Transcript SHP STRATEGIC FORUM October 2, 2010

The State of Home Health &
Care at Home
Pennsylvania Homecare Association
William A. Dombi
National Association for Home Care &
Hospice
[email protected]
May 20, 2011
CHALLENGES or OPPORTUNITIES
for HOME CARE?
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Are you surprised?---It’s both!
Changes are sudden, gradual, and distant
Political environment subject to change that
could trigger more change
Care delivery changes accelerating
Medicare regulation is somewhat of a wild card
Republican health care reform repeal efforts
underway
Overall environment favors home care
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Value proposition
Shift from fee for service utilization incentives in other
care sectors
New Congress and Health Care
Reform
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House Republican-led repeal efforts
underway
Policy driven or politics centered?
Alternative reforms?
Symbolic or successful?
New Congress and Health Care
Reform
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Course of Action
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Repeal fails—no vote in Senate
House majority attempting to defund
implementation
Will WH and House come up with some
compromises around the edges?
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Currently implemented reforms generally viewed
positively
2012 changes the dialogue depending on
election results (TBD)
Health Care Reform Litigation
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Constitutional challenges ongoing
3 courts uphold individual mandate; 2
courts overturn it based on Commerce
Clause
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Many other issues in litigation
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Florida decision finds whole law
unconstitutional
Employer penalty/mandate
Medicaid obligations on states
Supreme Court review likely in 2012
New Congress and Health Care
Reform
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House budget proposal
Repeal Affordable Care Act expansion of insured
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No funding for implementation
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Medicaid block grants
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Medicare vouchers/premium supports replace existing
“insurance” program
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Defined contribution vs, defined benefit
Beginning for under 55 (2011) population
Raise eligibility to 67 (2033)
Means tested supports
Present Challenges
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Providers need time to adjust as payment rates
are reduced and new administrative
responsibilities begin
2011-2014 are crucial years
HHAs still best positioned to take on new
opportunities inside and outside of Medicare
home health
Hospices face reduced rates, increased scrutiny,
and greater competition
Must deal with the “today” while moving forward
on “tomorrow”
2011: The Medicare Rate
Changes Begin!
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CMS Final Rule
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2.1% MBI
1 point MBI reduction (Affordable Care Act
required)
2.5% reduction in outlier budget (Affordable
Care Act required)
3.79% case mix weight change adjustment in
2011 (2012 not finalized)
Future HH PPS Payment Rates
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2014 rebasing
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May result in varied rates
CMS study on vulnerable populations
Case mix weight change adjustment
analysis
New MedPAC case mix adjustment model
in development: looking to drop therapy
threshold element
MEDICARE HOSPICE
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Rate reductions threaten care
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BNAF cuts increase risks
Limited inflation updates add pressure
Annual cap concerns grow
Limited (if any) margins with not alternative
payer offsets
MEDICARE HOSPICE
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New payment model in development
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No earlier than 2013
MedPAC recommends 1 point rate
increase in 2012
MedPAC still supports U-shaped payment
model
Oversight increasing as payments grow
MedPAC Home Health
Recommendations for 2012
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Institute new case mix adjuster
Freeze payment rates
Impose program integrity measures
including a moratorium on new HHAs
Accelerate rate rebasing to 2013 with 2
year phase-in
Impose a beneficiary copayment
MedPAC Copayment Proposal
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Episode based
Possibly set at $150 or 5%
Exclude episodes preceded by inpatient
hospital or SNF stay
Apply to Medicare-Medicaid dual eligibles
Permit MediGap supplemental isurance
coverage
2011 Regulatory Challenges
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Face-to-face physician encounter
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Home health
Hospice
Therapy assessments and documentation
F2F-Home Health
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Repeal and/or reform
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Reforms needed
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Exceptions for certain patient populations
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Inpatient discharges
Medically underserved areas
Vulnerable patients
Documentation requirements
Telehealth use
F2F--Hospice
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Different issues than home health
Concern for 3rd benefit period admissions
Roadblock in using contracted NPs
Cost increases without reimbursement
2011: The Health Care Delivery
Reforms Begin!
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Significant home care and hospice
opportunities!!!!!
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Chronic care management
Transitions in care
Accountable Care Organizations
Post-acute care bundling
Performance-based payment
Hospice concurrent care demo
CHRONIC CARE
MANAGEMENT
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Independence at Home Pilot
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Focus on certain diagnoses
Interdisciplinary team
Physician/NP directed
Shared savings
RFP in process
HHA-based CCM demo
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Monitoring, teaching, coaching, and telehealth
HH coverage criteria Not Applicable
Shared savings
TRANSITIONS in CARE
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Re-hospitalization prevention and
avoidance
Commercial opportunity
Hospital is the customer
Select discharge monitoring and
oversight
Accountable Care
Organizations
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Partner, participant, or outsider
Value defines role and opportunities
Creativity and connections creates
opportunities
Large physicians groups and/or health
systems are likely candidates to establish
ACOs
Home care/hospice=cost avoidance and
cost effectiveness
Post-Acute Care Bundling
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Who manages the bundle?
A community-based model!
Coordinates with institutional care PAC bundling
Functions include:
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HHA/hospice manages all discharges to community
Responsibilities for short-term inpatient care
Physician services in or out?
