Affordable Care Act andFederal Policy Update

Barbara GayDirector of Governmental Affairs

LeadingAgeApril 16, 2014

Affordable Care Act

• Outlook for continuation• Provisions of particular interest/concern to

LeadingAge• What you can do.

ACA Outlook

• House repeal strategies• Senate composition after 2014?• President Obama veto pen through 2016 –

then?• Enrollment process less than stellar• Delays in mandates

ACA Outlook

• Growing stake in the program– Over 6 million enrolled– 19 states expanded Medicaid, 5 more through use

of Medicaid to buy private insurance– Adult children– People with pre-existing conditions– Initiatives to reform health and long-term care

delivery system to bring down costs

Affordable Care Act Themes

• Pay for value, not volume• Better integration of services • More home- and community-based service

options• Avoid hospitalizations and rehospitalizations• Application of technology• Workforce development

ACA Employer Mandate

• New deadline for employers with between 50 and 99 employees – January 1, 2016

• Larger employers, 100+ employees – January 1, 2015• Applies to employees working 30 or more

hours/week• Information for employees and employers on

LeadingAge website: http://www.leadingage.org/Legal.aspx

Accountable Care Organizations• Delivery system reform:– Integrate services– Greater efficiency, fewer avoidable services– Group at risk for all beneficiary costs– Potential Medicare/health care savings

• More than 360 nationwide• 5.3 million Medicare beneficiaries covered• Concept flexible, many varying configurations possible for the

future

ACOs - Structure

• Beneficiaries don’t enroll, not restricted to any network, may not know they’re in an ACO

• Typical anchor – hospital, health plan, physician group

• ACOs contract with CMS to provide services at agreed-upon spending targets

• ACO can pocket savings for spending below targets• 33 quality indicators

ACOs – 3 Models

• Shared Savings – the basic plan, chosen by majority of ACOs

• Advance Payment – helps smaller ACOs with less capital with initial investment in staff and infrastructure

• Pioneer – ACO assumes more risk with potential for greater reward

ACO Pioneer ModelA Cautionary Tale

• More risk, more reward• 32 organizations chosen for 3 year program; 9

dropped out after 1 ½ years• $87.6 million Medicare savings after 1 year• Slower rate of spending growth/beneficiary – 0.3%

vs. 0.8% in traditional Medicare• 13 Pioneers saved enough to share with Medicare• 2 Pioneers owed Medicare $4 million

ACOsTools to Achieve Savings

• Provider quality and cost data• Care coordination, including transitions• Discharge planning/case management• Wellness, prevention, disease management• Bottom line – outcomes, not volume of

services

ACOsBe the Solution

• Anticipate needs and develop quality measures:– Hospital readmissions– Falls– Pressure wounds– Medication adverse events

• Special services – stroke rehab, wound care• Processes for managing care transitions• Doc – doc dialogue • LeadingAge Insights can help!

Bundling• “Bundles” payment across provider types for a single episode

of care• Incentive for providers to coordinate services and continuity

of care– Four approaches in Request for Applications– 1) Hospital stay– 2) Hospital stay plus post-acute care– 3) Post-acute care following hospital stay– 4) Prospective payment for all services during hospital stay

Hospital Readmissions Reduction• Hospitals’ Medicare reimbursement cut if they have higher-

than-average readmission rates for “applicable conditions”• Program began with 3 “applicable conditions” –

– Acute myocardial infarction– Heart failure– Pneumonia

• Beginning in 2015, other conditions likely to be added• Opportunity for post-acute care providers to help hospitals

reduce their readmission rates• LeadingAge Insights!

QAPI for Nursing Homes

• Quality Assurance and Performance Improvement programs

• Required for all nursing homes within a year of final regulation’s publication

• CMS developed on-line resource library and other tools for facilities to set up programs

• Reg may come out this year• Tools: Advancing Excellence, Quality First

Dual Eligibles

• Medicaid waiver available for up to 5 years, can be renewed

• Goal: better integration of benefits and administration by states/CMS

• Concerns – Access to essential services– Health plan experience with special needs of long-

term services and supports population

ACA Transparency Requirements• On request of Secretary, HHS Inspector General, the states, or

LTC ombudsman, SNF/NF must provide description of facility’s – governing body and organizational structure – information regarding additional disclosable parties

• SNF/NF must operate a compliance and ethics program effective in preventing/detecting criminal, civil, and administrative violations

Workforce• Authorizes geriatric education centers

– Training for health care professionals and family caregivers in chronic care management

• Expands geriatric care awards to advanced practice nurses, clinical social workers, other health professionals

