1. The State of Home Health & Care at Home Pennsylvania Homecare Association William A. Dombi National Association for Home Care & Hospice wad@nahc.org May 20, 2011

2. CHALLENGES or OPPORTUNITIES for HOME CARE? Are you surprised?---It’s both! Changes are sudden, gradual, and distant Political environment subject to change that could trigger more change Care delivery changes accelerating Medicare regulation is somewhat of a wild card Republican health care reform repeal efforts underway Overall environment favors home care Value proposition Shift from fee for service utilization incentives in other care sectors

3. New Congress and Health Care Reform House Republican-led repeal efforts underway Policy driven or politics centered? Alternative reforms? Symbolic or successful?

4. New Congress and Health Care Reform Course of Action Repeal fails—no vote in Senate House majority attempting to defund implementation Will WH and House come up with some compromises around the edges? Currently implemented reforms generally viewed positively 2012 changes the dialogue depending on election results (TBD)

5. Health Care Reform Litigation Constitutional challenges ongoing 3 courts uphold individual mandate; 2 courts overturn it based on Commerce Clause Florida decision finds whole law unconstitutional Many other issues in litigation Employer penalty/mandate Medicaid obligations on states Supreme Court review likely in 2012

6. New Congress and Health Care Reform House budget proposal Repeal Affordable Care Act expansion of insured No funding for implementation Medicaid block grants Medicare vouchers/premium supports replace existing “insurance” program Defined contribution vs, defined benefit Beginning for under 55 (2011) population Raise eligibility to 67 (2033) Means tested supports

7. Present Challenges Providers need time to adjust as payment rates are reduced and new administrative responsibilities begin 2011-2014 are crucial years HHAs still best positioned to take on new opportunities inside and outside of Medicare home health Hospices face reduced rates, increased scrutiny, and greater competition Must deal with the “today” while moving forward on “tomorrow”

8. 2011: The Medicare Rate Changes Begin! CMS Final Rule 2.1% MBI 1 point MBI reduction (Affordable Care Act required) 2.5% reduction in outlier budget (Affordable Care Act required) 3.79% case mix weight change adjustment in 2011 (2012 not finalized)

9. Future HH PPS Payment Rates 2014 rebasing May result in varied rates CMS study on vulnerable populations Case mix weight change adjustment analysis New MedPAC case mix adjustment model in development: looking to drop therapy threshold element

10. MEDICARE HOSPICE Rate reductions threaten care BNAF cuts increase risks Limited inflation updates add pressure Annual cap concerns grow Limited (if any) margins with not alternative payer offsets

11. MEDICARE HOSPICE New payment model in development No earlier than 2013 MedPAC recommends 1 point rate increase in 2012 MedPAC still supports U-shaped payment model Oversight increasing as payments grow

12. MedPAC Home Health Recommendations for 2012 Institute new case mix adjuster Freeze payment rates Impose program integrity measures including a moratorium on new HHAs Accelerate rate rebasing to 2013 with 2 year phase-in Impose a beneficiary copayment

13. MedPAC Copayment Proposal Episode based Possibly set at $150 or 5% Exclude episodes preceded by inpatient hospital or SNF stay Apply to Medicare-Medicaid dual eligibles Permit MediGap supplemental isurance coverage

14. 2011 Regulatory Challenges Face-to-face physician encounter Home health Hospice Therapy assessments and documentation

15. F2F-Home Health Repeal and/or reform Reforms needed Exceptions for certain patient populations Inpatient discharges Medically underserved areas Vulnerable patients Documentation requirements Telehealth use

16. F2F--Hospice Different issues than home health Concern for 3 rd benefit period admissions Roadblock in using contracted NPs Cost increases without reimbursement

17. 2011: The Health Care Delivery Reforms Begin! Significant home care and hospice opportunities!!!!! Chronic care management Transitions in care Accountable Care Organizations Post-acute care bundling Performance-based payment Hospice concurrent care demo

18. CHRONIC CARE MANAGEMENT Independence at Home Pilot Focus on certain diagnoses Interdisciplinary team Physician/NP directed Shared savings RFP in process HHA-based CCM demo Monitoring, teaching, coaching, and telehealth HH coverage criteria Not Applicable Shared savings

