2. Home Health and Hospice Policy Forum Tuesday, November 3, 2015 Peter Notarstefano, Director Home and Community-Based Services

3. Outline Medicare Policy Changes Home Health Proposed Rule Home Health Legislation Hospice Final Rule

4. 30% traditional/ fee-for-service Medicare payments to quality or value through alternative payment models by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018

5. Bundled Payment Initiative Program 101 Home Health agencies participating Model 2 ( acute and post acute) Model 3 (post acute only)

6. Accountable Care Organizations Home Health ACO providers 330 ACOs entered the shared savings program between 2012 and 2014 Common aspects of ACO-HHA transitional care partnerships: 1.ACO identifies and refers high risk individuals 2.HHA maintains contact and assesses need 3.HHA links patients to clinical and social services 4.ACO funds service through case rate or flat fee 5.Next Generation expands role of Home Health

7. IMPACT Act Improving Medicare Post-Acute Care Transformation Act Signed into law September 2014

8. IMPACT Act - Provisions Standardized assessment data From SNFs, home health, IRFs, long-term care hospitals by 2016 Data to include patient functional status, cognitive function, special services needed, physical impairments, comorbidities Standardized format to compare across settings Build on existing assessment tools, MDS and OASIS

9. IMPACT Act - Provisions Quality measure reporting – Functional status changes – Skin integrity – Medication reconciliation – Falls Begins October 1, 2016 All reporting requirements effective 1/1/2019 – Risk adjusted

10. IMPACT Act - Provisions Resource use measures from claims data: – Estimated per-beneficiary Medicare spending – Discharge to the community – Potentially preventable re-hospitalizations – All to be risk-adjusted Begins 1/1/2017 for home health agencies Medicare-certified hospice programs will be required to undergo a standard survey at least once every three years through fiscal 2025. Department of Health and Human Services (HHS) will conduct eligibility re-certification reviews of hospice programs that provide care to individuals if the number of cases in which care is provided for more than 180 days exceeds a percentage threshold of all care cases.

12. decreasing the national, standardized 60-day episode payment by 1.72% in both CY 2016 and 2017 Nominal Case-Mix Growth ? market basket update of 2.9% minus a mandated 0.6 percentage point productivity adjustment 3rd year of the 4-year phase-in of rebasing - downward adjustment of $80.95. What's in the 2016 Home Health Proposed Rule?

13. Financial changes in the rule Rural Add on of 3% extended for episodes and visits ending before 1/1/18 Rural Add-on payment for 60 day episode with Quality Data submitted = $3,026.52 NRS base rate was reduced from $53.23 to $52.92 No change in outliers

14. Proposed New Quality Measure Percent of Patients with Pressure Ulcers That Are New or Worsened (short Stay) NQF #0678 Would be collected using OASIS items – M1308 Current # of unhealed Pressure Ulcers at Each Stage or Unstageable – M1309 Worsening in Pressure Ulcer Status Since SOC/ROC

15. HH Value-based Purchasing in the Proposed rule Initially 9 states in the model Based on points earned Increased or reduced payment up to: 5% in 2018 and 2019 6% in 2020 8% in 2021 and 2022 Analysis: -lowest 20th percentile during the model’s 5% payment adjustment period could expect a downward adjustment of 2.04%. -highest 80th percentile would receive a 3.08% bump

16. Home Health Value Based Purchasing States in proposed rule- MA, MD, NC, FL, WA, AZ, IA, NE, TN All Medicare Patients being served ( including in reciprocal states) Evaluation of agencies performance (20 or more episodes /yr)

17. Home Health Value Based Purchasing Agencies would compete for the payment increases against other agencies of similar size in the same state -Small Volume Cohort agencies -Large Volume Cohort agencies Based on agencies past performance with CY 2015 as the baseline year

18. Proposed Measures 10 Process measures 15 Outcome measures Four new measures Initial 25 quality measures come from OASIS, Medicare claims, HHCAHPS survey and data collected directly from the agencies

