Delta Connect Blog

Rationale and Strategies for the Future from the National Home Care and Hospice State of the Industry Study

Posted by Crystal Parks on Sep 18, 2014 9:00:00 AM

Bob Fazzi, Ed. D, President and CEO of Fazzi Associates, discussed the National Home Care and Hospice State of the Industry Study at Delta’s 2014 National Customer Forum.  During his presentation Bob talked about the rapid change in the industry and what providers can do to be successful.   

During the Balanced Budget Act of 1997, the industry lost 1/3 of the home care agencies and 50% of the revenue that was projected for home care.  For those that survived, how did they do it?  They did it by changing.  Now is the time that significant changes should be taking place again.

Did you know that the U.S. is ranked #1 in healthcare expenditures? Healthcare costs continue to grow and grow and the industry can’t afford this growth.  Why does the industry have these problems?  Part of the reason is the way our healthcare system is structured. 

  1. Service specialization dominates
  2. Payment is specialty and silo focused. Everyone who serves the patient gets paid.
  3. Patient is viewed as a revenue source.
  4. Quality and cost are rarely related.
  5. Health care is highly fragmented and not an integrated system.

According to Bob, the industry needs to deal with these issues and create systems that will deliver health care at lower costs with higher quality outcomes.

What are some of the issues you need to look at as you begin looking at the changes taking place? You should be looking at competitive insights on your competitors and the industry so that you can make informed decisions.  And you should be ready to respond to Strategic points.

Through a four part blog post, Delta will provide Bob’s insights for the following questions:

  1. What do the industry changes mean for you?
  2. What should you do about the changes? 
  3. What is the rest of the industry doing? 
  4. What should you do for the future? 

Delta invites you to download the free National Home Care and Hospice State of the Industry Study to have the trend and best practices you need to manage your agency.


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Topics: Healthcare IT, home care industry, hospice industry, healthcare technology, homecare industry

Update on Hospice Quality Reporting Program

Posted by Crystal Parks on Sep 16, 2014 1:51:22 PM

Earlier this year hospices submitted data to CMS on two quality measures that impacted the 2015 payment year. Specifically, hospices had to submit data on two measures – a structural measure and the NQF #209 pain measure – by April 1, 2014. The data was collected by the hospices during calendar year 2013. On August 18, 2014 CMS released the analysis of this data, Hospice Quality Reporting Program Fiscal Year 2015 Reporting Cycle Data Analysis. Approximately 3,500 hospices submitted and attested to the data for both measures.

Nearly 100% of hospices answered “yes” to the only structural measure question: “Does your QAPI program contain 3 or more patient care related quality indicators?” This is consistent with the prior year’s response.

The findings from the FY 2015 closely mirror those from FY 2014 for both the structural measure and the NQF #0209 measure. This is true despite the fact that FY 2014 was based on one quarter of data and FY 2015 was based on four quarters of data. These findings support CMS’s decision to discontinue both measures for future reporting cycles in favor of implementing patient-level data collection using the Hospice Item Set (HIS) in the HQRP to collect standardized data to calculate seven QMs (six NQF-endorsed QMs and a modification of one NQF-endorsed QM).

Read more in the NAHC Report article


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Home Care Needs Unmet for Canadians

Posted by Rachel Alden on Sep 12, 2014 2:25:45 PM

Statistics Canada released a report this week entitled Canadians with Unmet Home Care Needs. The report provides information on Canadians who need home care and report that they do not receive either enough home care or any home care.

Statistics Canada and author Martin Turcotte listed the following key points from the report:

  • In 2012, 2.2 million individuals, or 8% of Canadians 15 years of age and older, received help or care at home because of a long-term health condition, a disability, or problems related to aging.
  • In 2012, nearly half a million Canadians, or 461,000 individuals 15 years and older, needed help or care in the 12 previous months for a chronic health condition, but did not receive it. They are referred to as persons with ‘unmet’ home care needs.
  • Of the 2.2 million Canadians who received home care in 2012, 15% (331,000) did not receive all the help needed. They are referred to as persons with ‘partially met’ home care needs.
  • Home care recipients with a physical disability were more likely to have partially met needs (18%) than care receivers without a disability (10%).
  • Persons with unmet or partially met needs reported higher levels of stress and negative feelings. For example, 62% of care recipients with partially met needs experienced loneliness, compared with 31% of those whose needs were met.


