Where the Money Comes From and Where it Goes: How to Help Your Staff Understand the Financial Realities of your Program -A Panel Discussion Gary Castillo, Tri-Cities Chaplaincy Chris McFaul, Horizon Hospice Mark Rake-Marona, Franciscan Hospice & Palliative Care WSHPCO Annual Conference, Session 5C 1
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WSHPCO Annual Conference, Session 5C 1. 2 3 Payer20132012 Medicare Hospice Benefit87.2%83.7% Managed Care or Private Insurance6.2%7.6% Medicaid Hospice.
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Where the Money Comes Fromand Where it Goes:
How to Help Your Staff Understand the Financial Realities of your
Program
-A Panel DiscussionGary Castillo, Tri-Cities Chaplaincy
• Higher RHC rates days 1-60: $186.84• Versus $159.34 through September 30, 2015• Versus $161.89 October first through December 31, 2015
• Lower RHC rates days greater than or equal to 61: $146.83• Versus $159.34 through September 30, 2015• Versus $161.89 October first through December 31, 2015
Estimated RHC High Rates After Rate Reductions 2017 through 2023
Published national rateNet increase after reductions
MEDICARE PAYMENT
www.HospiceAnalytics.com 18
“Days follow the Patient”• Example One: Live discharge on RHC day 45• Less than 60 days later, patient reenrolls (any hospice)• That reenrollment day is day 46 and $186.84 is daily rate• 15 days later (day 61), the lower $146.83 rate starts
• Example Two: Live discharge on day 77 (lower rate in effect)• At least 60 Days without hospice care• Patient reenrolls (even on day 61)• Higher daily rate is paid• The 60 day clock begins again
www.HospiceAnalytics.com 19
Service Intensity Add-On• Optional, as-needed additional rate for high-intensity
service during last seven days of life: up to four hours total per day paid at CHC rate ($39.37 per hour*).• $0-$1,100/beneficiary who dies on service• Day must be billed as RHC day.• Day occurs during last seven days of beneficiary’s life (and
beneficiary’s dc deceased).• Direct patient care provided by RN or SW (i.e., in person).• The proposed rule excluded SIA payments if the beneficiary
was being served in a SNF or NF – the final rule includes SNF/NF.
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Changes to Other RatesType of Care New Rate Versus
Continuous Home Care (CHC)
$944.79 $929.91
Inpatient Respite Care (IRC) $167.45 $164.81
General Inpatient Care (GIP)
$720.11 $708.77
• Wage Index Adjustments• Market Basket Increase 1.6%• Final Year BNAF Phase Out• Adjustment Factor 1.018%• -2% for Hospice Agencies that DO NOT Submit
Required Quality Data
Revenue Modeling
Dec. 2015 January 2016
100 * 161.89 * 31 Days 1-60 60 +
$501,859.00 10 186.8 90 146.8 $467,576.10
20 186.8 80 146.8 $479,979.20
30 186.8 70 146.8 $492,382.30
Census = 100 40 186.8 60 146.8 $504,785.40
50 186.8 50 146.8 $517,188.50
60 186.8 40 146.8 $529,591.60
70 186.8 30 146.8 $541,994.70
27 Deaths SIA: 2 hrs x 2 days 4252
30 Deaths SIA: 3 hrs x 3 days 10630
30 Deaths SIA: 3 hrs x 4 days 14173
Revenue Modeling
Dec-15 January 2016- $34,283
100 * 161.89 * 31 Days 1-60 60 +
$501,859.00 10 186.8 90 146.8 $467,576.10
20 186.8 80 146.8 $479,979.20
30 186.8 70 146.8 $492,382.30
40 186.8 60 146.8 $504,785.40Census = 100