19. Outcome measures Improvement in ambulation (M1860) Improvement transfer (M1850) Improvement bathing (M1830) Improvement dyspnea (M1400) Discharge to community (M2420) Improvement pain (M1242) Improvement oral meds (M2020) Prior function ADLs/IADLs (M1900)

20. Outcome Measures Acute care hospital 60 days post Emergency Dept w/o hospitalization CAHPS- Care of patients CAHPS- Communication between provider/patient CAHPS-specific care issues CAHPS-overall rating HHA CAHPS-willingness to recommend HHA

21. Process Measures Timely initiation of care (M0102, M0030) Care Management (M2102) Fall risk assessment (M1910) Pressure ulcer prevention/care (M1300, M1400) Depression Assessment (M1730) Influenza data collected (M1041)

22. Process Measures Influenza immunization received (M1046) Pneumococcal vaccine received (M10510) Reason Pneumococcal vaccine not received (M1056) Drug interaction on all meds provided (M2015)

23. Proposed New Measures Adverse event/ improper medication (Outcome) Influenza vaccine HHA personnel (Process) Herpes zoster vaccine : patients (Process) Advance care plan (Process)

24. Total Performance score = payment adjustment Each state will have their own benchmark Each state will have their own Achievement Threshold Equal weight each measure 1-10 points Higher of HHAs achievement or improvement for each measure ( based on threshold, benchmark and baseline) 90% Process /outcome measures 10% new measures

25. Comprehensive Care for Joint Replacement (CCJR) Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement mandate all hospitals in 75 geographic areas to participate in this bundled payment initiative ( SD not included in proposed ) hospitals accountable for costs incurred from the time an orthopedic patient receives surgery to 90 days after discharge Home health agencies not at financial risk, and would not directly receive incentive payments out of the “reconciliation”

26. HH Temporary moratoria Regional, temporary moratoriums on enrollment of new fee-for-services Medicare, Medicaid providers Based on OIG & DOJ findings- fraud risk & high utilization First Round- Miami, FL area and the Chicago, IL area. Second Round-Ft. Lauderdale, Detroit, Dallas, Houston Third Round – extension round 1 and 2 July 2015 extended FL, IL, MI & TX

27. Home Health Home Health Planning Improvement Act HR 1342 and S 578 Bipartisan support

28. S. 1650 Home Health Documentation and Program Improvement Act of 2015 Require CMS to accept forms completed by the home health agencies that are reviewed and signed by the referring physician Exempt home health agencies from collecting documentation for beneficiaries discharged from a hospital or skilled nursing facility within 14 days prior to the initiation of home health System to resubmit claims that were denied solely due to compliance issues with the face-to- face documentation requirements

29. Bill that we oppose H.R. 3298, Medicare Post-Acute Care Value- Based Purchasing Act – Would supersede the Value based Purchasing programs already going into effect, with a bigger payment withhold – 2 cosponsors, no Senate bill

31. FY 2016 Hospice Final Rule Create 2 different payment rates for routine home care (RHC) -higher base payment rate first 60 days of hospice and reduced base payment rate days 61 or over Service Intensity Add on = Continuous Home Care (CHC) hourly payment rate X the amount of direct patient care provided by RN or SW during the last 7 days of a beneficiary’s life.

32. FY 2016 Hospice Final Rule 1.3% ($200 million) increase in payments for FY 2016 (includes a 1.8% payment update – 0.7% budget neutrality adjustment factor align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the fiscal year for FY 2017 and later CBSA-OMB Delineations changes Clarification Regarding Diagnoses on Claim Form

33. Medicare Care Choices Model receive supportive care services typically provided by hospice, while continuing to receive curative services CMS will pay a per beneficiary $400 for 15 or more days per calendar month and $200 for services provided for less than 15 days in a calendar month

34. Hospice Legislation Medicare Patient Access to Hospice Act of 2015 (H R 1202/S 1354)

35. Contact Information Peter Notarstefano, Director of HCBS LeadingAge 202 508-9406 pnotarstefano@leadingage.org