Healthcare policymakers continue to support the move from expensive hospitals to outpatient, ambulatory, and home health settings in ways that will change where and how medical laboratories collect lab specimens
Clinical laboratories have adapted to many changes in the past decade and the increased demand for home healthcare is one of them. Thus, predictions from the US federal Government Accountability Office (GAO) that the number of home care jobs in the US will grow by 40% in the next 10 years will be of interest to medical laboratory managers.
Though “home care” and “home healthcare” differ in their cost and coverages, the GAO clearly expects the trend for treating people outside of expensive hospitals to continue and likely accelerate, requiring the nation’s medical laboratories to find new ways to provide services to the physicians they support, while also creating new systems for collecting laboratory specimens from patients being treated in their homes.
The federal agency attributes the growth in home care to demand from older adults and people with disabilities, the GAO said in its recently released report, titled, “Fair Labor Standards Act Observations on the Effects of the Home Care Rule.” Other experts concur. This is also significant for clinical laboratories because Medicare patients typically use more clinical lab testing services than younger people enrolled in commercial health plans.
“We believe [the GAO’s report] serves as a positive for home health and a negative for hospitals and other brick-and mortar care,” Laffer Healthcare Intelligence (Laffer) wrote in an e-mail to Dark Daily. “While COVID-19 has disrupted demand in some ways, growth in this industry (home care) is expected to grow substantially over time.”
How Home Care Differs from Home Healthcare
Home care differs from home healthcare in significant ways. In its report, the GAO defined home care as “non-medical” help by personal care and home health aides with “activities of daily living such as dressing, grooming, eating, or bathing.”
By contrast, according to Medicare, “In general, the goal of home healthcare is to provide treatment for an illness or injury … Home health care may also help you maintain your current condition or level of function, or to slow decline.”
While Medicare covers much of home healthcare, consumers usually pay out-of-pocket for home care, although some Medicaid programs may cover home care services for those eligible to receive them “as an alternative to institutional care,” the GAO report noted.
The annual median cost of home care is $53,000, while the average cost of a semi-private room in a nursing home facility is $90,000/year, according to a Genworth cost-of-care study on long-term care the GAO-cited in its report.
More than three million people work in home care, “one of the nation’s fastest growing industries,” the GAO report noted, citing 2018 data.
Karen Abrashkin, MD (above), Medical Director of Northwell Health House Calls, examines a patient during a home visit checkup. In a news release, she said, “We know our older, chronically ill patients want to receive medical care at home as long as possible. We are dedicated to providing high-quality care and giving patients access to the appropriate healthcare provided at the right time.” (Photo copyright: Northwell Health.)
Growth in Home Care Mirrors Growth in Home Healthcare
“If home care is booming, so, too, will home healthcare—a setting that has much lower costs for services than acute care hospitals,” said Robert Michel, Editor-in-Chief of Dark Daily and its sister publication The Dark Report. “And one issue for clinical labs is that they will need a way to cost effectively collect specimens from patients who are being provided healthcare and personal care services in their homes.”
The GAO report predicts a huge increase in home care employment by 2030. With more patients opting to be treated at home for high-acuity and chronic healthcare conditions, such massive growth may be coming for home healthcare as well. For clinical laboratory managers, this is a call to step up outreach to the homebound by working with home care and home healthcare providers.
Medical laboratory inpatient test volume may continue to decline as the Medicare hospital readmission reduction program expands in 2017 and state population health programs garner funding
We are now several years into the Medicare program that is designed to reduce hospital readmissions. Statistics from these years show encouraging progress in reducing the readmission rate of Medicare patients. This is a trend that has important implications for all hospital-based clinical laboratories.
Hospitals are the most expensive site of care in the entire healthcare system. In its ongoing battle to reduce healthcare costs, the Centers for Medicare and Medicaid Services (CMS) implemented a carrot-and-stick program called the Hospital Readmission Reduction Program (HRRP) aimed at lowering hospital readmission rates nationwide.
Established in 2013 by the Affordable Care Act (also known as Obamacare), the HRRP lowers reimbursements to acute care hospitals that have high rates of Medicare readmissions within 30 days of initial discharge, and increases reimbursements to hospitals that lower their readmission rates, a March 2017 Kaiser Family Foundation (KFF) Issue Brief explained.
And, according to the KFF, these programs are having an impact. Readmission rates dropped by 8% nationwide as hospitals found ways to avoid the stiff financial penalties and earn the financial rewards. Additionally, patients are increasingly choosing ambulatory care settings, or to receive care at home, rather than re-entering hospitals. This has lowered states’ readmission rates even further.
From a healthcare cost perspective, this is good news. However, these programs have had unintentional consequences as well. The federal initiatives and state population health programs responsible for lowering readmission rates also directly impact medical laboratories by simultaneously reducing the flow of inpatient testing volume.
At the same time, clinicians at the nation’s hospitals—in their efforts to avoid readmissions—have a motive to become more effective at ordering the right medical laboratory test at the right time, and to use the lab test results to more effectively treat the patient. Thus, for the nation’s hospital labs, the Medicare program to reduce readmissions has both an upside and a downside.
Programs, Data Mining That Help Providers Avoid Readmissions
Hospitals nationwide are operating programs aimed at attracting federal financial rewards for keeping people healthy, and from being admitted to hospitals due to conditions that could have been prevented, USA Today reported.
The provider experienced a 20% drop in patients being readmitted within 30 days of surgery, due to its “bundled payment” plan for heart failure, the USA Today article noted. Hip and knee replacement readmissions were down 25% 30 days after discharge as well.
“Without the funding we got through CMMI, it’s hard to imagine we’d be in the position we’re in today,” stated Janice Nevin, MD, CEO of Christiana Care.
Janice Nevin, MD (above), CEO of Christiana Care Health System, Wilmington, DE, is concerned that the upcoming changes to the ACA will affect the funding the healthcare provider has received from the CMS Innovation Center. “I would strongly urge that we keep the commitment to CMMI (because) you have to innovate to learn,” she told USA Today. (Photo copyright: Christiana Care Health System.)
Changes to HRRP for Dual-Eligibles Could Affect Penalties
Some patients are more expensive than others. Patients who draw both Medicare and Medicaid funding simultaneously, for example. These “dual-eligibles” are disproportionately expensive for hospitals to treat, reported Modern Healthcare.
CMS is proposing to adjust penalties in the HRRP to reflect the proportion of patients who are dual-eligible, presumably hoping the change will both lower costs and reduce penalties on healthcare providers.
Hospital Readmissions Data from 49 States
CMS data show that between 2010 and 2015 hospital readmission rates fell by 8%, reported Healthcare Finance News. Other key data recently released by CMS and reported by Healthcare FinanceNews:
· 49 states reduced avoidable hospital readmission rates since 2010;
· Vermont’s readmission rate rose slightly from 15.3% in 2010 to 15.4% in 2015;
· In 43 states, readmission rates fell by more than 5%;
· 11 states had a more than 10% drop in readmission rates;
· The fall in readmission rate translates to about 104,000 hospital readmissions avoided for Medicare beneficiaries in 2015 and 565,000 readmissions averted since 2010; and
· Avoidable admissions, occurring within 30 days of initial discharges, account for more than $17 billion in Medicare annual expenditures.
Action Steps for Clinical Laboratories
Pathologists and lab leaders need to efficiently work with colleagues, especially when caring for hospitalized patients with conditions relative to the HRRP. Clear and patient-friendly discharge instructions for diagnostics are important. And, the lab’s coordination with post-acute-care providers, such as skilled nursing facilities, on follow-up testing is key to avoiding unnecessary readmissions.