50 186.8 50 146.8 $517,188.50
60 186.8 40 146.8 $529,591.60
70 186.8 30 146.8 $541,994.70
27 Deaths SIA: 2 hrs x 2 days 4252
30 Deaths SIA: 3 hrs x 3 days 10630
30 Deaths SIA: 3 hrs x 4 days 14173
Revenue Modeling
Dec-15 January 2016
100 * 161.89 * 31 Days 1-60 60 +
$501,859.00 10 186.8 90 146.8 $467,576.10
20 186.8 80 146.8 $479,979.20
30 186.8 70 146.8 $492,382.30
40 186.8 60 146.8 $504,785.40
Census = 100 50 186.8 50 146.8 $517,188.50
60 186.8 40 146.8 $529,591.60
70 186.8 30 146.8 $541,994.70
27 Deaths SIA: 2 hrs x 2 days 4252 + $40,00030 Deaths SIA: 3 hrs x 3 days 10630
30 Deaths SIA: 3 hrs x 4 days 14173
Revenue Modeling
Dec-15 January 2016
100 * 161.89 * 31 Days 1-60 60 +
$501,859.00 10 186.8 90 146.8 $467,576.10
20 186.8 80 146.8 $479,979.20
30 186.8 70 146.8 $492,382.30
Census = 100 40 186.8 60 146.8 $504,785.40
50 186.8 50 146.8 $517,188.50
60 186.8 40 146.8 $529,591.60
70 186.8 30 146.8 $541,994.70
27 Deaths SIA: 2 hrs x 2 days 4252
30 Deaths SIA: 3 hrs x 3 days 10630
30 Deaths SIA: 3 hrs x 4 days 14173
Revenue Modeling
Dec-15 January 2016
100 * 161.89 * 31 Days 1-60 60 +
$501,859.00 10 186.8 90 146.8 $467,576.10
20 186.8 80 146.8 $479,979.20
30 186.8 70 146.8 $492,382.30
Census = 100 40 186.8 60 146.8 $504,785.40
50 186.8 50 146.8 $517,188.50
60 186.8 40 146.8 $529,591.60
70 186.8 30 146.8 $541,994.70
27 Deaths SIA: 2 hrs x 2 days 4252
30 Deaths SIA: 3 hrs x 3 days 10630
30 Deaths SIA: 3 hrs x 4 days 14173
Summary of the 8/6/15Hospice Final Rule
www.HospiceAnalytics.com 26
Oregon
1
Washin
gton
2
Vermon
t 3
Alaska
4
North D
akota
5
Maine
6
Minnes
ota 7
New H
amps
hire
8
Wyoming
9
Montan
a 10
South
Dakota
11
Distric
t of C
olumbia
12
Massa
chus
etts
13
Californ
ia 14
Virginia
15
Utah 1
6
New York
17
Hawaii
18
Iowa
19
Nebras
ka 2
0
Marylan
d 21
Colorad
o 22
Kansa
s 23
Wiscon
sin 2
4
Arizon
a 25
Mississ
ippi 2
6
North C
arolina
27
Alabam
a 28
Idaho
29
West V
irginia
30
Missou
ri 31
Kentuc
ky 3
2
Penns
ylvan
ia 33
Nation
al
South
Carolina
34
Delaware
35
New Je
rsey
36
Conne
cticu
t 37
Indian
a 38
Michiga
n 39
Tenne
ssee
40
Oklaho
ma 41
Rhode
Islan
d 42
Georgi
a 43
Louis
iana
44
Illinois
45
Nevad
a 46
Ohio 4
7
Arkans
as 4
8
New M
exico
49
Florida
50
Texas
51
$0
$100
$200
$300
$400
$500
$600
$517
$503
$494
$486
$476
$472
$465
$464
$462
$462
$458
$448
$446
$429
$426
$422
$422
$419
$419
$416
$412
$409
$406
$405
$403
$401
$397
$397
$397
$394
$390
$388
$387
$381
$380
$380
$376
$376
$375
$371
$364
$348
$345
$342
$338
$335
$326
$322
$319
$319
$316
$313
National:+$381
Hospice Reimbursement Modeling(based on levels of care only, no SIA or wage index adjustment)
www.HospiceAnalytics.com 27
www.HospiceAnalytics.com 28
Quality Reporting• Submit HIS-Admission and HIS-Discharge record for each
patient admission or face 2% rate reduction.• No new quality measures proposed for FY2017; some
changes to timeline, requirements for new hospice agencies.• Public reporting timeline not yet set, but coming!• Areas for future quality measure development:
• Patient/proxy reported pain outcome.• Claims-based measures looking at skilled visits in last days of life,
burdensome transitions in/out of hospice, rates of live discharge.• Responsiveness of hospice to patient /family needs.• Hospice team coordination/communication.
