As the president and CEO of Androscoggin Home Healthcare + Hospice in Maine, a state that has seen some of the highest Medicare Advantage (MA) penetration rates in the country, Ken Albert has had to learn what it takes to be successful working with managed care partners.

Scheduling clear rate-negotiation timelines with payers is critical. So too is a provider’s ability to demonstrate value in the form of its ability to lower health care costs and improve outcomes for a given payer’s members.

In this Future in Focus interview, Home Health Care News sits down with Albert to learn more about his company’s approach to payer strategy. During the conversation, Albert also discusses how AI is disrupting the home-based care space and shares his policy “musts” for the rest of 2023.

To start, I’ll ask you to look back over the past few years to the very beginning of 2020. From then until now, how would you describe the overall progress home-based care has seen in the U.S. – and what are some of the best examples of that advancement?

I think there are three real dominant areas. Through the pandemic, the relevance and the integral nature of home-based care became clear. Primary care offices were essentially closed. The acute care system was in turmoil. We obviously saw a spike in the discharge rate to home health for very good reason.

That experience, I think, demonstrated to the health care sector broadly the ability for home health organizations to maintain individuals in their home and help to keep those patients out of the hospitals. That, of course, allowed for more capacity for COVID patients.

Since 2020, we’ve seen evolving unification of the industry, in general, around important political and policy concerns. That’s evidenced by the Preserving Access to Home Health legislation in 2022 and 2023. There’s recent litigation against CMS, which was a year in the making. That all required extensive collaboration throughout the industry.

The same was and is occurring in the hospice arena, with regard to clear intentions for hospice reforms. We’ve historically, over the years, been occasionally fractured in our approach to some of these things. I think we’re seeing tremendous unification now.

And lastly, I’d focus again on the hospice side, with the administration’s plans for hospice regulatory reform. Over the past few years, we’ve seen — for very good reasons — spotlights be put on various states in our country with regard to hospice fraud, waste and abuse. That is something that hospice providers, in general, have been long-time advocates and collaborators on. Providers want to avoid negative behaviors in the industry.

In what ways has your own organization advanced during this period?

We have a different culture now. Having gone through the pandemic, we have a different level of resilience. I think we’re stronger as an organization. We’ve always had positive culture, but I think that we were all in the trenches together. We were really focused on supporting one another.

Secondly, from a business perspective, we’ve really focused on revenue diversification — adding additional service lines, including behavioral health. We’ve been ramping up our merger and acquisition analyses over that timeframe. We’ve had a structured plan beginning two years ago, looking ahead to the next few years beyond now. What it boils down to, it’s ensuring access to quality home health services. That’s the approach we’re taking. In Maine, given its rural nature, we want to make sure that regardless of the community you live in that you have access.

And we have a much more strategic and targeted approach to the management of Medicare Advantage. We have the fourth-highest penetration in the country behind Alabama, Michigan and Florida. When you look at our specific geographic service area, if you look at the county-level data, we’re four points ahead of Alabama. We have had to shift. We’re roughly around 58% or 59% Medicare Advantage, and that changes the business model significantly. We’ve had to be very structured and entrepreneurial in our approach towards the clinical management of patients, but also in how we structure our business environment around payers.

Looking ahead, what is the single most important thing that needs to happen in order to further accelerate home-based care in the U.S., and why?

Historically, MedPAC has looked at Medicare margins as the barometer for setting rates. That analysis has informed – rightly or wrongly – rate negotiations, in general. Two things need to occur. Federal government needs to stop looking at Medicare margins alone as the barometer for the overall financial health and well-being of organizations. That just is no longer the case.

The assumptions that are being made about the overall welfare of home health providers, based on Medicare margins, is dangerous. It is the overall margin that is going to be the definitive factor in whether or not home health organizations are going to be able to serve communities. I worry about rural America in that regard — and rural providers.

