Connect Four in Achieving Legislative and Administrative Change

1. Connect Four in Achieving Legislative and Administrative Change Barbara Burandt RN, CNAA, BC, JD MHCA Government Relations Director

2. Legislative Issues • COLA Increases • PCA Rate Cut – “Administrative Costs over12%” • Class B Licensure Language Changes • Health Insurance Coverage for LTC Workers • Health Care/Medical Home • Community Care Act

3. Administrative Changes • Standardized Billing for all Health Care Providers; • E-Health Initiative; • Home Health Reimbursement Study • Customized Living Rate Tool • Model County Waiver Services Contract • Spend-downs

4. Stakeholder Groups Preparing for 2009 • MA Home Care Statutes • Vulnerable Adult Statute • Home Care Licensure Statute • State Profile Tool Grant (CMS)

5. Care Coordination Project • MHCA Care Coordination Workgroup

6. COLA Increases • 2% enacted in 2007 Session – vulnerable to cuts • Governor’s Bill proposed delaying the increase until 2009; • House Bill proposed maintaining the 2% as enacted; • Senate Bill proposed maintaining the 2% increase but delayed the date until 10/1/2008

7. PCA Rate Cut • Senate proposed a cut to PCA payments for Agencies whose administrative costs were over 12%; • The proposal was pulled off the table because DHS told the Senate that they would have no way to determine whose adminstrative costs were over this threshold; • Senator Berglin was emphatic that the issue would be looked at again in 2009! • The Office of the Legislative Auditor will be auditing agencies who provide PCA services between now and next fall – DHS says that this will give them more information on the range of administrative costs and will help DHS find a way to audit administrative costs!

8. Class B Licensure Language Changes • HF3955/SF3168 • Two Issues: 1. Type of tasks that a home care aide can provide: • Added "assistance with ambulation, transfers, and toileting" 2. Supervision “Opt Out” Option: • Gives clients/families the option to choose to be more "consumer directed" by choosing to have supervision moved from every 62 days to less often with an minimum requirement of every 180 days.

9. Health Insurance Coverage for LTC workers • This language is included in the Health Care Transformation Bill (h3391 – house version only) • Calls for a “study” to be completed by 12/15/2008; • Recommendation for a rate increase in LTC employers dedicated to the purchase of employee health insurance in the private market. • Three levels of insurance: • The coverage provided to state employees; • The coverage provided to MinnesotaCare enrollees; and • The benefits provided under an average private market insurance product, but with a deductible limited to $100/person.

10. Health Care/Medical Home Model • House Version (H3391/S3099) • Pay-for-Performance System by • Medical groups and clinics • Demonstrating optimum care in serving individuals with chronic diseases, for clients on Statue Funded Programs. • Also to develop a Patient Incentive Health Program to provide incentives and rewards to patients enrolled in state funded programs who have agreed and met personal health goals established by their Primary Care Provider to manage chronic disease, at a minimum for: • Diabetes, • High Blood Pressure, and • Coronary Artery Disease.

11. Health Care/Medical Home - 2009 • Selection of a Primary Care Clinic • Initial Health Assessment • Certification of individual clinicians to be “health care home” – optional • Each patient will have an ongoing relationship with a provider trained as a personal clinician to provide first contact, continuous, and comprehensive care for a patient’s health care needs. • Clinicians include primary care physicians, nurse practitioners, physician assistants, and appropriate other specialists as long as they are certified as health care home providers

12. Health Care/Medical Home • Care Coordination – the personal clinician in coordination with other health care providers is responsible for providing and monitoring the patient’s health care needs or for arranging, or assisting with arrangements for, appropriate care with other qualified professionals. • Health care must be coordinated across all provider types, all care locations, and the greater community. • The coordination applies to care for all stages of life, including preventative care, acute care, chronic care, and end-of-life care. • Care coordination must include ongoing planning to prepare for patient transition across the types of care and provider types.

13. Care Coordination continued… • The care team shall also coordnate with those providing for the social service needs of the individual, if this is necessary to ensure a successful health outcome. • Care coordination msut be provided in a manner appriprate to the patient’s race, ethicity, and language. • A personal clinician and care team may utilize county health care and social service providers to satisfy these requirements. • Selection of a health care home does not limit a person’s ability to seek care from other providers.

