In-District Action Kit

Transcription

1 In-District Action Kit Summer King Street Suite 100 Alexandria, VA

2 How to Use This Kit There are big things afoot in D.C., and your Members of Congress will be home in August to listen to you and make sure that they re accurately representing your views in Washington features more in-district time for your Members of Congress, especially in the House of Representatives. You can be sure that you will be able to track down your federal officials through community events, bus tours, ribbon cuttings, constituent coffees, town halls, and increased press coverage. The recess is one of the few stretches of time to reconnect with constituents and really hear the local angle on national issues. This is where you come in. This kit contains the resources you will need to make the most of the 2011 recesses: tip sheets to help you get facetime with your Members of Congress, background information on the Medicare Hospice Benefit, as well as template letters to help you request personal meetings and invite them to tour your programs. To round out the kit, we have included the most current talking points on the pressing issues facing the hospice community. The included fact sheets can be used to describe the top two issues that have the potential to impact end-of-life care: 1) securing your Elected Officials support for the HELP Hospice Act, and 2) the long-standing challenge of Medicare reimbursement rate protection. We know you are busy, so we have tried to make it as quick and easy as possible for you to get active with advocacy this year. Here s how: 1) Get on the calendar. We recommend that you get your meeting request letters in as soon as possible. or fax your requests to your Representatives local district offices. You can find this information online, in the local phone book, or you can ask us for it by sending an to info@nhpcohan.org. 2) Watch your inbox. Occasionally, we will send you an if we hear that your Members of Congress are hosting community forums or town halls. In most cases, all you have to do is show up to these events; there is no need to register in advance. 3) Be prepared. Familiarize yourself with the included talking points and basic resources, such as the included fact sheet on the HELP Hospice Act, the Rate Cut messaging document, and local facts about how many patients are served in your state. The included fact sheets can be shared with your Members of Congress and used as leavebehind materials. 4) Give yourself a pep talk. There s no need to be nervous. You are a voter. You take care of voters. Your family is full of voters. Members of Congress are elected to represent you. So, relax, have fun with it, and be polite. 5) Get creative. What we offer you in this kit is just a starting point. If you have an upcoming event or some other ideas that you think are ripe for advocacy involvement, go for it. 6) Let us know how it goes. We want to hear what you are doing, and we may even want to brag on you. So, send us pictures and drop us a line at info@nhpcohan. And, most importantly, we re here for you. Let us know if you have any questions or just want to bounce an idea off of us.

3 Program Visit Case Study Hospice of Southern Maine Recently, Congresswoman Chellie Pingree (ME-1 and a local aide visited an inpatient unit at the Hospice of Southern Maine (HSM). She was greeted by Mary Pinto, the program s Director of Finance. Ms. Pinto and the team at HSM had prepared a comprehensive site visit, one that seemed to leave a lasting impression on Rep. Pingree. The visit started with the distribution of several key materials a copy of the HSM s Mission & Vision, their quality initiatives, and a quick list of the community benefits of hospice care. Ms. Pinto also took advantage of many of the informational documents supplied by NHPCO s Legislative Action Center website The Medicare Payment System fact sheet, the CMS Medicare Hospice Benefit form, the Duke Study, the NHPCO 2009 Edition Hospice in America and Pediatric Palliative paper, a letter written by NHPCO President Don Schumacher to the Senate Finance Committee, and a side-by-side comparison detailing key differences (and NHPCO preferences) between the Senate and House versions of the health care reform bill. Rep. Pingree was then led to a short reception with volunteers, staff and several members of the HSM Board of Directors. She then toured the 18-bed facility with the Clinical Director and Assistant Medical Director. These tours help to create a lasting impression on elected representatives about the important services hospices provide- they give concrete examples of exactly what sorts of things the Medicare Hospice Benefit covers. After touring the facility, Rep. Pingree sat with several local end-of-life care community professionals and discussed the challenges faced by hospice. During these discussions, Congresswoman Pingree expressed surprise at the extent to which HSM depended on the Medicare Hospice Benefit for revenue. It is in these conversations that the value in site visits and small discussions can truly be found. Every time a Representative learns in a personal way a little more about how precarious running a hospice can be, we as advocates have done our job. The discussion on the Medicare Hospice Benefit continued, with members of the HSM explaining the many services the Medicare Payment provides. They stressed the uniqueness of the benefit- the fact that it covers a wide range of services and even all medications needed by a patient. Medication expenses seemed to particularly resonate with Rep. Pingree, due in part to her work on the issue as a State Representative. Creating these personal connections with Members of Congress is what makes site visits so helpful in our hospice advocacy efforts. They are the story behind the numbers. If a Representative has a busy schedule, they may only glance at the volume of calls or s from constituents. By contrast, when they are out visiting local Hospice programs there is a much higher chance that they will take the time to truly listen to our stories, our problems, our triumphs. HSM is a great case study for a site visit. Representatives serve their districts scheduling an appointment with your Member of Congress might not be nearly as hard as you would imagine. You can find many talking points and narratives on the Hospice Action Network web page, and you can find and contact your representatives on our Legislative Action Center. And, if you need us to work with you on customizing materials, just contact the Public Policy staff.