19. TRANSITIONS in CARE Re-hospitalization prevention and avoidance Commercial opportunity Hospital is the customer Select discharge monitoring and oversight

20. Accountable Care Organizations Partner, participant, or outsider Value defines role and opportunities Creativity and connections creates opportunities Large physicians groups and/or health systems are likely candidates to establish ACOs Home care/hospice=cost avoidance and cost effectiveness

21. Post-Acute Care Bundling Who manages the bundle? A community-based model! Coordinates with institutional care PAC bundling Functions include: HHA/hospice manages all discharges to community Responsibilities for short-term inpatient care Physician services in or out? Shares in discharge planning

22. Medicaid Home Care Rebalancing of LTC spending continues Risks to home care support with strained budgets PPACA incents home care Major home care expansion through federal money (FMAP) Community Free Choice Option Removal of barriers to HCBS services Money Follows the Person Demo extension Spousal impoverishment protection

23. CLASS Act: Federal LTC Insurance Community Living Assistance Services and Support Payments made to cover individuals with ADL needs in home or nursing facility Premium withholding in wages Opt-out of program authority Participation begins 2010 Eligibility based on ADL needs Benefit payments begin 5 years after implementation (2016- 2017 est.) Preset daily payment to insured Boon to Private Pay home care Supplemental support to Medicare/Medicaid home care Proposed rule and CLASS Commission announcement expected soon

24. Advocacy Action Plan SECURE THE STRATEGIC ROLE CONGRESS INTENDS FOR HOME CARE AND HOSPICE IN ADDRESSING THE NATION’S ACUTE, CHRONIC, AND LONG TERM CARE NEEDS ENSURE HOME CARE AND HOSPICE PARTICIPATION IN TRANSITIONS IN CARE AND OTHER HEALTH CARE DELIVERY REFORMS ENSURE HOME CARE AND HOSPICE PARTICIPATION IN TRANSITIONS IN CARE AND OTHER HEALTH CARE DELIVERY REFORMS ALLOW NPs AND PAs TO SIGN HOME HEALTH PLANS OF CARE ALLOW NPs AND PAs TO SIGN HOME HEALTH PLANS OF CARE RECOGNIZE TELEHOMECARE INTERACTIONS AS BONA FIDE MEDICARE AND MEDICAID SERVICES RECOGNIZE TELEHOMECARE INTERACTIONS AS BONA FIDE MEDICARE AND MEDICAID SERVICES ENACT A COMPREHENSIVE HOME AND COMMUNITY BASED LONG TERM CARE PROGRAM FOR ALL AGE GROUPS ENACT A COMPREHENSIVE HOME AND COMMUNITY BASED LONG TERM CARE PROGRAM FOR ALL AGE GROUPS

25. PRIORITIES 2011 ENSURE APPROPRIATE AND ADEQUATE REIMBURSEMENT FOR AND ACCESS TO MEDICARE HOME HEALTH SERVICES OPPOSE COST SHARING FOR MEDICARE HOME HEALTH SERVICES OPPOSE COST SHARING FOR MEDICARE HOME HEALTH SERVICES BLOCK CMS REGULATORY “CASE MIX CREEP” CUTS AND REQUIRE A NEW PROCESS FOR CALCULATING CASE MIX ADJUSTMENT BLOCK CMS REGULATORY “CASE MIX CREEP” CUTS AND REQUIRE A NEW PROCESS FOR CALCULATING CASE MIX ADJUSTMENT ESTABLISH REASONABLE STANDARDS FOR REBASING MEDICARE HOME HEALTH SERVICES PAYMENT RATES ESTABLISH REASONABLE STANDARDS FOR REBASING MEDICARE HOME HEALTH SERVICES PAYMENT RATES REPEAL OR REFORM MEDICARE HOME HEALTH FACE-TO- FACE ENCOUNTER REQUIREMENT REPEAL OR REFORM MEDICARE HOME HEALTH FACE-TO- FACE ENCOUNTER REQUIREMENT ENSURE FULL MARKET BASKET UPDATES TO MEDICARE HOME HEALTH ENSURE FULL MARKET BASKET UPDATES TO MEDICARE HOME HEALTH ENSURE MEDICARE ADVANTAGE AND FEE-FOR-SERVICE ENROLLEES RECEIVE IDENTICAL HOME HEALTH BENEFITS ENSURE MEDICARE ADVANTAGE AND FEE-FOR-SERVICE ENROLLEES RECEIVE IDENTICAL HOME HEALTH BENEFITS