14. Health Care Home: Care Delivery • Health Care Home must provide or arrange for access to care 24 hours a day, seven days a week; • Personal-centered care; • Patient-directed, decision-making process; • Care delivery facilitated by the use of health information technology; • Care must be provided in a culturally and linguistically appropriate manner; • Continuous quality improvement, must be based on evidenced based medicine and use of clinical decision-support tools

15. Health Care Home: Care Delivery • Must use methods to enhance access to care, including: • Open scheduling; • Expanded hours; and • New communication methods such as e-mail, phone consulation, and e-consults • Providers certified as health care homes must offer their health care home services to all patients with complex or chronic health conditions who are interested in participation. • Quality measures must be collected and publically reported; • Comprehensive care plan – for those who have complex or chronic disease – • Based on health history; • Tests, assessments, and • Other information, including being culturally appropriate.

16. Health Care Home: Care Coordinators • Health care homes must utilize care coordinators to manage care provided to patients with complex or chronic conditions. • Care coordinators must be trained to provide services that are appropriate for the race, ethnicity and language of the patient. • Care Coordination includes: • Identifying patients with complex or chronic conditions; • Assisting primary care providers in care coordination and education; • Helping patients coordinator their care or access needed services, including preventative care; • Communicating the care needs and concerns of the patient to the health care home; • Collecting data on process and outcome measures; • Overseeing the development, maintenance, and implementation of care plans, and • Meeting other criteria as specified by the commissioner.

17. Health Care Home: Care Coordination Fee • Payment to clinics on a per member per month; • Payment will vary by thresholds of care complexity. • Primary Care Physician payments may be increased • Demonstration projects will begin in July 2009

18. Payment Restructuring/Based on Quality • To be adopted by 2010; • Must include payments to: • Primary care physicians; • Specialty care physicians; • Health care clinics; • Hospitals; • And other providers who provide services included in the evidence-based benefit set and design developed under section 2U.04 (work in progress).

19. Care Package Pricing • Time Line: July 1, 2010 • Providers must submit a package for the provider’s treatment of the patients and chronic conditions; • Until January 1, 2013 no provider shall submit package prices for the risk-adjusted cost of care for the conditions specified that represents an increase of more than the increase in the previous year’s consumer price index for all urban consumers plus two percentage points, or a decrease of more than 15 percent below the provider’s risk-adjusted cost of care calculated based on the provider’s average pricing levels for the previous calendar year. • Provider must keep the pricing for one year without changes.

20. Care Pricing: Packages • This package pricing does not apply to: • Medicare • Work Compensation; • No Fault Auto Insurance; or a • State public health care program. • Affordability: If the sum of premiums, deductibles and other out-of-pocket costs paid by an individual or family for health coverage does not exceed the applicable percentage of the individual or family’s gross monthly income as specified. (range from 1.5% to 7-8%). Subsidys would be available.

21. Goals for Universal Coverage • 94% insured by the end of fiscal year 2009; • 96% insured by the end of fiscal year 2011; • 97% insured by the end of fiscal year 2012; and • 98% insured by the end of fiscal years 2013 and thereafter. • Must be based on an annual survey of the Minnesota population below the age of 65 to be conducted or contracted for by commissioner of health – must include questions regarding type of insurance, amount of cost-sharing, and potential barriers to public program enrollment.

22. Community Care Act - 2008 • Three Priority Strategies: • Expand Core Services • Increase Aging Services Grant Programs • Establish New, Ongoing Grant Funding for home modifications/home repair and escorted and volunteer transportation services; and • Fund a comprehensive evaluation of the State’s current institutionally-based elder abuse prevention and adult protection services and the vulnerable adults act in consultation with multiple stakeholders. • Improve Access • Establish a three-year demonstration via the MN Board on Aging for local pilot projects that improve the mobility of seniors. • Evaluate the incentives and barriers that limit access to culturally appropriate eldercare, hospice services, customized living services and utilization of other waiver services. • Strengthen Caregiver Support • Expand MN Board on Aging grants and improve caregiver support service utilization. • Support Financial incentives for family caregiving.

23. Administrative Updates

24. Electronic Billing/Standardized Process • Mandated by July 15, 2009; • Administrative Uniformity Committee (AUC) webpage: • http://www.health.state.mn.us/auc/. • Mission: To develop agreement among Minnesota payers and providers on standardized administrative processes when implementation of the processes will reduce administrative costs. • The Administrative Uniformity Committee (AUC) is a broad-based group representing Minnesota health care public and private payers, hospitals, health care providers and state agencies.