4 5 Steps to Effective Meetings with Members of Congress 1. At your meeting, briefly and sufficiently describe the key issue. Focus on only one or two key issues. For the August 2011recess, HAN suggests the HELP Hospice Act and protection of the Medicare Hospice Benefit. Your time may be limited to 10 or 15 minutes. Include points about how the issue affects the Member s constituents, including your patients and employees. Always prepare a solution for every problem you present. 2. Bring written materials to leave with your Member of Congress. Include a brief cover memo with attachments expanding on your key issues. For your own use, develop talking points and stick with your message. Written materials and leave-behinds are also available on the Hospice Action Network website. 3. Tell your Member of Congress how important your organization is to the district and/or state. Describe the population you serve, the types of services you provide, list numbers of patients and employees served in areas where you operate, point out the cost-effectiveness of hospice care, and the difference that your services make in your patients lives. Explain how the HELP Hospice Act would positively affect your local area and program. 4. Ask for a commitment regarding support of the HELP Hospice Act. Don t worry- you re not being pushy. Members of Congress are used to being asked for their supportit s their job to support their constituents. Asking for support of the HELP Hospice Act is one of the most direct ways you as an Advocate can affect change for hospice. The more co-sponsors a bill has, the more likely it is to be passed into law. By having your Representatives sign on, we increase the chances that the HELP Hospice Act can help hospices now and in the future. 5. Follow up, and follow up again. Within a few days of your visit, send a letter thanking the Member of Congress for his or her time, and briefly restate your ask for support. Follow up a week later with a phone call to see if you can provide any additional information.

5 5 Steps to a Great Facility Tour 1. Fax or a polite, professional invitation letter to the Member of Congress in care of the staff person who schedules meetings. You might want to cc the Legislative Assistant (LA) for health issues, as well as the District Director, who manages the Member s offices in the state. Mention the number of patients served by your facility, your service area and the number of employees. HAN can help you in finding current contact information for Health LA s and District Directors. 2. Be as flexible as you can about the timing of a tour. This would likely occur during one of the district work periods, when Congress is not in session. Allow adequate time for the Member and his or her staff to get a sense of your operation, and leave some time for questions. 3. In conversations with staff about a potential tour, offer to invite the local media or a photographer to accompany the Member on the tour. If a tour is scheduled, alert the press beforehand about the visit and explain to them how Medicare policy affects your organization. 4. During the tour, involve employees and patients, if possible. Let the Member of Congress meet some of the people involved in your program. Your Member represents employees, patients, and their families. 5. Share key facts about your program. These include: what types of patients your organization serves, what types of services and equipment are provided, how many employees work at the facility, the economic impact of the facility in the region, and other information about the role that your organization plays in the community, and in the lives of patients and their families.