26. PRIORITIES 2011 ENSURE APPROPRIATE AND ADEQUATE REIMBURSEMENT FOR AND ACCESS TO HOSPICE SERVICES REVISE REQUIREMENTS FOR HOSPICE FACE-TO- FACE REQUIREMENT REVISE REQUIREMENTS FOR HOSPICE FACE-TO- FACE REQUIREMENT PRESERVE THE FULL MARKET BASKET UPDATE FOR THE MEDICARE HOSPICE BENEFIT PRESERVE THE FULL MARKET BASKET UPDATE FOR THE MEDICARE HOSPICE BENEFIT REJECT ADDITIONAL BENEFICIARY COPAYMENTS FOR MEDICARE HOSPICE SERVICES REJECT ADDITIONAL BENEFICIARY COPAYMENTS FOR MEDICARE HOSPICE SERVICES ENSURE ACCESS TO HOSPICE CARE FOR RURAL PATIENTS ENSURE ACCESS TO HOSPICE CARE FOR RURAL PATIENTS MONITOR PAYMENT REVISIONS TO MEDICARE HOSPICE BENEFIT MONITOR PAYMENT REVISIONS TO MEDICARE HOSPICE BENEFIT

27. PRIORITIES 2011 PROTECT AND EXPAND ACCESS TO HOME AND COMMUNITY-BASED SERVICES UNDER MEDICAID ESTABLISH MEDICAID HOME CARE AS A MANDATORY BENEFIT AND SUPPORT REBALANCING OF LONG TERM CARE EXPENDITURES IN MEDICAID PROGRAMS IN FAVOR OF HOME CARE ESTABLISH MEDICAID HOME CARE AS A MANDATORY BENEFIT AND SUPPORT REBALANCING OF LONG TERM CARE EXPENDITURES IN MEDICAID PROGRAMS IN FAVOR OF HOME CARE MANDATE HOSPICE COVERAGE UNDER MEDICAID MANDATE HOSPICE COVERAGE UNDER ENSURE APPROPRIATE MEDICAID RATES FOR HOME CARE AND HOSPICE ENSURE APPROPRIATE MEDICAID RATES FOR HOME CARE AND HOSPICE INCREASE FEDERAL MEDICAID PAYMENTS TO STATES INCREASE FEDERAL MEDICAID PAYMENTS TO STATES

28. PRIORITIES 2011 PROTECT ACCESS TO HOME CARE AND HOSPICE SERVICES, INCLUDING FOR CARE PAID DIRECTLY BY INDIVIDUALS MODIFY EMPLOYER RESPONSIBILITIES IN HEALTH REFORM TO ADDRESS HOME CARE SPECIFIC NEEDS MODIFY EMPLOYER RESPONSIBILITIES IN HEALTH REFORM TO ADDRESS HOME CARE SPECIFIC NEEDS OPPOSE CHANGES TO THE COMPANIONSHIP SERVICES EXEMPTION TO THE FAIR LABOR STANDARDS ACT OPPOSE CHANGES TO THE COMPANIONSHIP SERVICES EXEMPTION TO THE FAIR LABOR STANDARDS ACT

29. NAHC MEDICAID ADVOCACY PROJECT Focus on federal Medicaid CMS now actively overseeing state compliance LTC rebalancing a priority at CMS MACPAC underway Supportive of state-specific efforts Use of legislative, regulatory, and legal forums Significant research projects

30. Preparing for Change Re-engineering, Restructuring, or Refinement? Right People New skills may be needed Right Partners Right Tools Technology Focused data and information Right Efficiencies Value-related cost Right Plan Short and long term

31. Meeting Both Challenges and Opportunities Value proposition Integrated Dynamic Evidenced-based Outcome driven Clinical Financial