Transcript Slide 1

Affordable Care Act and
Federal Policy Update
Barbara Gay
Director of Governmental Affairs
LeadingAge
April 16, 2014
Affordable Care Act
• Outlook for continuation
• Provisions of particular interest/concern to
LeadingAge
• What you can do.
ACA Outlook
• House repeal strategies
• Senate composition after 2014?
• President Obama veto pen through 2016 –
then?
• Enrollment process less than stellar
• Delays in mandates
ACA Outlook
• Growing stake in the program
– Over 6 million enrolled
– 19 states expanded Medicaid, 5 more through use
of Medicaid to buy private insurance
– Adult children
– People with pre-existing conditions
– Initiatives to reform health and long-term care
delivery system to bring down costs
Affordable Care Act Themes
• Pay for value, not volume
• Better integration of services
• More home- and community-based service
options
• Avoid hospitalizations and rehospitalizations
• Application of technology
• Workforce development
ACA Employer Mandate
• New deadline for employers with between 50 and 99
employees – January 1, 2016
• Larger employers, 100+ employees – January 1, 2015
• Applies to employees working 30 or more
hours/week
• Information for employees and employers on
LeadingAge website:
http://www.leadingage.org/Legal.aspx
Accountable Care Organizations
• Delivery system reform:
– Integrate services
– Greater efficiency, fewer avoidable services
– Group at risk for all beneficiary costs
– Potential Medicare/health care savings
• More than 360 nationwide
• 5.3 million Medicare beneficiaries covered
• Concept flexible, many varying configurations possible for the
future
ACOs - Structure
• Beneficiaries don’t enroll, not restricted to any
network, may not know they’re in an ACO
• Typical anchor – hospital, health plan, physician
group
• ACOs contract with CMS to provide services at
agreed-upon spending targets
• ACO can pocket savings for spending below targets
• 33 quality indicators
ACOs – 3 Models
• Shared Savings – the basic plan, chosen by
majority of ACOs
• Advance Payment – helps smaller ACOs with
less capital with initial investment in staff and
infrastructure
• Pioneer – ACO assumes more risk with
potential for greater reward
ACO Pioneer Model
A Cautionary Tale
• More risk, more reward
• 32 organizations chosen for 3 year program; 9
dropped out after 1 ½ years
• $87.6 million Medicare savings after 1 year
• Slower rate of spending growth/beneficiary – 0.3%
vs. 0.8% in traditional Medicare
• 13 Pioneers saved enough to share with Medicare
• 2 Pioneers owed Medicare $4 million
ACOs
Tools to Achieve Savings
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Provider quality and cost data
Care coordination, including transitions
Discharge planning/case management
Wellness, prevention, disease management
Bottom line – outcomes, not volume of
services
ACOs
Be the Solution
• Anticipate needs and develop quality measures:
– Hospital readmissions
– Falls
– Pressure wounds
– Medication adverse events
• Special services – stroke rehab, wound care
• Processes for managing care transitions
• Doc – doc dialogue
• LeadingAge Insights can help!
Bundling
• “Bundles” payment across provider types for a single episode
of care
• Incentive for providers to coordinate services and continuity
of care
– Four approaches in Request for Applications
– 1) Hospital stay
– 2) Hospital stay plus post-acute care
– 3) Post-acute care following hospital stay
– 4) Prospective payment for all services during hospital stay
Hospital Readmissions Reduction
• Hospitals’ Medicare reimbursement cut if they have higherthan-average readmission rates for “applicable conditions”
• Program began with 3 “applicable conditions” –
– Acute myocardial infarction
– Heart failure
– Pneumonia
• Beginning in 2015, other conditions likely to be added
• Opportunity for post-acute care providers to help hospitals
reduce their readmission rates
• LeadingAge Insights!
