Thursday, July 19, 2018
Health

Insurance companies turning to home health care in a big way

NEW PORT RICHEY — After the hospital released her in December, Betty Herz got a call from her Medicare Advantage company.

It wasn't about the bill.

Instead, a representative from Humana posed a question: Would she like to have a care manager visit her New Port Richey home free of charge?

Herz agreed. She had recently been diagnosed with myasthenia gravis, a rare autoimmune condition that causes debilitating muscle weakness, and was having trouble adjusting.

"I thought this would be a big help," she said.

Across the country, the number of seniors enrolled in in-home care management programs is exploding. Humana's program, Humana at Home, serves nearly 1 million people nationwide, 37,000 of whom live in Florida, and is growing by about 1,500 members daily, said Kate Marcus, director of telephonic care management.

Insurance companies say the programs, usually offered through their Medicare Advantage plans, can help keep seniors out of the hospital, and even extend their lives.

"A lot of what we focus on is helping people understand their conditions," Marcus said. "We want to make sure someone who has diabetes and COPD and rheumatoid arthritis understands how to manage those three things."

But the programs have also come under scrutiny from federal health officials, who have questioned whether home visits are just a way for insurers to bring in more revenue.

• • •

With about 1,800 employees, Humana at Home is based in St. Petersburg and is one of the area's largest employers. Several hundred people alone staff the call center.

The program launched in 2004 as a joint effort by Humana and the pharmaceutical giant Pfizer to address the needs of high-cost Medicare users. What was then called Green Ribbon Health later became part of Humana.

Humana at Home is available to Medicare Advantage members in 49 states. Participants are selected based on the severity of their health problems. Most receive care over the phone. Those with the most acute needs qualify for home visits.

The social workers and nurses who make home visits don't provide hands-on medical treatment. Rather, they assess the member's general health, activity level and risk of falling, and make sure they are following their health management plans.

"We also coordinate things like transportation with their church, meal delivery, etc.," Marcus said. "We try to go beyond the traditional types of care."

Herz's care manager, a veteran social worker named Laura Moore, comes weekly.

Of late, Herz's biggest issue has been the cost of her pills. One prescription, a drug called pyridostigmine bromide, costs $116 a month.

For the past several weeks, Moore has been searching for discount prescription drug programs for which Herz is eligible. She has also been working with Herz's neurologist to get the medication placed on a different "tier" so it costs less.

"We've done a lot," Herz said.

• • •

There's a reason Humana at Home is growing. A recent internal analysis found participants had 45 percent fewer hospitalizations than expected. Another peer-reviewed study found participants were 26 percent more likely to live longer.

The lower hospitalization rates benefit participants, who are more susceptible to infection during hospital stays, said chief of operations Craig Drablos. But it also saves Humana money.

"The savings we generate, we put back into the benefits for the following year," Drablos said, explaining that increased savings can drive down premiums and co-pays.

Aetna, the insurer that is acquiring Humana, has called Humana at Home an example of "high-quality clinical care" that keeps people on their medication.

Other companies have followed suit.

As of 2015, OptumCare had made more than 1 million home visits to UnitedHealthcare Medicare Advantage beneficiaries, said Scott Theisen, OptumCare executive vice president.

Its program, known as HouseCalls, works a little differently. Physicians assistants and nurse practitioners use visits to measure members' body mass index and blood pressure, and conduct blood-sugar screenings.

Outside of Medicare, Tampa-based insurance company WellCare offers home visits to more than 10,000 members enrolled in its Staywell Health Medicaid plans in Florida.

Like Humana, WellCare connects members with community-based organizations that can help with meals, transportation, shelter and clothing, said Michael Radu, senior vice president of clinical operations.

"The care plan depends on what the member wants," Radu said, noting the member's priority might be as small as attending bingo night.

• • •

Despite its growing popularity, home care management has been controversial. An investigation by the Center for Public Integrity in 2014 found that as the number of home visits had ballooned, so too had the "risk scores" insurers submitted for payment, putting upward pressure on Medicare costs.

The Centers for Medicare and Medicaid Services weighed in, raising concerns that in-home assessments were "merely a strategy by (Medicare Advantage) plans to find and report more diagnostic codes to CMS, generating higher levels of coding and, therefore, payment than assumed under our risk adjustment methodologies."

Last year, CMS considered a change to Medicare policy that would exclude some information and diagnoses obtained during in-home visits from the risk-score calculations.

The proposal "opened up Pandora's box," said Tricia Neuman, director of the Kaiser Family Foundation's Program on Medicare Policy.

Amid strong pushback from the insurance industry, CMS backed off.

Neuman said both sides of the debate had merit.

"On the one hand, for people who are frail and living at home, it can be very beneficial to have someone come to their home," she said. "But there's also some evidence that shows the risk assessments have been used by some to do upcoding."

Herz says she is glad Humana at Home will continue.

"I was totally lost when I got the diagnosis," she said. "Now, I feel like I'm headed in the right direction."

Contact Kathleen McGrory at [email protected] or (727) 893-8330. Follow @kmcgrory.

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