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Topics: home care industry

NAHC Reports Companionship Exemption Lawsuit Progress

Posted by Rachel Alden on Sep 3, 2014 9:17:34 PM

The NAHC Report shared an update today on the companionship overtime exemption lawsuit. We have included an excerpt from that article for you. Please share your comments with us.

The lawsuit challenging the US Department of Labor (DoL) rule that effectively eliminates the application of the overtime pay exemptions for companionship and live-in domestic services is rapidly progressing in federal court in Washington, D.C. The National Association for Home Care & Hospice (NAHC), along with its co-plaintiffs, filed a reply this week to the US Department of Labor’s efforts to dismiss the lawsuit that followed the plaintiff’s Motion for Summary Judgment.

In its filing, the DoL argues that it has the power to reinterpret the Fair Labor Standards Act exemptions - even if those new interpretations are in complete conflict with the nearly 40 year-old standards. Those standards have been consistently applied by the DoL since 1975 - and have been defended intensely at the U.S. Supreme Court by the Department.

The DoL has attempted to convince the court that it is only interpreting an ambiguous law and that its interpretation should be accepted unless it is irrational, arbitrary, or capricious. In that regard, DoL explains that the home care industry has changed greatly since 1975 and that workers are now engaged in caregiving as a vocation, not simply helping family and friends.

NAHC and its co-plaintiffs responded with full force. Amplifying the positions taken in their original brief, NAHC and co-plaintiffs argue that the plain language of the law is very clear: Congress intended the exemptions to apply to “any employee” in the respective positions regardless of the identity of the employer. Further, NAHC argues that the law focuses on employees who provide care to persons with disabilities and infirmities, not on their employers. The consumers of care and the nature of the work by the caregivers have not changed since 1975. Its use has grown significantly since 1975, but the work itself is very much the same.  Given that the DoL itself estimates that 98 percent of companionship services workers will be outside of the overtime exemption if the new rule is allowed to stand, NAHC and its co-plaintiffs argue that DoL’s changes are irrational, arbitrary and capricious as Congress’s intended beneficiaries of the original exemption, the vulnerable and needy consumers of care, will be deprived of the intended benefit of affordable care. As such, DoL’s “changes in the industry” explanation does not fit.



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Topics: private duty home care

Free Hospice Teleconference

Posted by Crystal Parks on Aug 29, 2014 12:12:16 PM

NAHC and the Hospice Association of America will be hosting a free hospice teleconference on Thursday, September 4 at 1:00 p.m. Eastern Time.  During the "What Do the CMS' Hospice Cost Report Changes Mean to You?" teleconference, experts will discuss the significant implications of these changes for hospice. Experts include Val J. Halamandaris, NAHC President; Theresa M. Forster, NAHC Vice President for Hospice Policy & Programs; Katie Wehri, Hospice Operations; Robert J. Simione, Managing Principal, Simione Healthcare Consultants, LLC. Providers will have the ability to ask questions regarding the final version of the Hospice Cost Report changes.

The final version of the Hospice Cost Report was posted on the CMS website on Friday, August 29, 2014. As anticipated and reported previously by NAHC, CMS has made minimal changes between the version release in November 2013 and the final instructions and forms. 

To reserve your space, send an email to Cheryl Lee ( The first 300 to email will participate, members will be given priority. The call-in number is 1- 800-289-0459; the conference code will be emailed prior to the call. 


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Virtual Private Duty Marketing Master Class

Posted by Crystal Parks on Aug 28, 2014 2:07:52 PM

Private duty providers have the unique opportunity of attending Stephen Tweed's Private Duty Marketing Master Class virtually as part of Delta's virtual National Customer Forum. Having this class virtually will help attendees keep their costs down.virutalconference

Stephen will conduct the Marketing Master Class on September 10th from 8:30 am to 4:30 pm Eastern, and non-medical home care providers are welcome to register and attend the entire workshop for only $49! Simply register for the September 10th access. 

The timeline for this virtual program will be different and condensed into one day; however, you'll still receive all the benefits of the Private Duty Marketing Master Class. View the condensed schedule

Unable to attend the live virtual workshop?  You can still register for the Private Duty Marketing Master Class and view the workshop on-demand at your leisure.  

We hope you can join us for this virtual class!


