Home Care Association of Colorado May 6, 2016

Transcription

1 Home Care Association of Colorado May 6, 2016 William A. Dombi Vice President for Law National Association for Home Care & Hospice Legislative enactments and proposals affecting home care and hospice Medicare and Medicaid home care and hospice regulatory developments Medicare face-to-face rule litigation update Status of Medicare/Medicaid payment innovations VBP PAC bundling CJR pilot DoL FLSA Wage and Hour activity in home care 1

2 Physician Medicare payment model replaced SGR -> Value based Reimbursements End to annual patch $215 Billion in costs Offsets ($70 billion) Split contributions from providers and beneficiaries 1% rate update in 2018 HH surety bond changes Gains No home health copay 2 year extension of HH rural add on Home Health Care Planning Improvement Act of 2015 (allows NPs/PAs to sign home health plans of care.) H.R.1342, S.578 Preserve Access to Medicare Rural Home Health Services Act of 2015 (extends the payment increase (add-on) for Medicare home health services in rural areas through 2020.) S.2389 Medicare Home Health Flexibility Act of 2015 (allows home health agencies the flexibility to open cases and conduct initial assessments when skilled nursing care is not provided.) S Home Health Documentation and Program Improvement Act of 2015 (requires CMS to develop a standardized form for beneficiary eligibility; allows a home health agency to complete the form to be reviewed and signed by the referring physician.) S

3 To amend title XIX of the Social Security Act to require the use of electronic visit verification for personal care services furnished under the Medicaid program, and for other purposes. (requires states to have in place a system for the electronic verification of visits conducted as part of personal care services.) H.R Ensuring Access to Affordable and Quality Home Care for Seniors and People with Disabilities Act (would preserve the companionship services exemption) H.R S Palliative Care and Hospice Education and Training Act (would amend the Public Health Service Act to increase the number of permanent faculty in palliative care education programs.) H.R.3119 Care Planning Act (would provide assistance to individuals with serious health conditions by giving them access to more information about potential treatment options and ensuring that the course of treatment they arrive at is consistent with their personal goals, values and preferences.) S Medicare Patient Access to Hospice Act of 2015 (would grant Medicare beneficiaries, upon election of hospice care, the right to select their PAs to serve as their attending physicians for purposes of hospice care.) S.1354 H.R

4 Hospice CARE (Commitment to Accurate and Relevant Encounters) Act (allows hospices to utilize PAs and other appropriate clinicians to perform the required face-to-face encounter, and also provide additional time for hospices to complete the faceto-face encounter when exceptional circumstances occur.) H.R Hospice Care Access Improvement Act of 2015 (creates a one-year demonstration program testing a two-tiered payment system for hospice patients receiving routine care based on the length of their stay.) H.R MedPAC Annual March Report to Congress Most Medicare provider types assessed for payment adequacy HOME HEALTH: 2016 average margin: 8.8% (12.7% in 2012) Access to care, capital OK Margins affected by recent changes but still healthy RECOMMENDATIONS: NO update in 2017 Elimination of therapy utilization as a payment level determinant under HHPPS The institution of a second round of rate rebasing in 2018 Hospice Care

5 HOSPICE Care access, availability of providers, access to capital are all adequate Margins for 2016 estimated at 7.7% (excl bereavement, volunteer services) Live discharge rate dropped 1.2% between 2013 and 2014 RECOMMENDATIONS: NO UPDATE for FY2017 Reprint payment reform and medical review recommendation Reprint MA/hospice recommendation Anticipate future discussion of hospice in nursing facilities Hospice Care NEW ITEMS: Hospice: 1.7 ppt update reduction in each of 2018, 2019, and 2020 Create a hospice-specific market basket index Other budget neutral policy changes CMPs for failure to update enrollment records Medicaid Expansion states 3 yrs. At 100% match for new eligibles Prior authorization for Medicare FFS items and services REPEATS: 1.1 ppt cut in updates for HH, other PAC providers in 2017 and 2019 through 2026 HH copayments for new patients -- $100 per episode beginning in 2020 PAC bundled payments and VB purchasing User Fees for resurveys; exploring risk-based approach to surveying Hospice Care

