Key Takeaways of the PHA Conference 2024- Series 2

Key Takeaways of the PHA Conference 2024- Series 2

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Ruby Mehta: Welcome to the CareSmartz360 on Air Podcast, a home care Podcast and I’m Ruby Mehta, VP Sales at Caresmartz.

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Ruby Mehta: In the line of experts of the 2024 Pennsylvania Home Care Conference. Next, we have Bill Dombi, the president of the National Association of Home Care and Hospice on the panel.

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Ruby Mehta: Welcome, Bill! How are you?

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William Dombi: I’m doing well, Ruby. Thanks for giving me this opportunity.

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Ruby Mehta: Thank you. Thank you. You. You don’t need an introduction. But just for our listeners here. With nearly 40 years of experience in healthcare Law and Policy Bill has been involved in virtually all legislative and regulatory efforts affecting home care and hospice since 1975

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Ruby Mehta: during the Conference Bill. You spoke about every aspect of the home care landscape. Be it Medicare, home health, Medicare, Hospice, Medicaid, Hcbs. Private duty, personal Care Medicaid advantage and innovation for healthcare at home. So I will let you talk about a lot of that stuff now and then. Go from there.

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William Dombi: Yeah, you know, I I think just the outline that you gave of the subject areas is really the central focus that I can offer that being, that the breadth and depth of care in the home continues to expand.

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William Dombi: You know that within you know that the decades of work that I have been involved in care in the home. You know, it’s almost, you know, kind of like what we’ve seen and technology where we have. You know, computers that one time fill the room, and now they’re in our hands as smartphones with more and more power. Care in the home has done the same, you know, growing to a point where we now have.

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William Dombi: you know, a an ability to pretty much provide

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William Dombi: all types of care in the home setting that would otherwise be provided in a skilled nursing facility, and many times only in a hospital as well. So just. An exciting time for healthcare at home in terms of that breath. In that depth

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William Dombi: technologies have been a big part of it. We’re just hoping, and part of the job that I have is to make sure that payers like Med Medicare, you know, Medicaid Medicare advantage plans, the Va. etc. Keep up with these advances, you know. So

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William Dombi: You know, those programs tend to be a bit stodgy and you know, to modernize them is really what we need at this point to take full advantage of this great system of healthcare and home that we’re growing. So I’m open to any questions that you might have, that you think the listeners would find some value. And you know anything. Softballs, hardballs, anything you want to throw at me.

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Ruby Mehta: Okay, thank you. Thank you, Bill. I think the 1st question is, we wanna tell our listeners what specific services are covered by Medicare home health. Let’s start with that.

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William Dombi: Well, you know interestingly, the Medicare Home Health Benefit is not much changed from what it was when it 1st started in 1965. It covers. It is a medicalized, a healthcare focused one

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William Dombi: rather than a custodial care one. So you have coverage for intermittent skill, nursing care, physical therapy, speech, language, pathology, occupational therapy, medical social services, home health aide services, and even medical equipment and supplies will come from it. So it’s a it’s a bundled package of services

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William Dombi: intended actually to meet the needs of a vast population of Medicare beneficiaries. Some people once thought it was supposed to be a short term benefit to restore people’s function that continues to be part of it. But so are longer term services for people who have chronic illnesses, people who aren’t even gonna recover, people who might choose to stay at home as life.

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William Dombi: it starts to end for them, but not choosing hospice services. So a very broad, very flexible benefit tied to one other element, the patient has to be what’s known as confined to the home, or the short word being homebound. That doesn’t mean that they’re absolutely unable to leave the home. But it’s gonna be pretty difficult for them to leave the home, and they’re gonna need another person or some sort of equipment to do so. So a benefit that I would describe as

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William Dombi: really well invented back in 1,965 that has changed with the times quite, quite successfully. So it’s not.

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William Dombi: You know, comparable to the benefit that Medicaid may offer for home and community based services which relies mostly on personal care, kinds of support that many people who are elderly or highly disabled W. Will absolutely need a much more of a long term care benefit under the Medicaid program. So

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William Dombi: yeah, 2 very important programs and home healthcare, not the only ones, but 2 very important ones.

