2. Affordable Care Act and Federal Policy Update Barbara Gay Director of Governmental Affairs LeadingAge April 16, 2014

3. Affordable Care Act Outlook for continuation Provisions of particular interest/concern to LeadingAge What you can do.

4. ACA Outlook House repeal strategies Senate composition after 2014? President Obama veto pen through 2016 – then? Enrollment process less than stellar Delays in mandates

5. ACA Outlook Growing stake in the program – Over 6 million enrolled – 19 states expanded Medicaid, 5 more through use of Medicaid to buy private insurance – Adult children – People with pre-existing conditions – Initiatives to reform health and long-term care delivery system to bring down costs

6. Affordable Care Act Themes Pay for value, not volume Better integration of services More home- and community-based service options Avoid hospitalizations and rehospitalizations Application of technology Workforce development

7. ACA Employer Mandate New deadline for employers with between 50 and 99 employees – January 1, 2016 Larger employers, 100+ employees – January 1, 2015 Applies to employees working 30 or more hours/week Information for employees and employers on LeadingAge website: http://www.leadingage.org/Legal.aspx http://www.leadingage.org/Legal.aspx

8. Accountable Care Organizations Delivery system reform: – Integrate services – Greater efficiency, fewer avoidable services – Group at risk for all beneficiary costs – Potential Medicare/health care savings More than 360 nationwide 5.3 million Medicare beneficiaries covered Concept flexible, many varying configurations possible for the future

9. ACOs - Structure Beneficiaries don’t enroll, not restricted to any network, may not know they’re in an ACO Typical anchor – hospital, health plan, physician group ACOs contract with CMS to provide services at agreed-upon spending targets ACO can pocket savings for spending below targets 33 quality indicators

10. ACOs – 3 Models Shared Savings – the basic plan, chosen by majority of ACOs Advance Payment – helps smaller ACOs with less capital with initial investment in staff and infrastructure Pioneer – ACO assumes more risk with potential for greater reward

11. ACO Pioneer Model A Cautionary Tale More risk, more reward 32 organizations chosen for 3 year program; 9 dropped out after 1 ½ years $87.6 million Medicare savings after 1 year Slower rate of spending growth/beneficiary – 0.3% vs. 0.8% in traditional Medicare 13 Pioneers saved enough to share with Medicare 2 Pioneers owed Medicare $4 million

12. ACOs Tools to Achieve Savings Provider quality and cost data Care coordination, including transitions Discharge planning/case management Wellness, prevention, disease management Bottom line – outcomes, not volume of services

13. ACOs Be the Solution Anticipate needs and develop quality measures: – Hospital readmissions – Falls – Pressure wounds – Medication adverse events Special services – stroke rehab, wound care Processes for managing care transitions Doc – doc dialogue LeadingAge Insights can help!

14. Bundling “Bundles” payment across provider types for a single episode of care Incentive for providers to coordinate services and continuity of care – Four approaches in Request for Applications – 1) Hospital stay – 2) Hospital stay plus post-acute care – 3) Post-acute care following hospital stay – 4) Prospective payment for all services during hospital stay

15. Hospital Readmissions Reduction Hospitals’ Medicare reimbursement cut if they have higher- than-average readmission rates for “applicable conditions” Program began with 3 “applicable conditions” – – Acute myocardial infarction – Heart failure – Pneumonia Beginning in 2015, other conditions likely to be added Opportunity for post-acute care providers to help hospitals reduce their readmission rates LeadingAge Insights!

16. QAPI for Nursing Homes Quality Assurance and Performance Improvement programs Required for all nursing homes within a year of final regulation’s publication CMS developed on-line resource library and other tools for facilities to set up programs Reg may come out this year Tools: Advancing Excellence, Quality First

17. Dual Eligibles Medicaid waiver available for up to 5 years, can be renewed Goal: better integration of benefits and administration by states/CMS Concerns – Access to essential services – Health plan experience with special needs of long- term services and supports population

18. ACA Transparency Requirements On request of Secretary, HHS Inspector General, the states, or LTC ombudsman, SNF/NF must provide description of facility’s – governing body and organizational structure – information regarding additional disclosable parties SNF/NF must operate a compliance and ethics program effective in preventing/detecting criminal, civil, and administrative violations

19. Workforce Authorizes geriatric education centers – Training for health care professionals and family caregivers in chronic care management Expands geriatric care awards to advanced practice nurses, clinical social workers, other health professionals Traineeships for those preparing for advanced degrees in geriatric nursing Increase number of providers specializing in geriatrics and ensure more providers have geriatric training Issue - funding

