice. Without us they’re not going to get what they want,” he warned. “So I commend you for choosing to be here,” he told a group made up of NAHC’s board of directors and heads of its Forum of State Associations, along with key leaders of home care and hospice.
These attendees had more choices to make in two productive days at the Boca Raton Resort and Club, a splendid hotel on the Florida beach. They were there to engage in strategic planning sessions in seven areas of home care and hospice: advocacy/PR, private duty, workforce, technology, hospice, Medicare home health, and Medicaid home health. Their agenda was to give their field a unified vision, imbue it with a fresh sense of mission, and chart a course ahead. All three are needed because life’s no beach right now for home care and hospice. The industry faces new rules and laws that pose problems for both providers and patients. “We’re being besieged on all sides,” said Michele Quirolo, president and CEO of VNA of Hudson Valley. “Unless we take time to get together and come up with an action plan, our industry will suffer. This is a good time to connect with people in all aspects of home care and hospice.”
Her colleagues agreed as they chatted about what had brought them to the meeting. “It’s very important for a wide variety of people to give their thoughts on our strategic direction,” said Mary Suther, president of Suther’s Solutions. “Getting perceptions from all different fields in the industry assures we’re responding to the needs of people we serve,” said Elaine Stephens, executive vice president of Home Care & Hospice at Masonic Health System. “This is an opportunity to contribute to the success of the industry,” according to Karen Thomas, president of Oxford Healthcare. “We have to have the best strategy to survive, and the only way we can achieve our goals is to make a plan we can share with providers at home,” said Kim Gaffey, president and CEO of Gaffey Home Nursing & Hospice. And the congress was the place to do it, added Craig Mandeville, CEO of Forcura. “This is the key event for key leaders in home care and hospice. It’s a great way to find ways to improve your company.”
And now is the time to think about better ways to serve customers, attendees pointed out. “Strategic planning is especially important this year because of all the changes that affect the industry,” said Pat Drea, vice president of Visiting Angels. “Changes are happening, and it’s smart to collaborate with our peers on how we want to handle them,” noted Kim King, COO of Home Care Network. As health care reform goes on, “the important thing is ensuring home care is at the table in ACOs and transitions-in-care work,” said Maggie Short, administrator for University of Virginia Health System. “Reimbursement is important because it’s important to our clients,” noted Rob Goodsell, VP at Home Healthcare Solutions. And declining payment does pose a threat to the field. Yet “home care will never go away. People will not let it go away,” maintained Jeneane Brian, chief clinical officer at Allscripts. “We have to figure out how to have good-quality models that make home care more affordable, efficient, and safe.”
That was among the goals of the congress, said Lucy Andrews, CEO of At your Service Home Care. “We need to come away with a unified plan that addresses the onslaught against home care so we can engage with our members.” And to succeed at it, “you need the most current information,” Quirolo explained. “I don’t want to read a 500-page bill, so I’m glad NAHC does such a good job of synthesizing what’s coming out of Washington, DC. The bottom line is you need to be informed. Coming to a conference like this is the easiest and best way to do it.”
But attendees were being called on to do more than listen, Halamandaris pointed out in a call to action. “What I’m promising you,” he said, “is that at the end of this conference, there will be action. When that action takes place, you will be invited to ensure all of us make commitments. We need you to contribute your ideas and motivate us so we stay on track with our plans.” And it will be easier to do if we know what we can expect from our nation’s leaders. “So I’m trying to read people’s minds. What is the Obama administration about when it comes to Medicare? What is their plan for home health care?” It’s important to know where the other side’s going when they’re pushing for changes that aren’t in our interest, he told the group. “Once we establish that we can make a plan that will lead to the growth of home care and hospice.”
To establish where DC is going, Halamandaris convened an expert panel of NAHC staff: Jeff Kincheloe, vice president for government affairs; Bill Dombi, vice president for law; Theresa Forster, vice president for hospice; Mary Carr, vice president for regulatory affairs; and Richard Brennan, vice president for technology policy. The panel discussed possible Medicare cuts, the implementation of health care reform, proposed home health copayments, proposals to pay for the SGR, face-to-face requirements, Medicaid, the employer mandate — and especially what’s on our lawmakers’ minds.
