RECALCULATING A long term care update

Transcription

1 RECALCULATING A long term care update A discussion with HFMA, Maine Chapter and Brett Seekins, Senior Manager with Baker Newman Noyes October 9, 2014

2 Let s talk about Whatever you d like to talk about ACA Programming for LTC Nursing Homes Skilled Nursing Homes Private Non-Medical Institutes / Residential Care Services Home Health Agencies Hospice Home and Community Based Services PACE and LTSS Programs Alzheimer s and Dementia Care in Maine Wrap Up

3 Achieving ACA Balance CHOICE REFORM

4 PPACA - Some Choices Don t Really Matter 4

5 The Collaboration of Care Model ACUTE P&W POST- ACUTE SENIOR CARE CENTER REHAB SERVICES CBO/AAA PATIENT SKILLED CARE IL NURSING HOME ASSISTED LIVING HOME HEALTH MEMORY CARE

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7 Nursing Homes Medicaid Payment Shortfalls National, New England, ME Reimbursement in Maine Cost of Care Issues LD 1776 Nursing Home Provider Tax - Going down? Going away? ACA Demo s hurting NF Census? By design? Maine State House Speaker Mark Eves, Maine Council on Aging, AARP, AAAA, Governor s Council on Long Term Care

8 MaineCare NF Reimbursement Maine State pays NF s for allowable Direct, Routine and Capital Costs via a per diem / daily rate MaineCare utilized 3 NF Peer Groups Cost Limits and Caps in play Maine is a NF Provider Tax state (6%) today. Scaling down to 3.5% over next 4 years Maine s average MaineCare NF Medicaid Shortfall is projected to be greater than $(22) per patient per day for FY 2013, National AVG ($24), MA ($37), NH ($57), VT ($18), CT ($25), RI Maine s average MaineCare payer mix is between 65-70% - MUCH higher in Rural settings Rural NF s are weak financially and at risk operationally PACE? CANF? Urban NF s face fierce staffing competition from health systems, physician practices, schools, Malls, hotel industry causing economic pressures The Medicare SNF cross-subsidization / profit no longer covers the Medicaid shortfall based on national averages since 2007

9 SNF and CROSS-SUBSIDIZATION 9

10 Skilled Nursing Facilities FY15 Payment Update - Claw back (0.4%), (2.0%) overall 2% Unadjusted for Wage Index net Sequestration Adjustment OMB Bulletin No MAJOR changes to MSA and CBSA designations 5 year Medicare Payment slide MedPAC SNF s Billed ¼ claims incorrectly in FY 2009 $1.9B! MedPAC 90% Increase in Ultra-High Therapy RUGS $5.7B 2006 to $10.7B in 2008 SNF s don t bill / code properly - Medicare Cross-Subsidization fallacy New SNF Cost Report Schedules? Direct Care, Ancillary Hrs./$$$ 3 Day Rule going away? Where are my SENIOR EMERGENCY ROOMS?

11 OIG SNF Industry Concerns Billing CMS higher paying RUGS though beneficiary characteristics largely unchanged - Case Mix Creep 25% of 2009 Claims Billed in ERROR - $1.9B (CMS changed to a new RUGS version) 37% of SNF stays did not meet care plan or service requirements 26% of SNF stays didn t develop resident care plans that met requirements / measurable objective timelines +19% resident care plans didn t address one / more problems identified in the patient assessment 7% resident care plans didn t meet measurable objectives or timelines 31% of stays didn t meet discharge planning requirements 16% of SNF stays didn t have summaries of beneficiary stay or status at discharge 23% of SNF stays didn t have post discharge plans of care Medical Reviewers Issues w/ quality of care, wound care, medication management, therapy and overutilization of therapy

12 PNMI s / Residential Care Facilities Reimbursement today Reimbursement tomorrow? Personal Care Homes? Multi-Level Nursing Homes Problematic? Do Other States have this model? Or, are those residents NF eligible? CMS, SSA, ADA, CFR, Olmstead thoughts about our PNMI/ResCare program Maine should be a national model

