The End of an Era (The Exit Interview with Bill Dombi)

HomeCare | By Hannah Wolfson

A little less than a year ago, William Dombi, the president of the National Association of Homecare and Hospice (NAHC), called his young granddaughters onto the stage at the organization’s annual conference. He would be retiring soon, he told the crowd, in part to be able to spend additional time with them—and to finally get a little rest.

Over the past four decades, Dombi has been tirelessly involved in most efforts in Washington affecting home health and hospice, including the expansion of the Medicare home health benefit in 1980, the creation of the hospice benefit in 1983, the creation of the home health prospective payment system and national health care reform legislation in 2010. He joined NAHC as its lead counsel in 1987 and helmed the landmark lawsuit that reformed the Medicare home health services benefit.

Now NAHC is merging with the National Hospice and Palliative Care Organization (NHCPO); that newly allied group is in the process of selecting new leadership. With his end-of-year departure looming, HomeCare sat down with Dombi to look back at past achievements and see what comes next for the industry.

HomeCare: How are you feeling about leaving? I imagine it’s somewhat mixed.

Dombi: It depends on the day. I mean, obviously, I've committed a huge part of my life to working at the National Association for Home Care and Hospice and am extraordinarily excited about the new Alliance, as we’re calling it, because it's been something we've worked toward for quite a few years; we’ve had a lot of starts and stops but now we’ve crossed the finish line on that. I’m excited about it, but also kind of excited not to have to get deep into the weeds of the integration of the two organizations, which I think is going to take a lot of work. We've been going through that on a daily basis, actually. … I've long put in my head that this day would be coming. Frankly, when I took over following (previous NAHC President) Val Halamandaris’ passing, the board asked how long can you stay? And I said three years. And they asked if I could guarantee four. So I said okay, and then they said five, and now we’re at eight. So it's not like these thoughts are new thoughts or anything's abrupt.

HC: But you have other things you want to do, right?

Dombi: There are definitely things that I'm looking at, but I think I've concluded that I have to stay intellectually stimulated, and a prime way of doing that is to still have some engagement in where I've devoted myself for those decades. And so, because I don't know yet exactly what that's going to be, we have a lot of conversations ongoing, but apparently, others besides myself feel that I bring some value, even in my waning years. … Whatever I put together for the plans, I have to have a little bit of free time.

HC: When you look back—as far back as you want to look—is there any one thing that feels dramatically different? How would you compare the earlier days of the home health world and where it is now?

Dombi: When you look back, you’ve kind of got 20/20 vision. But I can look back at the first day that I came to the association in 1987, and from thereafter, it's been an incredible time of change. It's never really had a calm, stable moment: changes in reimbursement systems, changes in technology. Things that were serious threats and serious opportunities coming along have been what's happened over those four decades. So, in terms of looking back, it's: Did we grab the opportunities that were there? Did we withstand those threats that were there? Did we overcome them? How did we overcome them? I think probably this happens to lots of people—you do reflect on the past as it relates to learning something.

When you're young, you don't think of history as important, but when you get older, history starts teaching you things that you should have learned earlier on. Now, hospice is going through many of the same kinds of challenges that home health went through in the 1990s, with issues of program integrity, questions raised about the quality of care, reimbursement models. … It’s history repeating itself…

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US is Drastically Behind Other Wealthy Nations on Healthcare, Despite Spending the Most

HealthcareDive | By Rebecca Pifer

The Commonwealth Fund analyzed the healthcare systems of 10 nations and found the U.S. ranked last in access to care, health outcomes and overall.

The United States continues to drag behind other industrialized nations when it comes to healthcare, according to new research from the Commonwealth Fund.

America ranked last overall among 10 high-income countries in health system performance — despite spending nearly twice as much on healthcare, according to the research foundation, which has compared the U.S. healthcare system with those of other nations for the past twenty years.

“Our health system is continuing to lag far behind other nations when it comes to meeting our citizens’ basic healthcare needs ... We spend the most and get the least for our investment,” Commonwealth Fund President Joseph Betancourt said during a Wednesday press briefing.

The foundation’s analysis adds onto a mountain of research highlighting how the U.S. spends far more on healthcare than other wealthy countries, despite similar healthcare utilization. Much of the difference has been attributed to higher prices in the U.S., rooted in causes ranging from high hospital consolidation tamping down on competition, to inefficiency and administrative waste, to a lack of universal health insurance coverage.

Meanwhile, America’s higher healthcare spending is not mirrored by better health outcomes. The nation ranks the worst among comparable countries in many metrics, including life expectancy and maternal mortality.

