brock slabach, mph, fache september 20, 2017 sr. vice ...340b: proposes changing reimbursement for...
TRANSCRIPT
Slide 1
Nebraska Rural Health Association
September 20, 2017
Brock Slabach, MPH, FACHE
Sr. Vice-President
National Rural Health Association
Leawood, KS
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Slide 2
Improving the health of the 62 million who call rural America home.
NRHA is non-profit
and non-partisan.
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Slide 3 National Rural Health Association Membership
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Slide 4 Destination NRHAPlan now to attend these upcoming events.
RHC/CAH Conference—September 26-29, 2017 • Kansas City, MO
Policy Institute—February 6-8, 2018• Washington, DC
Annual Conference—May 8-11, 2018• New Orleans, LA
Rural Hospital Innovation Summit—May 8-11, 2018• New Orleans, LA
Visit RuralHealthWeb.orgfor details and discounts. 4
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Slide 5 The Rural March to
Population Health
• Market Realities
• Chronic Disease
• Alternative Payment Models• Accountable Care Organizations
• Global Budgeting
• Population Health• Social Determinants of Health
• Alignment Imperative
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Slide 6
Federal
Employee/Commercial
State
Market Pressures Increasing
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Slide 7 Industrialized Countries:
Annual Spending by Age
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Slide 8 Chronic Disease Growth
Projections
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Slide 9 Chronic Disease
Growth Projections
Source: State of Healthcare 2010
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Slide 10 Prevalence of Medicare Patients with 6 or more Chronic Conditions
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Slide 11
11
Taxes, Clean Indoor Air Policies
Menu labeling, School Food Policies
Reduce alcohol outlet density
Partner referral services
Work force development
Minimum wage, Paid family/medical leave
Expand early childhood programs
Nurse home visiting programs
Zoning/incentives for mixed-use development
Reducing bus emissions
Pedestrian/cycling in master plans
Coverage, medical homes
EHRs, Public Reporting, Payment Reform
Tobacco Use
HEALTH BEHAVIORS (30%)
Diet & Exercise
Alcohol & Drug Use
Sexual Activity
CLINICAL CARE (20%)Access to Care
Quality of Care
SOCIAL & ECONOMIC FACTORS (40%)
Education
Employment
Income
Family & Social Support
Community Safety
PHYSICAL ENVIRONMENT (10%)
Air & Water Quality
Housing & Transit
LENGTH OF LIFE: 50%
QUALITY OF LIFE: 50%
HEALTH OUTCOMES
HEALTH FACTORS
POLICIES & PROGRAMS
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Slide 12 First Things First
Care Redesign
• PCMH
• Clinical Integration
• Care Management
• Post-acute Care
• EHR
• Data Analytics
Care redesign should not outpace
Changes in payment
New Payment Arrangements
• MACRA
• Care Transformation Costs
• Care Management Payments
• Shared Savings
• Episodes of Care Payments
• Global Payments
Population
Health
Transformation
Source: Joseph F. Damore, Premier Health Alliance, March, 2015
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Slide 13
1. Preparatory2.
Transformational3.
Implementation4. Expansion
Four Stages to Population Health
• Education
• Assessment
• Gap Analysis
• Operational Plan
• Primary Care
• PCMH
• Clinical Integration
• Care management
network
• Network
development
• Health informatics
• Defined population
• Payor partner
• Post-acute
• Employee health
plan
• Commercial
arrangement
• Medicare
• Medicaid
• Employer
contracting
• Uninsured
Source: Joseph F. Damore, Premier Health Alliance
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Slide 14 Resulting Realities• Federal efforts to contain cost based on Triple Aim
• MACRA, transforming PFS from volume to value
• Hospital spending on Medicare
• Medicaid reductions: AHCA, BCRA
• ACA:
• High deductible plans with increasing coinsurance payments
• Designed to transfer risk from insurance company to provider
• This will continue under whatever scheme is developed on ACA replacement
• Consumerism
• Price becomes paramount both in insurance premium and patient spending
choices
• Driving down “costs” through transparency, giving consumer knowledge
• Quality star ratings will continue to develop the other side of the equation
• Innovation
• CMMI and Medicaid programs will continue to introduce change that will
incentivize consumers and providers along the track of Triple Aim
o EPM, ACOs, Global Payment, CPC+ and its variants, DSRIP (state Medicaid 1115
waivers), etc.
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Slide 15
Page 15© 2017 The Chartis Group, LLC. All Rights Reserved.
