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Episode 62

Decoding Medicaid’s fixed-cost system challenges with Jeff Humber

Jeff Humber: 0:00
We are providing care to the Medicaid population, we can’t pass along extra costs, and so part of the struggle from state to state is helping legislators see the impact that those rates have on our ability to provide services, primarily in the hiring and retaining of caregivers. It’s important to be able to show how the services that we are providing will actually generate a cost savings this year and the next year and the next year if we’re able to keep people safely in their homes and out of really expensive hospitals and nursing facilities.

Erin Vallier: 0:48
Welcome to another episode of the Home Health 360 podcast, where we speak to home based care professionals from around the globe. I’m your host, Erin Vallier, and today I am joined by a dear friend in the industry Jeff Humber. Jeff lives in Fort Worth, Ginger, so congrats for that 36 years.

Jeff Humber: 1:13
Thank you. He’s a very patient woman.

Erin Vallier: 1:16
You guys have a daughter about to graduate from the University of Oklahoma too, so that’s a double congratulations.

Jeff Humber: 1:23
Thank you, thank you.

Erin Vallier: 1:24
You’re a Sam Bird University graduate that’s worked in health and human services in both the public and the private sector for more than 30 years. Jeff currently serves as a vice president for peer relations for acts of care, which is a national leader of home health, hospice and personal care, and serves as the co-chair for government affairs for the Texas Association of Home Care and Hospice. I’m really excited to have you here today, jeff.

Jeff Humber: 1:54
Thank you, erin. It’s really good to be here with you, yeah.

Erin Vallier: 1:57
Before we dive into the topic today, which is all things Medicaid landscape, could you share with the audience just exactly what does it mean to be a VP of peer relations? That sounds important.

Jeff Humber: 2:13
Oh my goodness, it’s certainly not as important as the people who are actually in the homes providing the care to our clients and our patients. We have some incredible caregivers and accent care. We have personal care assistants in the home. We have nurses, therapists all over the country. But with my role it’s a lot of different hats, Erin.

Jeff Humber: 2:34
Sometimes in my role I find myself teaming up a new relationship with a managed care payer, joining them with our contracting and credentialing team, especially if they are new to a market. Sometimes my job, and really all the time, it’s about the growth of the company. How do we utilize this partnership with a Medicaid managed care payer, whether it’s an insurance company or a state agency, to grow our business and really develop our impact in communities? Sometimes it’s introducing service coordinators within that payer to our frontline staff to make sure that relationship is complete. One thing that I really enjoy doing is working with managed care organizations on value based plans, where we are going above and beyond what the state regulatory agency says we must do, but we’re actually striving to meet better healthcare outcomes for the folks that we’re serving. And then we can also weep into individual customer service issues, bringing the managed care organization to the table if we need to address some problems, some challenge and working with a particular patient or client.

Erin Vallier: 3:52
That’s a lot, and it does sound very important. Introducing new payer sources so that you can diversify, which that’s super important, and then managing to grow the relationship within the existing payers is what I’ve got. That’s extremely important to the success of any business. So I’m glad you’re the one talking about this today. I’m sure you’re going to be full of all of the knowledge that everybody is itching to learn about Medicaid. Now, when you talk about Medicaid, it’s really difficult to talk in absolutes, because each state has the liberty to do things differently.

Jeff Humber: 4:26
Very true.

Erin Vallier: 4:27
So one of the most common variances that you see from state to state.

Jeff Humber: 4:32
You know, I wish I could put this on a t-shirt or a bumper sticker, but if you, if Medicaid in one state, you know it in just one state because it really does take on a different meeting, a different legislative intent, a different payer, patient intent in every state. Some of the things that we see similarly is probably the focus of Medicaid managed care on assessing and generating the authorizations that provide that allow us to provide service to their members State to state. Typically, a state agency owns the eligibility decision and then, depending on what program that patient or that client finds themselves in whether it’s a waiver program each state decides how they spin that off. That person and I’ll speak to Texas, for instance is then assigned to a Medicaid managed care payer For Texas.

Jeff Humber: 5:34
There are different categories. There are children’s health insurance programs. We have star kids, we have the chip program. The program that works with our seniors and the disabled population is called star plus. There are four MCOs in Texas that have that contract to manage the care of those clients and patients in Texas. Some states will handle their own assessment post eligibility. For instance, a state agency may choose to have one of their own nurses go to the home and assess the client for their ability to handle all of the activities of daily living coaching, cleaning, ambulating, those kinds of things. Some states will only handle the eligibility piece but then pass the assessment on to a case management agency that they contract with or one of the Medicaid managed care MCOs.