The consensus was that Congress is torn between saving home care and saving taxpayers’ cash. “The good news,” Kincheloe said, “is that there are members of Congress who see home and community-based care at the center of health care reform, so there are opportunities out there. The bad news is that lawmakers are eager to cut spending to Medicare fee-for-service providers,” like many of those in the room. “This is wonderful Washington,” Dombi said tongue in cheek. “They all tell you how much they love the home health benefit, but they don’t want to give it the support it ultimately needs. Entitlement is a dirty word in Washington today. It goes hand in hand with budget deficits. But advocates for home care are in a stronger position than those who want to do it damage. We can derail a lot of those things that are intended to do nothing more than spend less money,” Dombi pointed out.
“The administration is really trying to manage its expenditures,” Forster agreed. “While there’s great promise in some of the models that have come out, like ACOs and bundled payments, many people perceive the end form of these models to be somewhere down the road. And the greatest issue is that we see much greater control of costs, but we don’t see much in the way of managing care, the whole goal of improving the health care system. Instead, what we are seeing is more of an insurance-based model where they’re negotiating contracts and trying to keep costs down, which is not always the best way to go.” Nor is the way they’re trying to end the traditional carve-out of hospice from Medicare Advantage. “Now MedPAC is seeking to make hospice part of the managed care package, and this is a real threat. We have to be on the offensive so patients continue to have choices and hospices keep providing all the services needed at end of life.”
And we have to stay on the offensive since managed care is not going away under health care reform. “The major programs in the ACA are all about trying to reduce costs,” Brennan said. “The problem is the downward pressure you all are feeling from payment reductions will affect your ability to invest and take advantage of innovations that will redefine the way health care is delivered. We need to use advanced technologies like telehealth and EHRs to be strong players. So you’re at a difficult place where you need to leverage use of your resources and also experiment with new models of care.” Health care reform depends on it despite all the roadblocks government puts in home care’s way. This leads to a confusing contradiction, Brennan pointed out, because “the new models of care cannot function without home care.”
And home care will find it harder to function if Congress acts on the president’s proposal to put in copays for Medicare home health. “The president’s proposal is probably the most reasonable of the ones that are out there,” Kincheloe said, “but it’s still egregious. It would be $100 for an episode beginning in the community if it hasn’t been preceded by a hospital or community stay. It would begin in 2017 and would apply to new Medicare beneficiaries who become eligible that year and beyond. If they go for that, our fear is they might choose to eliminate restrictions like implementation date. And of course we think it’s absolutely goofy to have to put someone in a hospital before you can give them home care.”
This attack on the home health benefit, Dombi said, “makes us feel like we’re under siege,” as does the recent rule to rebase home health by 14 percent over the next four years. The reason for the rule, Dombi explained, “is we’ve been too successful. The way MedPAC measures success is through profit margins, and their view is our profit margins are too high.” But what does too high mean in the commission’s view? “If you were to ask MedPAC commissioners what is too high, they would say anything above zero,” Dombi laughed. “They truly don’t understand what it takes to run a business. They rarely put their feet on the ground to understand that you have to make payroll, let alone invest in new technologies. Moreover, MedPAC doesn’t take into account all the accumulated cuts over the years. Somehow home care agencies manage to cope with payment reductions, so they’re testing you to see how far you can go before you break. The image of fraud and abuse is also an excuse to cut rates and make new rules. So we’ve given some constructive proposals to Congress and CMS for saving funds through value-based purchasing.”
Will they listen? CMS probably won’t, Carr scoffed as she recalled the constant complaints she’d heard about CMS. “Face-to-face is on top,” she said, “because of all the denials related to the rule. And this is a symptom of a much bigger problem. CMS is really scrambling about how to handle fraud and abuse. They’re using a lot of patchwork mechanisms, including 16 contractors who are doing medical reviews and tripping over one another. But face-to-face gets all the attention, and the only thing I can advise those of you who are out there working hard is to take it one day at a time.” And keep your eyes open, she advised. “We don’t know what they’re going to drop on us next.”
