BIRMINGHAM, Alabama (July 21, 2020)--The COVID-19 death toll in nursing homes has hit unprecedented levels, with some estimating that 40% of all deaths due to the virus in the United States have occurred in those institutions. How will that impact the future of aging in America? What changes do legislators need to make to Medicaid and Medicare to allow more access to homecare? To learn more, HomeCare spoke with David J. Totaro, chief government affairs officer for BAYADA Home Health Care. Totaro is also the chairman of the Partnership for Medicaid Home-based Care, a Washington, D.C.-based alliance of Medicaid homecare providers, managed care companies, national and state homecare assoications and technology companies.

HomeCare: Do you think the public is going to become more aware of or be more focused on choosing homecare as opposed to institutional care because of all the news about deaths and infection in institutions?
Totaro: Who in today’s pandemic, if they have to make that decision about where to put their elderly parent or uncle or aunt, would choose a skilled nursing facility? I think this a pandemic has given homecare a time to shine and we’ve been able to step up even with certain issues that haven’t been addressed. But certainly, the future of healthcare is in the home.

HomeCare: What are some of the things that need to be addressed?
Totaro: Low reimbursement rates, outdated policies such as presumptive eligibility—that is, when you’re discharged from an acute care setting you’re automatically eligible under Medicaid to go into a nursing home; however if you choose home there’s usually a 6-9 month approval  process and we’ve been trying to get an equal footing for almost a decade now. Unfortunately, many folks who choose to go into a nursing home and then choose to apply to get Medicaid coverage for care at home never really get home… We have been lobbying the Centers for Medicare & Medicaid Services (CMS) for four years now and I think we’re getting closer each year to getting something addressed on this issue… I think the pandemic will be an accelerant to not only this but other policies such as telehealth. During the pandemic, the use of telehealth has been expanded, now the only thing that isn’t covered is the cost.


HomeCare: Are you seeing any change in the responsiveness in Washington? Are they too busy to listen, or maybe are they more aware of homecare’s needs given the public health emergency?
Totaro: That’s a very interesting question! Not only in terms of the federal government, but in state and local government as well, the legislators across the board have been much more available in the pandemic and their staffs than they were in face to face encounters. I think the move to Zoom and the need to stay at home and work remotely has actually made it easier for them to schedule meetings... I’ve been very pleased with how much easier it is and how many times we can have a longer, in-depth conversion. Even for some of the action alerts that go out—when we send a large number of emails to offices—we’ve been receiving customized responses. In general, the pandemic has certainly highlighted the need for addressing the entire health care system.

HomeCare: Staffing is always a huge issue for home health agencies. How has the pandemic impacted business and staffing for BAYADA? Is it making it harder to recruit and retain workers? Totaro: What did make it harder is that originally we did not have the proper personal protective equipment (PPE) to protect our caregivers. Secondly, the unemployment package on steroids enabled many of our caregivers to stay at home… There were just so many different factors. We saw a drop in about 15-18% of our business. In about three-week period of March, we lost about our previous two years’ growth. We have started to come back. People who had coronavirus were going into hospitals, now they’re coming out and we do have the PPE to take care of our caregivers. We reacted quickly. We went through tough times; we furloughed over 900 employees, we all took significant 10-20% pay cut and our CEO took a 100% pay cut. But we’ve weathered it and we’re back about where we were in early March… We’re seeing that our caregivers and aides are starting to come back as well. I don’t know what’s going to happen in the fall, if the schools do not open in the fall as planned or if we have another big wave.

HomeCare: What can homecare advocates do to make sure the public values what they do? Totaro: We have to continue to be vocal and make others aware of the kind of quality of care we can provide at a less expensive cost… We’re also working a lot on the state level. Our No. 1 focus in every state in terms of advocacy efforts is getting the reimbursement rates increased. Many states haven’t addressed them in 10 years. No. 2, we are taking our presumptive eligibility message to the states as well. We think it’s easier if we can get it done through CMS and they can issue a blanket waiver. But we are working on it with states. We’re close to having something done in Pennsylvania. We’ve been working on that for three to four years and we did finally get legislation that’s been introduced.