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Home care past, present, and future: Opportunities and challenges in a managed care environment
Minding Our Business
Home Care Past, Present, and Future: Opportunities and Challenges in a Managed Care Environment BY KEITH
KERTLAND,
HISTORY OF MEDICARE AND HOSPITAL-BASED HOME CARE Since Medicare was first signed into law in 1964 by President Lyndon Johnson, the Medicare home care model and, indeed, Medicare itself has undergone a dramatic evolution in a relatively short time. Originally developed to provide care to chron ically ill seniors and primarily as a posthospital discharge service, the Medicare home care model was ADDRESS FOR CORRESPONDENCE: Keith Kertland Presidentand CEO VNA and Hospiceof Northern California
1900 PowellSt., Suite 300 Emeryville, CA 94608
3 16
HOME
CARE PROVIDER
MA, MBA
cost based, with clear-cut criteria for services. Home
care was, at that time, regarded as a “stepchild” of the hospitals, an ancillary service. In the 198Os, many hospitals throughout the country began developing their own home care services as part of their continuum of care, with an eye on the decided advantage of revenue generation. Shortly after that, the inception of diagnosis-related groups (DRGs) precipitated the movement of Medicare patients through the acute care hospitals faster, and patients began to be discharged “sicker and quicker.” Hospital lengths of stays decreased, but so did the number of Medicare home care visits per patient. In addition, in California in particular, the Medicare fiscal intermediary has always had a more stringent review process, and now the number of billable patient visits has been reduced. AS a NOVEMBER/DECEMBER
1996,
VOL.
1 NO. 6
MINDING
OUR BUSINESS
KERTLAND
result, the halcyon days for home care are rapidly ending. With the advent of DRGs, the American Hospital Association was able to convince Medicare that hospital-based home care was more costly because of the Medicare cost report methodology, and an “addon” amount was added to the hospital-based Medicare home care cost cap. This created a financial disadvantage to community-based agencies and the national home care firms. Hospitals not only had a higher cost cap, but they were also able to use overhead to maximize that reimbursement. Growing opposition from the non-hospital-based home care organizations finally resulted in the loss of hospitals’ “add on” in 1993. In the early t990s, Medicare home care was growing faster than any other part of the health care delivery system. Although home care consumed only a small percentage of the total Medicare dollars (3% to 4%), the rate of growth caused concern for the Health Care Financing Administration (HCFA) and therefore for Congress. The home care industry responded to these concerns with dire predictions of patients ending up in emergency departments, hospitals being flooded, and physicians’ offices being swamped if home care was altered in any way. However, the industry’s credibility was brought into question as investigations of kickbacks (focused predominantly on the infusion companies) began to gain media attention. In addition, the wide discrepancy in visit patterns between the states (ranging from 100 visits per patient in Texas to 35 visits per patient in California) and the approximately 100% difference between the for-profit and not-for-profit home care agencies’ visits per patient raised skepticism among other providers besides the government. In 1994, the Medicare home care rates were frozen for 2 years, but the wage index portion of the cost cap was adjusted, resulting in increases. Although these increases were relatively small, the home care industry continued its rapid growth and Wall Street began to take a keener interest than they had in the past. Home care became the “in” thing to own, invest in, and start. Many in the industry were puzzled and surprised by this sudden interest because home care had long been seen as the “poor stepchild” of health care. The timing of Wall Street and other investors and providers starting home care companies seemed “a day late and a dollar short.” Given trends in reimbursement, growing competition, and managed care, home care is no longer the investment strategy for the late 90s. Proposals
Facing the Home
Care Industry
Because the freeze had little impact on slowing Medicare growth, HCFA began to look at other potential reimbursement methods to stifle the NOVEMBER/DECEMBER
19%. VOL.