All data sourced from HCRIS, 2017. Please refer to Methodology for additional details. 1 Methodology sourced from Rural Health Works, 2016.2 Methodology sourced from The World Bank, 2017.
Estimated Impact of Medicaid Cuts under the AHCA on Rural Communities
$4.1Bloss to GDP
within the first year2
37,000jobs lost
within the first year1
$1.4Bloss in revenue within the first
year
Total Rural Hospital Revenue Lost within the First Year of Medicaid Cuts the AHCA
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Slide 16
Page 16© 2017 The Chartis Group, LLC. All Rights Reserved.
Rural Communities in Medicaid Expansion States would Suffer Twice the Impact
Total Impact to Rural Hospitals in
Medicaid Expansion States
Total Impact to Rural Hospitals in
Non-Medicaid Expansion States
$2.7Bloss to GDP within the first year
24,000jobs lost within the first year
$963Mloss in revenue within the first year
$477Kmedian loss in revenue per hospital
within the first year
$1.4Bloss to GDP within the first year
13,000jobs lost within the first year
$453Mloss in revenue within the first year
$242Kmedian loss in revenue per hospital within
the first year
All data sourced from HCRIS, 2017. Please refer to Methodology for additional details.
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Slide 17 So, Where are we today on AHCA/BCRA?
• Senate bill gets a stunning defeat. (Murkowski, Collins and McCain vote no.)
• Senate voted to proceed to debate. 51-50 vote.
• 20 hours of debate.
• Several votes were expected, but very few offered.
Majority Leader McConnell “needed to pitch a perfect game” to pass the healthcare bill. “Unfortunately, he pitched a two-hitter.”
- Republican Senator requesting anonymity
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Slide 18 NRHA to Congress: Vote NO on the House and Senate bills• Less health coverage: According to the Congressional Budget Office, about 2.9 million rural
Americans would lose their coverage by 2020.
• More hospital closures. The AHCA also fails to restore hundreds of billions of dollars in reductions to Medicare’s hospital payments under Obamacare that offset the cost of increased coverage. Since the AHCA would also eliminate coverage for 24 million Americans by 2026, hospitals would be stuck dealing with the Medicare cuts along with the loss of revenue from people with coverage.
• Unaffordable premiums for older, rural Americans. Could charge older Americans who buy their own coverage up to 5 times the cost for younger individuals.
• Worsens rural economy. The combination of higher insurance premiums and fewer rural hospitals would put rural areas at a disadvantage in attracting jobs to their area. In addition, health care is, by itself, a big part of rural economies.
• Less treatment for opioid addiction. Loosens requirements for health plans to cover a minimum level of health care costs will make the treatment less accessible; andcuts to Medicaid will have an outsized impact on substance abuse treatment because Medicaid covers 25% of this treatment throughout the country.
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Slide 19 Two avenues forming…
1. Problem Solvers’ Caucus:• Provide mandatory funding for "cost sharing reduction" payments to
insurance companies to hold down out-of-pocket costs such as deductibles and co-payments in Obamacare plans for households earning below 250% of the poverty level;
• Create a stability fund that states can use to reduce premiums and limit insurer losses, especially for people with pre-existing conditions;
• Change the mandate that employers provide coverage to apply only to companies with 500 or more employees, compared with the current 50-employee threshold, and define a full-time workweek as 40 hours, up from 30 hours;
• Repeal the 2.3% sales tax on medical devices;• Modify sections of the Affordable Care Act to make it easier for states
to innovate and enter into compacts to allow for the sale of coverage across state lines.
2. Lindsey Graham (R-S.C.) Proposal: Granting great deference to states.
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Slide 20 2017 Market-place penetrationTHINNING FIELD Kaiser August, 2016
“Most of the counties with just one insurer in 2017 would be predominantly rural.”
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Slide 21 Congress: The September Agenda• Raise debt ceiling
• Fund government
• Harvey Relief
• Flood Insurance Program
• Children’s Health Insurance Program
• Fix ACA
• Tax Reform
• DACA
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Slide 22 MUST-DO LEGISLATION
• CHIP REAUTHORIZATION
• RURAL MEDICARE EXTENDERS
• SOME TYPE OF MARKET STABILIZATION
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Slide 23 Advocacy Agenda• Children’s Health Insurance Program (CHIP) extension past Sept.
30, 2017. There are 5.6 million children covered currently.