But one thing is clear, Dombi added. “Face-to face is an administrative burden beyond any administrative burden. It benefits the bad guys and burdens the good guys. But CMS has pretty much turned a deaf ear on this. We have a state of confusion about what acceptable documentation is, but CMS is absolutely convinced this rule is working because spending is down on home health. And spending is down not just in those areas they thought were risky. It’s down in all parts of the country. So it’s time to complain, and the complaints need to come from physicians. We’ve got to get the physicians to complain to their members of Congress, as well as to CMS. And maybe it’s time for us to file a lawsuit on the face-to-face encounter. We need to stand up for ourselves once again, even if there are risks involved. Sometimes you have to get punched in the face.”
But it’s not as perilous as it might appear, explained Stan Brand, NAHC’s general counsel and former chief counsel to the House of Representatives. “When Bill started talking about lawsuits,” he said, “my adrenaline started pumping. I’ve made a living out of suing the feds. But when I come to a group of caregivers like this, people who are by definition soft, there is a big gap between that and why you would sue the government. So I just want to give you a little perspective and explain to you that there is a rationale. However you may think of the government as a citizen, it’s a different matter when you come before federal court. You go to the White House and Congress as supplicants. You go to federal court as someone with inalienable rights, and a lot of funny things happen. When the government is behind its bureaucratic barricade, it can pretty much tell you the moon is made of green cheese and get away with it. But when it comes into federal court before an independent-minded judge, it can’t get away with that stuff. The government gets defensive. The government stumbles. The government bumbles — and things happen. Granted, the government is an 800-pound gorilla with tons of resources, but federal court is a great leveler. It’s a place where there’s nowhere to hide,” and it may be the best venue for softhearted caregivers — now that it’s time to get tough. “Our hearts are here because of what you all have done,” Brand said, “but we’ll be using our heads on this one.”
We’ll need both head and heart to answer the needs of another 800-pound gorilla. “That’s the baby boom generation,” as Halamandaris explained. “We could be talking about all kinds of things. But the 78 million baby boomers who are going to need home care and hospice trump everything else. So it would be something if we could connect with them, along with the 41 million seniors who are now on Medicare, and the 12 million people who are disabled. If we could become the spokesperson for these groups, we would speak for something in the neighborhood of 131 million people.” And what does it take to speak for them before Capitol Hill? “Washington runs on money, respect, and noise,” Halamandaris observed. “We have more respect than anyone, especially among the many who have experienced hospice. We can make noise, and we’re raising funds through the Home Care & Hospice PAC, thanks to Bill Simione, founding chairman of the Home Care & Hospice Financial Managers Association. I think we have what it takes to get through the current morass without serious damage.”
That’s especially true if the industry has a concrete plan. “So we want to know the issues we should be focusing on today and tomorrow,” Dombi told the group. “We want to know your goals relative to these issues. And we want to know your strategies and tactics to achieve these goals. As you think about all this, take resources into account, and remember, we’re not just looking for a strategic plan for NAHC. We’re looking for broader strategies for the industry at large,” he said as attendees split into separate groups. After putting their heads together for some time, the groups gave their thoughts on charting the course ahead.
Like many other industries, home care needs to go electronic, Brennan said for the technology group. “We need to use technology to demonstrate our value equation: how we have great outcomes and reduce hospitalizations. We need to come up with common measures that can be captured and shared. Our value is in how we use data to prove our case to other partners like ACOs and medical homes. Though they’re larger than home care, they can’t exist without it, so let’s figure out where we fit in these models of care. We need to understand where the new revenue sources are and how we can use technology to help keep the Medicare home health program intact.”