25. E-Health Mandate - 2015 • The purpose of the initiative is to:Empower Consumers with information to make informed health and medical decisions. Inform and Connect Healthcare Providers by promoting the adoption and use of interoperable Electronic Health Records and electronic health information exchange. Protect Communities and Improve Public Health by advancing efforts to make public health systems interoperable and modernized.Enhance the Infrastructure through:• Adoption of standards for health information exchange.• Policies for strong privacy and security protection of health information.• Funding and other resources for implementation.• Assessing and monitoring progress on adoption, use and interoperability

26. Minnesota E-Health Vision • The Minnesota e-Health Initiative will accelerate the adoption and use of Health Information Technology to improve healthcare quality, increase patient safety, reduce healthcare costs and enable individuals and communities to make the best possible health decisions. • We will do this by: • Connecting healthcare providers – clinicians and facilities – to assure continuity of care for every patient • Using national standards to guide electronic data interoperability, quality measurement and community health improvement and reduce the risk of investment • Empowering consumers to understand and access personalized health information to facilitate active management of their health • Improving public health, primary prevention and enabling community preparedness • Informing health research and policy development • Leveraging existing information systems and incrementally adding improved ones • Increasing adoption of health information technology and levels of informatics skills, knowledge and competencies • Safeguarding privacy and confidentiality of information • Maintaining outcomes that focus on the patient/person • Contributing to the development of federal standards efforts

27. Home Health Reimbursement Study • The study is now available on-line:http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5428-ENG. • Numerous recommendations were made: • Communications • Reimbursement • Billing and Coding • Technology • Quality/Best Practices • Access • Care Coordination • PCA

28. Customized Living Worksheet • Regular Meetings with DHS to determine format of the tool; • Advocate to make the tool more user friendly; • Defined when to use Customized Living/24 Hour Customized Living • Advocated to broaden the definition of 24 hour Customized Living

29. Model HCBC Waiver County Contract • Two Problems Identified: • Audit requirements; and • Requirement for Insurance Coverage – increments not in keeping with available coverage. • After months of e-mails, phone calls, finally had first meeting with DHS May 3rd. A second meeting is planned for May 20th.

30. Spend-Down Survey • Identified as a priority at the Public Policy Conference 2007; • Developed a Collaborative Project with MHHA, CPM, and MHCA. • Conducted a Survey of Provider Members to determine the impact of spend downs on providers; • Waiting now for session to be done so that MHCA can meet with MHHA, CPM to aggregate findings and take information to DHS with a request for change!

31. Stakeholder Groups

32. MA Home Care Services • Includes: • Home Health; • Private Duty Nursing; and • PCA Services • Preparation for proposing Statutory changes for the 2009 Legislative Session • Outcomes and Goals: • Improve Transitions and Continuity of Services; • Address Accessibility Issues; • Strive for more Consumer Direction and Consumer Choice ; • Maintaining a Balance between Regulation and Flexibility; • Gain a Better Understanding of Services and Programs

33. Vulnerable Adult Statute • Looking at revising the language to move from a focus on Facilities to a focus on the Community • Subgroups include: • Education and Training – providers; • Protections; • Increased Scope of Statutes; • Reporting; • Definitions; and • Investigations.

34. Home Health Regulatory Framework Group • Looking at revision of Home Care Licensure Rules for revisions to bring to the 2009 Session; • Provider Growth in Minnesota 2000-2007: • Class A Only Providers: 207 to 372 • Class B Providers: 8 to 27 • Class C Providers: 83 to 61 • Class F Providers: 316 to 615 • HWS Providers: 780 to 1358 • Medicare Providers: 250 to 210 • Goal: To determine how licensure statutes must change to accommodate the rapid changes in number of different agencies as well as the pending increase in the number of seniors.

35. HCBS Expert Panel • CMS Grant to complete State Profile for HCBS • Minnesota’s Goals: • Increase the proportion of individuals supported in the community; • Increase the person-centeredness of our LTC system; • Ensure an accountable, sustainable, quality support system for Minnesota’s citizens. • Charge: • The panel will assist in developing a Profile of Minnesota’s HCBS and comment on the completed Profile to CMS. • In conjunction with the development of the State Profile, the panel will identify and discuss strategies for simplifying and otherwise improving Minnesota HCBS.

36. Care Coordination Project

37. Care Coordination Project • Discussed at the Business Meeting • Home Care’s Opportunity to Demonstrate our larger role in helping achieve goal of keeping Minnesotan’s in their homes! • Looks at collaboration with multiple service providers/vendors who are important in keeping individuals safe in their homes. • Funding most from the community, rather than depending on State or Federal dollars. • Hope to have several pilot projects moving ahead in 2008-2009.