1 NO.
6
growth. During the past few years, the home care industry has been fighting off a variety of potential changes, most of which did not make sense from a policy standpoint. “Bundling,” a proposal to add home care reimbursement to the hospital DRG, has been defeated several times. Although hospitals generally loved the idea of bundling, skilled nursing facilities, physicians, and home care hated it. Bundling assumed home care was an acute care-based service; it ignored the long-term care needs of the chronically ill or patients other than those who were hospitalized. HCFAs next strategy was to shift home care from Medicare Part A to Medicare Part B. Because home care is the only Medicare service without a co-pay, it seemed like a reasonable and logical step. However, because of the cost reporting method of the Medicare Home Care Program, the co-pays were regarded as unnecessarily high and likely to result in a bureaucratic nightmare and an increased cost for home care agencies trying to collect the co-pays on visits. However, Medicare reimbursement for the industry was going to change. The home care industry, while fighting the co-pay strategy, was beginning to get the message. The Prospective Payment System (PPS) that had been under a national demonstration grant for several years was becoming infinitely more attractive than any alternative. Co-pays, however, are not off the table and could easily be seen as an interim stop gap measure by HCFA and Congress until PPS can be implemented. Co-pays for home care will impact the industry significantly. First, many home care recipients are on fixed incomes and will be forced to choose which services they can afford. In addition, they will then need to decide how many visits of a particular service they can afford. Home care, already affected by the striking differences in managed care reimbursement, will need to either dramatically increase fundraising to offset the expected loss in not-forprofit agencies or further reduce its cost structure. In all likelihood, it will probably have to do both. Although co-pays may be viewed as a good public policy decision in states with high utilization and for those companies with high visit volumes, it is a policy that does not make sense in California with its already low volumes nor does it take into account the effect on the low-income patient population. Operation
Restore
Trust
Convinced that widespread fraud and abuse exist in home care, HCFA, along with the Office of the Inspector General (OIG), initiated “Operation Restore Trust” to get a handle on the purported abuse. The conviction and jail sentence for a CEO of a large national home care company, who was HOME
CARE PROVIDER
3 17
MINDING
KERTLAND
indicted for fraud and abuse, only added fuel to the abuse fire. However, this growing oversight of home care has created some tension and concern as rumors and facts are intermingled to create horror stories. Many home care agencies have undertaken compliance review programs to ensure that their organizations meet both the letter and spirit of the Medicare home care regulations. The bottom line, however, is that the home care industry will experience substantial reductions of visits as agencies and field staff focus on “appropriate levels of care,” and the threat of providing “unnecessary care” permeates each organization. Again, Operation Restore Trust is probably a necessary effort, but it is interesting that California is one of its target states. The national average of Medicare visits per patient is 60, whereas in California the average of Medicare visits per patient is 35. Given the high utilization and visit ratios of other states like Texas and Florida and the established managed care environment in California, this strategy of targeting California seems odd. Hospitalbased agencies are also part of the target group for this investigation.
Medicare
HMOs
As Medicare HMOs proliferate and enrollment increases, the elderly patient population is shifting from the traditional Medicare model to a managed care fee-for-service or capitated reimbursement model. For every 1000 visits that shift from Medicare to a Medicare HMO, the reimbursement is decreased at least $35,000 to $40,000. The greater the HMO penetration, obviously the greater the impact on the reimbursement of the home care entity, and the more difficult it becomes for home care to be the revenue generator it was in past years. These cuts and changes begin to raise the question of whether the Medicare hospital-based requirements and the associated costs will exceed the net income or overhead allocation opportunities in the future. No financial incentive will continue for the hospital-based models, and so the focus will shift to freestanding models instead.
MEDICAID Medicaid is growing as an issue of national attention, with concern about recent legislation regarding welfare reform and health care resources in general as states review their programs. In California, the Medi-Cal system, as Medicaid is called, is moving toward managed care. Although Medi-Cal continues to use Treatment Authorization Requests (TARS) and reimburse at a low rate, the movement to a Medi-Cal managed care system is seen as an opportunity, given the expanded volumes and increased reimbursement in the new system. San Mateo 3 18
HOME
CARE PROVIDER
OUR BUSlNESS
County, for example, in which TARS are required and known for their challenges, has been at the forefront of this effort. The reimbursement by the County Health Plan is actually somewhat higher than the per-visit traditional Medi-Cal visit. Whether this level of reimbursement from the County can be sustained is probably doubtful. Medi-Cal will continue to be problematic for home care because of reimbursement, paperwork, and the changes recently passed by Congress relative to welfare reform.