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World Growing Grayer at a Break-Neck Pace

Posted by Rachel Alden on Aug 22, 2014 4:10:36 PM

CNNMoney posted in an article that by 2020, 13 countries will be "super-aged" -- with more than 20% of the population over 65 -- according to a report by Moody's Investor Service. That number will rise to 34 nations by 2030.

The article focuses on the negative impact on economic growth in upcoming years. However, the news means that the home care industry faces tremendous opportunities around the globe.

Click here for an interactive map showing when the nations will reach "super-aged" status. 


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Topics: home care industry

IN FOCUS: The FY2015 Hospice Payment Rule - Gear Up for Policy Changes

Posted by Lorraine Lodigiani on Aug 21, 2014 10:11:19 AM

Late Monday, August 4, the Centers for Medicare & Medicaid Services (CMS) issued a final rule governing hospice payment for fiscal year (FY) 2015: Medicare Program; FY 2015 Hospice Wage Index and Payment Rate Update; HospiceQuality Reporting Requirements and Process and Appeals for Part D Payment for Drugs for Beneficiaries Enrolled in Hospice.  PLEASE NOTE: this link will no longer work after publication of the final rule in the Federal Register, which is scheduled for Friday, August 22.  

The rule includes final payment rate information for the forthcoming federal fiscal year.  It also finalizes some key hospice policy changes and reminds hospices that other, previously-announced changes will become effective on October 1, 2014. If hospices have not previously begun to prepare, they are advised to do so now.

  • Imminent hospice policy changes addressed in the final regulation are as follows:
  • Timeframes for Filing the Notice of Election (NOE) and Notice of Termination/Revocation (NOTR)
  • Timeframe for Hospice Cap Determination and Overpayment Remittance
  • Addition of the Attending Physician to the Hospice Election Form
  • Coding Guidelines for Hospice Claims Reporting
  • FY2015 Final Payment Rates

This article provides in-depth focus on policy changes related to timeframes for filing the NOE and NOTR. Future articles will address other forthcoming changes.


Previously CMS has not imposed a time frame for submission of a notice of election (NOE) other than directing hospices to submit the NOE as soon as possible.  Similarly, there has been no requirement for filing of a Notice of Termination or Notice of Revocation (NOTR) and no explicit time frame for filing of a final hospice claim other than the existing one-year limit on claim submissions.  However, in recent years, delays in submission of hospice NOEs and filing of final claims have led to inaccuracies related to patient status in the CMS systems.   

These inaccuracies have been particularly problematic in efforts to ensure appropriate coordination of benefits for hospice patients with Part D prescription drug coverage.   As a result, earlier this year CMS proposed that hospices submit an NOE and NOTR within 3 days of the patient’s election date or patient’s termination or discharge date, respectively.  CMS finalized the rule with a timeframe of 5 days after the election date for filing of the NOE and 5 days after the termination/revocation date for the NOTR if the hospice has not filed a final claim.
Please note:  As of this writing, CMS has not issued instructions to its Medicare Administrative Contractors (MACs) to implement the timeframes for filing of the NOE and NOTR. It is unclear whether or not CMS will be able to enforce the NOE and NOTR filing requirements effective October 1.


Requirement: Effective October 1, 2014, hospices must file the NOE within five calendar days after the effective date of the election.

  • Timely filing is considered having the NOE submitted and accepted by the Medicare Administrative Contractor (MAC).
  • The date of election will count as day zero, so if a patient were admitted on a Thursday, the hospice must have the NOE filed, submitted and accepted no later than Tuesday.

Consequence: Hospices that do not submit the NOE in a timely manner cannot be reimbursed for any days of care prior to acceptance of the NOE by the MAC:

  • The hospice cannot charge the beneficiary for hospice care during this time and must continue to provide hospice care to the beneficiary.
  • CMS refers to these as ‘provider liable’ days.

Tips and Notes:

  • The NOE must be filed by DDE, mail or courier.
  • CMS did state they would look into the possibility of submitting the NOEs electronically but until then hospices must submit them via DDE, mail or courier.
  • Hospices should ensure that they are able to get the NOE submitted via DDE and develop a back-up plan for mailing or delivering the NOE by courier to the MAC should the ability to submit it via DDE be interrupted and the situation does not meet one of the four exceptions.
  • This may require a change in scheduling and staffing of personnel submitting the NOE.  For instance, if the person(s) submitting the NOEs does not come into the office at least weekly, is on vacation, or unexpectedly not able to submit the NOE, another staff member will need to be trained to submit the NOE and verify that it has been accepted.

