This post describes the impact of Medicare Part A and MA Reimbursement on HHAs grouped by their size using annual census. It reveals a successful strategy for dealing with Medicare Advantage leveraged by Small agencies.
In my last post, we divided up HHA cost report data by agencies defined by the way they are organized or how they view themselves as entities. In this post, we will explore revenue cycle differences based on a less complex variable, their size.
This story started when I put together a dashboard with simple counts of each of the metrics I was using in my posts. The main reason for doing this is to create a way of catching errors that might be reflected in the charts. These values are from the combined 2020 - 2023 cost reports. The averages are for all HHA cost reports which are defined by their HHA CCN and by fiscal year.
What struck me was the bottom row, average industry visits per census for Medicare Part A and MA are nearly identical, but Medicaid is almost three times higher. If the definition of a census is the same in all three settings, what would be the reason for this?
As it turns out, it is the other two averages, Medicare visits per census and Other (MA) visits per census, that provide the more interesting insights regarding HHA revenue cycle performance.
Medicaid only covers 3% of the total census for HHAs during the period of these reports. The visits are nearly triple that of the Medicare plans, but it is a small part of the total so the national average is unaffected. When we look at revenue in the cost reports, we can see that Medicaid pays much more per census than Medicare. Could there be a relationship between the higher visits and the higher revenue?
Exploring Medicaid reimbursement to the extent it would require to figure this out is beyond my ability. Each state has at least one plan. Each plan is allowed to create any sort of process they choose for distributing reimbursement to HHAs, assuming the service is covered. The complexity that this creates in revenue cycle management, especially for HHAs that cover multiple states, can be the subject of many future posts.
Medicare Part A reimbursement is straightforward. Assuming the LUPA visit threshold is met, your claim is processed through the PDGM formula and a predictable payment is received in about 10 days.
MA plans are much more like the Medicaid plans. They are free to implement any revenue cycle strategy they choose for reimbursing providers as a MA plan. They are motivated by three requirements for their revenue cycle process:
They must cover all Medicare Part A and Part B services.
They must pay out at least 80% of their premiums, but no more.
They must maintain an adequate network of providers for these covered services.
To maintain this network, they must provide coverage that will be accepted by these providers. This commercial health plan revenue cycle business model between these plans and healthcare providers has existed for a long time and little has changed. As I discussed in a previous post, hospitals have much higher reimbursement from commercial health plans, compared to Medicare, than what these plans pay HHAs.
Either these hospitals are much better at negotiating their rates, or they are able to bargain from a superior position of strength compared to the HHAs. These hospitals are often not individual facilities, but have their own definition of connected entities or “enterprises”, like we found in HHAs. These large healthcare networks can carry a big stick and in many cases, they can decide if a MA plan can even survive in their coverage area.
Could this type of dynamic exist between our HHA enterprises or large HHAs and these health plans? Might some agencies be more successful in obtaining better reimbursement? If so, what metric or KPI might identify these agencies or measure this?
The problem with the enterprise entity I used a couple posts ago is that it only works for 2022 and we have cost report data for three years. Another issue is that there are many HHAs that are a single entity by CCN that are very large and would be very influential in their markets. I do not want to lump them in with the smallest of agencies.
This time, I thought I would group them by size using annual census. The average HHA annual census from our first chart for 2020 - 2023 was 978 per fiscal year for a specific agency by CCN. To compare them by size, we need to create a small number of groups by census range. I found that these ranges create four groups by annual census that each include significant portions of our agency cost reports by either percentage of the total agencies or percentage of the total census. These are the percentages using 2021 cost report data, I will refer to them by t-shirt size:
The first significant insight when looking at these groups comes when we look at the ratio of Medicare Part A census to MA by HHA size. At the industry level, these two Medicare reimbursement models are almost equal by census, trending toward MA, but when we look at this KPI by the size of these agencies, we get a different picture.
It is clear that Small agencies have a much larger percentage of Medicare Part A patients than larger ones and there seems to be a direct relationship between agency size by annual census and the percentage of Medicare Part A patients.
Going back to some of the more familiar KPIs we measured by enterprise groups and for the industry in total, here are the industry totals (green) and the breakdowns by size for Medicare Part A profit margins by year.
