Public Hearing Assembly Committees on Health and Oversight, Analysis and Investigation Medicaid Transition to Care Management for Long Term Care December 7, 2012 Opening Remarks Chairman Gottfried, Chairman Hevesi, and Committee Members, thank you for the opportunity to present testimony on Medicaid s transition to managed care. I m Kathy McMahon, President and CEO of the Hospice and Palliative Care Association of New York State. Hospice and Palliative Care Association of New York State (HPCANYS) represents the state s certified hospice providers and palliative care providers, as well as individuals and organizations concerned with care for patients and their families at the end of life. Background Hospice serves patients at the end of life and provides pain and symptom management, addresses social, emotional and spiritual needs and provides care and support to the bereaved. Hospice services are provided in the home, nursing home, inpatient facilities, as well as hospice residences. Hospice uses a unique interdisciplinary team approach. Palliative Care, as defined by the World Health Organization, seeks to address not only physical pain, but also emotional, social and spiritual pain to achieve the best possible quality of life for patients and their families. Palliative care extends the principles of hospice care to a broader population that could benefit from receiving this type of care earlier in their illness or disease process. Why Hospice and Palliative Care Support New York s Triple Aim Approach Hospice and palliative care represent the paradigm for Medicaid Redesign s Triple Aim Approach Quality, Patient Centered Care, and Cost Effectiveness. 1
The Hospice and palliative care models are based on case management patientcentered care. Hospice and palliative care provide the quality, compassionate care that patients want and need, while being cost effective. Hospice is one of Medicare's most cost-effective programs: According to an independent study conducted at Duke University, hospice saves Medicare an average of $2,300 per patient, or nearly $2 billion a year. A recently published study by Aetna found that Liberalization of hospice benefits that permits continued curative treatment and removes limits on hospice benefits is a strategy that is financially feasible for health plan sponsors, insurers, and Medicare. (A Comprehensive Case Management Program to Improve Palliative Care, C.M. Spettell, PhD et al, Journal of Palliative Medicine, Vol. 12, Number 9, 2009) Data from the Dartmouth-Atlas of Health Care 2008, Tracking the Care of Patients with Severe Chronic Illness demonstrates more resources and more care (and more spending) are not necessarily better. A 2008 study by Dr. Sean Morrison validates costs savings associated with hospital-based palliative care consultation programs (Morrison, R.S., et al, 2008; Cost Savings Associated with US Hospital Palliative Care Consultation Programs. Archives of Internal Medicine, 163(16), 1783-1790) Palliative care alongside usual care has maintained or improved the quality of care while generating substantial cost savings. (Smith, T., Cassel, J.B.; 2009. Cost and Non-Clinical Outcomes of Palliative Care; Journal of Pain and Symptom Management, 38(1), 32-34) According to the National Hospice and Palliative Care Association s 2010 Family Evaluation of Hospice Care Survey, 94.4% of families reported that hospice care provided was consistent with the patient s end of life care wishes; and 98.3% would recommend hospice to others. The Medicaid Hospice Benefit enhances patient quality while also controlling costs. In addition to being cost effective, patient satisfaction is high. One study, conducted by Brown University, supported the role of hospice in nursing homes, concluding that hospice patients: 2
Are less likely to be hospitalized in the last 30 days of life; and Received superior pain assessments. Medicaid Redesign The Legislature is to be applauded for recognizing the important role of hospice and palliative care in the comprehensive redesign of the Medicaid system undertaken by the Medicaid Redesign Team in 2011. For example, MRT #209 included several proposals to expand hospice so that a broader population could access these services. In addition, MRT #109, through the Palliative Care Access Act (PHL 299-d), will facilitate access to palliative care for individuals in hospitals, nursing homes, home care and enhanced and special needs assisted living residences. HPCANYS is working in partnership with the Healthcare Association of New York State (HANYS) and the Center to Advance Palliative Care (CAPC) to seek grants to help implement the provisions of the Palliative Care Access Act. The effort undertaken by Medicaid Redesign provided an opportunity to take a look at how the State could provide better, more cost effective healthcare to the Medicaid population and resulted in numerous changes to the system. However, there exists both within and among these changes a plethora of moving parts, and the potential for an outcome that may not have been intended. Therefore, it is imperative that there be a strong oversight component to assure that key elements of Medicaid Redesign are not lost in the implementation process. Medicaid Transition to Managed Care To reiterate, as you move forward in implementing the numerous MRT recommendations, including the Medicaid transition to managed care, it is important to ensure access to hospice and palliative care for those individuals eligible for services. The devil is in the details, and scrupulous attention to the vast array to policies and regulations under development is required to assure that access to hospice and palliative care are indeed available as intended by the MRT and the Legislature. Specifically, we offer the following recommendations: As the state transitions to new Care Coordination Models (CCM), we implore the Legislature to assure that hospice and palliative care are fully integrated: 3
