Affordable Care Act and Federal Policy Update Barbara Gay Director of Governmental Affairs...
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Transcript of Affordable Care Act and Federal Policy Update Barbara Gay Director of Governmental Affairs...
Affordable Care Act andFederal Policy Update
Barbara GayDirector of Governmental Affairs
LeadingAgeApril 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 ModelA 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
ACOsTools to Achieve Savings
• Provider quality and cost data• Care coordination, including transitions• Discharge planning/case management• Wellness, prevention, disease management• Bottom line – outcomes, not volume of
services
ACOsBe 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 higher-than-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 long-
term 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 PurchasingLeadingAge 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_index.aspx?controls=hospitalizationsidentifybaseline
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