It looks like the agencies with the highest percentage of Medicare Part A patients, have the lowest profit margins under Medicare Part A. Not a good combination.
Let’s look at visits per census for Medicare broken down by size:
We can see a connection between size and visits per census, especially when looking at Small and XL. As CMS has noted, visits decreased under PDGM compared to the previous payment model. This cost report data shows that they hit a floor in 2022. I believe that the difference in visits from 2019 to 2022 is the difference in visits supported under PPS compared to what is required without any visit incentives other than providing quality care. This difference is what fuels the current CMS behavioral adjustments. CMS states proudly in the final rule, the BA affects all agencies equally. The profit margins by HHA size shows that it does not.
This large variance in visits between Small and Large agencies is related to their very different capacity to scale this industry effort to lower visits under PDGM. This scaling issue is the basis for the incorrect estimations by CMS when estimating expenses under each of the final rules. They assume that any reduction in visits has a direct and immediate impact on HHA costs for all HHAs by the ratio of the visit reduction to the previous visit total.
The truth is that smaller agencies with less staff are unable to reduce costs by reducing visits until the total visits reduced is equal to or greater than what can be performed by one FTE. For a large organization, they can manage this clinician supply directly in proportion to visit cuts. A small agency cannot make changes in staff through these visit reductions so they make these visits anyway.
Now let's take a look at the same data for Other insurance or the MA plans.
Now we see MA profit margins with the Small HHAs being the best performers and the XL ones as the worst. Once again, the opposite of the ratio of how these patients are distributed to these provider groups.
Here are the associated visits per size group under MA:
As we see in the original chart in the post, the national averages for Medicare Part A and MA visits per census are almost the same. This is also true when you compare Large and XL over these years, but Small agencies provide many more visits to MA patients than they do for Medicare Part A. By year it is 57%, 93%, 55%. This is hidden in the overall data because of the relative size of this census population (10%).
Just like the Medicaid data at the beginning of the post, it appears that there might be a connection between visits and revenue under MA.
In our last post, we developed a new KPI called Operating Efficiency and discovered that the top 10 enterprises in 2022 most successfully leveraged this strategy to improve margins. Looking at this KPI now by size and by year, we can see that it is declining for all the sizes, except for the Medium HHAs that seem to be improving. It might be that this range of agencies by census is the “Goldilocks” size for HHAs when it comes to leveraging Operating Efficiency.
Now let’s look at agencies reporting a negative net income on the cost report.
Small agencies lead the way, but all groups are getting worse each year. In fact, the Large and XL groups had the largest net increase in HHAs reporting a loss from 2021 to 2022.
Small agencies have the best margins under MA and the lowest for Medicare Part A, the opposite is true of the largest ones However, Small agencies are 70% Part A and XL ones are only 37%. Each group has a majority of their patients covered under the plan with their lowest performing margins.
If we look at Medicare Part A and MA combined, we can get a total picture of the impact of both of these plans on HHA profit margins by size:
We can see that the best performers by 2022 are the Small HHAs. Even though they are only 30% MA, their successful strategy in dealing with MA has mitigated the damaging impact MA plans have on the rest of the HHAs.
Like Operating Efficiency, the Medium HHAs seem to be adapting to these revenue cycle issues and they are steadily improving their overall Medicare profit margins. Large and XL seem to be experiencing rapidly declining Medicare margins.
There may be other ways to divide the home health industry into subsets that expose data insights like these. I am especially curious about these XL HHAs and the “Other Enterprise” group in the previous post. These poor margin performers seem to be operating without a profit motive. I suspect that this might be the manifestation of a new industry trend to manage HHAs not as profitable organizations on their own, but as part of an overall healthcare network including other provider types intended to collectively provide a healthcare network to health plans capable of qualifying these plans as MA plans.
Health plans are buying up these agencies and other provider types as a way to insure the availability of provider networks for their MA beneficiaries in their plans. If this is the case, they may be less interested in the profits of these individual HHAs than the overall profits created through their own revenue cycle process including the premiums provided by CMS and the associated payments to all providers collectively. If I can figure out a way to explore this, I will.
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