“While other nations have successfully met their health needs, the United States health system continues to lag significantly,” said David Blumenthal, former president of the Commonwealth Fund.

‘In a class by itself’

For its analysis of health system performance, the Commonwealth Fund analyzed wealthy nations in five areas: access to care, administrative efficiency, equity, health outcomes and care process.

The top three countries overall were Australia, the Netherlands and the United Kingdom. However, differences in overall performance between most countries were “relatively small,” according to the report.

The U.S. was the only outlier, with “dramatically lower” health system performance.

America “really is in a class by itself,” Blumenthal said. “This is not, in the United States, a high-value health system.”

The U.S. ranked dead last in access to care, health outcomes and overall Healthcare system performance rankings

When it comes to care access, Americans are more likely to report financial barriers to care than citizens in other countries, the Commonwealth Fund found. The report cites the nation’s fragmented insurance system that has left millions of Americans uninsured.

Meanwhile, rising prices have fueled increases in out-of-pocket costs for covered consumers, which could incentivize patients to skip care. And, U.S. patients are more likely than their peers in other countries to report they don’t have a regular doctor or care site, the Commonwealth Fund found.

The U.S. healthcare system is also bloated with inefficiencies, according to the report. Doctors and patients in America were significantly more likely to report issues related to insurance approvals and billing than those in other countries.

It’s also highly inequitable, with the largest disparity in performance between low-income and high-income individuals, according to the Commonwealth Fund.

Meanwhile, Americans live the shortest lives and have the most avoidable deaths. Life expectancy is more than four years below the average of all ten countries, due in part to the ongoing substance abuse epidemic and pervasive gun violence, the report found. The U.S. also had higher rates of excess deaths due to the coronavirus pandemic compared to other nations.

In the report’s lone bright spot, the U.S. ranked second out of the 10 nations when it comes to care process: functions of the healthcare system that are essential to high-quality care, like prevention, safety and patient engagement.

The country’s strong performance in care process is likely the result of intensive policy interest in ensuring people get preventive care stemming from value-based care models in Medicare and run by other insurers, researchers said…

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3 Insights Home-Based Care Providers Must Know About the Proposed Home Health Rule

Home Health Care News | By Jack Silverstein
 
Over the past two years, CMS has proposed large cuts to home health Medicare payments, leaving providers concerned over their ability to deliver care and run their businesses. Even when CMS finalized cuts that were smaller than their original proposals, providers still faced challenges over thin margins.
 
The 2025 proposed rule brings additional cuts that may further strain the industry’s ability to serve all patients. That was already a challenge before the pandemic, when only 77% of those needing care in 2018 received it. Six years later, that number is down to 65%.
“It’s a critical opportunity for us as an industry to make sure that the leaders at CMS, and the leaders in Congress, are recognizing the value of home health services within the continuum of care and within the entire health care ecosystem,” says John Gochnour, President and COO of The Pennant Group. “The home health proposed rule doesn’t do that.”
 
Here are three insights home health providers must know about the new rule and how they can successfully navigate it.
 
Not all providers are affected equally
 
The proposed rule includes a payment decrease in the aggregate of 1.7%, translating to about $280 million in lost revenue. Yet the impacts vary widely based on geography and patient case mix. Some factors, such as wage index, have seen erratic changes year after year.
 
“Turnover and wage costs are not changing abruptly. You’re not all of a sudden paying more one year and then less the next year.” says Scott Pattillo, Chief Strategy Officer, Homecare Homebase. “So it’s really important that you know — based on your geographic mix, your patient mix, your patient types and your acuity types — how it’s going to impact your agencies.”
 
The industry’s financial pressures are mounting — and the new rule doesn’t always account for that
 
Running a home health business is challenging enough on its own. It gets even trickier when CMS views the industry substantially differently than providers do.
“CMS is of the opinion that there are very high margins in Medicare,” Pattillo says. “They believe there’s a 17% margin on Medicare claims.”
 
Pattillo notes that CMS’s response to last year’s provider comment letters was that: “In a 17%-margin environment, we just don’t understand how a 1% to 2% decrease can impact anything materially. Taking 1% to 2% of that 17% margin does not make sense to us that it would destabilize the industry.”
 
But CMS’ view that providers see a 17% margin on Medicare claims does not account for multiple important factors, including:

• Wage increases and the inflationary environment
• The high number of Medicare Advantage patients that providers care for
• The high number of MA plans with reimbursement rates under the cost of care

Those last two are the big ones. Providers may have a 17% margin if they only took Medicare patients, but when half of their patients are under MA plans, their margins come out to more like 1-5%. In short, home health agency margins are much slimmer than CMS implies.
 