MANAGED
CARE
Managed care fee-for-service may be seen as home care’s worst nightmare. Like physicians, the home care nurse and therapist had always enjoyed a sense of autonomy and independent decision making, and it was this autonomy that attracted nurses to home care. Partnering with physicians, the home care nurse could offer clinical solutions and jointly develop a plan of care. Enter managed care: the home care nurse now discovers himself or herself not partnering with the physicians but trying to negotiate needed visits with health plans, many of whom see home care as an unnecessary expense and demand reauthorization every few visits. The partnerships between home care and the HMO case managers were not initially successful because of the dramatically reduced reimbursement coupled with increased paperwork, special billing demands, and an often “hostile” relationship. However, through ongoing education and the support of physicians who have had to advocate on their patients’ behalf, HMOs are beginning to understand the role home care can play. Much to the home care industry’s surprise, HMO case managers are even ordering MSW visits with the realization and understanding that social issues can affect outcomes and have negative care and financial consequences. Also, as with physicians, managed care’s payment system was higher than Medi-Cal but dramatically lower than Medicare. HMOs demanded specialty programs, after-hours coverage, and hi-tech nursing, all for the same low price. As these trends continue and fee-for-service reimbursement of the agency increases, it will ultimately redesign the infrastructure and may in some case, depending on the size and sophistication of the home care organization, threaten their long-term financial viability.
CAPITATION Capitation is an interesting model in reimbursement. As an alternative to traditional Medicare/Medi-Cal or fee-for-service managed care, it has the advantage of being clinically driven: what is usually clinically right for the patient is more often than not financially the best outcome. For home care, capitation aligns NOVEMBER/DECEMBER
1996, VOL.
1 NO.6
MINDING
OUR BUSINESS
KERTLAND
the home care clinicians and physicians in a manner never expected. Home care under capitation becomes an extension of the physician practice, and the home care nurse becomes the eyes and ears of the physician in the patient’s home. Partnering with physicians to solve problems, develop clinical programs, and work together on utilization management refocuses the home care process on clinical care, outcomes, and the psychosocial impact on care of the patient living in their home environment. A comprehensive cap for home care allows coordination of care at all levels, promotes creative services and new ways to monitor patients, and helps serve as a cost-avoidance strategy. Under capitation, the partnership between home care and the medical group has become so important that some home care agencies are exploring the possibility of shifting the cap to the medical groups from the acute care hospitals, with the intent of an alignment of clinical outcomes and financial performance.
HOME
CARE’S
FUTURE
Medicare reimbursement will move to a PPS mode1 in the next few years. Although some suggest that the PPS will be implemented in 1997, HCFA says it is not ready, despite the demonstration project. It appears that implementation in fiscal 1998/99 seems more realistic. The industry will aggressively lobby for PPS if the threat of co-pay seems to be gaining momentum. One issue still under debate is whether hospitals will be able to allocate “indirect overhead” under the new model. Direct overhead allocation will most likely be covered in PPS. Given the demands of capitation to add services and new programs, it is unlikely that home care will be able to keep costs within the PPS model. Volume and size become critical issues to achieve these objectives. Capitation will become the payment source of choice for medical groups that understand and appreciate home care’s role as an extension of the physician practice and fully use the cost-avoidance structure. Medical groups that try to economize on home care and keep a fee-for-service model may
NOVEMBER/DECEMBER
1996, VOL.
1 NO.
6
l
l
l
find themselves at a disadvantage in the marketplace. Home care’s cap will increase, but not proportionately, as the acute care hospital’s role continues to evolve and more patients can stay at home or at a lower level of care. In all likelihood, the home care industry will find that some combination of the per visit and case rates will occur and will need to prepare for that shift with strong utilization management systems and models. Local markets and relationships will be key to home care’s survival. Volume will be absolutely critical if home care is to be able to support the medical group and hospital by providing needed clinical care in creative ways and to assist with cost avoidance. The competition will be fierce as the for-profit companies begin to understand the need to provide comprehensive home care. The for-profit home care companies will move aggressively, quickly, and at a low price. With significant capita1 resources behind them, these companies can “buy” the marketplace, obtain statewide or regional contracts with lower rates, and quickly infiltrate the marketplace. Community-based home care/hospice agencies need the ability to strategically position themselves by offering clinical programs and partnering with medical groups and physicians while remaining cost competitive.
CONCLUSION All is not lost, however. Despite reimbursement decreases, opportunities exist for the industry to succeed in this new environment through strategic partnerships and new services, such as DME or pharmacy joint ventures. As the reimbursement continues to change, home care agencies will need sophisticated utilization management and comprehensive case management models to maintain strong clinical and financial outcomes and to ultimately be successful. Keith Nurse
Ket-tland,
MA,
Association
Emeryville,
MBA,
is president
and Hospice
and CEO
of Northern
of the Visiting
California
in
California.