Managed Care: It is imperative that hospice and palliative care not be marginalized as managed care is implemented. Referral to hospice within managed care must be seamless, and access to the hospice benefit and palliative care must not be impeded in any way. The process to integrate hospice and palliative care into managed care must be scrutinized to identify any unintended consequences that could have a negative impact on access to those services and should, in fact, encourage referral to hospice. Managed Long Term Care (MLTCP): We urge you to allow participants in MLTCP to access their hospice benefit without disenrolling from MLTCP. We have identified two major barriers to the disenrollment requirement: It is very likely that the patient will die within the 30-60 days it takes to disenroll from MLTCP; or The loss of services caused by disenrollment creates an untenable choice for patients rather than lose current services (e.g. home health aide), they will forego the election of hospice. This creates a conundrum for policy makers their intent to expand hospice is inadvertently blocked by the unintended consequence created by the disenrollment requirement. States such as Arizona, Florida, Ohio, Georgia, Massachusetts, Michigan and Texas are allowing long term care waiver beneficiaries who also qualify for the Medicare hospice benefit to receive both when the care is coordinated. The Medicaid transition to managed care is one component of a fast changing health care environment. We ask that you also keep in mind other changes recommended during the MRT process to ensure access to hospice and palliative care for those individuals eligible for services: Dual Eligible Patients (MRT #101) Integrate hospice and palliative care into the demonstration projects currently under development. Patient Centered Medical Homes (MRT # 209): Integrate hospice and palliative care into Patient Centered Medical Home pilot projects. 4
Accountable Care Organizations (MRT # 209): Integrate hospice and palliative care into Accountable Care Organizations. Chronic Disease: Include hospice and palliative care in the protocols for chronic illnesses. Conduct a pilot project with NYS hospices and palliative care providers to gather data to support palliative care for Medicaid recipients with chronic illness. Hospice in Nursing Homes: Provide incentives for nursing homes to make hospice care available through contracts with their local hospices. In 2009, only 27% of Medicare beneficiaries who died in a nursing home in New York had been admitted to hospice, compared to 54% nationally (Hospice Analytics Market Report). This is a lost opportunity to reduce Medicaid expenditures since Medicaid saves 5% of the nursing home rate if the resident is on the Hospice Medicare benefit. Similar results are likely to be found in other long term care settings. Conclusion Last year, when you accepted the 79 recommendations of the Medicaid Redesign Team, you committed your support to the expansion of hospice and increased access to palliative care. To truly make that happen, we all must be diligent moving forward. As I said, the devil is in the details. We have been working with the Department of Health to assure that policy and procedures regarding Medicaid s transition to managed care include seamless, easy access to hospice and palliative care and we ask for your assistance with this effort. HPCANYS is proactive we established an Innovations/Managed Care Task Force in May of this year, and just last week rolled out a Web-based managed care tool kit to help position hospice and palliative care providers for success in the new managed care environment. Remember, if hospice is not a key component of the State s Medicaid transition to managed care: More patients will receive end of life care in an acute care setting rather than in their home; Medicaid will pay for expensive pharmaceutical treatments, rather than the hospice per diem; and 5
The state will pay about 5% more per day for hospice eligible Medicaid patients in nursing homes. Integrating palliative care into models of care for patients with chronic illnesses will improve outcomes, increase patient satisfaction, and provide cost savings. Thank you for recognizing the importance of hospice and palliative care as Medicaid transitions to managed care. On behalf of all New Yorkers with chronic illnesses and terminal diseases, we urge you to assure that hospice and palliative care continue to be included in the State s Medicaid managed care transition plan in a meaningful way that will not impede access to these services. We stand ready to assist in any way possible. CONTACT INFORMATION: Kathy A. McMahon President and CEO Hospice and Palliative Care Association of NYS 2 Computer Drive W., Suite 105 Albany, NY 12205 Phone: 518/446-1483 Fax: 518/446-1484 e-mail: kmcmahon@hpcanys.org 12-07-12 6