At the same time, “we need to align our industry with the health care redesign going on,” said Lisa Harvey-McPherson. She spoke for the Medicare group on how to equip agencies for the current landscape in health care. “We need to restructure to participate in new health care models,” she said, “and we need to prepare our clinicians to respond to them, too. We need to move away from seeing ourselves as post-acute providers and see ourselves as a population-based delivery model. We have to make CMS account for their contractors’ actions and continue to fight rebasing so agencies can get reimbursement that’s fair.”
Money issues, among other things, were also on the minds of the hospice group. “We’re concerned about staying financially viable under hospice payment reform, so we support a demonstration project first on payment reform,” said Tom Moreland for the hospice group. “We also reject the idea of including hospice in Medicare Advantage, but if it happens, there should be a way to opt out and maintain patient choice. Our goal is for everything to stay the same for hospice patients under Medicare Advantage, and we want to be at the table when decisions are made about Medicare Part D for patients enrolled in hospice.”
The increasing number of patients enrolling in Medicaid under health care reform led the Medicaid group to express a number of thoughts. “The biggest change we see is from fee-for-service to managed care,” said Bob LeBeau. “So we need federal reform that allows us to successfully migrate to managed care, and we need a more cooperative way of working with payors. At present, we have no data sets whatsoever on Medicaid, so we must work as an industry on identifying them. And we need to have service provision standards that include adequate access to care. Most states think Medicaid reimbursement is adequate — even though it is not.”
In general, raising prices for consumers is not an answer, noted the private duty group. “This makes it important to recruit an adequate pool of caregivers,” Pat Drea pointed out. “If the price gets too high, consumers will go to the underground economy. So our goals are to have more caregivers, allowing us to keep giving affordable care; establish training initiatives supported by community resources; and provide employees with career ladders to foster retention. Keeping employees is essential, along with addressing a number of regulatory and environmental issues: the employer mandate, the companionship exemption, and the threat of unionization.” Answers to these issues include obtaining the voice of the disabled community to oppose the companionship exemption, diversifying program models, and expanding the number of caregiver assignments to hold down costs, Drea explained. “We also have a responsibility to communicate with caregivers who will be deeply affected by this and working multiple jobs.”
In addition, it’s important to tell clients what’s going on in agencies and why. Changes in reimbursement affect the quality of care, Jeannie Stoker pointed out for the workforce group. “We need higher reimbursement to pay a fair wage, so we need to educate consumers about the costs of high-quality care in the home. Barring higher reimbursement, we can do a better job of giving caregivers nonfinancial incentives to keep them on. We have to show them how much we appreciate them and how much consumers appreciate what they do. Looking ahead, we need to have a strategy for professional staffing since there’s going to be a serious nursing shortage in 2020. Ways to attract tomorrow’s nurses include encouraging nursing students to intern with home care agencies and partnering with other people to provide better training. We have to rebrand ourselves and send the message that home care is about people.”
Rebranding was also very much on the minds of the advocacy/PR group. “We should adopt a two-prong strategy,” Karen Thompson said for the group. “It will consist of public relations and the Home Care & Hospice PAC. We need to start a campaign about our value and broadcast a single message: This is health care at home. And to bring our message home on Capitol Hill, we need a well-funded PAC. Our goal should be to raise $100,000 by June 1, 2014, and we could use Skype presentations at state association meetings to make appeals for support. We could ask each state association for $2,000, which would get us to $100,000. And agencies that give this amount will be recognized as diamond PAC members.”
Having a well-funded PAC and broadcasting a compelling message should put across the most important point of all: home is the best place to give people the health care they need. That’s the industry’s vision and the congress was a valuable step toward making it come true, Halamandaris acknowledged as he thanked attendees for their efforts. They had set an agenda for action both today and tomorrow — one that spoke to both patients and providers. But their work had only begun, as Halamandaris pointed out. “Now we have to let the world know we’re not going to be passive. We have to make it happen.”
About the Author: Lisa Yarkony, PhD, is the managing editor of CARING Magazine. She has expertise in health systems both past and present. She can be reached at email@example.com.