In a few months, the at-home care industry will lose its most ardent and connected champion on Capitol Hill. But like so many influential leaders who’ve decided to move into another phase of life, William Dombi is not taking his baton with him - he’s passing it on.
He announced in May that he is retiring at the end of 2024.
Dombi joined the National Association for Home Care & Hospice (NAHC) as vice president for law in 1987. Since then, he’s played a crucial role in advancing the home care and hospice industries. His contributions include expanding Medicare's home health coverage, overseeing the implementation of the home health prospective payment system in 2000, and various other significant successes.
In the same year he joined NAHC, Dombi led a landmark legal case that significantly altered the extent of coverage provided under Medicare benefits. He’s been the president of NAHC since 2018.
Dr. Steven Landers, a former director of home care at the Cleveland Clinic, has taken the mantle from Dombi, becoming the CEO of the newly minted National Alliance for Care at Home, which wedded NAHC with the National Hospice and Palliative Care Organization.
The Home Care Innovation Forum sat down with Dombi to get his take on the future of The Alliance, thoughts on maintaining legislative influence on Capitol Hill, and insights on arguably the most significant development in home health care this year - providers shying away from Medicare Advantage.
Dombi might be retiring, but he’s not riding into the sunset.
“To quote Rep. John Lewis, an incredible member of Congress who’s no longer with us, I'm on my way, ‘but I still have time to make a little bit of good trouble,’” he said.
This transcript has been edited for length and clarity.
In Washington, D.C., when voices are divided, you typically lose. While you still have an uphill battle to accomplish things, you have a much better chance of success when united. In the hospice world, we found that as we were moving towards the merger, the years of being siloed were not helpful. We worked much closer together as we approached the merger, and we gained strength from this unity. When we walked into conversations on Capitol Hill or with regulatory bodies, they were much more attentive and receptive to what we had to say.
I may be overstating this, but at the same time, we recognize that The Alliance does not yet have a fully unified care-at-home community. There are still other voices that we need to work on bringing together, even if only in a virtual way, without having them part of the same corporate organization. There's added power in being able to say we represent twice the number of providers out there.
One other benefit from this is the energy it brought to the joint membership, having that closer bond between the organizations now that we're working together. This aspect will bring a potency that adds to the unification element.
It's simple math that's finally being recognized and applied. Let me give you an example: MedPAC stated in their public meeting today (Oct. 11) that the margin for Medicare home health agencies in traditional fee-for-service is 22%. We can replicate that calculation and potentially come up with other results, but even by duplicating their calculation, we can still have reasonable confidence in that number.
However, when you look at a provider that does both traditional Medicare and Medicare Advantage, with a sprinkling of Medicaid, that 22% margin drops to somewhere between 2% and 4%. Half of these providers are bordering on zero or below. Why are they shying away? How long do you think the traditional program wants to subsidize the Medicare Advantage program?
You'll probably see a sign for one of the Medicare Advantage plans at a ballpark. They're marketing themselves with big dollars, while the providers of care are having to use some of their own margins to subsidize them.
Providers tried for many years to convince these plans of home health's value, considering innovative approaches to payment for services and management. It's not that they've given up, but they've come to the realization that the only true leverage they have is to say no.
No one's looking for massive profits from Medicare Advantage, but a fair share of payment is what this is about. We're seeing this happen with large and small companies, as well as for-profit and not-for-profit companies. There was an era when some big companies said the future was in Medicare Advantage and went all-in on it, almost going out of business because of it.
Number one, this is about the fourth or fifth generation of the same idea. I sat in the Capitol when (former lawmaker) Claude Pepper gave an address to a joint Congress session about the need to support the elderly and disabled with home-based care for their long-term care needs. There was a new program within Medicare Part B.
He was the head of the House Committee on Aging and dedicated his life to improving support for older adults. He was one of many, and there were many versions of this idea as well. It's been around for a long time but has run into roadblocks.
Someone asked me, "What do you think the chances are of this happening now? What's different than those other times?" My response was:
A Washington Post editorial also pointed out that there are a lot of devils in the details, and the details aren't even known yet. Think about it: AARP has estimated there's about $500B of unpaid caregiving by friends and family. So the demand, if you make a program available to the Medicare beneficiary population, could even go beyond early estimates, especially if family members start saying, "I don't want to do this anymore."
I sometimes aspire to the concept that the best defense is a good offense. Some people reverse that, too. We have so much more that we could do as a community to care for people, but we're spending so much time on other issues.
I said this to Sen. Cardin (D-Md.) as well: I never thought when I got involved in this many years ago, in a beneficiary organization, that I'd spend so much time on provider payment rates. Something has to be there, at least in balance, on an offensive effort to expand opportunities, to highlight those opportunities, to develop a movement.
We need a movement where you've got healthcare people, social workers, and consumers - just general people - demanding something like Harris's proposal. It might have a hefty price tag, but people are saying, "Yes, this is the greatest human advance we could make." When you look in retrospect at creating the Social Security program or creating Medicare and Medicaid - those were big deals that are even bigger than anybody ever expected in terms of their role in our lives.
So, I'd love to see a way to fight that balance. I'm not calling it proactive versus reactive. I'm calling it offensive because it really is that. We've had undertones of that at times. Our skilled nursing facility at-home proposal was an effort that created a lot of excitement within the home care community. It brought a lot of consternation in the nursing home world, but it didn't get the movement status that might have helped it along.
We need to start with something very important: We have to replace the champions that were there and expand the group of those champions in any way we can. We've already technically identified some replacement champions and are working to ensure they are as strong, if not stronger. We still have Susan Collins, but how much longer will we have her on the Republican side?
I'm not going to name any names because it might be premature, but we've had some entrees into the next generation of congressional supporters and are working on a strategy. I am working with Steve Landers and the rest of The Alliance board to craft a game plan for the future regarding the advocacy side of things. It needs more than just advocacy alone.
We're working to launch - and we need significant resources to get there - a campaign relative to the image of healthcare services at home. I don't mean a "Got Milk?" white mustache kind of thing, but to make it multi-dimensional, focused on both the person receiving the care and the value of being one of those caregivers, a nurse dedicated to working in the home care.
So, these things are in the works. Item number one was getting people to recognize we need to do it. You've recognized we need to do it, and we've got people acknowledging that we need to do it. Then we need a commitment of resources to get there, and then we need to get to the details of how it is for the individuals that are there and how we maximize the value. That includes, sometimes, an area people feel is an ugly part of our political life: raising funds for donations and contributions to political campaigns.
But the lessons are sometimes ignored. When Harris's proposal came out, I went to the communications people. I said, "Look, I think it might help if we just listed all of the U.S. presidents since LBJ who signed legislation that either created or expanded access to home care, Republican or Democrat alike.”