• Pass Save Rural Hospitals Act (SRHA) HR 2957
• Reject reductions in Medicare funding for indirect medical education and direct GME while passing the Resident Physician Shortage Reduction Act (S 1301/HR 2267) which increase the number of Medicare funded residency positions
• Pass the Standard Merger and Acquisition Through Equal Rules Act (HR 659) which rebalance merger review between DOJ/FTC
• Support Conrad 30 and Physician Access Reauthorization Act (S 898/HR 2141)
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Slide 24 Environmental Review
• ACA Reform: individual insurance market?
• Mortality Rates Increasing in rural areas of US
• Opioid Crisis
• Regulatory Relief
• Federal budget for FY 2018
• Federal Debt Ceiling
• OPPS
• PFS
• MACRA, QPP and MIPS
• Workforce shortages
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Slide 25 Regulatory Update• MACRA/ QPP
• Proposed rule released June 30, comments were due August 21
• Increasing the threshold to exclude MIPS eligible clinicians or groups
• MIPS exempt: ≤$90,000 in Part B allowed charges OR ≤200 Part B beneficiaries
• Voluntary reporting for FQHC/RHC with opt-out of Physician Compare data reporting
• Includes virtual groups
• Scoring:
• 60% quality - Small practices do not need to meet data completeness threshold for full credit
• 0% cost
• 15% improvement activities - Report on no more than 2 medium or 1 high-weighted activity to reach the highest score
• 25% Advancing Care Information (Meaningful Use) - Hardship exemptions available for small and rural providers
• Final Score Bonus: 5 bonus points to final score for practices of 15 or fewer clinicians
• No Rural Bonus (comments requested)
• 3 point Complex Patient Bonus (not specific to small or rural providers) – based on HCC (note these tend to be lower in rural)
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Slide 26 Resources for practices:
• TCPI: Practice Transformation Networks (PTN)
• Designed for all clinicians/clinic type
• RHC/FQHC eligible
• Listing of PTN Contractors
• National Rural Accountable Care Consortium (NRACC) national in scope
PTN and focuses on rural practices (RHCs)
• Support for Small Practices: Small Underserved and Rural
Support (SURS)
• RHC and FQHCs are not eligible to participate, PFS clinics only
• HPSA will qualify for service
• 15 Clinicians or less
• TMF is the Oklahoma contractor: [email protected]
• Additional resources:
• QPP.CMS.GOV
• Quality Improvement Organizations (QIO)
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Slide 27 Regulatory Update
• CY 2018 Outpatient PPS• Released July 13 – comments due Sept 11• 340B: proposes changing reimbursement for Part B drugs at 340B hospital to Average
Sales Price (ASP) – 22.5% from ASP+6%
o Only impacts part B drugs paid under PPS (does not impact CAHs or other 340B meds)
o Requesting comments on how to use the savings
• Two year moratorium on enforcement of direct supervision requirement for outpatient therapy services
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Slide 28 CY 2018 Physician Fee Schedule
• Released July 13, 2017 – Comment due September 11
• Changes to Chronic Care Management Code for RHCs and FQHCs:
• Creates general and Psychiatric chronic care management codes
• Codes not based on severity like the single CCM code
• Diabetes prevention program – based on CDC developed program – for non-diabetic patients at risk
• Can provide incentive (but not inducements)
• Cannot be done by telemedicine
• Site Neutral Policy for new Hospital Outpatient Department (HOPDs)– result of Bipartisan Budget Act of 2015 – initial policy in last year’s rule limited grandfathering beyond language of statute, NRHA and other urged extending policy only as far as necessary by law – seeking comment on how implementation is going
• Reducing current PFS payment rates for non-excepted off-campus provider-based hospital departments paid under the PFS by 50%
• Adds new codes for telehealth services
• Updating beneficiary assignment policies for RHCs and FQHCs in MSSP ACOs by removing the attestation requirement
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Slide 29 Demand for Regulatory Relief1. Non-enforcement of 96-Hour Rule Condition of Payment requirement.
2. Common-sense approach needed for “exclusive use” standard.
3. Prohibit the direct supervision requirements for outpatient therapy services.
4. CMS should make full use of flexibility already given by Congress regarding rural Graduate Medical Education (GME).
5. Sole Community Hospitals (SCH) and CAHs should be eligible for Indirect GME
6. Expand Medicare coverage of telehealth services.
7. Implement the National Quality Forum (NQF) Rural Metrics Report Recommendations.
8. Adjust rural readmission measures to reflect differences in sociodemographic factors.
9. Suspend hospital star ratings.
10.Hold Medicare Recovery Audit Contractors (RACs) accountable.