Reprint no. 69/i/78859
HOME
CARE PROVIDER
3 19
Home Care Past, Present, and Future: Opportunities and Challenges in a Managed Care Environment BY KEITH
KERTLAND,
HISTORY OF MEDICARE AND HOSPITAL-BASED HOME CARE Since Medicare was first signed into law in 1964 by President Lyndon Johnson, the Medicare home care model and, indeed, Medicare itself has undergone a dramatic evolution in a relatively short time. Originally developed to provide care to chron ically ill seniors and primarily as a posthospital discharge service, the Medicare home care model was ADDRESS FOR CORRESPONDENCE: Keith Kertland Presidentand CEO VNA and Hospiceof Northern California
1900 PowellSt., Suite 300 Emeryville, CA 94608
3 16
HOME
CARE PROVIDER
MA, MBA
cost based, with clear-cut criteria for services. Home
care was, at that time, regarded as a “stepchild” of the hospitals, an ancillary service. In the 198Os, many hospitals throughout the country began developing their own home care services as part of their continuum of care, with an eye on the decided advantage of revenue generation. Shortly after that, the inception of diagnosis-related groups (DRGs) precipitated the movement of Medicare patients through the acute care hospitals faster, and patients began to be discharged “sicker and quicker.” Hospital lengths of stays decreased, but so did the number of Medicare home care visits per patient. In addition, in California in particular, the Medicare fiscal intermediary has always had a more stringent review process, and now the number of billable patient visits has been reduced. AS a NOVEMBER/DECEMBER
1996,
VOL.
1 NO. 6
MINDING
OUR BUSINESS
KERTLAND
result, the halcyon days for home care are rapidly ending. With the advent of DRGs, the American Hospital Association was able to convince Medicare that hospital-based home care was more costly because of the Medicare cost report methodology, and an “addon” amount was added to the hospital-based Medicare home care cost cap. This created a financial disadvantage to community-based agencies and the national home care firms. Hospitals not only had a higher cost cap, but they were also able to use overhead to maximize that reimbursement. Growing opposition from the non-hospital-based home care organizations finally resulted in the loss of hospitals’ “add on” in 1993. In the early t990s, Medicare home care was growing faster than any other part of the health care delivery system. Although home care consumed only a small percentage of the total Medicare dollars (3% to 4%), the rate of growth caused concern for the Health Care Financing Administration (HCFA) and therefore for Congress. The home care industry responded to these concerns with dire predictions of patients ending up in emergency departments, hospitals being flooded, and physicians’ offices being swamped if home care was altered in any way. However, the industry’s credibility was brought into question as investigations of kickbacks (focused predominantly on the infusion companies) began to gain media attention. In addition, the wide discrepancy in visit patterns between the states (ranging from 100 visits per patient in Texas to 35 visits per patient in California) and the approximately 100% difference between the for-profit and not-for-profit home care agencies’ visits per patient raised skepticism among other providers besides the government. In 1994, the Medicare home care rates were frozen for 2 years, but the wage index portion of the cost cap was adjusted, resulting in increases. Although these increases were relatively small, the home care industry continued its rapid growth and Wall Street began to take a keener interest than they had in the past. Home care became the “in” thing to own, invest in, and start. Many in the industry were puzzled and surprised by this sudden interest because home care had long been seen as the “poor stepchild” of health care. The timing of Wall Street and other investors and providers starting home care companies seemed “a day late and a dollar short.” Given trends in reimbursement, growing competition, and managed care, home care is no longer the investment strategy for the late 90s. Proposals
Facing the Home
Care Industry
Because the freeze had little impact on slowing Medicare growth, HCFA began to look at other potential reimbursement methods to stifle the NOVEMBER/DECEMBER
19%. VOL.