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Ruby Mehta: Yeah, yeah, I agree

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Ruby Mehta: in your career. 40 years, almost. Bill, what are the innovations that you have seen in the healthcare industry in general. What are the latest, latest innovations that you’re seeing?

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William Dombi: Yeah, I think it’s a combination that fits into the high tech high touch. Part of what home care is.

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William Dombi: you know innovations, both

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William Dombi: clinical as well as operational back office kinds of innovations very much tied to technology in a lot of ways. And

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William Dombi: I’ve even had personal experiences with them. That I’ll start with that one because it just always comes to the front of my brain. My son needed special healthcare services when he was a toddler.

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William Dombi: and

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William Dombi: most of the time the needs were being met in a hospital. He was getting infused. Various therapies generally antibiotics and like

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William Dombi: and we then

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William Dombi: approached our insurance company, Blue Cross, Blue Shield at the time, and said, Would you consider trying home infusion therapy because there had been some great advances in it.

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William Dombi: It was not in the benefit package and so we traded benefits. And the next thing you know he’s getting the drugs administered at home through home infusion therapy with professional staff combined with my wife and myself doing it, and he never went back to the hospital as a result of it today he would never even be allowed to go to the hospital. In the 1st place, because it is now not just ubiquitous. It is the state of how that care is gonna be delivered

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William Dombi: when it comes down to other clinical innovations. We have home chemotherapy home dialysis going on but most recently the things that stand out are remote, patient monitoring and virtual visits.

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William Dombi: and that’s actually had 2 generations. It it began back in the late nineties

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William Dombi: from a number of companies that are no longer even in the business of doing that, like Kodak, was one of them. Kodak’s not in a lot of business now, but it was getting big into virtual visits and

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William Dombi: it didn’t work at that time as well as it needed to, in terms of even adoption, let alone the technology side of.

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William Dombi: But today you won’t find a home healthcare company or a Hospice, or many other home care companies that are not engaged in virtual visits and remote, patient monitoring. 24, 7, monitoring artificial intelligence connects to it, to try to send warning signs when a patient’s condition might be worsening and needing some attention. So th those innovations have brought efficiency and

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William Dombi: brought depth to the service

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William Dombi: in one other way.

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William Dombi: You can’t always get, say, a clinical specialist in wound care

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William Dombi: to be available at every home health agency throughout the United States at all times, but through those connections, those virtual connections, you could have a home health agency nurse in the home, in person

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William Dombi: connected with

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William Dombi: the nurse specialists dealing with highly complex wounds to be able to deal with, to take care of the patient, including taking the smartphone, putting the camera on the wound, and having a resolution that far exceeds with the human eyes, seems to be able to see so some really incredible advances on the on the technology side to deliver care in the home setting.

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Ruby Mehta: Yeah, yeah, it it has

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Ruby Mehta: improved lately with Covid. Everyone saw the benefit of technology, and

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Ruby Mehta: especially in the and in this industry, I’ve seen a lot of technological development happening in the last few years.

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William Dombi: Well, if you mentioned Covid, you know a tragedy. You know. The pandemic killed

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William Dombi: just millions of people across the world. The

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William Dombi: silver lining was home care, a related one where people became much more aware of their capabilities. I tried to stretch home care and found that it wasn’t gonna break, you know, taking care of people who couldn’t find a bed in the hospital.

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William Dombi: bringing them home with resources that provided you know superb care in a quarantine situation better than they could get if they were in a hospital certainly better than in a skilled nursing facility. So you know as much as we see that tragedy. Sometimes opportunity comes from it as well, and this was one of them.

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Ruby Mehta: True. Yeah, it is.

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Ruby Mehta: Now, changing gears from technology. A little bit here, Bill. But

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Ruby Mehta: I think our listeners would really benefit with this, what’s your take on the Medicaid access, final rule.

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William Dombi: You know, there are a lot of good things in that rule. You know, they relate to protections for

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William Dombi: providing access to care Medicaid homes. A community based service, you know, is the long-term care program in the United States. It far surpasses. Now the nursing home patients. Population under Medicaid spending is greater than that, and that has been a multi decade battle to get there. That included Congressional support and litigation all the way to the US. Supreme Court, as well.

