11/8/2013...11/8/2013 3 Congressional Concerns •Physician Payment Fix - Sustainable Growth Rate (SGR) •Unless Congress intervenes, physicians face a roughly 30% payment cut starting

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Outlook for Home Healthcare and Hospice:

Realizing our Potential through new Care Delivery and Payment Models

Minnesota Home Care Association

November 13, 2013

Industry Challenges: CLARITY

• Lack of clear framework and definition • Lack of clearly defined value proposition • Lack of clarity on new care delivery and

payment models • Lack of clarity on future of home health

benefit

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HELLO FROM WASHINGTON

These Guys.

Congressional Concerns

• Appropriations • No appropriations bills passed as of

November 7, 2013. • Debt Ceiling Debacle

• October: 14 Day shutdown • January: Groundhog Day?

• www.healthcare.gov – will it ever work?

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Congressional Concerns

• Physician Payment Fix - Sustainable Growth Rate (SGR) • Unless Congress intervenes, physicians face a

roughly 30% payment cut starting in January. • This year, the cost of “fixing the SGR” is

significantly reduced—from roughly $300 billion over ten years to $130 billion over ten years.

Is there a window here for home health?

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HOW DID WE GET HERE?

Affordable Care Act • Goals:

• Better outcomes • Better Health Status • Lower costs

• Tactics: • Delivery System Reforms

• Objectives: • Prevention • Wellness and Health Promotion • Care Coordination

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Drivers:

• Health care costs

• Health reform

• Improved HIT

• Greater stake-holder alignment

Physician-

managed

health

rather than

health plan

managed

care

• New models of care delivery

and coordination • Payment aligned with goals • New tools for clinical

alignment • Better PHM capabilities • Experience in performance

management/ data reporting • Experience in population risk

adjustment/ risk mitigation • Increased awareness of

prevention and wellness value

• Educated, empowered patients

Creating need for new skill sets, policy, tools and competencies

TURNING THE SHIP:

A Change in Paradigm Outcomes-driven care demands a delivery model that encourages/

drives engagement across payers, providers , patients and care delivery sites through shared accountability and risk.

What is Accountable Care? Accountable care is a term that

is often a proxy for the desired

outcome of health reform efforts:

high quality care at the best

possible cost

Accountable care requires

physicians to change how they

deliver care and to work with

other providers and payors in

collaborative ways

Key Elements to Achieve Accountable Care

Significant care coordination between providers caring for a patient

Ability to collect and share information across care givers and patients

Performance transparency across the system and stakeholders

Shifting to a primary focus on patient health & care outcomes rather than

on transactions/intensity of services

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WHICH BRINGS US TO TODAY

National Averages for Patient Outcomes While

in Home Health Care, 2013

Measure Percent

Wounds improved or healed after operation 89

Had less pain when moving around 67

Got better at bathing 66

Breathing improved 64

Got better at walking or moving around 59

Got better at getting in and out of bed 55

Got better at taking drugs correctly by mouth 49

Had to be admitted to hospital 17

National Averages for How Often Home Health Team Met Quality Measures Related to Patient Care, 2013

Measure Percent

Checked patients for pain 99

Treated heart failure symptoms 98

Checked patients for the risk of developing pressure sores (bed sores) 98

Checked patients for depression 97

Treated patients’ pain 98

Checked patients’ risk of falling 94

Included treatments to prevent pressure sores (bed sores) in the plan of care 96

Took doctor-ordered action to prevent pressure sores (bed sores) 95

For diabetic patients, got doctor’s orders, gave and educated about foot care 93

Began care in timely manner 92

Taught patients (or their family caregivers) about their drugs 92

Determined whether patients received a flu shot for the current flu season 69

Determined whether patients received a pneumococcal vaccine (pneumonia shot) 68

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Current Priorities

• Post Acute Care Reform • Home Health

• Home Health Rebasing • Copays

• Hospice

• Short Stay Reimbursements • Hospice Payment Reform

VNAA-VNSNY Vulnerable Patients Study

• 40 percent of Medicare Home Health PPS episodes have costs that exceed reimbursement.

• Clinically complex patients, with no/ limited caregiver assistance, require more skilled nursing and less therapy.

• Key factors: poverty, frail status, poorly controlled chronic conditions, need for respiratory, IV or Infusion therapy, problematic pressure ulcers , incontinence, lack of medication adherence.