QAPI for Nursing Homes
• Quality Assurance and Performance Improvement
programs
• Required for all nursing homes within a year of final
regulation’s publication
• CMS developed on-line resource library and other
tools for facilities to set up programs
• Reg may come out this year
• Tools: Advancing Excellence, Quality First
Dual Eligibles
• Medicaid waiver available for up to 5 years, can be
renewed
• Goal: better integration of benefits and
administration by states/CMS
• Concerns
– Access to essential services
– Health plan experience with special needs of longterm services and supports population
ACA Transparency Requirements
• On request of Secretary, HHS Inspector General, the states, or
LTC ombudsman, SNF/NF must provide description of facility’s
– governing body and organizational structure
– information regarding additional disclosable parties
• SNF/NF must operate a compliance and ethics program
effective in preventing/detecting criminal, civil, and
administrative violations
Workforce
• Authorizes geriatric education centers
– Training for health care professionals and family caregivers in chronic
care management
• Expands geriatric care awards to advanced practice nurses,
clinical social workers, other health professionals
• Traineeships for those preparing for advanced degrees in
geriatric nursing
• Increase number of providers specializing in geriatrics and
ensure more providers have geriatric training
• Issue - funding
And now, a few words about
Medicare
Medicare - Current Issues
• “Doc fix” (SGR) – therapy caps
• Observation days – H.R. 1179, S. 569
• Post-acute care payment reform
Medicare “Doc Fix”
Therapy Caps
• Permanent “doc fix” to correct flawed
physician payment formula, prevent large cuts
in reimbursement still pending
• Another temporary doc fix passed 3-31-2014
– H.R. 4302
– Lasts through March 31, 2015
Doc Fix – H.R. 4302
Post-acute care provisions:
• Extends therapy caps exceptions process
• Delays ICD-10 effective date until 10/1/2015
• Value-based purchasing for skilled nursing facilities
Doc Fix/Therapy Caps
• LeadingAge concerns
– Therapy caps relief must be included in doc-fix
legislation
– Post-acute care should not be the pay-for
• H.R. 4302 satisfied us on both counts
Value-Based Purchasing for SNFs
• CMS to develop SNF readmission measure by
10/1/2015
• By 10/1/2016, readmission measure refined to show
risk-adjusted, potentially preventable readmissions
• By 10/1/2019, readmission measures to be linked to
value-based purchasing strategy.
– Incentive payments for high performers; penalties
for low performers.
Value-Based Purchasing
LeadingAge Concerns
• CMS should allow stakeholder input in
development of readmission measures
• Measures must be risk adjusted at:
– Nursing home level (homes serving lower-income
populations, for example)
– Beneficiary level (complex care needs)
Hospital Readmission Rates
• Begin tracking your rates now
• Put quality improvement systems in place to
identify opportunities to reduce preventable
hospitalizations.
• Advancing Excellence has a tool:
https://www.nhqualitycampaign.org/star_ind
ex.aspx?controls=hospitalizationsidentifybasel
ine
Medicare Observation Days
• H.R. 1179/S. 569
– Time spent in a hospital under observation counts
toward the 3-day stay requirement
– Beneficiaries leaving the hospital after a period of
observation are to be considered to have been
discharged.
• Urging members of Congress to cosponsor
3 Day Stay Requirement
• H.R. 3144 would repeal. No cosponsors, little chance
of passage
• Integrated systems at risk for all patient costs already
excepted from the rule
• CMS can do pilots allowing patients to receive skilled
medical services in nursing homes
• CMS lacks infrastructure to monitor potential
“churning” of patients between long-stay and skilled
care levels within a nursing home
Medicare Post-Acute Care Reform
Finance-Ways and Means Chairs’ letter 6/19/13:
• Too much variation in per-beneficiary Medicare spending on
post-acute care
• No guidelines on types of “patients” appropriate for each
setting
• Different payment rates to different provider types for
patients with similar conditions
• MedPAC, Obama Administration, other experts have called for
payment reform
Ways and Means/Finance Concerns
• Specific areas of interest:
– Quality – comparing across settings
– Value-Based Purchasing
– Reducing Hospital Readmissions
– Bundled Payments
– Site Neutral payments
LeadingAge Comments
• Well-integrated post-acute care will eliminate
inappropriate use of expensive services
• Essential to determine needs across settings
• Medicare spending per beneficiary already growing
more slowly
• Take a broader view of post-acute care and its
funding mechanisms (say the word “Medicaid”)
• Eliminate silos between acute, primary, specialty and
post-acute providers
IMPACT Proposal
• Improving Medicare Post-Acute Care
Transformation – “IMPACT”
• Issued by Ways and Means and Finance
Committees March 18
• Outlook? Little time left in the present
congressional session
• Committee staff indicate committee action
possible early summer
• Never say never.
IMPACT Proposal
Standardized assessment data
• From SNFs, home health, IRFs, long-term care
hospitals by 2016
• Eventually to include hospitals, cancer
hospitals, critical access hospitals (by 2019)
• Data to include patient functional status,
cognitive function, special services, etc.
• CARE tool?
IMPACT Act
• Quality measure reporting
– Functional status changes, skin integrity, med
reconciliation, etc.
• Resource use measures from claims data ->
per-beneficiary spending
• All data to be publicly reported by 2017-2018.
• SNF Quality Reporting program by 2019, 2%
penalty for failure to comply
IMPACT Proposal
• LeadingAge questions:
– OASIS and MDS revised or replaced?
– Nursing home oversight system?
– Risk adjustment needed to account for varying
care needs
• Ultimately proposal envisions standard
payment system based on individual needs,
rather than setting in which provided.
What You Can Do
• Make it real for policymakers – how do their
policies affect your residents, staff and
community
• Cultivate relationships
• Tell your story
• Tools – LeadingAge website, Contact Congress,
staff