1 NO.
6
growth. During the past few years, the home care industry has been fighting off a variety of potential changes, most of which did not make sense from a policy standpoint. “Bundling,” a proposal to add home care reimbursement to the hospital DRG, has been defeated several times. Although hospitals generally loved the idea of bundling, skilled nursing facilities, physicians, and home care hated it. Bundling assumed home care was an acute care-based service; it ignored the long-term care needs of the chronically ill or patients other than those who were hospitalized. HCFAs next strategy was to shift home care from Medicare Part A to Medicare Part B. Because home care is the only Medicare service without a co-pay, it seemed like a reasonable and logical step. However, because of the cost reporting method of the Medicare Home Care Program, the co-pays were regarded as unnecessarily high and likely to result in a bureaucratic nightmare and an increased cost for home care agencies trying to collect the co-pays on visits. However, Medicare reimbursement for the industry was going to change. The home care industry, while fighting the co-pay strategy, was beginning to get the message. The Prospective Payment System (PPS) that had been under a national demonstration grant for several years was becoming infinitely more attractive than any alternative. Co-pays, however, are not off the table and could easily be seen as an interim stop gap measure by HCFA and Congress until PPS can be implemented. Co-pays for home care will impact the industry significantly. First, many home care recipients are on fixed incomes and will be forced to choose which services they can afford. In addition, they will then need to decide how many visits of a particular service they can afford. Home care, already affected by the striking differences in managed care reimbursement, will need to either dramatically increase fundraising to offset the expected loss in not-forprofit agencies or further reduce its cost structure. In all likelihood, it will probably have to do both. Although co-pays may be viewed as a good public policy decision in states with high utilization and for those companies with high visit volumes, it is a policy that does not make sense in California with its already low volumes nor does it take into account the effect on the low-income patient population. Operation
Restore
Trust
Convinced that widespread fraud and abuse exist in home care, HCFA, along with the Office of the Inspector General (OIG), initiated “Operation Restore Trust” to get a handle on the purported abuse. The conviction and jail sentence for a CEO of a large national home care company, who was HOME
CARE PROVIDER
3 17
MINDING
KERTLAND
indicted for fraud and abuse, only added fuel to the abuse fire. However, this growing oversight of home care has created some tension and concern as rumors and facts are intermingled to create horror stories. Many home care agencies have undertaken compliance review programs to ensure that their organizations meet both the letter and spirit of the Medicare home care regulations. The bottom line, however, is that the home care industry will experience substantial reductions of visits as agencies and field staff focus on “appropriate levels of care,” and the threat of providing “unnecessary care” permeates each organization. Again, Operation Restore Trust is probably a necessary effort, but it is interesting that California is one of its target states. The national average of Medicare visits per patient is 60, whereas in California the average of Medicare visits per patient is 35. Given the high utilization and visit ratios of other states like Texas and Florida and the established managed care environment in California, this strategy of targeting California seems odd. Hospitalbased agencies are also part of the target group for this investigation.
Medicare
HMOs
As Medicare HMOs proliferate and enrollment increases, the elderly patient population is shifting from the traditional Medicare model to a managed care fee-for-service or capitated reimbursement model. For every 1000 visits that shift from Medicare to a Medicare HMO, the reimbursement is decreased at least $35,000 to $40,000. The greater the HMO penetration, obviously the greater the impact on the reimbursement of the home care entity, and the more difficult it becomes for home care to be the revenue generator it was in past years. These cuts and changes begin to raise the question of whether the Medicare hospital-based requirements and the associated costs will exceed the net income or overhead allocation opportunities in the future. No financial incentive will continue for the hospital-based models, and so the focus will shift to freestanding models instead.
MEDICAID Medicaid is growing as an issue of national attention, with concern about recent legislation regarding welfare reform and health care resources in general as states review their programs. In California, the Medi-Cal system, as Medicaid is called, is moving toward managed care. Although Medi-Cal continues to use Treatment Authorization Requests (TARS) and reimburse at a low rate, the movement to a Medi-Cal managed care system is seen as an opportunity, given the expanded volumes and increased reimbursement in the new system. San Mateo 3 18
HOME
CARE PROVIDER
OUR BUSlNESS
County, for example, in which TARS are required and known for their challenges, has been at the forefront of this effort. The reimbursement by the County Health Plan is actually somewhat higher than the per-visit traditional Medi-Cal visit. Whether this level of reimbursement from the County can be sustained is probably doubtful. Medi-Cal will continue to be problematic for home care because of reimbursement, paperwork, and the changes recently passed by Congress relative to welfare reform.