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William Dombi: You know. But Medicaid has always been a program which is under funding

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William Dombi: services.

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William Dombi: Many healthcare sectors faced the same issues that we face in Hcbs.

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William Dombi: and one of them is compounded in the Medicaid access rule, in that the underfunding has led to compensation to caregivers who do incredible work. Keep people at home. Keep your loving relatives, you know, in the home setting many people and the requirement that the rule end up with compensation levels, having 80% of the payment rates spent on compensation to the caregivers, a meritorious goal.

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William Dombi: You know, we absolutely support higher compensation.

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William Dombi: But if the

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William Dombi: rates are under funding the ability to do so, there’s going to be consequences to that. The final rule did have some positives attached to it in terms of improvement.

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William Dombi: defining what goes into the compensation. Calculation was expanded, defining what gets excluded from the overall calculation as a cost, things like nursing supervision to make sure, quality of care being rendered. It doesn’t get into the equation as it did before, but you know, it does in many ways. We look at this rule and say great intentions that execution

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William Dombi: and one of the reasons why I think the Administration chose to go down the path was its commitment

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William Dombi: to helping

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William Dombi: compensate and show the respect for the caregivers, the direct care workers out there delivering the care again, something we support, but at the same time the Administration didn’t have the power to increase payment rates.

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William Dombi: you know, or increase the Federal share of payments. The Administration had tried, but didn’t succeed before Congress to get that added Federal support in the mix that’s there. So we’re concerned that the rule will have an unintended consequence of reducing access to care.

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William Dombi: Fortunately, there’s a 6-year window before compliance deadline comes about, and a lot can happen in that 6 year period of time

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William Dombi: we, we hope that things don’t become adversarial, as it relates to the policy, but that we have, you know, some open-mindedness that occurs relative from the States and increasing payment rates, and from the Federal Government and the Congress to provide some financial support, because in reality, if the State is paying

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William Dombi: $20 an hour for the service.

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William Dombi: You know. $16 an hour is not mathematically possible to provide to that worker and still deliver the care to train the workers

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William Dombi: to pay for the travel time, to get to the person’s home, to do the billing, to stay compliant with program integrity. So again, a lot of positives. We sometimes

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William Dombi: indicate that the 80-20 part of it is, you know, is really going to be not just a challenge. It may be a disaster. But 90% of the access rules are otherwise things that we supported. You know, elements of accountability for the States to make sure that they’re setting up delivery systems that actually deliver care to provide access to care. So this is gonna be a challenging time

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William Dombi: for Medicaid

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William Dombi: home and community-based services for providers for the States, for the, for the patients to get there. We’re hoping

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William Dombi: that at least the rule, you know, leaves one message out there that this is a priority population

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William Dombi: that needs to have high-quality care

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William Dombi: accessible to meet their needs. It’s kinda hard to fix this after the fact. If you don’t deliver care to people, you know, who needs it at that moment. And that we do see them an advancement of

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William Dombi: bills like the better care Better Jobs Act, you know, pending before Congress to to get some real attention

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William Dombi: bottom line. It’s a matter of money matter.

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Ruby Mehta: Yeah.

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Ruby Mehta: yeah. So, Bill, we have been. I mean every conference that I attend and people that I talk to. I hear a lot about the workforce crisis.

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Ruby Mehta: And it’s been ongoing.

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Ruby Mehta: Some agencies. I talked to some providers. They manage their employees really well. And they have strategies in place but overall for the industry. What’s your what have you seen? What? What are your best advices? Just shed some light on workforce management?

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William Dombi: Yeah, yeah, I mean, what we’ve seen is that the cause of the shortage is multi-dimensional.

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William Dombi: You know, you can’t just point to one shortfall compensation rate paid by Medicaid, you know, as a full explanation of all of it. And it’s not just limited to personal care attendance. It’s nursing therapy services as well. Compensation for all of the employee classes in home care, you know, is a challenge, because so much of the care

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William Dombi: is paid for by way of government programs, Medicare, Medicaid, Va, and so on. And if it comes to private pay.

