LeadingAge NY Annual Conference Reimbursement Reimbursement...Comprehensive Care for Joint...

5/20/2016

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LeadingAge NY Annual Conference Reimbursement Update

Darius KirsteinDirector of Financial Policy & [email protected]‐867‐8841

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VBP

Reimbursement Update

The Reimbursment Landscape• Dash to VBP

Medicare Issues Update• Proposed SNF PPS Rule

• Part B

• New Initiatives

Medicaid Issues Update• Medicaid Rate Adjustments

• Other Medicaid Funding Issues

• Medicaid Managed Care

• VBP

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The Landscape

• Cost based, volume driven, government set, “any willing provider”

Fee‐for‐Service

• Reporting penalties, quality payments, pay for performance, standardized payments

Pricing/ Episodic Payments • contractual

arrangements, ACOs, Health Homes, bundled payment

Managed Care

• DSRIP, provider partnerships, value based payment, shared savings, risk arrangements

Alternative Payment Arrangements

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Many changes in a short time…

The Landscape

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“What New York State’s Medicaid VBP Plan is Not:

An attempt to make providers do more for less: In fact, the intent is the opposite. Under the State’s VBPapproach, reducing lower value care and increasing higher value care in equal proportions should lead to higher margins rather than lower margins.”

…how the State will plan and implement its goal of 80‐90% of managed care payments to providers using value based payment methodologies by end of demonstration year five (2019).

NY Medicaid VBP for MLTC/Long Term Care Population is the second phase, but its coming

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The Landscape

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Alternative payments a focus for Medicare too

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Source: LeadingAge NY analysis of 2014 RHCF‐4 cost report data

The Landscape

Provider finances vary

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The Landscape

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*Two additional states calculated, Virginia and North Dakota, had Medicaid rates slightly greater than cost

Source: ELJAY, LLC & Hansens Hunter & Co., PC, A Report on Shortfalls in Medicaid Funding for Nursing Center Care

Medicaid payment worse in NY than most other states

• 13 MLTC rate packages listed on state’s outstanding rate inventory are for effective dates 4/1/15 or earlier

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The Landscape

State payments to MLTC plans lag and are not always adequate

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The Landscape

Medicaid Global Cap

• Grants “super‐powers” to Commissioner of Health to reduce spending if Medicaid expenditures exceed projections

• $17.7 billion in SFY 2015‐16 • $18.8 billion in SFY 2016‐17

• $19.6 billion in SFY 2017‐18

• Through Feb., SFY 2015‐16 Medicaid spending was $56 M (0.3%) over cap

• No shared savings

• Medicaid total enrollment Feb 2016: 6,198,505

• Increase of 22,438 enrollees (0.4%) since March 2015

Labor Rule Changes

• Various wage mandates and implications of FLSA, especially for home care providers

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Medicaid Global Cap and New Labor Mandates

Medicare Issues Update

Proposed SNF PPS Rule for FFY 2017

Part A Rate Proposal• 2.1 percent market basket increase

• Reflects a .5 percentage point “productivity” adjustment

• No forecasting error adjustment

• 2015 projected was 0.2 percentage points higher than actual

• $800 million higher than last year

•Wage Adjustment updates vary by region

• most counties in the eastern part of the state

• NYC area

• Rochester area

• Most of Western and Central NY

• Ulster County

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Part B• Medicare Physician Fee Schedule (MPFS) determines Medicare Part B rates paid to physicians and other practioners, along with the ancillary rates paid to nursing homes and home care providers for ancillary services

• “Sustainable Growth Formula” repealed (no more “doc fix”)

• 0.5 percent annual increases through 2019

• “Merit‐based Incentive Payment System” (MIPS) consolidates current practitioner quality programs (Physician Quality Reporting System (PQRS), Meaningful Use (MU), and Value Based Payment Modifier (VBM) programs)

• extended the current Medicare therapy caps exceptions process for another two years, through December 31, 2017

• replaces the market basket update in FFY 2018 with a one percent update for post‐acute providers including long‐term care hospitals, skilled nursing facilities, inpatient rehabilitation facilities, home health and hospice providers

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Physician/Practitioner Quality Incentive Payments

Merit‐Based Incentive Payment System (MIPS)

• new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (VM or Value‐based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program in which Eligible Professionals (EPs) will be measured on:

• Quality

• Resource use

• Clinical practice improvement

• Meaningful use of certified EHR technology

Alternative Payment Models (APMs)

• new ways to pay health care providers for the care they give Medicare beneficiaries. For example:

• From 2019‐2024, pay some participating health care providers a lump‐sum incentive payment.

• Increased transparency of physician‐focused payment models.

• Starting in 2026, offers some participating health care providers higher annual payments.

• Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs.

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• 2 percent sequestration cut continues


Medicare SNF Value‐Based Purchasing Program (SNF VBP)

The Protecting Access to Medicare Act of 2014 (PAMA) requires that VBP apply to SNF payments beginning in October 2018

• Two percent withhold of SNF Part A payments

• Partially earned back based on a SNF’s re‐hospitalization rate and level of improvement (50‐70%)

• CMS tasked with:• specifying a risk adjusted re‐hospitalization measure

• calculating a score for each SNF

• providing the measure and score reports to SNFs for review and make it available to the public

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SNF VBP Measures

• The 2016 final rule adopted the SNF 30‐Day All‐Cause Readmission Measure, (SNFRM) for use in the SNF VBP Program

• risk‐standardized rate of all‐cause, unplanned, hospital readmissions for SNF Medicare beneficiaries within 30 days of their prior proximal short‐stay acute hospital discharge

• Legislation requires CMS to specify a more refined hospitalization measure as soon as practicable

• 2017 proposed rule CMS specifies a SNF 30‐day Potentially Preventable Readmission Measure (SNFPPRM) as the refined measure

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Value‐Based Purchasing Program (VBP)

• The primary difference between the two measures is that the former focuses on all‐cause unplanned readmissions, the proposed one focuses on readmissions that are potentially preventable. For readmissions during a SNF stay, “preventable” is defined as “avoidable with sufficient medical monitoring and appropriate treatment.”

