The rise of Medicare Advantage (MA) has restructured the home care landscape, but has put home health providers in a precarious position, while increasingly unstable for beneficiaries.
This is adjusting to increased penetration of MA, with a major change in patient care methods, including care plans adjustments, according to leaders at Lewiston, a Maine-based nonprofit provider and well health partner. Ken Albert, CEO of Andwell Health Partners, said in a recent episode of Home Health Care News' podcasts that MA is rapidly becoming a “failed policy.”
Previously known as Androscoggin Home Healthcare + Hospice, Andwell Health Partners offers home health, palliative care, hospice services and many other services throughout Maine.
Albert sat down with HHCN to discuss the headwinds of the industry, the new service lines and innovations plotted for the organization, the future of Medicare Advantage, and how nonprofits must innovate to survive the innovations of nonprofits.
The following is edited for choice, length and clarity from that conversation.
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HHCN: I know there's Andwell's two-year plan. Can you talk to me through your priorities and where you're two years from now?
Albert: Ultimately, from a prioritization perspective, it's really about sustainability of a non-profit mission. Looking at hospice exceeding 80% nationwide, home health care exceeds 70%, so we have to ask ourselves. Where is the space for nonprofits after acute medical supplies? Truly, the ultimate priority for us is to ensure that our quality, our workforce, and refunds can sustain our non-profit mission in rural America.
We are in an age of significant changes in healthcare that emerged from needs, and today's healthcare costs for governments and other payers are important. So, how do we think differently and in more innovative ways from our acute care partners in primary and specialized care and colleagues in the long-term care industry? How can providing the services you need look different?
Again, I will focus on the countryside of America. I think it's different in urban and rural areas. We don't think we can stand in our silo any more. And we'll have to come out and see what a true partnership in healthcare delivery across that continuum really means. For businesses like Andwell Health Partners, where does Maine's value proposition lie for healthcare delivery systems? Where are our historical skills and how do we use them? Where do we build and grow new skill sets to meet the demands of the people we serve?
Looking at the industry broadly, the rise in Medicare advantage is a problem. How does it affect nonprofits like Andwell?
I understand the appeal of Medicare's advantages and, from a policy standpoint, the ultimate intention of Medicare's advantages, but I think that the benefits of Medicare are becoming a rapidly failing policy in America.
It is attractive to consumers because of the shiny opportunities and shiny things that are expensive and the benefits of Medicare can offer. Speaking of failed policies, if there is a reimbursement structure that does not continuously assess the impact on the healthcare delivery system itself, there is the medicare advantage of important quarterly profits, and we can see the erosion of rural care as part of the healthcare continuum is unable to do mathematics work from a provider's perspective, unable to finish, and seeking outdoor care. Whether that Medicare Advantage policy is actually effective.
I argue that when you're causing a shutdown and critical access hospitals in America is declining, the policy isn't working. Here we have beneficiaries, consumers and attractive products. Also, as long as there is a specific Medicare margin or other third-party payer margin that offsets the loss of Medicare advantage, it really does not affect the choice that consumers will engage in another program, such as Medicare Advantage products, as opposed to traditional Medicare.
But… I think the rural areas of our country are canary people in the coal mines. Looking at a significant shortage of hospitals and providers, as well as physicians and advanced practice nurse practitioners, consumers are ultimately affected due to access. We are approaching access crisis situations in many parts of our country. For example, in Maine, primary care can be accessed for three, four or six months. Access to home care is extremely difficult due to refunds. In a short order, I think we can see a shift in the consumer perspective of Medicare Advantage.
What changes should I make to my organization to work in this environment?
We've made some major changes. Maine has been in the top five in the nation for several years now when it comes to penetrating Medicare advantage. We are penetrated with Medicare advantages of about 67% to 70%. Now, remembering when we were 50%, we actually always have those days again.
Historically, in home health, there has been a delivery model built around Medicare and participation conditions for payment. The surge in Medicare Advantage Plans has led to Medicare Advantage Rules, different contractual obligations from each other, certainly different from traditional Medicare. Therefore, we had to design a healthcare delivery model based on the type of refund. Therefore, home care patients are no longer home care patients. You have to look at what the payer's source is. You need to know that the refund will be for that and adjust the delivery accordingly.
We have conversations with patients who have historically become accustomed to getting physical therapy and nursing two or three days a week, and you are now a Medicare Advantage plan. Your plan may allow us to be there to provide all the services you are requesting, but they will only pay for a portion of it. Approval and payment are two very different things.
Medicare Advantage is a highly transactional product. In other words, you must be able to accept the benefits that are included in your MA product. Once you reach the point where the burden of your illness affects your physical, emotional and cognitive abilities, the benefits of Medicare benefits begin to disappear because you are unable to participate in those benefits. From a consumer perspective, approaches to care delivery had to be adjusted to meet the individual's nature associated with insurance products.
Andwell Health Partners is a list of a range of services, home hygiene, behavioral health, hospice palliative care, mobile wound care, and more. Are you planning to expand that list even further?
We'll be aiming for several new service lines over the next few years. I like to put them in the innovation type service category. The perfect example: Two years ago, we launched Mobile Physical Therapy, Mobile Rehabilitation, occupational therapy. We've innovated it and got some funding for it, and just don't provide a refund perspective in the way innovation forecast predicted. That's why we're bringing that type of service up.
The kinds of innovative services that always appear, the innovative services that we always want to play with are actually all dependent on what we need in the community we serve.
It's not like there's anything new shiny coming here. Let's jump on the trends of that era. We evaluate whether it will become a traditional line of service or something that will come from innovation. You need to assess whether you have a skill set. Whether the community needs it. Do community healthcare delivery partners think that in the provision of a particular service line or what is the role of Welle Health Partners? It's really market preparation. Can I scale it? Do you have the skillsets and resources needed to provide a specific service?
We have a palliative medical center under Andwell Medical Partners, a medical practice that is a medical group. Maine Palliative Care Center is where we provide inpatient and outpatient care, clinical-based and home palliative care. We do some research at the Palliative Medicine Center and run Fellowship, a nurse practitioner fellowship training model.
We are launching an Aging Health Center in Maine. Therefore, we will set up programs such as a guide to begin on July 1st. I received a feasibility grant to explore primary care at home. Given the costs associated with primary care at home, we know that traditional primary care at home, which relies on part B reimbursements, is not sustainable. But can collaboration and partnerships with ACO explore the meaning around primary care at home? Can I see other models of refunds with payers where primary care in the home makes sense?
In Maine, speaking to long-term care and supportive living and memory care providers, geriatric psychiatry is truly a service not only in Maine, but all across the country. We are also looking for ways to fill in that blank. Do we have resources and are we the right organization to do it? It's necessary, so we're looking for a community partner to see if we know if it's the best place to offer it. I know I need to deliver it. It's the question of who we can get there and how we can get there.