There are four circumstances that may be eligible for an exception to the timely filing requirement.  The hospice must document the situation meeting the exception and request the exception.  

Only if the MAC grants the exception are the consequences waived for the hospice. MACs will provide hospices with information about exceptions processes/policies in the future.  The four situations CMS listed for exceptions are:

  1. Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate;
  2. An event that produces a data filing problem due to a CMS or MAC systems issue beyond the control of the hospice;
  3. A newly Medicare-certified hospice that is notified of that certification after the Medicare certification date, or which is awaiting its user ID from its MAC; or
  4. Other circumstances determined by CMS to be beyond the control of the hospice.

CMS stated in its comments that it will not allow exceptions for hospice personnel issues; internal IT systems issues that the hospice may experience; the hospice not knowing the requirements; and failure of the hospice to have back-up staff to file the NOE.

NAHC and HAA recommend that hospices:

  • Add a compliance audit to their program that audits for the submission of the NOE within the required timeframe and process for documentation that the NOE has been accepted by the MAC;
  • Modify processes and staffing as needed to ensure compliance;
  • Develop a back-up submission plan;
  • Modify policies and procedures to reflect this new requirement, its exceptions, and the hospice’s modified processes, and;
  • Make every effort to submit and have the NOE accepted as soon as possible after election as CMS indicates it may consider shortening the five day requirement in the future.

NOTR (Notice of Termination/Revocation) FILING Requirement  

Effective October 1, 2014 hospices must file the NOTR within five calendar days after the effective date of discharge or revocation, unless the hospice has submitted a final claim.

  • Timely filing is considered having the NOTR submitted and accepted by the Medicare Administrative Contractor (MAC).
  • The date of revocation or discharge will count as day zero so if a patient revoked on a Thursday, the hospice must have the NOTR filed (submitted and accepted) or a final claim submitted no later than Tuesday.

Consequence:  CMS will not impose any consequences for late filing of the NOTR - or not having a final claim submitted - at this time but will consider doing so in the future.  Late filing of the NOTR could negatively impact a beneficiary’s access to Medicare-covered items and services. It could also have negative consequences for any hospice provider taking the patient onto service following the termination or revocation.

Tips and Notes:

  • CMS has not issued final instructions to the MACs to implement the NOTR requirement but it is likely that CMS will require use of bill type 81B as the NOTR.
  • If this is the case, significant systems changes will be needed.  
  • Forthcoming instructions to the MACs will provide additional detail.

NAHC and HAA recommend that hospices:

  • Add a compliance audit to their program that audits for the submission of the NOTR or the final claim within the required timeframe and process for documenting acceptance by the MAC;
  • Modify processes and staffing as needed to ensure compliance
  • Develop a back-up submission plan;
  • Modify policies and procedures to reflect this new requirement and the hospice’s modified processes, and;
  • Make every effort to submit and have the NOTR accepted as soon as possible after termination/revocation as CMS indicates it may consider shortening the five-day requirement in the future

NAHC has submitted several questions that have been raised by hospice providers specific to implementation of the NOE/NOTR requirements to the MACs and will provide responses and additional details as they become available.  

Additional updates will be featured in future issues of NAHC Report and Hospice Notes.

From the NAHC Report article


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Topics: Hospice Payments

Home Infusion Demo Maps A Way Forward For Future Medicare Changes

Posted by Lorraine Lodigiani on Aug 19, 2014 12:02:52 PM

A Medicare demonstration project bundling payment for home infusion of intravenous immune globulin (IVIG) maps a potential way forward for future reimbursement changes involving home infusion more broadly, which would benefit larger providers like BioScrip, Walgreen, CVS, Express Scripts, privately-held Diplomat that recently filed an S-1 and privately-held AxelaCare Health.  While the demonstration will have limited impact in the near term, given that insurers tend to piggy back on Medicare even though it comprises less than 15-20% of the industry payer mix for specialty home infusion providers, the policies CMS wants to test could have reverberating effects among all insurers and bring consistency to the current haphazard state of home infusion reimbursement. 