www.HospiceAnalytics.com 29
A Final Thought…We are concerned that some hospices are making determinations of hospice coverage based solely on cost and reimbursement. It was very clear throughout the development, and years after the implementation, of the Medicare hospice benefit that hospices were expected to make good on their promise to do a better job in the provision and coordination of care than conventional Medicare services for those who were at the end of life. However, if hospices are not making good on that promise, it results in increased burden on hospice beneficiaries and their families – both clinically and financially – and is not in keeping with the intent of the Medicare hospice benefit as originally developed and implemented in 1983.
~CMS2016 Hospice Proposed Final Rule
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How the Expenses Work
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Routine Home CareMileage, 2%
Other Levels Loss, 1%Ambulance, 1%
Comfort Therapy, 1%
Treatments, Labs, Diagnostics, 3%
Pharmacy, 9%
Equipment, 3%
Supplies, 3%
Clinical Staff Benefits, 12%
CHI/FHS Overhead, 6%FHPC Overhead, 11%
Nursing Home Room and Board, 1%
Clinical Staff Salaries, 47%
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Medicare Cost Reports5 Cost Reporting Period (mm/dd/yyyy) From: 01/01/2013 To: 12/31/2013
6 Provider Identification Number
6 National Provider Identifier (NPI) Number
7 Type of Control (see instructions) 1
PART II
Title XVIII Title XIX Title XVIII Title XIX
Unduplicated Unduplicated
Enrollment Days Unduplicated Unduplicated Skilled Nursing Nursing Other Total
Medicare Days Medicaid Days Facility Days Facility Days Unduplicated Unduplicated Days
1 2 3 4 5 6
8 Continuous Home Care 27 27
9 Routine Home Care 144,054 5,229 27,075 17,946 167,229
10 Inpatient Respite Care 126 14 126 8 148
11 Inpatient General Care 404 91 150 645
12 Total Hospice Days 144,584 5,334 27,201 18,131 168,049
PART III
Title XVIII Title XIX
Skilled Nursing Nursing
Title XVIII Title XIX Facility Facility Other Total
1 2 3 4 5 6
13 Number of Patients Receiving Hospice Care1811
109 327 341 2,773
Total Number of Unduplicated Countinuous
14 Care Hours Billable to Medicare
15 Average Length of Stay 63 48 60 46 60
16 Unduplicated Census Count 1874 157 387 387 2,633
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Cost Reports - Continued CON- RECLAS-
EMPLOYEE TRACTED SIFICATION
SALARIES BENEFITS TRANSPOR- SERVICES (Increase/
COST CENTER DESCRIPTIONS (From (From TATION (From TOTAL Decrease)
Wkst A-1) Wkst A-2) (See inst.) Wkst A-3) OTHER (col. 1-5) (Fr Wkst A-6) SUBTOTAL
1 2 3 4 5 6 7 8
GENERAL SERVICE COST CENTERS
1 0100 Capital Related Costs-Bldg and Fixtures 691,567 691,567 691,567
2 0200 Capital Related Costs-Movable Equipment 235,254 235,254 235,254
3 0300 Plant Operation and Maintenance 17,204 17,204 17,204