6 SAMPLE LETTER: Request an In-district Meeting Date The Honorable [FULL NAME] United States Senate or House of Representatives Washington, DC (Senate) or (HOUSE) By Fax: [IN-DISTRICT OFFICE] Dear [STAFF MEMBER S NAME]: Team members from [INSERT HOSPICE NAME] would like the opportunity to meet with you in your office on [INSERT DATE]. Since our founding in [INSERT YEAR], [INSERT HOSPICE NAME] has cared for [INSERT NUMBER] individuals with a life-limiting illness and their families in [INSERT COMMUNITY/COUNTY/REGION]. During our visit, we would like to talk with you about our program, the services we provide our community and how we may be of assistance to you and the constituents we serve. We would appreciate any opportunity to meet with you. Please contact me at any time to schedule a meeting. I have enclosed my contact information. Sincerely, Your Name Title Hospice Name

7 SAMPLE LETTER: Thank You for the In-district Meeting Date [STAFF MEMBER S FULL NAME] [IN-DISTRICT OFFICE ADDRESS] By Fax: [IN-DISTRICT OFFICE FAX] Dear [INSERT STAFFER S NAME]: I am writing to thank you for meeting with me/[insert PROGRAM NAME] end-of-life care team at your office on [INSERT DATE]. You certainly made us feel welcome. Thank you again for spending time with us/me. I have enclosed my contact information, should you or a member of your staff need further information. Sincerely, Your Name Title Hospice Name

8 SAMPLE LETTER: Inviting a Representative to Visit a Program Date The Honorable [FULL NAME] United States Senate or House of Representatives Washington, DC (SENATE) or (HOUSE) By Fax: [SCHEDULER S FAX NUMBER] Dear Senator/Representative [LAST NAME]: On behalf of [INSERT NAME OF HOSPICE PROGRAM] in [INSERT CITY/TOWN], I would like to invite you to come tour our program during the upcoming recess. We would like to share with you the services our program has provided our community for the last [INSERT NUMBER] years. During your visit, we welcome you to sit in on one of our Interdisciplinary Team meetings, meet one of our patients and greet our volunteers. We are happy to work with your scheduler to find a date that works well for you. I will follow up on this scheduling request within a week. All of us at [INSERT NAME OF HOSPICE PROGRAM] look forward to offering you a more personal look at end-of-life care available in our community. Sincerely, Your Name Title Hospice Name

9 SAMPLE LETTER: Following Up on Request for Visit Date The Honorable [FULL NAME] United States Senate or House of Representatives Washington, DC (SENATE) or (HOUSE) By Fax: [SCHEDULER S FAX NUMBER] Dear Senator or Congressperson [LAST NAME]: I am writing to follow up on the scheduling request that I faxed to your attention on [INSERT DATE]. We at [INSERT HOSPICE NAME] are eager to meet with you to [INSERT REASON]. We are happy to work with you to find a time that is most convenient for you. [INSERT HOSPICE NAME] eagerly looks forward to any opportunity to meet. I have enclosed my contact information, should you or a member of your staff need further information. Sincerely, Your Name Title Hospice Name

10 SAMPLE LETTER: Thank You for Accepting Our Invitation DATE [Scheduler s Name] [Congressional Office] Washington, DC [SENATE] or [HOUSE] BY FAX: [SCHEDULER S FAX NUMBER] Dear [Scheduler s Name]: Thank you for working so patiently with us to schedule a visit from[insert SENATOR/REPRESENTATIVE NAME]. We are delighted that the visit will work for [HIS/HER] recess schedule. We ve already begun making preparations. I ll send you an agenda for your records in a week or so. Please don t hesitate to contact me, should you have any questions or concerns. Thank you again, Your Name Title Hospice Name