MANAGED
CARE
Managed care fee-for-service may be seen as home care’s worst nightmare. Like physicians, the home care nurse and therapist had always enjoyed a sense of autonomy and independent decision making, and it was this autonomy that attracted nurses to home care. Partnering with physicians, the home care nurse could offer clinical solutions and jointly develop a plan of care. Enter managed care: the home care nurse now discovers himself or herself not partnering with the physicians but trying to negotiate needed visits with health plans, many of whom see home care as an unnecessary expense and demand reauthorization every few visits. The partnerships between home care and the HMO case managers were not initially successful because of the dramatically reduced reimbursement coupled with increased paperwork, special billing demands, and an often “hostile” relationship. However, through ongoing education and the support of physicians who have had to advocate on their patients’ behalf, HMOs are beginning to understand the role home care can play. Much to the home care industry’s surprise, HMO case managers are even ordering MSW visits with the realization and understanding that social issues can affect outcomes and have negative care and financial consequences. Also, as with physicians, managed care’s payment system was higher than Medi-Cal but dramatically lower than Medicare. HMOs demanded specialty programs, after-hours coverage, and hi-tech nursing, all for the same low price. As these trends continue and fee-for-service reimbursement of the agency increases, it will ultimately redesign the infrastructure and may in some case, depending on the size and sophistication of the home care organization, threaten their long-term financial viability.
CAPITATION Capitation is an interesting model in reimbursement. As an alternative to traditional Medicare/Medi-Cal or fee-for-service managed care, it has the advantage of being clinically driven: what is usually clinically right for the patient is more often than not financially the best outcome. For home care, capitation aligns NOVEMBER/DECEMBER
1996, VOL.
1 NO.6
MINDING
OUR BUSINESS
KERTLAND
the home care clinicians and physicians in a manner never expected. Home care under capitation becomes an extension of the physician practice, and the home care nurse becomes the eyes and ears of the physician in the patient’s home. Partnering with physicians to solve problems, develop clinical programs, and work together on utilization management refocuses the home care process on clinical care, outcomes, and the psychosocial impact on care of the patient living in their home environment. A comprehensive cap for home care allows coordination of care at all levels, promotes creative services and new ways to monitor patients, and helps serve as a cost-avoidance strategy. Under capitation, the partnership between home care and the medical group has become so important that some home care agencies are exploring the possibility of shifting the cap to the medical groups from the acute care hospitals, with the intent of an alignment of clinical outcomes and financial performance.
HOME
CARE’S
FUTURE
Medicare reimbursement will move to a PPS mode1 in the next few years. Although some suggest that the PPS will be implemented in 1997, HCFA says it is not ready, despite the demonstration project. It appears that implementation in fiscal 1998/99 seems more realistic. The industry will aggressively lobby for PPS if the threat of co-pay seems to be gaining momentum. One issue still under debate is whether hospitals will be able to allocate “indirect overhead” under the new model. Direct overhead allocation will most likely be covered in PPS. Given the demands of capitation to add services and new programs, it is unlikely that home care will be able to keep costs within the PPS model. Volume and size become critical issues to achieve these objectives. Capitation will become the payment source of choice for medical groups that understand and appreciate home care’s role as an extension of the physician practice and fully use the cost-avoidance structure. Medical groups that try to economize on home care and keep a fee-for-service model may
NOVEMBER/DECEMBER
1996, VOL.
1 NO.
6
l
l
l
find themselves at a disadvantage in the marketplace. Home care’s cap will increase, but not proportionately, as the acute care hospital’s role continues to evolve and more patients can stay at home or at a lower level of care. In all likelihood, the home care industry will find that some combination of the per visit and case rates will occur and will need to prepare for that shift with strong utilization management systems and models. Local markets and relationships will be key to home care’s survival. Volume will be absolutely critical if home care is to be able to support the medical group and hospital by providing needed clinical care in creative ways and to assist with cost avoidance. The competition will be fierce as the for-profit companies begin to understand the need to provide comprehensive home care. The for-profit home care companies will move aggressively, quickly, and at a low price. With significant capita1 resources behind them, these companies can “buy” the marketplace, obtain statewide or regional contracts with lower rates, and quickly infiltrate the marketplace. Community-based home care/hospice agencies need the ability to strategically position themselves by offering clinical programs and partnering with medical groups and physicians while remaining cost competitive.
CONCLUSION All is not lost, however. Despite reimbursement decreases, opportunities exist for the industry to succeed in this new environment through strategic partnerships and new services, such as DME or pharmacy joint ventures. As the reimbursement continues to change, home care agencies will need sophisticated utilization management and comprehensive case management models to maintain strong clinical and financial outcomes and to ultimately be successful. Keith Nurse
Ket-tland,
MA,
Association
Emeryville,
MBA,
is president
and Hospice
and CEO
of Northern
of the Visiting
California
in
California.
Reprint no. 69/i/78859
HOME
CARE PROVIDER
3 19