20. And now, a few words about Medicare

21. Medicare - Current Issues “Doc fix” (SGR) – therapy caps Observation days – H.R. 1179, S. 569 Post-acute care payment reform

22. Medicare “Doc Fix” Therapy Caps Permanent “doc fix” to correct flawed physician payment formula, prevent large cuts in reimbursement still pending Another temporary doc fix passed 3-31-2014 – H.R. 4302 – Lasts through March 31, 2015

23. Doc Fix – H.R. 4302 Post-acute care provisions: Extends therapy caps exceptions process Delays ICD-10 effective date until 10/1/2015 Value-based purchasing for skilled nursing facilities

24. Doc Fix/Therapy Caps LeadingAge concerns – Therapy caps relief must be included in doc-fix legislation – Post-acute care should not be the pay-for H.R. 4302 satisfied us on both counts

25. Value-Based Purchasing for SNFs CMS to develop SNF readmission measure by 10/1/2015 By 10/1/2016, readmission measure refined to show risk-adjusted, potentially preventable readmissions By 10/1/2019, readmission measures to be linked to value-based purchasing strategy. – Incentive payments for high performers; penalties for low performers.

26. Value-Based Purchasing LeadingAge Concerns CMS should allow stakeholder input in development of readmission measures Measures must be risk adjusted at: – Nursing home level (homes serving lower-income populations, for example) – Beneficiary level (complex care needs)

27. Hospital Readmission Rates Begin tracking your rates now Put quality improvement systems in place to identify opportunities to reduce preventable hospitalizations. Advancing Excellence has a tool: https://www.nhqualitycampaign.org/star_ind ex.aspx?controls=hospitalizationsidentifybasel ine

28. Medicare Observation Days H.R. 1179/S. 569 – Time spent in a hospital under observation counts toward the 3-day stay requirement – Beneficiaries leaving the hospital after a period of observation are to be considered to have been discharged. Urging members of Congress to cosponsor

29. 3 Day Stay Requirement H.R. 3144 would repeal. No cosponsors, little chance of passage Integrated systems at risk for all patient costs already excepted from the rule CMS can do pilots allowing patients to receive skilled medical services in nursing homes CMS lacks infrastructure to monitor potential “churning” of patients between long-stay and skilled care levels within a nursing home

30. Medicare Post-Acute Care Reform Finance-Ways and Means Chairs’ letter 6/19/13: Too much variation in per-beneficiary Medicare spending on post-acute care No guidelines on types of “patients” appropriate for each setting Different payment rates to different provider types for patients with similar conditions MedPAC, Obama Administration, other experts have called for payment reform

31. Ways and Means/Finance Concerns Specific areas of interest: – Quality – comparing across settings – Value-Based Purchasing – Reducing Hospital Readmissions – Bundled Payments – Site Neutral payments

32. LeadingAge Comments Well-integrated post-acute care will eliminate inappropriate use of expensive services Essential to determine needs across settings Medicare spending per beneficiary already growing more slowly Take a broader view of post-acute care and its funding mechanisms (say the word “Medicaid”) Eliminate silos between acute, primary, specialty and post-acute providers

33. IMPACT Proposal Improving Medicare Post-Acute Care Transformation – “IMPACT” Issued by Ways and Means and Finance Committees March 18 Outlook? Little time left in the present congressional session Committee staff indicate committee action possible early summer Never say never.

34. IMPACT Proposal Standardized assessment data From SNFs, home health, IRFs, long-term care hospitals by 2016 Eventually to include hospitals, cancer hospitals, critical access hospitals (by 2019) Data to include patient functional status, cognitive function, special services, etc. CARE tool?

35. IMPACT Act Quality measure reporting – Functional status changes, skin integrity, med reconciliation, etc. Resource use measures from claims data -> per-beneficiary spending All data to be publicly reported by 2017-2018. SNF Quality Reporting program by 2019, 2% penalty for failure to comply

36. IMPACT Proposal LeadingAge questions: – OASIS and MDS revised or replaced? – Nursing home oversight system? – Risk adjustment needed to account for varying care needs Ultimately proposal envisions standard payment system based on individual needs, rather than setting in which provided.

37. What You Can Do Make it real for policymakers – how do their policies affect your residents, staff and community Cultivate relationships Tell your story Tools – LeadingAge website, Contact Congress, staff