11 FACT SHEETS

12 Medicare Hospice Benefit More than 90% of hospices in the United States are certified by Medicare. Medicare defines a set of hospice core services, which many hospices surpass through voluntary, community-based efforts. The Medicare Hospice Benefit, initiated in 1983, is covered under Medicare Part A (hospital insurance). Medicare beneficiaries who choose hospice care receive a full scope of non-curative medical and support services for their terminal illness. Hospice care also supports the family and loved ones of the patient through a variety of services, enhancing the value of the Medicare Hospice Benefit. The Medicare Hospice Benefit provides for: n Physician services n Counseling n Nursing care n Social work service n Medical appliances and supplies n Spiritual care n Drugs for symptom management and pain relief n Volunteer participation n Short-term inpatient and respite care n Bereavement services n Homemaker and home health aide services Who is Eligible? Medicare has three key eligibility criteria: n The patient s doctor and the hospice medical director use their best clinical judgment to certify that the patient is terminally ill with a life expectancy of six months or less, if the disease runs its normal course; n The patient chooses to receive hospice care rather than curative treatments for their illness; and n The patient enrolls in a Medicare-approved hospice program. Payment for Hospice: n Medicare pays the hospice program a per diem rate that is intended to cover virtually all expenses related to addressing the patient s terminal illness. n Because patients require differing intensities of care during the course of their disease, the Medicare Hospice Benefit affords patients four levels of care to meet their needs: Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care. n 96% of hospice care is provided at the routine home care level which is reimbursed at approximately $135 per day. n The Hospice Benefit rates have increased annually based on the Hospital Market Basket Index. With the advent of costly new drugs and treatments like palliative radiation, the average cost to hospices has risen much faster than the hospice benefit reimbursement rates. n Hospices that are Medicare-certified must offer all services required to palliate the terminal illness, even if the patient is not covered by Medicare and does not have the ability to pay.

13 1655 N. FORT MYER DRIVE, SUITE 1250 ARLINGTON, VA (703) FAX (703) Memorandum (March 17, 2011) TO: Office of Health Policy, NHPCO FROM: The Moran Company SUBJECT: Summary of Profit Margin Analysis for Urban and Rural Hospices, The 2010 Patient Protection and Affordable Care Act (ACA) and the hospice payment rules have implemented the phase-out of the Budget Neutrality Adjustment Factor (BNAF), the annual hospital market basket adjustment, and the reduction to the market basket update due to a decrease in the productivity factor. The Moran Company estimated the effect of the changes on profit margins for Medicare-certified hospices, particularly hospices that serve patients in rural areas. 1 We estimate that the median Medicare profit margin for the hospice industry could decrease from 4% in 2008 to -11% by Hospices that serve mostly rural patients would be the most severely affected (profit margin decreases ranging from 0% in 2008 to -16% in 2019). We estimate that 66% of hospices could have negative Medicare profit margins by 2019 (61% of moderately rural and 76% of mostly rural hospices). Summary of Analysis Hospices were classified as urban (less than 50% of patient days in a rural county), moderately rural (50-74% rural) or mostly rural (75%+ rural) using the % Medicare Standard Analytic Files (Table 1). Table 1: Urban and Rural Composition of Hospices Included in Trend Analysis Using cost and revenue data from the Hospice Cost reports and the Medicare claims data, we calculated Medicare profit margins per patient day for each hospice and estimated profit margins based on the three policies affecting hospice rates (Table 2). 2 We estimate that median Medicare profit margins for all hospices would decrease from 4% in 2008 to -11% by 2019 when applying the market basket update to costs (Figure 1). 3 For urban hospices, median profit margins are estimated to decrease from 6% to -10%. Profit margins are also estimated to decrease significantly for rural hospices (0% to -16% for mostly rural hospices and 9% to -6% for moderately rural hospices). We estimate that the percent of hospices with negative profit margins would increase from 43% in 2008 to 66% in 2019 (Figure 2). The percent 1 This memorandum summarizes the findings of an October, 2010, study. Please see the complete memorandum for more detail on the methodology employed for this analysis and results. 2 Profit Margin = (Medicare revenue/patient day Total reimbursable/bereavement/volunteer costs/patient day) Medicare Revenue/patient day We do not account for hospice repayments associated with the cap policy. Additionally, this analysis relies upon Medicare hospice cost reports which may contain errors and variations in the completeness of reporting. 3 We report trends using median profit margins rather than mean profit margins because of considerable variability and incompleteness in cost report data resulting in extreme high and low values. THE MORAN COMPANY