Any benefit from such potential changes would come on top of various positive underlying factors: (1) a growing Medicare population; (2) expansion of insurance coverage; (3) the need for insurers and/or PBMs to have sufficient pharmacy networks that offer specialty and home infusion drugs; (4) an increased emphasis on cost-effective strategies, especially those designed to keep people in the home; and (5) the fact that many infused therapies lack treatment alternatives for chronic conditions like immunodeficiencies, autoimmune disorders, and hematologic disorders.  These factors have led to some consolidation among this fragmented industry over the years [e.g. Walgreen's purchase of Express Script's CuraScript and Omnicare's Option Care; Express Script's merger with Medco and its Accredo unit; CVS's purchase of Coram from privately-held Apria; BioScript's buying spree of CarePoint, HomeChoice Partners, and InfuScience; and Diplomat's purchase of privately-held MedPro Rx.]

Recently, CMS said it is setting up a three-year demonstration project to bundle payment for IVIG supplies and services for home use to Medicare beneficiaries who are not home-bound or receiving home health. Ordered by statute and starting in October, the project is restricted to 4,000 patients with primary immune deficiency disease (PIDD).  Although limited in scope, this project is being watched by CMS, MedPAC, policymakers, and patient groups to monitor access, compliance, and healthcare outcomes to see if this design can apply to home infusion more broadly, considering that more people are entering the system and suffering from chronic illnesses that may be more cost-effectively treated in the home.

The current reimbursement framework for home infusion is convoluted. Most insurers and government programs pay a separate rate for the infused therapy - and potentially a per-diem amount for the supplies, equipment, and pharmacy services - and another amount for nursing.  Medicare heeds this piecemeal approach but often does not reimburse for the supplies and nursing, since such coverage depends on the actual therapy, patient's illness, and circumstances.  Given that insurers use Medicare as a guide, any policy changes to make home infusion more comprehensive would be felt more broadly, including potential disruption to smaller operators lacking the infrastructure to handle the service/patient volume or absorb cost increases. 

Medicare's various forms of home infusion:

  • Home infusion for IVIG is reimbursed under Medicare Part B for patients with PIDD at a statutory rate of 106% average sales price.  Unless the beneficiary is homebound or eligible for home health as part of post-acute care, CMS won't pay for any nursing or supplies to administer IVIG.  Additionally, most Medicare claims for IVIG are for other illnesses and are not reimbursed under this paradigm, often forcing patients to be treated outside the home, at a cost to the government.
  • Home infusion for select anti-infective, chemotherapy, inotropic, and pain management therapies may be paid under Medicare Part B at a different rate, but only for (1) certain indications; (2) homebound beneficiaries; and (3) administration with an external infusion pump - thus triggering Medicare's durable medical equipment benefit.  CMS will not pay for nursing care unless the patient is eligible for home health.
  • Home infusion for other treatments, such as antibiotics or rheumatoid arthritis, off-label indications for the therapies above, or for beneficiaries that are not homebound, Medicare Part D provides the treatment and reimburses the home infusion pharmacy at a negotiated rate, but it does not reimburse for any ancillary supplies or nursing service.

From the NAHC Report Article. The article was written by Beth Mantz Steindecker, Vice President, Health Care Analyst at Washington Analysis, an institutional research firm 


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Topics: Home Care reimbursement

Agency Lessons After California Supreme Court Decision

Posted by Rachel Alden on Aug 15, 2014 1:21:43 PM

Earlier this week, NAHC posted an excellent article following the California Supreme Court decision that the caregiver assumes risks when working with dementia patients. We wanted to point out the list at the end of the article which shares a few lessons for home care agencies as a result of the decision.

First, the agency-employer should make sure that the assigned workers are fully aware of the care setting and client’s condition on all assignments. This will help manage risks and put competent workers into the care of clients.

Second, home care agencies should provide adequate training and support for workers specific to the nature of the clients they serve. For example, serving clients with a form of dementia requires directed training and support that is different than providing services to individuals with physical disabilities.

Third, agencies should take all reasonable measures to reduce foreseeable risks in the home care environment that are due to any hazardous condition related to the nature of the client and her care needs. 

These steps help manage risks that a worker will be injured, clients needs will not be met , and agencies will fail to adhere to community standards of practice and/or licensing laws and accreditation standards. In addition, it will reduce the risks of litigation that involves any and all of the stakeholders involved.

What other advice or thoughts would you share?


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