In addition to that, I think we’re seeing Congress raising an eyebrow, if not a lot more than that, with regard to Medicare Advantage. The pendulum has swung too far in the direction with Medicare Advantage without the appropriate regulatory oversight. Whether it’s rate structure, whether it’s prior authorizations for reimbursement, the list goes on. You know, it’s not uncommon to see plans that are not paying within 90 days, regardless of what the contract says. I think there needs to be some scrutiny of the Medicare Advantage markets and some appropriate oversight to restore some balance.

In your view, what are the top 2-3 ways that technology specifically has advanced home-based care in recent years?

I see three areas that I can touch on here, starting off with telehealth. The necessity for telehealth during the pandemic became clear. As an organization, we’ve been providing telehealth for nearly 25 years. We deploy nearly 700 units on any given day into our service area. We were able to be nimble in how we use telehealth over the past few years. Moving forward, how we manage care and utilize remote patient monitoring, given the workforce challenges, is going to be really important for us. It will never replace the human being health care professionals in the home. But I do think it is going to become an integral tool in how we manage care overall.

Note with regard to telehealth, though: Our industry for years has been giving that away. We have been incurring the cost of telehealth and demonstrating the value proposition in the process. We’ve done a very good job of doing so, with regard to decreased hospital readmission rates, overall patient satisfaction and decreased isolation for some of our more vulnerable populations that we serve.

As the margins shrink in other areas of ours and others’ service lines, I think you’re going to see providers really having to make difficult decisions with regard to carrying costs associated with telehealth. I’ve talked to hospital executives and, you know, they’re going to need to partner on the investment of telehealth. They certainly see the value. But they’re perfectly fine with us carrying the economic burdens — and that has to change.

I would also say virtual meeting technology has been a major development. It has been around, but it’s now enhanced and meaningful. It has radically changed how we do business on all levels: how we communicate; how we engage with our own staff and external stakeholders; how we engage with regulators; how we work with legislators on both the state and federal levels. It has changed the face of business, and I think it will continue to do so as these platforms expand and improve.

The other area is electronic health records. I haven’t been shy about saying this before: If you look at the United States in the acute care arena, 15-20 years ago, you saw multiple providers of electronic health record services with the hospitals. Today, that has decreased to a small handful. There’s really two or three large players in the market. That has benefited the acute care industry significantly, and it also has allowed those technology providers, along with the acute care industry, to have a much more significant seat at the table in regard to reforms and government relations. We have to do the same thing in the post-acute and the home- and community-based service arena.

I’m not suggesting that we have to reduce the amount of EHR providers to two or three. I think there are other strategies we can employ to achieve the same result as the acute care sector. We need to get better at the full integration of the EHR — the business components, the interrelationship with payers, particularly governmental payers, to influence the evolution of health care. I would also say that along with that, health care at home is evolving very rapidly. I spoke earlier about diversification — whether that is evolving wound management programs within Part B, whether that is evolving Part B therapy programs, behavioral health. But EHRs in our sector are largely focused on home health, private-duty and hospice, and they are very challenged to respond to the markets — at least as quickly as providers are having to respond to the marketplace. We have to create our EHR platforms in such a way that we’re not having to go back to the drawing board every time a provider desires to diversify its clinical portfolio and, therefore, its revenues.

What emerging technology trend do you see disrupting home-based care most over the next 5 years, and why?

I’ll start with AI. Home health and hospice providers, plus palliative care providers, have been using AI over the past few years in different ways. Some, for example, have used it for the clinical management of patients. I think we’re getting very good at that, and we have some partnerships in the market along those lines.

We’re getting very, very good at identifying the overall cost of care from all payer sources — and for any given patient. Every interaction that they have with a health care provider, we can see that and know what the overall cost of care is. As a result of that, we can know where a particular patient is receiving care — all of the touch points. We’re able to define a plan of care that’s much more effective clinically as well as cost effective.

From a disease management perspective, I think AI is also going to be tremendously helpful in providing the historical perspective to allow us to gain a better understanding about the trajectory of any particular disease. That allows us to be more clinically effective. We can utilize that data to demonstrate our value proposition to payer sources. I think that AI is going to be very significant for our industry and, from a strategic perspective, it will become an imperative.