6 Rebalancing of LTC spending continues Just less than 50% of Medicaid LTC spending now in home care States balance in spending wide ranging ACA incents home care Higher federal match to low balance states (BIP) New HCBS option benefit States increasing Medicaid home care audits and oversight Big focus on caregiver qualifications by OIG Documentation weaknesses on care plans ad authorizations Major movement to managed care Medicaid Proposed Rule on Managed Medicaid MLTSS (Managed Long Term Services and Supports) Duals Demonstration Programs Final rule issued: February 2, 2016, Eff. July 1, /pdf/ pdf F2F for initial ordering of HH services: Ordering physician must document the occurrence of a F2F encounter Clinical findings must show that encounter related to home health services order F2F may be performed by physician or authorized NPP Physician still must order HH services F2F occurs no earlier than 90 days prior/no later than 30 days after SOC May use telehealth (not phone) As much as 2 year delay if state legislative action needed Hospice Care

7 Also clarifies Coverage of HH services cannot be contingent on need for nursing or therapy services Medicaid HH not subject to homebound requirement HH services may NOT be limited to services furnished in the home: Can be in any setting where normal life activities take place NOT where payment could be made under Medicaid for inpatient services/r & B Hospice Care Methods for Assuring Access to Covered Medicaid Services Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability /medicaid-and-childrens-health-insuranceprogram-chip-programs-medicaid-managed-care-chipdelivered 7

8 HHPPS 2016 final rule Rates Value-Based Purchasing pilot Face to Face rule/lawsuit Program Integrity/Claims Reviews Star Rating System ticles/2015/11/05/ /medicare-and-medicaidprograms-cy-2016-home-healthprospective-payment-system-rateupdate-home 8

9 HHPPS 2016 Payment Rates Continued Rate Rebasing Recalibration of Case Mix Weights (again) Wage Index Changes Outlier Payment Model Case Mix Creep Adjustments (again!) Value Based Purchasing Model Payment rate updates Market basket Index (inflation factor): 2.3% Productivity Adjustment: 0.4 Case mix creep adjustment: 0.97% (2016, 2017, and 2018) Rebasing + updates + adjustment = Reduction in spending of $260 million in

10 Case Mix Creep adjustment Relies on out of date data on nominal case mix changes No increase in spending Case mix weights recalibrated Industry cannot survive further rate reductions What can be expected with 2017 HHPPS rule? CMS unlikely to change path Congressional efforts underway, but limited Delay and replace Repeal and replace with Value Based Purchasing Study Impact of rebasing mixed Margins down, but less than forecast New HHAs in market Consolidation/Acquisitions shows market promise Limited access concerns surfacing MedPAC recommending deeper rate cuts 10

11 CMS pilots a VBP: Starting in 2016 Baseline year 2015 Performance year 2016 Payment year states mandatory participation of all HHAs (NC included) 3-8% payment withhold for incentive payments greater upside benefit and downside risk Phase-in to 8% performance measures Achievement and improvement Process, outcomes, and patient satisfaction Comparison based on smaller-volume and largervolume State-based comparison Congressional proposal introduced in July (W&M sponsors) Substitute for SGR legislative cuts Integrated PAC VBP rather than individualized sectors Starting in FFY 2020 Geographic based measures based solely on PAC spending Withhold range at 3-8% with 50-70% redistribution Limited direction on performance measures PAC sector-specific per beneficiary spending(dangerous) Significant discretion given CMS Home health non-pac: in or out??? MedPAC supports hospital readmission penalties 11

12 Generally supportive of VBP as a payment model reform Details matter! Details here raise concerns Amount at risk 2% is max in other sectors At risk levels may prevent improvements as resources depleted Measures are complex, subject to manipulation, and leave out patient stabilization Do not reflect population served in home health Will overlap with bundling, ACOs, and other innovations No benchmarks until April Benchmarks based on all patients with OASIS, not just Medicare FFS Effective 1/1/15 Eliminates physician narrative requirement Requires certifying physician to have sufficient records to support certification Rejects physician payment claims for certification/recertification when home health claim denied for noncompliant certification/recertification CMS began nationwide prepayment probe and educate on 10/1/15 (5 claims from each HHA) Limited pre-2015 claims review on F2F currently CR 9189; and-guidance/guidance/transmittals/2015- Transmittals.html 12

