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Medicare Advantage’s use of cost-reducing tools such as copays, prior authorizations and restricted provider networks may be preventing home healthcare providers from delivering higher-quality care, according to one home healthcare leader. 

“We’ve seen copays with Medicare Advantage [and] $50 per visit is going to deter people from taking necessary care,” William Dombi, president of the National Association for Home Care & Hospice, said in an interview with McKnight’s Home Care Daily Pulse. “The prior authorization system is going to discourage home health agencies and the attending physician from going to the mat and spending a lot of time, only to get a patient on service who’s going to cost them more money than they’re going to get paid.”

A new study found that MA beneficiaries, on average, receive fewer home health visits and experience worse functional outcomes than traditional Medicare enrollees. More than 285,000 beneficiaries — 178,195 enrolled in traditional Medicare and 107,102 enrolled in an MA plan — comprised a sample in a study published Friday by JAMA Health Forum

MA-aligned participants had an average home health length of stay that was 1.62 days shorter than traditional Medicare patients, or roughly 3.5% less care, it found. MA patients also received 4.9% fewer nursing visits, 2.7% fewer physical therapy visits, 2.9% fewer occupational therapy visits, 5% fewer speech therapy visits and 5% fewer home health aide visits, on average, than Medicare fee-for-service beneficiaries.

Compared to traditional Medicare beneficiaries, MA patients had a greater likelihood of being discharged to the community after receiving post-acute care. However, they were also more likely to live alone, have fewer support resources and have lower odds of functional improvement at the time of discharge. All these factors may reduce MA patients’ level of independence at home and place greater strain on family and unpaid caregivers, according to the study.

Cost-reduction tools

The care differences may be due to the cost-limiting tools at MA insurers’ disposal, the researchers said. One of these, prior authorization, allows MA plans to manage service utilization and thereby reduce costs. Lately, the practice has attracted the ire of lawmakers and home care providers alike as patients report lengthy waits and frequent denials limiting access to care. The Centers for Medicare & Medicaid Services sought to address these issues in its recently proposed Interoperability and Prior Authorization Final Rule, which would require managed care plans to make prior authorization decisions in a more timely manner.

Meanwhile, MA plans’ use of limited provider networks, another common cost-management strategy, often leaves beneficiaries without high-quality options for home health services, Dombi noted.

“The patient population served by Medicare Advantage patients does not tend to get the five-star providers,” he said. “The network is not made up of what’s considered those high-value providers necessarily.”

Home care’s role

Still, the value that home care providers bring to MA plans cannot be understated, according to Dombi. Solutions, he said, can be found through dialogue about home care’s value for MA beneficiaries.

“Medicare Advantage plans should be viewing home health agencies as their best clinical partner because there are really no other levels of care or service sites other than the home that can bring so much value to the plan,” Dombi said. “What you can do is educate the plans — if they will only open up their minds — to that value. If they were to do so, they would say we’re better off if we serve more patients with home health than less, we’d be better off if we have extended stays, and likely we’d be better off if we paid extra to get better care.”