1. Nuts and Bolts: ACOs, Medical Home and Bundled

2. Where are we going? With or without the full PPACA: Concentrated Markets Collaborations Care management for chronic illness Medicaid populations under tighter control Experimentation in patient incentives Physicians at the center [even when employed] Distanced health delivery by telehealth War zone with fraud and abuse enforcement

3. Nuts and Bolts of ACOs There are many would-be ACOs forming Only 35 up and approved as of March 2012 Many in California About 50% nationally are doctor controlled Many federal rules now attached to models Outside the ACO box means no waivers Contracting to ACOs has special requirements and calls for special skills in negotiating and visioning

4. GAO Report: 8 Senators There are no exceptions and safe harbors specifically for financial incentive programs, and the Stark [physician self-referral] law's no risk' requirement for new exceptions makes it difficult for CMS to craft an exception that allows for innovative, effective programs while ensuring that the Medicare program and patients face no risk from abuses, (GAO-12-355), March 2012.

5. AntiKickback (AKS) and Civil Monetary Penalty (CMP) Acts Kickbacks include fees for making referrals to a person or entity, or other forms of value which could include cross-referrals Brokers are being prosecuted for AKS Special access opportunities could include fees for participating in electronic referral system. OIG Advisory Opinion 11-06 Systems which reward providers for reducing services may violate the CMP Act

6. Practical Examples from the ACO World Discussion of Examples Inter-active dialogue with CAHSAH audience about their experiences What would serve homecare and hospice best? Do we need best practices here or is it too soon? Do we need professional associations or is this too difficult under the Anti-Trust laws?

7. Are Medical Homes happening? Understanding the limitations of the past Geisinger Health System is not a clonable experience If States are pushing back on healthcare reform are they dooming the Medical Home? Realities from the physician perspective – resources, delivery models, not many Marcus Welbys, also not many SuperPersons. Can you take your MDs to a Medical Home?

8. State Based Medical Home Incentives The ACA provides States with 90% Federal matching for health home services for Medicaid enrollees with multiple chronic illnesses, one chronic illness and at risk for a second, or a single serious mental illness John Muir Health's patient-centered medical home program -- based in Concord -- began in 2010 and has reported a 43% drop in hospitalizations and a 14% drop in emergency department visits among its patients.

9. New York State Proposal The States 4 categories of high-cost Medicaid enrollees: developmental disabilities long term care service needs behavioral health conditions* two or more chronic illnesses* including mental illness, substance abuse, asthma, diabetes, heart disease, hypertension, and HIV/AIDS. [*First to develop; 7/11/11 notice]

10. Relationships and Contracts Health homes will be expected to develop provider networks with community-based providers Providers need to conceptualize their services, describe their shared risks and liabilities, and declare those which they will not undertake In telehealth networks, what do home health agencies and hospices BRING and CONTROL?

11. Subcontracting for Skills Does the HHA or hospice have the skill set for the mental health aspect of the proposed care coverage in the Health Home, the ACO or the Network If not, now is the time to reach out to health professionals working in telemental health, telerehab, and palliative care with telehealth support Subcontracting will have different feel and content that usual PT or MSW Ind. Contractor

12. Matching COPs to Contract Promises What COPs are drawn into question if HHA or hospice has a free-flowing and shared responsibility for care planning How does the provider have sole responsibility for care planning in the context of ACOs Need basis for renegotiating responsibilities Need Fraud and Abuse Kickback protections

13. Report from the Commonwealth Fund on the VA 2011 The Veterans Health Administration: Implementing Patient-Centered Medical Homes in the Nations Largest Integrated Delivery System, September 2011

14. Experimental Demos The Beacon Projects [$12-13 million each] Patient Care Transitions Program Independence at Home Bundling projects Quality projects in long term care setting

15. Bundling Models Model 1: inpatient stay & physician services Model 2: hospitalization and post- acute for 30 or 90 days at applicants choice Model 3: post-acute providers, care w/in 30 days of D/C and minimum 30 days Physician, Part B, DMEPOS and related re-hospitalization Prospective payment to hospitals in Model 4

16. HHS Community Care Transitions Program HHS Says: Transition from one source of care to another risk for communications failures, procedural errors, and unimplemented plans. People with chronic conditions, organ system failure, and frailty at highest risk because care is more complicated and they are less resilient when failures occur. Strong evidence hospital readmissions caused by flawed transitions.

