Home healthcare needs shoring up

ONE OF THE MANY challenges facing the Massachusetts health care system today is how to handle the increasing need to provide care for the state’s most vulnerable populations, including individuals with complex behavioral health needs, age-related illness like dementia, and chronic medical conditions.

The goal is to get patients back home whenever possible following medical treatment.  In many cases there is a need for ongoing care in the home provided by a nurse or other home health care professional who visits to administer medication, take vital signs, tend to wounds, assist with daily living activities such as bathing and dressing, and generally assess patient needs according to a plan of care.  This enables patients to have continuous access to the care they need.  Many of the most vulnerable are covered by MassHealth, the state Medicaid program.

What many may not realize is that home health care is the foundation for a stable, more cost-effective health care system in Massachusetts.

The value proposition is clear: The cost to MassHealth for daily home care visits is about $25,000 per patient per year – compared to roughly $38,000 for a single hospitalization, which on average lasts four days.  An ambulance trip to the hospital costs nearly $1,000 – a potentially preventable expense equal to 15 home visits by a nurse.

The state invests in home health care services, setting reimbursement rates for MassHealth.  The level of funding has fallen short of the true need for years, creating a damaging cumulative effect, and is now complicated by the fallout from the pandemic.

Nursing shortages, a prevalent problem across the health care industry, have hit home care particularly hard.  Compared to the hospital or office environment, caring for complex patients in their home requires an unusual skillset that is not as easily replaced.  During the height of the COVID-19 crisis, home care nurses heroically delivered care, including vaccines, to isolated, homebound patients.  Unfortunately, now nurses are leaving home care in greater numbers for better-paying jobs in other parts of the health care system, and many are leaving Massachusetts altogether for areas where housing is less expensive.

Home health care agencies also face higher administrative costs, negatively affecting their ability to offer competitive wages and invest in workforce development.  Onerous prior authorization requirements add tremendous administrative cost and complexity.  Yes, the state needs to ensure that care is going to people who are eligible to receive it, but the process for doing so is broken. This widens the chasm between home health and other providers that are competing for clinical staff.

The state has proposed a rate increase of 2.3 percent in nursing-related rates.  This does not come close to matching the dramatically elevated costs of hiring clinical staff in 2023, particularly when considering that home health agencies must compete with better-funded institutional employers like hospitals.

The irony is that if home health agencies can’t hire nurses to take care of patients at home, those same patients will end up in a hospital at an exponentially higher cost.  Home health patients often have multiple co-morbidities and need highly specialized, yet compassionate, care.  Without proper compensation, these patients’ access to care will be limited, only furthering the health inequity that MassHealth has vowed to overcome.  Many of these patients are seniors who were once among the hardest-working people you would ever meet.  When they were younger and had their health, they made our communities run, building roads, delivering mail, and teaching our children.  Many others are often immigrants and do not speak English as a first language, or sometimes at all.

We are already seeing some home health agencies forced to retreat from service areas because of the staffing constraints, creating greater health disparities in access to quality, affordable care for those who are covered by MassHealth.  More patients who wish to remain in their homes and communities – avoiding nursing homes, which also cost the state much more – will struggle to access the needed home health services.

This will stretch our health care system in ways we haven’t yet experienced.  It will aggravate a hospital emergency department “boarding” crisis that is already the worst ever seen, as patients move back and forth between hospital and home. While policymakers may seek to replace nurses with non-skilled caregivers, the skilled care that patients need demands a licensed clinician.

We need to shore up, not shortchange, home health care so that other parts of the system can also operate effectively and efficiently. The patients are counting on us.

Attorney Paul W. Shaw is a partner at Verrill. He represents home health care agencies.