The State of Home Health & Care at Home

Pennsylvania Homecare Association

William A. Dombi

National Association for Home Care & Hospice

wad@nahc.org

May 20, 2011

CHALLENGES or OPPORTUNITIES for HOME CARE?

Are you surprised?---It’s both! Changes are sudden, gradual, and distant Political environment subject to change that

could trigger more change Care delivery changes accelerating Medicare regulation is somewhat of a wild card Republican health care reform repeal efforts

underway Overall environment favors home care

Value proposition Shift from fee for service utilization incentives in other

care sectors

New Congress and Health Care Reform

House Republican-led repeal efforts underway

Policy driven or politics centered? Alternative reforms? Symbolic or successful?

New Congress and Health Care Reform

Course of Action Repeal fails—no vote in Senate House majority attempting to defund

implementation Will WH and House come up with some

compromises around the edges? Currently implemented reforms generally viewed

positively 2012 changes the dialogue depending on

election results (TBD)

Health Care Reform Litigation

Constitutional challenges ongoing 3 courts uphold individual mandate; 2 courts

overturn it based on Commerce Clause Florida decision finds whole law unconstitutional

Many other issues in litigation Employer penalty/mandate Medicaid obligations on states

Supreme Court review likely in 2012

New Congress and Health Care Reform

House budget proposal Repeal Affordable Care Act expansion of

insured No funding for implementation

Medicaid block grants Medicare vouchers/premium supports replace existing

“insurance” program Defined contribution vs, defined benefit Beginning for under 55 (2011) population Raise eligibility to 67 (2033) Means tested supports

Present Challenges

Providers need time to adjust as payment rates are reduced and new administrative responsibilities begin

2011-2014 are crucial years HHAs still best positioned to take on new

opportunities inside and outside of Medicare home health

Hospices face reduced rates, increased scrutiny, and greater competition

Must deal with the “today” while moving forward on “tomorrow”

2011: The Medicare Rate Changes Begin!

CMS Final Rule 2.1% MBI 1 point MBI reduction (Affordable Care Act

required) 2.5% reduction in outlier budget (Affordable

Care Act required) 3.79% case mix weight change adjustment in

2011 (2012 not finalized)

Future HH PPS Payment Rates

2014 rebasing May result in varied rates

CMS study on vulnerable populations Case mix weight change adjustment

analysis New MedPAC case mix adjustment model

in development: looking to drop therapy threshold element

MEDICARE HOSPICE

Rate reductions threaten care BNAF cuts increase risks Limited inflation updates add pressure

Annual cap concerns grow Limited (if any) margins with not alternative

payer offsets

MEDICARE HOSPICE

New payment model in development No earlier than 2013

MedPAC recommends 1 point rate increase in 2012

MedPAC still supports U-shaped payment model

Oversight increasing as payments grow

MedPAC Home Health Recommendations for 2012

Institute new case mix adjuster Freeze payment rates Impose program integrity measures

including a moratorium on new HHAs Accelerate rate rebasing to 2013 with 2

year phase-in Impose a beneficiary copayment

MedPAC Copayment Proposal

Episode based Possibly set at $150 or 5% Exclude episodes preceded by inpatient

hospital or SNF stay Apply to Medicare-Medicaid dual eligibles Permit MediGap supplemental isurance

coverage

2011 Regulatory Challenges

Face-to-face physician encounter Home health Hospice

Therapy assessments and documentation

F2F-Home Health

Repeal and/or reform

Reforms needed Exceptions for certain patient populations

Inpatient discharges Medically underserved areas Vulnerable patients

Documentation requirements Telehealth use

F2F--Hospice

Different issues than home health Concern for 3rd benefit period admissions Roadblock in using contracted NPs Cost increases without reimbursement

2011: The Health Care Delivery Reforms Begin!

Significant home care and hospice opportunities!!!!! Chronic care management Transitions in care Accountable Care Organizations Post-acute care bundling Performance-based payment Hospice concurrent care demo

CHRONIC CARE MANAGEMENT

Independence at Home Pilot Focus on certain diagnoses Interdisciplinary team Physician/NP directed Shared savings RFP in process

HHA-based CCM demo Monitoring, teaching, coaching, and telehealth HH coverage criteria Not Applicable Shared savings

TRANSITIONS in CARE

Re-hospitalization prevention and avoidance

Commercial opportunity Hospital is the customer Select discharge monitoring and

oversight

Accountable Care Organizations

Partner, participant, or outsider Value defines role and opportunities Creativity and connections creates

opportunities Large physicians groups and/or health

systems are likely candidates to establish ACOs

Home care/hospice=cost avoidance and cost effectiveness

Post-Acute Care Bundling

Who manages the bundle? A community-based model! Coordinates with institutional care PAC

bundling Functions include:

HHA/hospice manages all discharges to community Responsibilities for short-term inpatient care Physician services in or out? Shares in discharge planning