11.More accurate price standardization of CAH swing bed claims is needed.
12.Performance comparisons should occur between equivalent cohorts in MIPS.
13. Implement appropriate validation survey rotations for CMS Validation Surveys.
14.Create a culture of consultation/education as part of CMS mandated surveys.
15. Improper MAC denial of Low-Volume Hospital Adjustment
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Slide 30 Mapping the Opioid Crisis
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Slide 31 Deaths per 100,000 residents
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Slide 32 “Follow the pills and you will find overdose deaths…” Charleston Gazette
• “The trail of painkillers in West Virginia leads to southern coalfields, to places like Kermit, population 392. There, out-of-state drug companies shipped nearly 9 million highly addictive — and potentially lethal — hydrocodone pills over two years to a single pharmacy in the Mingo County town.”
• Rural and poor, Mingo County
has the fourth-highest prescription
opioid death rate of any county in
the United States.
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Slide 33 Rural Mortality Rates.A Rural Divide in American Death
Center for Disease Control January, 2017 Study:
“The death rate gap between urban and rural America is getting wider”
• Rates of the five leading causes of death — heart disease, cancer, unintentional injuries, chronic respiratory disease, and stroke — are higher among rural Americans.
• Mortality is tied to income and geography.
• Minorities, especially Native Americans die consistently prematurely nation-wide, but more pronounced in rural.
• Startling increase in mortality of white, rural women. Causes:• Risky lifestyle (smoking, alcohol abuse, opioid abuse, obesity)• Environmental cancer clusters• Suicides
January 2017
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Slide 34 Hospital Closure Crisis
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Slide 35
• 6,000 areas in the U.S. are primary care health shortage areas; • 4,300 areas are dental health shortage areas; and • 3,500 areas are short of mental health shortage areas.
Or this…
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Slide 36 Save Rural Hospitals Act
Rural hospital stabilization (Stop the bleeding)– Elimination of Medicare Sequestration for rural hospitals;
– Reversal of all “bad debt” reimbursement cuts (Middle Class Tax Relief and Job Creation Act of 2012);
– Permanent extension of current Low-Volume and Medicare Dependent Hospital payment levels;
– Reinstatement of Sole Community Hospital “Hold Harmless” payments;
– Extension of Medicaid primary care payments;
– Elimination of Medicare and Medicaid DSH payment reductions; and
– Establishment of Meaningful Use support payments for rural facilities struggling.
– Permanent extension of the rural ambulance and super-rural ambulance payment.
Rural Medicare beneficiary equity. Eliminate higher out-of pocket charges for rural patients (total charges vs. allowed Medicare charges.)
Regulatory Relief– Elimination of the CAH 96-Hour Condition of Payment (See Critical Access Hospital Relief
Act of 2014);
– Rebase of supervision requirements for outpatient therapy services at CAHs and rural PPS See PARTS Act);
– Modification to 2-Midnight Rule and RAC audit and appeals process.
Future of rural health care (Bridge to the Future)
Innovation model for rural hospitals who continue to struggle.
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Slide 37 Future Model: Community Outpatient Model
• 24/7 emergency Services
• Flexibility to Meet the Needs of Your Community through Outpatient Care:
• Meet Needs of Your Community through a Community Needs Assessment:
• Rural Health Clinic
• FFQHC look-a-like
• Swing beds
• No preclusions to home health, skilled nursing, infusions services observation care.
• TELEHEALTH SERVICES AS REASONABLE COSTS.—For purposes of this subsection, with respect to qualified outpatient services, costs reasonably associated with having a backup physician available via a telecommunications system shall be considered reasonable costs.”.
• “The amount of payment for qualified outpatient services is equal to 105 percent of the reasonable costs of providing such services.”
• $50 million in wrap-around population health grants.
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Slide 38 United…Our voice is loud
1. Demand flaws of ACA be fixed;
2. Demand hospital closure crisis be fixed;
3. Demand fair funding for rural health safety net;
4. Demand meaningful regulatory relief.
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Slide 39 United…Our Voice is Loud
• Rural Can Lead
• Population Health
• Collaborative Care Models
• Care Management Programs
• High Risk Populations
• Chronic Disease Management
• Care Transitions/Post-acute Care
• Episodes of Care
• Health Information Technology
• Leadership/Cultural Transformation
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Slide 40
T H A N K Y O U
Questions?
Brock Slabach
Senior Vice President
National Rural Health Association
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