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Challenge: CMS Rebasing NPRM • CMS proposed a 14 percent payment reduction

for each of the next four years (2014-17) for Medicare home health services.

• 17 percent reduction for rural providers upon 2015 expiration of 3 percent rural add-on.

• VNAA strongly opposes the proposed 14 percent payment cuts.

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Home Health: MedPAC Response to NPRM MedPAC cited key indicators of need for home health payment reform: • Rapid growth in number of providers • Substantial increase in number of episodes (65%

increase between 2002-2010) • Decreases in the average number of visits per episode • Double digit Medicare margins • Substantial utilization variation based on geographic

area • Recognized fraud and abuse

Home Health: MedPAC Rec’s to CMS

• Shorten rebasing phase in from four years to two • Revise the case mix adjusters to focus on therapy

visits rather than skilled nursing visits • Conduct medical review in counties with

substantial increases in utilization

VNAA Response to Rebasing NPRM • Protect access for vulnerable patients and finalize the

ACA-mandated study to determine the cost of care for vulnerable populations.

• Use more current home health cost reports. • Consider the cost of care (including costs for

mandated reporting and documentation requirements).

• Conduct a full four-year impact analysis of the proposed cuts.

• Consider the impact of multiple other cuts on the home health industry.

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Challenge: Home Health Copayments

• Implementation of copayments for home health services would decrease access to medically necessary home health services for both post-acute and community admissions.

• Oldest and sickest Medicare beneficiaries would not be able to make copayment.

• VNAA, American Hospital Association, AARP, Leadership Council on Aging and other national healthcare and patient groups oppose copayments.

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Challenge: Program Integrity • Expand moratoriums on new providers. • Increase oversight by federal and state government . • Target medical review and other enforcement

activity toward agencies at highest risk of fraud and abuse

• Provide relief for well-established, reliable and compliant providers.

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Hospice: Short Stay Reimbursement

MedPAC data shows a pattern of systematic underpayment for short stays. VNAA has urged CMS to: • Increase reimbursement for short stay cases. • Ensure that the cost of serving complex hospice

patients are adequately considered. • Ensure that quality measures are fair for short stay

patients.

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Hospice: Payment Reform

VNAA urges CMS to expeditiously make payment reforms that will: • Reduce improper use of the inpatient hospice rate • Reduce the incentive for excessively long hospice

stays • Eliminate the incentives for aggressive

recruitment of hospice patients in nursing homes and assisted living facilities

Hospice: MedPAC Indicators

MedPAC cited key indicators of need for hospice payment reform:

• Substantial increase in number of for-profit hospice providers

• Substantial increase in LOS • Substantial increases in margins • Industry reports of hospices enrolling patients who

do not meet eligibility criteria

Hospice: MedPAC Rec’s to CMS

• Eliminate the 2014 payment update • Conduct a focused medical review of hospices

with many long stay patients • Implement the “U-shaped” payment curve

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WHAT DOES THE FUTURE LOOK LIKE?

Opportunity: Delivery System Reform • PPACA created new care delivery models to:

• increase quality and value • improve health status and outcomes • reduce costs

• Home health providers support: • Bundled Payment for Care Improvement (PBCI) • Accountable Care Organizations • Patient Centered Medical Homes • Independence at Home and other medical home

models • Dual eligible demos to improve care coordination

Opportunity: Post-Acute Care Reform • Congressional Committees of Jurisdiction RFI on

Post Acute Care (PAC) Issues. • PAC Reform likely to be 2014 Congressional focus. • VNAA solutions:

• “Deem” home health • Promote use of Community Admissions • Eliminate Homebound Requirement • Provide funding support for HIT adoption • Increase “program integrity” activities • Support use of Nurse Practitioners

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Initial Patient Destinations Following an Inpatient Hospital Stay for Medicare

Beneficiaries, 2011

Death 362,433 (3%)

Community 6,071,583

(56%)

Other 373,375

(3%)

LTACH 121,093

(3%)

IRF 322,088

(8%)

SNF 2,071,396

(52%)

HHA 1,450,818

(37%)

Formal Post-Acute Care

Settings 3,965,395

(37%)

Overview: Home Health Is Cost-Efficient

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WHAT ARE WE DOING ABOUT IT?