“The individual elements of cost of care are absolutely not going down,” Pattillo says. 
 
“There is nothing that has gotten cheaper about caring for patients, and we know the acuity of those patients is rising in terms of the way that they’re coming into your home health agencies.”
 
Adjusting to the new rule starts with turning to HCHB
 
When a new rule proposal is released, care providers turn to the HCHB Analytics Impact Model to review the rule’s potential impact and figure out what changes they need to make.
“The first thing that we do after the proposed rule is released is look to the Homecare Homebase model,” Gochnour says. “We then work from that to refine and understand, because we operate in 14 states across the country, so we have a lot of variability in how a proposed rule is going to impact each individual operation.”
 
The HCHB dashboard allows companies to see where they fit in the new rule. Benefits include insight into:

• The variability in CMS’s methodology
• How that variability your branches in different states
• How your agency will be affected by case mix changes
• The potential effect you will see to your revenue
• The ability to understand when and how to add new service lines
  
  

“We use this model to really estimate that impact and immediately provide our local operators with some insight into what the impact is going to be for them, so that they can begin honing in on what changes they may need to make,” Gochnour says.
 
This article is based on a recent HHCN-HCHB webinar featuring Scott Pattillo and John Gochnour. HCHB delivers powerful new tools and intuitive software that’s easy to learn and use. From scheduling, routing, documentation and reporting to intake, billing, and compliance we give you everything you need to boost productivity and profits while empowering exceptional patient care. To learn more, visit hchb.com.

Policymakers Should Help Address the Crisis of Older Adult Falls

Forbes | By Richard Howells

Older adult falls result in 38,000 deaths, 1 million hospitalizations, and 3 million emergency department visits each year, along with $80 billion in health care costs, including $53 billion to Medicare.
 
Too many Americans have lost loved ones due to falls. The Centers for Disease Control and Prevention (CDC) estimates that falls among older adults result in 38,000 deaths, 1 million hospitalizations, and 3 million emergency department visits each year, along with $80 billion in health care costs, including $53 billion to Medicare. Yet, most falls are preventable, and most occur at home. We can—and must—do more to help older adults avoid fatalities and injuries like fractures and traumatic brain injury from falls.
 
Given the enormous health and economic toll, one might think policymakers would make this issue a priority. Unfortunately, this hasn’t been the case. Despite the occasional Congressional champion, introduction of legislation, or agency activity on falls prevention, the attention given to this issue does not match its urgency. For example, falls prevention has not been a significant focus this year in Congress’ appropriations process or in the committees tasked with improving health or reducing health care costs.
 
Falls usually occur due to one or a combination of three reasons: home hazards, such as a lack of bathroom grab bars, loose rugs, stairs, poor lighting, or out-of-reach electrical outlets; medication side effects or medical conditions, such as visual or cognitive impairment; and, a lack of balance caused by a variety of illnesses, disabilities, or physical inactivity.
 
In previous testimony to the U.S. Senate Special Committee on Aging, I called for the executive branch to develop a falls prevention action plan and to better coordinate home modification programs to substantially reduce falls and their associated health care costs. Here are three specific steps that should be taken:
 
First, policymakers should make more community-based falls prevention programs accessible to seniors. This includes creating pathways for Medicare beneficiaries with traditional fee-for-service to access these programs, as well as providing incentives for Medicare Advantage plans. Programs such as A Matter of Balance, the Otago Exercise Program, and tai chi exercise programs have been recommended by the U.S. Preventive Services Task Force to prevent falls in community-dwelling adults 65 years or older who are at increased risk.
 
Second, policymakers should pay clinicians specifically to screen for falls risk, intervene to reduce risk factors, and refer patients to additional falls prevention programs and specialists. The CDC’s Stopping Elderly Accidents, Deaths & Injuries (STEADI) tool offers clinicians an evidence-based algorithm to help patients reduce fall risk. Currently, Medicare pays clinicians to assess for falls risk as part of the Annual Wellness Visit. 
 
However, falls prevention is just one of several dozen components of the visit, and there often is not enough time to focus on it. Moreover, only a minority of seniors receive the wellness visit.
 
Third, government agencies should identify and streamline the various home modification resources available across federal agencies to help older adults make their homes more age-friendly. This should include facilitating opportunities for our most vulnerable seniors enrolled in both Medicare and Medicaid. The aging and disability networks, such as Area Agencies on Aging and Aging and Disability Resource Centers, reach millions of older adults and could be effectively utilized to disseminate these resources.