13 Home Health Agencies Trending down Reimbursement, 4yr Payment Reduction, HHRGS, HCPS codes, Case mix Case Mix CREEP HHA THE ANSWER to health care reform Benefit under care of MD, Need for SN,PT,OT,SP,MSW & HHA services and must also be homebound MedPAC 1 in 4 questionable billing /$590M overpayment CCTP, AAA, Personal Care PPS care needs up $$$ up Face to Face big issue 90d pre / 30d post Audits underway If CMS later determines F2F ineligible denied coverage / $

14 Hospice Under fire by CMS thinking that payments have substantially increased, hospice periods have increased, but hospice hours haven t changed in many years Still providing Routine Home Care, Continuous Home Care, Inpatient Respite Care and General Inpatient Care FY 2015 net 1.4% Payment Increase New Cost Report Caps on Payments: 1) # of Inpatient Care Days and 2) Aggregate Payment amount ($26,700) Requiring Notice of Election and Notice of Termination/Revocation be filed be file TIMELY within 5 calendar days lose payment Patient must ELECT PHYSICIAN of THEIR CHOICE MedPAC Payment methodology may lead to provider to seek out beneficiaries inappropriately. Spending in 2005 $4.3B and 2009 $4.3B? Hundreds of Providers had beneficiaries residing in NF s while billing

15 15 FY 2000 Medicaid LTC $$$ Source: CMS Medicaid Statement of Expenditures

16 16 FY 2011 Medicaid LTC $$$ Source: CMS Medicaid Statement of Expenditures, annual estimate

17 Home and Community Based Services New Rule Out not well received by industry seen as very restrictive HCBS Services to be conducted in the Home or the Community setting Other sights (Nursing Home) construed as congregating, segregating and isolating members in an institution that have a right to be treated in their home and community Olmstead Act, Americans with Disability Act, Social Security Act all speak to HCBS and caution against congregating, segregating and isolating these beneficiaries in other than HCB settings New Rule States, you should read the new rule and, and - take an inventory of the HCBS waiver programs that you re providing and, and get back to us and tell us what you re providing and, and tell us if you re compliant with the new rules and, and if you re not in compliance we ll give 5 years to straighten things out. But, you re not required to actually do this inventory.

18 PACE and LTSS Program of All Inclusive Care for the Elderly Nursing Home Eligible and 55 years or older Medicaid capitated payment Medicare frailty adjusted base rate Medicaid Eligible full payment covered, Medicare Eligible only member - makes up Medicaid payment, Medicaid/Medicare Eligible full payment covered, Not Eligible for either pay monthly rate Must be a Non-Profit PACE provider Services conducted as part of a Patient Centered Care Plan heavily case managed designed to keep the member at home All inclusive services from IADL s, Respite, Adult Day Programming, Mental Health, Therapies, Drugs, Meals, Assisted Living, NF and Acute hospital stays virtually everything included in the rate and you can keep your PCP Demonstration Programs may be coming to Maine SCO s and ICO s

19 Alzheimer s and Dementia Care in Maine Big problem 37,000 with Alzheimer's and Dementia Related Disease increases to 53,000 by in 3 seniors dies with ALZ or another Dementia OOP expenses for long term care givers twice as expensive as local care givers 15.4M caregivers Provided 17.5B hours of unpaid care of $216B

20 ACA Programming for LTC The Affordable care set in motion many programs to improve public health and de-incentivize volume based payments lower volumes and potential for lower census ACO, PACO and Advance Payment ACO Bundled Payments Value Based Purchases Community Care Transition Program Independence at Home Programs

21 Questions? Answers??

22 They Said It! Always laugh when you can. It s cheap medicine. (Lord Byron) I learned along time ago that minor surgery is when they do the operation on someone else, not you. (Bill Walton) A hospital bed is a parked taxi with the meter running. (Groucho Marx) By medicine, life may be prolonged, yet death will seize the doctor too. (William Shakespeare) I got the bill for my surgery. Now I know why doctors wear masks. (James H. Boren) A Short History of Medicine 2000 B.C. - "Here, eat this root." 1000 B.C. - "That root is heathen, say this prayer." 1850 A.D. - "That prayer is superstition, drink this potion." 1940 A.D. - "That potion is snake oil, swallow this pill." 1985 A.D. - "That pill is ineffective, take this antibiotic." 2000 A.D. - "That antibiotic is artificial. Here, eat this root." (Author Unknown)

23 Contact Information Brett Seekins Senior Manager ext Thank you!