Home-Based Care Providers Still Waiting for Payer Equity

Home-based care has taken on a more prominent role in the broader health care continuum, but there are still challenges bubbling underneath the surface.

One of these challenges is a lack of payer equity, John Kunysz, president and CEO of Intrepid USA Healthcare Services, said last month at Home Health Care News’ Capital+Strategy conference.

“I want payers to treat us all the same,” he said. “The games that payers play are stunning in our industry. Normally, if we were a consumer, we wouldn’t put up with it. Our patients don’t know about all those games that get played. We’ve got to stop that, and have this sense of equity of treatment and equity of payment processes.”

Texas-based Intrepid USA has more than 60 locations spanning 17 states, making it one of the largest home health providers in the U.S., especially among those with a rural focus.

Kunysz noted that his past experience on the revenue cycle side of things has given him some perspective on the issue.

“I’m an ex-revenue cycle person, so I know the every ‘nth’ denial method,” he said. “What we’re finding now is interesting loopholes from the Medicare Advantage (MA) plans, where we go through the process and they deny and deny.”

This places providers in a tricky position because even as the entity delivering care services, they aren’t allowed to appeal these denials. This duty falls on the original referring physician.

“Do you think that the original referring physician cares at all,” Kunysz said. “Are they going to give us any time to help us refute that claim? No, they’re not, so the payers are really slick on finding ways to kind of stick it to the providers. It should be about truly partnering with us to provide care to patients at a more cost-effective setting.” 

Kunysz is not alone in feeling that way.

Susan Ponder-Stansel, president and CEO of Alivia Care, believes that providers are up against the challenge of figuring out how to deliver the care consumers want – and get positive outcomes – while dealing with MA plans that currently have more clout than them.

“There is this push from CMS to get out of the fee-for-service business and to just push more to the MA plans,” she said. “The challenge for us as providers is the asymmetry in that relationship, and the fact that plans are really looking at medical loss ratio — and how many of the 100 pennies in each dollar they get to keep.” 

Alivia Care is a provider of home health, hospice palliative and personal care services. The company operates across 32 counties in North Florida and Southeast Georgia.

Challenges loom large

Though home-based care leaders are strategizing on how to work around under-the-radar challenges, the more well-known ones, such as staffing shortages, still loom large.

Like many industry peers, Alivia Care is seeing the demand for care services, but the company doesn’t have enough staff on the personal care side.

Unlike other care settings, personal care clients are typically paying out of pocket.

“Since most of [the clients] are paying, … you can’t move the cost up necessarily the way you would in other settings because you’re going to eliminate a certain segment of your market each time you have to move it up,” she said. “That’s a big worry for me, figuring out how we acquire the quality [caregivers] we need, and keeping the pricing so the customers can afford it.”

At the same time, home-based care leaders looking to attract new talent will have to take into account their staff’s preferences in order to make the overall position more appealing, according to Kunysz.

“I’ve talked about making this job cooler than being a barista at Starbucks, a Geek Squad member at Best Buy, or an Apple Genius. … We’ve got to let somebody who has an interest in musical theater take care of Robert Goulet or Julie Andrews,” he said.

Aside from staffing and the cost of services, another pain point at Alivia Care has been making sure the company’s home health segment is prepared for the nationwide expansion of the Home Health Value-Based Purchasing (HHVBP) Model.

For context, Alivia Care entered the home health market with the acquisition of Better Life Home Health in 2021.

“We bought an existing organization and then brought in great leaders who have been in nothing but home health,” Ponder-Stansel said. “To start talking about value-based care and thinking about care planning, working from that plan of care, medical and social work, all of those things that really are going to go into looking at our outcomes, and how we align our outcomes with the needs of the payer or the referral source. That’s been a pain point.”

By Percy