14 2 of hospices with negative margins that service mostly rural areas would increase from an estimated 50% to 76%, and would increase from 39% to 61% for moderately rural hospices. Table 2: Assumptions for Calculating Changes in Revenue and Costs for Hospice Profit Margin Trend Analysis, Assumptions Revenue Analysis Cost Analysis Column Effective Date (October 1) Hospital Market- Basket Increase 1 Annual Percent Reduction for BNAF Phase-Out 2 Estimated Productivity Factor 3 Annual Change in Revenue Market Basket Update % -1.6% 0.8% 2.4% % -1.6% 0.8% 2.4% % -1.6% 0.8% 2.4% % -1.6% 0.8% 2.4% % -0.4% -1.6% 0.4% 2.4% % -0.4% -1.6% 0.4% 2.4% % -0.4% -1.6% 0.4% 2.4% % -0.4% -1.6% 0.4% 2.4% % -0.4% 2.0% 2.4% % -0.4% 2.2% 2.6% % -0.3% 2.1% 2.4% 1 CBO estimates for ; values provided for are actual market-basket increases. 2 BNAF reduction, 7 year reduction of 4.2%; beginning at % in This reduction is only applied to the wage portion of the hospice rate (68.7%). 3 Productivity reduction- 1.3% for all providers with 0.3% delay to 2013 from 2010 Patient Protection and Affordable Care Act (ACA). Figure 1: Estimated Median Profit Margins, Figure 2: Estimated Percent of Hospices with Negative Profit Margins, THE MORAN COMPANY

15 THE MEDICARE HOSPICE BENEFIT & RECENT CHANGES IMPACTING THE HOSPICE COMMUNITY The Medicare Hospice Benefit: Established in 1983 to provide Medicare beneficiaries with access to high-quality end-of-life care. Last year, over 1.5 million Americans and their families benefitted from the hospice care model, a team-oriented approach to medical care, pain management, and emotional and spiritual support tailored to the patient's needs and wishes during their final days. More than 88 percent of hospice patients are Medicare beneficiaries. 1 Medicare pays hospice a flat, per-diem rate that covers all aspects of the patient s care, including all provider services and drugs as well as all medical equipment and supplies. While the number of beneficiaries using hospice has more than doubled since 2000, hospice comprises only 2 percent of total Medicare expenditures, the least of any direct patient service provider under the program. 2 According to recent MedPAC data, hospice margins average only 2.8 percent. 3 Recent Rate Cuts: The hospice community has been subject to several regulatory and legislative changes in recent years. A 2009 CMS rule initiated a seven-year phase out of the Budget Neutrality Adjustment Factor (BNAF), a key element in the calculation of Medicare hospice wage index. Elimination of the BNAF will ultimately result in a permanent reduction in hospice reimbursement rates of approximately 4.2 percent 4. The Affordable Care Act (ACA) further altered the Medicare hospice rate formula through the introduction of a productivity adjustment factor, that will reduce annual hospice payments by an additional 11.8 percent over the next ten years. Hospice is a highly labor-intensive model of care where such productivity gains are not as achievable relative to other areas of our health care system. The Moran Company recently conducted an analysis of the impact of these two cuts on hospice margins over the next decade 5. Moran Company Analysis - Estimated Median Profit Margins, (All Hospices, Urban, and Rural Hospices) 1 - NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA: National Hospice and Palliative Care Organization, October CMS Report: According to MedPAC s 2010 projection, the average hospice margin is 4.6 percent. We use the 4.6 percent projection and subtract 1.5 percent (costs related to nonreimbursable bereavement services) and an additional.3 percent (costs associated with maintaining statutorily mandated volunteer services) to get 2.8 percent. 4 -The percentage is 2.8% after the statutory annual Market Basket update is taken into account. 5 Moran Company report available here: HospiceProfitMarginSummary.pdf