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William Dombi: you’re dealing with a population that is not exactly all deep pocketed. They have a limited amount of money to spend, and they stick with their budget, and so they might deprive themselves of the level of care that they may need.

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William Dombi: but compensation. The financing aspect of it is there. But it goes, as I mentioned, beyond that, safety’s come up often as a reason for the shortage in home care. The nurses in particular, look at home care and question whether or not it is a safe environment to work in and

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William Dombi: home cock care companies have worked hard to create that safe workplace for people. But it’s not like a workplace that they can control, because the person’s going to someone else’s home, and in a neighborhood different than where the office might be, and there are steps that are taken on that but more and more needs to be done. We’re working our own end of it to try to create toolkits to help people do that. But we’ve heard this issue from national surveys of that concern regarding safety of services

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William Dombi: on the home care, aid side of it.

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William Dombi: A factor beyond the aspect of compensation is image and respect and opportunity.

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William Dombi: you know the image is, is not something, then people necessarily aspire to become a home period. Some people do, but you know it’s not. It’s not really at the level of, you know, that kind of positive image getting the respect that it really does deserve when someone’s caring for your loved ones.

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William Dombi: You know, and so that that becomes an aspect of it along with opportunities, opportunities either to stay on that job or opportunities to move up the ladder. Clearly, we could find people who started off as a nursing assistant who ended up with a Phd. In nursing and Deli, you know, running healthcare programs today. But in many cases it might be viewed as a bit of a dead end job. So we need to create those kinds of opportunities along with it.

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William Dombi: When we’re looking at the explanations.

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William Dombi: You can’t ignore 2 other factors, one, the education system.

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William Dombi: we’re losing nurse professors to teach nurses for the next generation. How do we address it in the education sphere? And ultimately beyond that? Do we have enough people in this country

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William Dombi: to fill the jobs that are out there. Homecare aids for one of them in particular. So we end up having a very politically sensitive issue of immigration and coming into the discussion along the way. So multidimensional and multifaceted remedies that are needed to to take care of this. It’s not the 1st shortage we’ve had. But this one is really really deep. At this point.

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Ruby Mehta: Yeah.

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Ruby Mehta: Yeah. And what other challenges do you see in the current homecare system? Bill.

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William Dombi: I think there’s clearly more opportunities than challenges, and they’re clearly challenges to go beyond workforce and financing. But

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William Dombi: you know, I think

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William Dombi: the biggest challenge, probably that we do have is the modernization

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William Dombi: of the various programs that are out there, that finance healthcare services at home, be they Commercial Insurance, Medicare Medicaid, etc. But also one other aspect of things is.

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William Dombi: You know, the healthcare community at large has to take its head outside of the 4 walls that it’s spending most of its time in, you know whether they’re the administrator of a hospital or physician practices and seeing you know. How can things be done in the home setting for me? We’re gaining ground on that day in and day out.

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William Dombi: but there still is a bit of a bias. You know it, and it may be that physicians make more money if they specialize in things to bring people into hospitals. Hospitals continue to attract, you know, just

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William Dombi: billions of dollars to build more hospitals on it. But the challenges are there. But I have seen progress, you know, for example, in the technology sphere, technology healthcare technology companies are focusing their attention on community care even more than they’re focusing on institutional care. So there’s an awareness factor that continues to need to be improved.

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William Dombi: There’s a cultural element of seeing care in the home actually as a reward to somebody for contributing so much in their life as compared to seeing. Going into the hospital. You know, if you have a chance to go to the hospital. You must be special, and they are now special to be in the home setting. But again I

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William Dombi: I’m not kept up at night on the challenges. You know. What keeps me up at night is is all the ideas flowing not just through my brain, but from others to me, and stuff on all the opportunities that are there so

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William Dombi: really, honestly, very bullish on the future of healthcare services at home.

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Ruby Mehta: Yeah, well, thank you so much, Bill. That is the wealth of knowledge that you have. And you shared it with our audience with our listeners today. I wanna thank you for giving us this time. On your Friday afternoon. And I hope you have a great weekend.

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William Dombi: And same to you, Ruby, and thanks again for the opportunity. Very much appreciate it.

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Ruby Mehta: Thank you so much.