Erin Vallier: 6:34
It seems like it might be.

Jeff Humber: 6:36
It really is. It really can change from state to state. For instance, in Texas for the star plus program, those four managed care organizations handle their own assessment. They decide how many hours per week, per month, a client would receive of in-home personal care.

Erin Vallier: 6:55
Depending on what state you’re working in, the eligibility criteria changes and then how that eligibility is managed. It could either be the state going in and deciding what you can do, or they pass it to a care manager, or they may pass it to agency themselves. You really got to know your stuff if you’re planning to work across multiple states, is what I’m hearing.

Jeff Humber: 7:18
It pays to really study the state regulations of any state that you want to provide services in to know what your role is going to be as a provider of care. Where will you be the best fit? What parties will you be contracting with? Will you be contracting directly with a state entity? Will you be contracting directly with an insurance company, like a Medicaid managed care organization?

Erin Vallier: 7:43
That’s a lot. You need a dedicated resource per state. I know that states differ a lot in their Medicaid structures, just by what you’ve mentioned, but there’s undoubtedly some governance aspects that remain consistent. It is a government provider, right. They don’t want to have everything completely different. So what are some of the shared elements that happen to transcend those state boundaries?

Jeff Humber: 8:12
You’re right in that the state agencies also have to follow CMS guidelines for Medicaid.

Jeff Humber: 8:20
There are going to be similar criteria for Medicaid eligibility across many states.

Jeff Humber: 8:26
One example that we’ve seen most recently, as states are now unwinding what happened during COVID with eligibility, is CMS can dictate to a state whether or not they can, let’s say, break eligibility or end eligibility because of a public health emergency.

Jeff Humber: 8:46
At one time CMS said states during this period of time for people who are on the Medicaid program in your state for these programs and where they would typically come off of eligibility if they didn’t meet certain criteria, they’ll shall keep them on right now. And so CMS exercised that kind of muscle with the states. But since the public health emergency is now over, states are now unwinding that and you’ve probably heard quite a bit in the news of some of the challenges that some states are facing with people who had been on Medicaid and now they’re not, either because their eligibility changed maybe they had an increase of resources or income or they just didn’t turn in their paperwork and it’s more of an administrative decision. Cms still has authority over states in some areas of policy, but those states do have quite a bit of autonomy as to how that is handled at the local level.

Erin Vallier: 9:48
Gotcha. So it’s multi-layered, which makes it even that much more complex to be successful as a Medicaid business. Wow, it is. So that sounds like it’s really crucial that agencies advocate for themselves to secure reimbursement rates and the flexibilities that they need in order to deliver the quality care that they want to deliver. How can organizations effectively advocate for themselves in the complex environment.

Jeff Humber: 10:16
Sure, that’s a great question, and agencies need to advocate for themselves as a business, but also, and very importantly, for the very people that they care for. You know, it’s our job to make a positive impact in the lives of the people that we serve. The best way to do that is to ensure that we are compliant with state regulations, but also that those state regulations help us provide the best care possible to those patients and clients. So I’m going to hit this a couple of different ways from state to state. The Medicaid reimbursement rates that are paid will differ greatly from state to state. For instance, in one state in the Pacific Northwest, a Medicaid reimbursement rate might be in the neighborhood of $27 per hour, and of that that gives you enough flexibility to be able to hire a caregiver and keep those caregivers and retain those caregivers. In other states, that reimbursement rate may just be in the neighborhood of $12 to $14 an hour, and it becomes more difficult to hire with fruit and retain caregivers, as those caregivers are generally in a pool of direct care workers that are also being hired by the restaurant industry, by the hotel industry, those industries, as the economy changes, they can pass along extra costs to their customers. However, when we are providing care to the Medicaid population, we can’t pass along extra costs, and so part of the struggle from state to state is helping legislators see the impact that those rates have on our ability to provide services, primarily in the hiring and retaining of caregivers.