When we think about advancing home-based care, we can talk about moving the needle with a variety of key decision-makers and gatekeepers. Looking exclusively at the policy space, what are some home-based care advancements you’d like to see turn into reality?

The Preserving Access to Home Health legislation, that has to happen on some level. If we don’t have that legislative success, or if we’re separately not successful in the judicial arena, that is going to compromise our industry. We need to have success there. All of that really is around the concept of budget neutrality and how rates are structured.

Hospice reforms, I think, are going to be very important for us, too. We’re at 49% in the United States in terms of Medicare beneficiaries who are embracing the hospice benefit. We’re making significant progress over the years. I believe we’re at a juncture where if we do not see reforms, appropriate reforms, that address fraud, waste and abuse, then we will have an erosion of the public trust in the hospice benefit.

The other piece we need to address as a society – with regard to the triple aim – is serious illness reform. Whether we do that through palliative care or through some of the adjacent models out there. I think that the government is waiting for the private sector to do something about this, and vice versa. Many of us were, and have been, investing in serious-illness-management models over the years. We’ve invested millions of dollars ourselves in that, using and reinvesting from our margins in other areas into managing chronic serious illness in the community. As those margins erode, you can’t use those funds to offset your losses. We’re going to have to find a way to pay for it,if we’re going to decrease the overall health care spend on chronic disease and end-of-life serious illness in the United States.

Then there’s also advancing home-based care and advocating on behalf of providers in the context of payers, including managed care. What degree of progress has the home-based care field made in communicating their value to payers, in your view?

I think we’ve made some modest headway there, but I hesitate to even say that. Our sector, whether we talk about conveners or traditional payers, at the end of the day, we are an ancillary market for those groups. We are negotiating — in many, many instances — with the ancillary-market divisions/departments within the payer structure. And that is a challenge. Those point people are often not decision-makers, or key decision-makers, with regard to determining value. They’re working from a formula. That has to change.

Ultimately, it’s going to take both the providers and the payers to understand the true implications of what we do. There’s just a lack of knowledge of the integral nature of the services we provide.

Generally, as we conduct this interview in mid-2023, do you believe payers currently recognize the value of home-based care services? If they don’t, or if there’s still understanding that needs to happen, how are you and your organization contributing to those efforts?

We’ve implemented a rate-negotiation schedule with, I would say, about 70% of our payers. And this is true in the Medicaid arena as well as with Medicare Advantage, where we are renegotiating our rates.

But then what we’re also doing is we have a portfolio, if you will, specific to that payer and the population of our patients covered by that payer. It has our quality data, our volumes, geographic areas that we’re serving them in, some of the challenges with regard to public health, etc. It has information on access to health care in those areas. We have a very different approach to how we’re sitting down payers for each negotiation. But in addition to that, we are having intermittent, if you will, meetings with them in between rate negotiations to develop relationships moving forward. And again, we’re showing the dashboards that we’re using. We’re showing trend data with regard to our overall care management of specific patient populations.

Looking ahead again, what’s on your advocacy to-do list for the rest of 2023?

Toward the top, there’s the Preserving Access to Home Health legislation, for sure. There’s hospice reform. I’d really like to move forward with the Palliative Care and Hospice Education and Training Act (PCHETA). That’s been hanging out there for almost 15 years now.

Continuing to advance Medicaid is another important area. I think states are going to be forced to look very seriously at how they’re able to maintain providers for Medicaid beneficiaries amid cost and labor pressures.

What trends, challenges or opportunities do you see helping – or hindering – the advancement of home-based care over the next 12 months?

Workforce is something I haven’t touched on yet, but workforce is clearly the No. 1 challenge. That is top of mind for all of us in the industry.

I think another trend is, if you look to 1995, we had 18% of health care provided in the home and in the community. There’s been this long-standing policy, this desire to shift health care from facility-based care into the home and into the community. We’ve been operating over the years with that understanding. In 2020, we moved that needle to 63% of health care being provided in the home and in the community. We saw a real shift. However, what’s not been occurring, and we’re we’re in the middle of this battle right now, is the alignment of the reimbursement policy around the location of care. I think that trend is something we’re going to need to manage as an industry.

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