16 PRESERVE AND PROTECT THE MEDICARE HOSPICE BENEFIT Support the HELP Hospice Act Action Requested: We are deeply concerned about the effect further modifications to the Medicare hospice benefit will have on quality patient care and access to these valuable services. The hospice community asks that the 112 th Congress support the Hospice Evaluation and Legitimate Payment (HELP) Act, legislation to (1) require the Secretary to establish a payment reform demonstration program to test and evaluate any prospective payment revisions to hospice, (2) increase hospice survey frequency to every 3 years, and (3) amend the new face-to-face encounter requirement to reflect operational realities for hospice programs, and the needs of the patients and families they serve. The HELP Hospice Act has been introduced by Senators Wyden and Roberts (S. 722), and efforts for a House companion bill are underway. 1. Sensible Hospice Payment Reform The ACA included a MedPAC recommendation to transfer hospice payment authority from Congress to the Secretary of Health and Human Services. MedPAC also recommended, and the ACA statute required, the Secretary to collect and analyze extensive data prior to implementing a new payment system for hospice, on or after fiscal year Noting a lack of reliable, comprehensive data upon which to base a new payment methodology, The hospice community calls upon Congress to direct the Secretary to pilot any new payment methodology first through a two-year, 15-site demonstration program. This approach would help to overcome the current lack of reliable, comprehensive data upon which HHS can rely to evaluate potential payment methodologies. A pilot program allows for any recommended payment reform schemes to be tested across a representative sample of the hospice community to assess their impact on beneficiary access to hospice services. COST: $3 million for the budget forecast period More Frequent Hospice Surveys An HHS Office of the Inspector General (OIG) report found that the current certification system for hospice was not providing sufficient oversight relative to other Medicare providers. OIG noted that the frequency of hospice certification is far different from the certification frequencies required by nursing homes, hospitals, and home health agencies and recommended regulatory or statutory changes to increase certification frequency. According to the report, the majority of hospices were surveyed within 6 to 8 years (depending upon available resources), while almost 15 percent averaged 3 years past due. 6- All cost estimates in this document are based on a Moran Company assessment of budgetary implications of the hospice proposal, available upon request. 7- OIG Report:

17 The hospice community urges Congress to institute a 3-year survey frequency requirement. This recommendation is consistent with the survey industry standard for hospices set forth by accrediting organizations, such as the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). COST: No cost under OMB score keep guideline Hospice Face-to-Face Encounter Adjustments The ACA included the MedPAC recommendation to require a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient upon election of the Medicare hospice benefit, before the end of 180-day recertification period and again for each 60-day recertification after that date. The hospice community supports the intent of the face-to-face encounter requirement and is working hard to be in compliance, even as the requirement stretches hospice physician and nurse practitioner resources. The hospice community is asking that Clinical Nurse Specialists and Physician Assistants also be allowed to conduct the face-to-face encounter, and that hospice programs be afforded 7 days after the initial election of services to fulfill the requirement. The current limits on who can conduct the face-to-face encounter and the tight timelines specified in the rule for compliance do not reflect the operational constraints of hospice programs, especially for small and rural hospices. Hospices may be forced to turn down certain patients seeking to elect hospice if they feel they will not be able to comply with the present timeline required to conduct the initial face-to-face encounter requirement. COST: No cost associated with modifications to the face-to-face encounter requirement. The National Hospice and Palliative Care Organization (NHPCO) is the largest nonprofit membership organization representing hospice and palliative care programs and professionals in the United States. The organization is committed to improving end of life care and expanding access to hospice care with the goal of profoundly enhancing quality of life for people dying in America and their loved ones. 8- OMB Circular A-11: No increase in receipts or decrease in direct spending will be scored as a result of provisions of a law that provides direct spending for administrative or program management activities.

18 Helpful Links Know the Issues! Hospice on Capitol Hill: Hospice and Health Care Reform: Get the Facts! Duke University Cost Study: Follow the Headlines! Hospice Advocacy News Room: Get Inspired! Hospice Advocate Spotlight: Keep it Going! Hospice Action Network Legislative Action Center: Ask for help: NHPCO HAN 2011