Shares in discharge planning
Medicaid Home Care
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Rebalancing of LTC spending continues
Risks to home care support with strained
budgets
PPACA incents home care
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Major home care expansion through federal money
(FMAP)
Community Free Choice Option
Removal of barriers to HCBS services
Money Follows the Person Demo extension
Spousal impoverishment protection
CLASS Act: Federal LTC
Insurance
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Community Living Assistance Services and Support
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Premium withholding in wages
Opt-out of program authority
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Payments made to cover individuals with ADL needs in
home or nursing facility
Participation begins 2010
Eligibility based on ADL needs
Benefit payments begin 5 years after implementation (20162017 est.)
Preset daily payment to insured
Boon to Private Pay home care
Supplemental support to Medicare/Medicaid home care
Proposed rule and CLASS Commission announcement
expected soon
Advocacy Action Plan
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SECURE THE STRATEGIC ROLE CONGRESS
INTENDS FOR HOME CARE AND HOSPICE IN
ADDRESSING THE NATION’S ACUTE, CHRONIC,
AND LONG TERM CARE NEEDS
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ENSURE HOME CARE AND HOSPICE PARTICIPATION
IN TRANSITIONS IN CARE AND OTHER HEALTH CARE
DELIVERY REFORMS
ALLOW NPs AND PAs TO SIGN HOME HEALTH PLANS
OF CARE
RECOGNIZE TELEHOMECARE INTERACTIONS AS
BONA FIDE MEDICARE AND MEDICAID SERVICES
ENACT A COMPREHENSIVE HOME AND COMMUNITY
BASED LONG TERM CARE PROGRAM FOR ALL AGE
GROUPS
PRIORITIES 2011
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ENSURE APPROPRIATE AND ADEQUATE
REIMBURSEMENT FOR AND ACCESS TO MEDICARE HOME
HEALTH SERVICES
 OPPOSE COST SHARING FOR MEDICARE HOME HEALTH
SERVICES
 BLOCK CMS REGULATORY “CASE MIX CREEP” CUTS AND
REQUIRE A NEW PROCESS FOR CALCULATING CASE MIX
ADJUSTMENT
 ESTABLISH REASONABLE STANDARDS FOR REBASING
MEDICARE HOME HEALTH SERVICES PAYMENT RATES
 REPEAL OR REFORM MEDICARE HOME HEALTH FACE-TOFACE ENCOUNTER REQUIREMENT
 ENSURE FULL MARKET BASKET UPDATES TO MEDICARE
HOME HEALTH
 ENSURE MEDICARE ADVANTAGE AND FEE-FOR-SERVICE
ENROLLEES RECEIVE IDENTICAL HOME HEALTH BENEFITS
PRIORITIES 2011
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ENSURE APPROPRIATE AND ADEQUATE
REIMBURSEMENT FOR AND ACCESS TO
HOSPICE SERVICES
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REVISE REQUIREMENTS FOR HOSPICE FACE-TOFACE REQUIREMENT
PRESERVE THE FULL MARKET BASKET UPDATE FOR
THE MEDICARE HOSPICE BENEFIT
REJECT ADDITIONAL BENEFICIARY COPAYMENTS
FOR MEDICARE HOSPICE SERVICES
ENSURE ACCESS TO HOSPICE CARE FOR RURAL
PATIENTS
MONITOR PAYMENT REVISIONS TO MEDICARE
HOSPICE BENEFIT
PRIORITIES 2011
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PROTECT AND EXPAND ACCESS TO HOME
AND COMMUNITY-BASED SERVICES UNDER
MEDICAID
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ESTABLISH MEDICAID HOME CARE AS A MANDATORY
BENEFIT AND SUPPORT REBALANCING OF LONG
TERM CARE EXPENDITURES IN MEDICAID
PROGRAMS IN FAVOR OF HOME CARE
MANDATE HOSPICE COVERAGE UNDER MEDICAID
ENSURE APPROPRIATE MEDICAID RATES FOR HOME
CARE AND HOSPICE
INCREASE FEDERAL MEDICAID PAYMENTS TO
STATES
PRIORITIES 2011
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PROTECT ACCESS TO HOME CARE AND
HOSPICE SERVICES, INCLUDING FOR
CARE PAID DIRECTLY BY INDIVIDUALS
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MODIFY EMPLOYER RESPONSIBILITIES IN
HEALTH REFORM TO ADDRESS HOME CARE
SPECIFIC NEEDS
OPPOSE CHANGES TO THE COMPANIONSHIP
SERVICES EXEMPTION TO THE FAIR LABOR
STANDARDS ACT
NAHC MEDICAID ADVOCACY
PROJECT
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Focus on federal Medicaid
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CMS now actively overseeing state
compliance
LTC rebalancing a priority at CMS
MACPAC underway
Supportive of state-specific efforts
Use of legislative, regulatory, and legal
forums
Significant research projects
Preparing for Change
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Re-engineering, Restructuring, or Refinement?
Right People
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Right Partners
Right Tools
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Technology
Focused data and information
Right Efficiencies
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New skills may be needed
Value-related cost
Right Plan
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Short and long term
Meeting Both Challenges and
Opportunities
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Value proposition
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Integrated
Dynamic
Evidenced-based
Outcome driven
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Clinical
Financial