Affordable Care Act and Federal Policy Update

2. Affordable Care Act andFederal Policy Update Barbara Gay Director of Governmental Affairs LeadingAge April 16, 2014

3. Affordable Care Act • Outlook for continuation • Provisions of particular interest/concern to LeadingAge • What you can do.

4. ACA Outlook • House repeal strategies • Senate composition after 2014? • President Obama veto pen through 2016 – then? • Enrollment process less than stellar • Delays in mandates

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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!

14. 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

15. 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!

16. 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

17. 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

18. 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

19. 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

20. And now, a few words about Medicare

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

22. 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

23. 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

24. 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

25. 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.

26. 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)

27. 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

28. 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

29. 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

30. Medicare Post-Acute Care Reform Finance-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

31. Ways and Means/Finance Concerns • Specific areas of interest: • Quality – comparing across settings • Value-Based Purchasing • Reducing Hospital Readmissions • Bundled Payments • Site Neutral payments

32. 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

33. 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.

34. 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?

35. 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

36. 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.

37. 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