Jeff Humber: 12:14
We want to really draw the picture for our legislators as to what that looks like. Let them see the plight of the individuals in their districts that we’re serving. Let them understand how putting a caregiver into a home, putting a nurse into a home you know, coupling a nurse with the family of a child with a disability can positively impact that family, help keep that individual out of an expensive nursing home environment and help that individual retain independence ongoing. I think there’s that perspective from the client, the patient side, as far as retaining independence and maintaining that that’s so important. But legislators are often working with very challenging state budgets and so they do the best they can with the money that they have to work with and they have spending limits. Some of those are statutory. So again, it’s important to be able to show how the services that we are providing will actually generate a cost savings this year and the next year and the next year If we’re able to keep people safely in their homes and out of really expensive hospitals and nursing facilities.

Erin Vallier: 13:34
It sounds like a real complex argument where you need the data to back it up, but you also need to pull on their heartstrings, because they have a loved one that’s aging and they want them to stay in the home. Now my question for you is what data are you using and how do you organize it, because it’s not just from one agency. You got to have a group, I’m assuming, because strength comes in numbers. How do you go about that?

Jeff Humber: 14:00
Yeah, I would look at the state regulatory agency’s information. So they’re going to have numbers of people on certain Medicaid programs grouped by county, grouped by region, and the ability to tell a legislator hey, you have this many people that are being served with this type of service in your county. This is why it’s important for you to understand the plight of those people so you can work with a state regulatory agency and I would also recommend you work with your state’s association. For instance, you have mentioned my involvement with TAC, the Texas Association of Home Care and Hospice. They will have people who, on a regular basis, professionally educate legislators, but they also are very much tied to their state’s regulatory agencies diving for that data and you may not have to go to the state regulatory agency. That state association may have a plethora of information to help you really put together that care message to a legislator that you’re talking to.

Jeff Humber: 15:05
As we pull together that data and we share that with the legislators, very often you will have legislators that are on really important committees, so your state’s finance committee whether it’s the Senate Finance Committee or House Appropriations or Senator of the House, Health and Human Services Committee you really want to focus on the members of that committee and their staff members. Usually, a legislator will have a staff member whose sole focus is healthcare, for instance, or some other industry. You want to get to know that person. They will be educated on the programs that you work with them, but they may have questions occasionally. They want to know how this will impact you as a provider. You want them calling you right. So you really want to set yourself up as a resource for those folks who are in a legislative capacity.

Erin Vallier: 16:02
It’s a very strategic approach. So partner with your state association. I think Texas has a really nice active association where I get them. Sometimes it’s hey, son, this petition, we have a voice going in and lobbying. So I guess the recommendation to the listeners would be if you see any of that, get involved, go talk to them and make yourself the go to person if they have questions. I like it, but it’s complicated, sounds like it takes a lot of dedication From your perspective. Jeff, what disparities exist in managed care from state to state? You’ve mentioned managed care a couple of times, and how do these disparities impact healthcare delivery?

Jeff Humber: 16:46
Thank you, Sure, I think the way that state legislature or a state regulatory agency, it’s all about the contract that they have with those managed chair organizations.

Jeff Humber: 16:59
What are they prescribing those managed chair organizations to do?

Jeff Humber: 17:04
It’s really important as providers, if you’re contracted with a Medicaid MCO, it may really be great nighttime reading right before you go to bed but get a copy of that state uniform contract between your state regulatory agency and the Medicaid managed care organization. It’s really enlightening and it will help you understand the roles of that managed chair organizations and how it may differ from state to state. Again, I think some of the disparities we will see will be how individuals are assessed to determine the number of hours, of the number of days that patient or client might receive for caregiving, let’s say. Some disparities also lie in how an organization is reimbursed for care, how a provider is reimbursed for care. Maybe they are only reimbursed for the actual care that’s given. Some states will require MCOs to also pay for the supervision of that care. Again, you want to peel the layers back a little bit and see what’s there from reimbursement perspectives, what is there from the assessment perspectives and how you go about receiving your authorizations for care, whether it’s from that MCO directly or through another party.

Erin Vallier: 18:24
Yeah, All important information to know if you’re going to deliver care and also if you’re going to go talk to your legislators and tell them exactly what you want.

Jeff Humber: 18:33
That’s right. Let’s keep in mind the plight of the individual receiving care. I don’t want to sound like I’m building a stereotype, but for a person of age who may also be dealing with some level of Alzheimer’s or dementia, and that family member that’s helping to take care of them is having to make some decisions and figure things out on their own, going through the eligibility process, it’s tough enough, but then they’re going to be faced with a choice. Okay, what health plan do you want to go with? What are the differences? Okay, now you’re with the health plan. The health plan is going to come visit you. They’re going to share with you a list of services that they can provide. Then you get to decide what agency provides those services in your home. Just becoming eligible starts a whole road of really important life decisions in the journey of that person’s healthcare. It’s important that our legislators understand what that journey is like for the people who are being served.