Medicaid Home Care

Rebalancing of LTC spending continues Risks to home care support with strained

budgets PPACA incents home care

Major home care expansion through federal money (FMAP)

Community Free Choice Option Removal of barriers to HCBS services Money Follows the Person Demo extension Spousal impoverishment protection

CLASS Act: Federal LTC Insurance Community Living Assistance Services and Support

Payments made to cover individuals with ADL needs in home or nursing facility

Premium withholding in wages Opt-out of program authority

Participation begins 2010 Eligibility based on ADL needs Benefit payments begin 5 years after implementation (2016-2017

est.) Preset daily payment to insured Boon to Private Pay home care Supplemental support to Medicare/Medicaid home care Proposed rule and CLASS Commission announcement expected

soon

Advocacy Action Plan SECURE THE STRATEGIC ROLE CONGRESS

INTENDS FOR HOME CARE AND HOSPICE IN ADDRESSING THE NATION’S ACUTE, CHRONIC, AND LONG TERM CARE NEEDS ENSURE HOME CARE AND HOSPICE PARTICIPATION

IN TRANSITIONS IN CARE AND OTHER HEALTH CARE DELIVERY REFORMS

ALLOW NPs AND PAs TO SIGN HOME HEALTH PLANS OF CARE

RECOGNIZE TELEHOMECARE INTERACTIONS AS BONA FIDE MEDICARE AND MEDICAID SERVICES

ENACT A COMPREHENSIVE HOME AND COMMUNITY BASED LONG TERM CARE PROGRAM FOR ALL AGE GROUPS

PRIORITIES 2011 ENSURE APPROPRIATE AND ADEQUATE

REIMBURSEMENT FOR AND ACCESS TO MEDICARE HOME HEALTH SERVICES OPPOSE COST SHARING FOR MEDICARE HOME HEALTH

SERVICES BLOCK CMS REGULATORY “CASE MIX CREEP” CUTS AND

REQUIRE A NEW PROCESS FOR CALCULATING CASE MIX ADJUSTMENT

ESTABLISH REASONABLE STANDARDS FOR REBASING MEDICARE HOME HEALTH SERVICES PAYMENT RATES

REPEAL OR REFORM MEDICARE HOME HEALTH FACE-TO-FACE ENCOUNTER REQUIREMENT

ENSURE FULL MARKET BASKET UPDATES TO MEDICARE HOME HEALTH

ENSURE MEDICARE ADVANTAGE AND FEE-FOR-SERVICE ENROLLEES RECEIVE IDENTICAL HOME HEALTH BENEFITS

PRIORITIES 2011 ENSURE APPROPRIATE AND ADEQUATE

REIMBURSEMENT FOR AND ACCESS TO HOSPICE SERVICES REVISE REQUIREMENTS FOR HOSPICE FACE-TO-

FACE REQUIREMENT PRESERVE THE FULL MARKET BASKET UPDATE FOR

THE MEDICARE HOSPICE BENEFIT REJECT ADDITIONAL BENEFICIARY COPAYMENTS

FOR MEDICARE HOSPICE SERVICES ENSURE ACCESS TO HOSPICE CARE FOR RURAL

PATIENTS MONITOR PAYMENT REVISIONS TO MEDICARE

HOSPICE BENEFIT

PRIORITIES 2011

PROTECT AND EXPAND ACCESS TO HOME AND COMMUNITY-BASED SERVICES UNDER MEDICAID ESTABLISH MEDICAID HOME CARE AS A MANDATORY

BENEFIT AND SUPPORT REBALANCING OF LONG TERM CARE EXPENDITURES IN MEDICAID PROGRAMS IN FAVOR OF HOME CARE

MANDATE HOSPICE COVERAGE UNDER MEDICAID ENSURE APPROPRIATE MEDICAID RATES FOR HOME

CARE AND HOSPICE INCREASE FEDERAL MEDICAID PAYMENTS TO

STATES

PRIORITIES 2011

PROTECT ACCESS TO HOME CARE AND HOSPICE SERVICES, INCLUDING FOR CARE PAID DIRECTLY BY INDIVIDUALS MODIFY EMPLOYER RESPONSIBILITIES IN

HEALTH REFORM TO ADDRESS HOME CARE SPECIFIC NEEDS

OPPOSE CHANGES TO THE COMPANIONSHIP SERVICES EXEMPTION TO THE FAIR LABOR STANDARDS ACT

NAHC MEDICAID ADVOCACY PROJECT

Focus on federal Medicaid CMS now actively overseeing state

compliance LTC rebalancing a priority at CMS MACPAC underway

Supportive of state-specific efforts Use of legislative, regulatory, and legal

forums Significant research projects

Preparing for Change Re-engineering, Restructuring, or Refinement? Right People

New skills may be needed Right Partners Right Tools

Technology Focused data and information

Right Efficiencies Value-related cost

Right Plan Short and long term

Meeting Both Challenges and Opportunities

Value proposition Integrated Dynamic

Evidenced-based Outcome driven

Clinical Financial