• Traineeships for those preparing for advanced degrees in geriatric nursing

• Increase number of providers specializing in geriatrics and ensure more providers have geriatric training

• Issue - funding

And now, a few words about Medicare

Medicare - Current Issues

• “Doc fix” (SGR) – therapy caps• Observation days – H.R. 1179, S. 569• Post-acute care payment reform

Medicare “Doc Fix”Therapy Caps

• Permanent “doc fix” to correct flawed physician payment formula, prevent large cuts in reimbursement still pending

• Another temporary doc fix passed 3-31-2014– H.R. 4302– Lasts through March 31, 2015

Doc Fix – H.R. 4302

Post-acute care provisions:• Extends therapy caps exceptions process• Delays ICD-10 effective date until 10/1/2015• Value-based purchasing for skilled nursing facilities

Doc Fix/Therapy Caps

• LeadingAge concerns– Therapy caps relief must be included in doc-fix

legislation– Post-acute care should not be the pay-for

• H.R. 4302 satisfied us on both counts

Value-Based Purchasing for SNFs

• CMS to develop SNF readmission measure by 10/1/2015

• By 10/1/2016, readmission measure refined to show risk-adjusted, potentially preventable readmissions

• By 10/1/2019, readmission measures to be linked to value-based purchasing strategy.– Incentive payments for high performers; penalties

for low performers.

Value-Based PurchasingLeadingAge Concerns

• CMS should allow stakeholder input in development of readmission measures

• Measures must be risk adjusted at: – Nursing home level (homes serving lower-income

populations, for example)– Beneficiary level (complex care needs)

Hospital Readmission Rates

• Begin tracking your rates now• Put quality improvement systems in place to

identify opportunities to reduce preventable hospitalizations.

• Advancing Excellence has a tool: https://www.nhqualitycampaign.org/star_index.aspx?controls=hospitalizationsidentifybaseline

Medicare Observation Days

• H.R. 1179/S. 569– Time spent in a hospital under observation counts

toward the 3-day stay requirement– Beneficiaries leaving the hospital after a period of

observation are to be considered to have been discharged.

• Urging members of Congress to cosponsor

3 Day Stay Requirement

• H.R. 3144 would repeal. No cosponsors, little chance of passage

• Integrated systems at risk for all patient costs already excepted from the rule

• CMS can do pilots allowing patients to receive skilled medical services in nursing homes

• CMS lacks infrastructure to monitor potential “churning” of patients between long-stay and skilled

care levels within a nursing home

Medicare Post-Acute Care ReformFinance-Ways and Means Chairs’ letter 6/19/13:• Too much variation in per-beneficiary Medicare spending on

post-acute care• No guidelines on types of “patients” appropriate for each

setting• Different payment rates to different provider types for

patients with similar conditions• MedPAC, Obama Administration, other experts have called for

payment reform

Ways and Means/Finance Concerns

• Specific areas of interest:– Quality – comparing across settings– Value-Based Purchasing– Reducing Hospital Readmissions– Bundled Payments– Site Neutral payments

LeadingAge Comments

• Well-integrated post-acute care will eliminate inappropriate use of expensive services

• Essential to determine needs across settings• Medicare spending per beneficiary already growing

more slowly • Take a broader view of post-acute care and its

funding mechanisms (say the word “Medicaid”)• Eliminate silos between acute, primary, specialty and

post-acute providers

IMPACT Proposal

• Improving Medicare Post-Acute Care Transformation – “IMPACT”

• Issued by Ways and Means and Finance Committees March 18

• Outlook? Little time left in the present congressional session

• Committee staff indicate committee action possible early summer

• Never say never.

IMPACT Proposal

Standardized assessment data• From SNFs, home health, IRFs, long-term care

hospitals by 2016• Eventually to include hospitals, cancer

hospitals, critical access hospitals (by 2019)• Data to include patient functional status,

cognitive function, special services, etc.• CARE tool?

IMPACT Act

• Quality measure reporting– Functional status changes, skin integrity, med

reconciliation, etc.• Resource use measures from claims data ->

per-beneficiary spending• All data to be publicly reported by 2017-2018.• SNF Quality Reporting program by 2019, 2%

penalty for failure to comply

IMPACT Proposal

• LeadingAge questions:– OASIS and MDS revised or replaced?– Nursing home oversight system?– Risk adjustment needed to account for varying

care needs• Ultimately proposal envisions standard

payment system based on individual needs, rather than setting in which provided.

What You Can Do

• Make it real for policymakers – how do their policies affect your residents, staff and community

• Cultivate relationships• Tell your story• Tools – LeadingAge website, Contact Congress,

staff