13 Physician documentation Physician required to provide HHA with such documentation if HH claim audited HHA can supply certifying physician with its documentation Must show that physician reviewed and signed off on it Corroborates physician documents CMS expects certification at the start of care or a soon as possible thereafter No formal rule standard on exact timing Expects prior to end of episode Significant confusion on how to administer and comply with the requirement CMS proposes electronic documentation template All HHAs will have 5 claims audited HHAs with high denial rate will have a second round MAC education of HHAs Early indications of excessive denial rate Physician records insufficient No reply to ADR Advocacy efforts Congress CMS Court 13

14 Longstanding rule with new interpretation: 42 CFR (b)(2) The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. Must be part of the recertification included in the recertification statement separate statement where it is clear that it is part of the recertification I certify that in my in my estimation services will be require for.. Agency may complete based on the physician estimate Combines outcome measures and process measures from Home Health Care Compare into a single score Process measures: Timely Initiation of Care Drug Education on all Medications Provided to Patient/Caregiver Influenza Immunization Received for Current Flu Season Outcome measures: Improvement in Ambulation Improvement in Bed Transferring Improvement in Bathing Improvement in Pain Interfering With Activity Improvement in Shortness of Breath Acute Care Hospitalization HHCAHPS Star Rating January 2016 (separate system) 14

15 Focus on Improvement measures Formula pushes scores to the middle Most HHAs with 3 Stars Consumer impression that 3 Stars is mediocre Patient experience (HHCAHPS) Star rating a different model More traditional design Consumer familiarity with model CMMI pilots/demos continuing 2100 participating providers in 360 demo agreements Limited home health participation; virtually no risk taking Evidence of impact still unavailable ACO experience shows some home health gains in use Administration support for expanded PAC bundling Congressional caution BACPAC bill Limited support Industry concerns 15

16 Affects total hip and knee replacement patients (April 1, 2016) Hospital payments at risk Target spending set by CMS geographic specific data Hospitals may share risk and savings with other providers First year: shared savings only Year 2 and beyond: shared savings and losses Covers costs through 90 days post hospital 67 hospital geographic areas in play Patient freedom of choice continues Providers paid at usual FFS rates Expansion/retraction/termination possible depending on results Home health impact: mixed, but mostly positive in the aggregate Three-year, five-state demonstration; start in Florida, Texas, Illinois; second phase: Michigan, Massachusetts Develop methods to identify, investigate and prosecute fraud CERT contractors identify 51.4% improper payment rate MAC review for PA If submitted for PA and approved, claim paid If submitted for PA and denied, denied (may appeal) If no PA submission but claim submitted and approved, 25% reduction in payment Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing- Items/CMS html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descen ding Advocacy Efforts are intense Hospice Care

17 New Payment Model (Beginning Jan. 1, 2016) Two- tiered payment system for RHC Days 1 60 of episode - - $ Days 61 and thereafter of episode - - $ Episode a hospice election period or series of election periods separated by no more than a 60- day gap SERVICE INTENSITY ADD-ON (SIA)-RN &SW 4hours daily max. in last 7 days of life 6/04/28/ /medicare-programfy-2017-hospice-wage-index-andpayment-rate-update-and-hospice-qualityreporting 17

18 Proposed Hospital market basket Productivity adjustment Add l ACA reduction Net market basket 2.8 percent percent (does NOT reflect impact of wage index changes) Hospice Care Code/Descrip-tion FY2016 Rate Proposed FY2017 Rate 651/Routine Home Care days 1-60 $ $ /Routine Home Care days 61+ $ $ Rates NOT adjusted for wage index or failure to meet HQRP requirements Hospice Care

19 Code/Descrip-tion FY2016 Rate Proposed FY 2017Rate Continuous Home Care (hourly rate for SIA) Inpatient Respite $ ($39.37/hr.) $ ($40.16/hr.) $ $ General Inpatient Care $ $ Rates are not adjust for wage index or failure to meet HQRP requirements Hospice Care CAP Year days of care Nov. 1, 2015 Oct. 31, CAP Year days of care Nov. 1, 2016 Sept. 30, CAP Year days of care Oct. 1, 2016 Sept. 30, 2017 Hospice Care