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Opportunity: Delivery System Reform • PPACA created new care delivery models to:

• increase quality and value • improve health status and outcomes • reduce costs

• Home health providers support: • Bundled Payment for Care Improvement (PBCI) • Accountable Care Organizations • Patient Centered Medical Homes • Independence at Home and other medical home

models • Dual eligible demos to improve care coordination

Opportunity: Post-Acute Care Reform

• Congressional Committees of Jurisdiction RFI on Post Acute Care (PAC) Issues.

• PAC Reform likely to be 2014 Congressional focus.

• VNAA response proposed key reforms including: • “Deem” home health • Promote use of Community Admissions • Eliminate Homebound Requirement • Provide funding support for HIT adoption • Increase “program integrity” activities

Opportunity: Managed Care Contracting

• Managed Medicaid • 9 percent average growth across states • 12 percent growth in 26 Medicaid expansion

states • Approximately 9 million low income residents

• Commercial Managed Care • Feedback from national insurers on home

health is a key opportunity

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Environmental Factors

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Sector growth

Reimbursement changes

Operational challenges

Public and private sector

calls for better managed

care

Impact of technology

Home health care sector needs a

quality differentiator.

Technology is a real disruptive

force in home health care.

Successful care transitions

require an unprecedented level

of cooperation among physicians

and other health care providers.

Leadership is required for

change

VNAA Response:

VNAA Is Positioned to Lead

Objectives • Lead Innovation and transformation in new care delivery payment

models

• Engage, connect and share knowledge, information and resources

Case Study Highlights: • New care delivery models (ACOs, PCMHs)

• New payment models (bundled payments, shared savings, shared risk)

• Quality reporting

• Aligning as strategic partners

• Business development tools

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What is the VNAA Blueprint for

Excellence?

VNAA Blueprint for Excellence is a pathway to expert practices for home health care providers, a touchstone

for the expanded value and role of home health and hospice in new delivery models.

The VNAA Blueprint supports workforce development and consistency of care delivery, to achieve better

health, better care and lower costs. The VNAA Blueprint strengthens care transitions and underscores the value

of accountable, measurable, coordinated care in the home health setting.”

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What is the VNAA Blueprint for

Excellence?

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• Free & Publicly Available to All

• Staff Training Resource

• Quality Improvement Tool

• Launch Date: September 26, 2013

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Learning Modules

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Clinical Condition

s

• Depression Screening

• Alzheimer's Disease

• Heart Failure

• COPD

• Hypertension

• CAD

• Ca

• Diabetes

Care Initiation

Patient Engageme

nt

• Patient self-management and self-activation

Patient Safety

Under Construction

End-of-Life

Caregiver / Social Support

• Critical interventions 1st & second visit

• Front loading • Scheduling MD

appt within 7 days

• Pneumonia vaccine

• Risk Assessment • Medication

reconciliation • Falls risk

assessment and intervention

• Exacerbation of condition or red flags

Operational Best Practices Guidance: Creating a Learning Culture • Leadership behavior • Using and understanding data • Facilitating ongoing learning

Under Construction

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VNAA Blueprint Attributes

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Vision Statement

Individuals and families receive personalized and coordinated care in the home and across the community.

Mission Statement

VNAA will support, promote and advance nonprofit providers of community-based healthcare

including home health, hospice and palliative care and health promotion services to ensure quality care within

their communities.

Strategic Goal: Advocate Appropriate Access and Reimbursement

• Objective: Advocate for expanded value and role of home health and hospice in new care delivery models

• Objective: Advocate for appropriate use of home health, hospice and palliative care

• Objective: Advocate value towards public and commercial payers

• Objective: Advocate for availability and interoperability of HIT

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Strategic Goal: Research and Promote improved outcomes, cost, value and individual and family experiences

• Objective: Identify and increase competency and knowledge of best practices

• Objective: Achieve a research partnership • Objective: Capitalize on member involvement • Objective: Secure funding for research

Strategic Goal: Lead innovation and transformation in new care delivery and payment models

• Objective: Assist members in replicating successful new models

• Objective: Demonstrate delivery of care and financial models that incorporate home health and hospice expertise

• Objective: Educate nonprofit agencies on engagement and contractual strategies

Strategic Goal: Engage, Connect and Share Knowledge, Information and Resources

• Objective: Increase growth • Objective: Increase awareness and outreach

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April 2-4, 2014 Las Vegas, NV

The year’s largest gathering of executives, clinical experts and thought leaders from the field of nonprofit home health and hospice.