17. CCTP Vision A care system in which each patient with complex needs has a care plan that guides all care; Moves with the patient across settings of care and time; Reflects the priorities of patient and family; and Meets the needs of persons living with serious chronic conditions.

18. CCTP Approach Build on evidence from research and pilots. Support local coalitions of hospitals, nursing homes, physicians, home health, consumer groups, and other stakeholders. Encourage formation of new coalitions where needed. Provide data, technical support, payment mechanisms, financial support, enhanced surveys, consumer information, training, and other mechanisms to help coalitions.

19. CCTP Strategy Create a broad based public/private partnership Tailor support to where providers are -match support to needs Walkers little track record, but interested in starting e.g. using QIO or AoA programs Joggers: proven track record, eligible for S 3026 Marathoners: established, mature coalitions eligible for S 3022 ACO support

20. CCTP Focus Consideration was given to hospitals whose 30-day readmission rate on at least two of the three hospital compare measures (Acute Myocardial Infarction [AMI], Heart Failure [HF], Pneumonia [PNEU]) falls in the fourth quartile for its state

21. CCTP Goal Build a national network of 2600 community focused care transition coalitions which partner hospitals with community resources

22. California Advanced Care Transitions (ACT) is a partnership between Californias Marin County Health & Human Service Agency, Division of Aging and Adult Services, and two hospitals: Marin General Hospital Novato Community Hospital

23. Independence@Home Boston Medical Center (Boston, Massachusetts) Christiana Care Health Services (Wilmington, Delaware) Cleveland Clinic Home Care Services: Medical Care at Home Program (Independence, Ohio) Comprehensive Geriatric Medicine P.C. (Brooklyn, New York) Doctors Making Housecalls, LLC (Durham, North Carolina)

24. Independence@Home Housecall Providers, Inc. (Portland, Oregon) MD2U (Louisville, Kentucky) National House Call Practitioners Group (Austin, Texas) North Shore – Long Island Jewish Health Care Inc.: Physician House Calls Program (Westbury, New York) RMED, LLC (Jacksonville, Florida) Visiting Nurse Housecall, LLC (Atlanta, Georgia)

25. Independence@Home Visiting Physicians Association, P.C. – Flint/Saginaw/Marysville (Flint, Michigan) Visiting Physicians Association, P.C. – Lansing/Ann Arbor (Okemos, Michigan) Visiting Physicians Association, P.C. – Milwaukee (West Allis, Wisconsin) Visiting Physicians Association of Texas, PLLC – Dallas (Irving, Texas) Wellness Resources Network, LLC (Sunrise, Florida)

26. Comprehensive Primary Care Initiative Arkansas: Statewide Colorado: Statewide New Jersey: Statewide New York: Capital District-Hudson Valley Region Ohio: Cincinnati-Dayton Region Oklahoma: Greater Tulsa Region Oregon: Statewide

27. Comprehensive Primary Care Initiative A management fee for Medicare benes · improved care coordination; · increasing patients access to care; delivering preventive care; · engaging patients/caregivers in managing their own care · individualized, enhanced care for patients with multiple chronic diseases & needs.

28. Home and Community Final rule in health reform law: a new Medicaid option for home and community- based services and supports, Community First Choice, with enhanced federal match rate. The rule will become effective 60 days after planned publication May 7. A proposed rule (CMS-2249-P2) allows design and tailoring home and community- based services to better meet the needs of Medicaid enrollees, particularly the elderly and disabled.

29. Is Telehealth Taking Off? The best way into an ACO, Medical Home or bundling opportunity for any provider not otherwise having clout The state of the research The progress with the VA in behavioral and mental health The home visit enabled by direct, or contracted website connections Giving up on direct reimbursement California progress

30. Telehealth Visioning Palliative Care - Montefiore Medical Center, New York Dynamic statistics in reduced hospitalizations: over 5 years; in recent research articles; pertaining to a broader range of diagnoses than only congestive heart failure [CHF]. New work in diabetes. Health IT generally in accountability Natural connections to the growing social media.

31. Legal and Regulatory Issues Licensure including across state lines Liability Consent 3d Party or direct to health provider? Statistics transmitted and/or coaching Is there a new safety and efficacy standard for the software translating or trending the data read by the medical device? What will the FDA do and what must you do?

32. Contact Info Deborah A. Randall, Esq. Health Services & Telehealth Consultant Law Office: Washington, DC law@deborahrandallconsulting.com Consulting Office: Poinciana, FL deborah@deborahrandallconsulting.com 202-257-7073 www.deborahrandallconsulting.com