20 Streamlined Patient-by-patient (Proportional) /28/15-9/27/ /28/16-9/30/ /1/17-9/30/18 Patients Payments Patients Payments 11/1/15-10/31/16 11/1/16-9/30/17 10/1/17-9/30/18 11/1/15-10/31/16 11/1/16-9/30/17 10/1/17-9/30/18 11/1/15-10/31/16 11/1/16-9/30/17 10/1/17-9/30/18 Hospice Care Two New Measures collection starts April 1, 2017: HIS Composite Measure 7 scores Measure PAIR Hospice Visits when death is Imminent (data extracted and entered onto HIS) Patients receiving at least 1 visit from RN, MD, NP, PA in final 3 days of life Patients receiving at least 2 visits from MSW, chaplain, spiritual counselor, LPN, or hospice aide in last 7 days of life 20

21 Hospice COMPARE and public reporting Summer 2017 CMS considering expansion of HIS as assessment instrument would NOT replace Initial and Comprehensive Assessments Hospice demographic data Summer 2016 Hospices meeting HQRP requirements published list late Summer 2016 STAR ratings?? usu. one year post public reporting CMS continues to monitor utilization trends for program integrity and potential future payment changes CMS monitoring impact of payment changes New movement toward reference to Hospice as post-acute provider??? 21

22 CMS MAY CONSIDER FUTURE CHANGES (legislation required): Adjust aggregate CAP by wage index Rebase aggregate CAP Use cost report data to establish average episode cost for use as CAP value Hospice Care TARGET AREAS Live Discharges/No Longer Terminally Ill (excludes transfer, revocation, discharge for cause, move out of service area) Live Discharges/ Revocations (NEW) Live Discharges/LOS days (NEW) Long Length of Stay (greater than 180 days) CHC in ALF RHC in ALF RHC in NF RHC in SNF Claims with Single Dx Code (NEW) No GIP or CHC (NEW) Hospice Care

23 ACA Section 1128J(d) -- report and return Medicare overpayment by the later of: Within 60 days of identification By date any corresponding cost report is due Final Rule published Feb. 12, 2016 with effective date of March 14, 2016 Hospice Care Impact on Home Health Outlier Cap, RAPs, and Hospice CAP HHAs and hospices don t know cap overpayment status until notified by MAC CMS: Hospice/home health cap determinations are made at the end of the year and provider may not be aware of the cap status until their MAC calculates the final cap amount. Therefore, the provider is not responsible to report and refund the overpayment until they have received the cap determination from their MAC. There can be no applicable reconciliation until the final cap amount is determined. Hospice Care

24 A stakeholder growing in impact Rule changes directly targeting home care companionship services exemption Live-in domestic services Policy positions informed through home care Joint employer Independent contractor DoL rule effectively eliminates minimum wage and overtime exemption Eliminates exemption for 3 rd party employment Changes definition of companionship services Excludes 3 rd party employers from live-in exemption Medicaid and disability rights advocates opposition Primary impact is on Medicaid and private pay services 24

25 DoL sees limited impact Transfer of dollars from employer/payer at $232M annually Industry sees greater impact Increased staff recruiting Higher staff turnover Shift to part-time workers Limited Medicaid rate support Lower customer satisfaction Appeal to U.S. Supreme Court Stay denied Petition for Certiorari in process 2/24 DoL response due 3/9 Reply due Expect Cert Petition ruling in May or June If cert granted, argument will be in October 2016 term 25

26 Post-lawsuit forecast Private parties sue state Medicaid programs, MCOs, and home care companies to enforce rules Industry retrenches to limit worker hours and establish new delivery models Turnover increases Client satisfaction diminishes Home care company costs increase Client costs increase with some reducing care levels CMS pushes states to fund overtime Ensuring Access to Affordable and Quality Home Care for Seniors and People with Disabilities Act (would reinstate the companionship services and live-in exemptions) H.R S Moderately stable times Opportunities for innovation Challenges remain in regulatory proposals/changes Quality remains high, but standards and oversight on the increase Manage today, plan for the future! 26