Erin Vallier: 19:36
I completely agree. How about question about the variety of things that Medicaid offers? I know that because there’s so much variability in autonomy among the states, there’s got to be this giant portfolio of services and programs that some of them probably aren’t widely known and it could be a real opportunity for providers to dip into that if they’re considering getting into Medicaid very seriously. Can you shed some light on any of those lesser known but valuable services available through the Medicaid program?

Jeff Humber: 20:10
Medicaid allows me to see my doctor. Medicaid allows me to get into the hospital or the ER if I need to. Medicaid allows me to have caregivers coming into my home to help me with cooking and cleaning and those activities of daily living. But relationships with those managed care organizations can also open up avenues to personal and residency response services. You might remember the old commercial I’ve fallen and I can’t get up. Individuals on Medicaid waiver programs can have that device paid for, so that provides an additional safety net to them.

Jeff Humber: 20:44
Dental services may be available through the state’s Medicaid program or that managed care organization. Medical transportation, so to and from your doctor or other place of treatment. Dysical therapy, speech therapy, occupational therapy, the use of medical equipment I need a wheelchair in a home, I need a walkthrough in a home, I need a hospital bed in a home. You want to communicate with your managed care organization for those things and also I’ll frame this as PCP appointment management the ability to call your managed care organization and have them set up your physician appointments and then your caregiver, who should know when those are and help make sure that you are making those appointments by accompanying you to your appointment. So those are some other services that a Medicaid managed care organization can help provide.

Erin Vallier: 21:40
That’s a lot, and it gives agencies a lot of opportunities to expand some of the services they’re providing. So that’s pretty exciting. I have one final question for you, jeff, because I know we’re approaching our time what is the single most important piece of advice you could give our listeners that will help them navigate the Medicaid landscape?

Jeff Humber: 22:02
Yes I would say don’t assume that you know everything about your state, because it’s a moving target, as new orders come from the feds through CMS, or there are budgetary changes that have to be addressed or client or patient care needs that have to be addressed by your state’s legislature. You want to stay informed, so stay involved, stay informed, get involved. I would say get on your regulatory agencies D list for any program changes for the programs that you work within, and if you contact their public information officer’s office, they will tell you how to do that. That’s a really good thing to do. Be your legislative partner’s best friend and resource. Be that person that they call when one of their constituents calls and asks a question. You want them to call you for your perspective.

Jeff Humber: 22:59
Stay involved with your state industry association for home care and hospice. And back to the legislators again. Don’t just wait for the legislative session to come to make visits to those folks. They get inundated with visits, people asking for things right around the legislative session when all of those votes are happening. Set a regular cadence. Go visit them quarterly or semi-annually. Make sure that they see you on a regular basis and that will really help build that relationship with them.

Erin Vallier: 23:32
Excellent advice. So stay on your toes, stay informed, get involved and build a relationship with the people that matter in the industry. I love it.

Jeff Humber: 23:41
That’s right. You’re advocating not just for your business, but for the people that you’re serving, and those are definitely some ways to do that.

Erin Vallier: 23:48
Fantastic, Jeff. I really appreciate you hopping on the show today and sharing all of this wisdom with the listeners. I am sure they have come away with a ton of actionable insights. It’s been a pleasure.

Jeff Humber: 24:02
Well, thank you for having me. It’s been a pleasure, and I work for Accent Care. We provide home health, hospice, palliative care and personal care throughout the country. We’re in 31 states. We’re based in Texas. If I can be a resource at all for your listeners, please let me know.

Erin Vallier: 24:20
Fantastic. We’ll make sure that there’s something in the show notes to let them know how they can find you and find Accent Care.

Jeff Humber: 24:27
That would be great. Thank you very much, excellent.

Erin Vallier: 24:30
Thank you or visit us on your favorite podcast platform.

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Home Health 360 - Episode 62

Episode Description

Drawing from the tapestry of Medicaid policies across the states, this episode explores effective advocacy and the significance of understanding the intricacies that shape care services. Jeff Humber, VP of Payor Relations at Accent Care, shares his experience providing quality care under Medicaid’s fixed-cost system. With host Erin Vallier, they discuss strategies for maintaining exceptional care, building relationships with managed care payers, and additional insights on everything from advocacy to caregiver recruitment and retention.

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