• Calculated using a full year’s worth of data

• Claims‐based so no additional reporting

• Risk adjusted

• Considers performance and improvement

• In the proposed rule CMS details the scoring methodology:• 2015 claims as the baseline period for calculating performance standards for FFY 2019 SNF VBP

• CY 2017 would be the measured performance period for FFY 2019 SNF VBP

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• The Improving Medicare Post‐Acute Care Transformation Act of 2014 (IMPACT Act) requires implementation of a quality reporting program for SNFs (SNF‐QRP)

• Starting FY 2018 (i.e. Oct. 2017), SNFs that do not satisfactorily report will have their market basket percentage updates reduced by two percentage points

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Medicare Issues UpdateQuality Reporting Program (QRP)

Four additional measures proposed in 2017 SNF PPS Rule:

• Discharge to Community: This proposed measure assesses successful discharge to the community from a SNF setting, with successful discharge to the community including no unplanned re‐hospitalizations and no death in the 31 days following discharge from the SNF. (2018)

• Medicare Spending per Beneficiary: The MSPB‐PAC SNF measure holds SNFproviders accountable for the Medicare payments within an “episode of care” (episode), which includes the period during which a patient is directly under the SNF's care, as well as a defined period after the end of the SNF treatment, which may be reflective of and influenced by the services furnished by the SNF. (2018)

• Potentially Preventable Readmission: The proposed measure assesses the facility‐level risk‐standardized rate of unplanned, potentially preventable hospital readmissions for Medicare FFS beneficiaries in the 30 days post‐SNF discharge. (2018)

• Drug Regimen Review: This proposed measure assesses whether PAC providers were responsive to potential or actual clinically significant medication issue(s) when such issues were identified. (2020)

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Bundled Payments for Care Improvement Initiative (BPCI)• Multiple phases and models

• LTC providers mostly in Models 2 and 3

• Participants by provider type:• Acute Care Hospitals (423)

• Physician Group Practices (441)

• Home Health Agencies (101)

• Inpatient Rehabilitation Facilities (9)

• Long‐Term Care Hospitals (1)

• Skilled Nursing Facilities (1071)

• Medicare continues to make fee‐for‐service (FFS) payments to providers and suppliers furnishing services to beneficiaries

• Actual expenditures are reconciled against a target price for an episode of care

• At the time of reconciliation, the total expenditures for all related services during a beneficiary’s episode are compared against a bundled payment amount (the target price)

• If the total expenditures are below the bundled payment amount, then CMS shares those savings with the Awardee; if the total expenditures are above the bundled payment amount, then the Awardee pays a recoupment amount to CMS

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Comprehensive Care for Joint Replacement (CJR)

• Episodic payment for DRGs 469 and 470 (Major joint replacement or reattachment of lower extremity) and 470

• Starts at hospital admission and ends 90 days post‐discharge in order to cover the complete period of recovery

• The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee‐for‐service beneficiaries

• As of Nov. 2015, approximately 800 hospitals are required to participate in the CJR Model (including NYC and Buffalo area)

• CMS provides participant hospitals with Medicare episode target prices

• 3 day stay may be waived and hospital may share savings (or risk) with providers

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Other Federal Developments

Older Americans Act (OAA) Reauthorization of 2015 signed into law in early 2016 (passed Congress with unanimous support)

• Helps provide efficient, person‐centered transportation services places seniors need to go, such as service providers, and states and area agencies on aging

• Adjusts the formula for supportive services, congregate meals, home‐delivered meals, and preventive services programs

• Improves Aging and Disability Resource Centers (ADRCs) cooperation and coordination with area agencies on aging and others in providing information and referrals regarding available home‐ and community‐based services.

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Payroll Based Journal

• CMS intends to begin collecting nursing home staffing data through the new Payroll‐Based Journal (PBJ) reporting system

• Oct. 1, 2015 start date for voluntary submitters

• Still on schedule

• Start data collection July 2016

• First report due to CMS Nov 14 (45 days after end of quarter)

• Resources:• CMS PBJ Manual and FAQs

• LeadingAge national listserv

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Dates to Remember

• Medicare Cost Report (5 months after FY ends, <10% Medicare may apply for waiver)

• Medicaid Cost Report (July 15)

• 2016 Capital Rate Appeals (June 10)

• Executive Compensation Report (end of June or Medicaid Cost Report Due Date, whichever later)

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Universal Settlement

• Up to $850 million over a five‐year period

• Roughly $350 million derived from the 0.8 percent cash receipts assessment

• Homes agree to drop nearly all pending lawsuits and rate appeals for rates in effect prior to Jan. 1, 2012

• Initial payment issued by trustees starting late March• Distributions related to specific litigation sent to attorney of record for distribution to home

• Other distributions sent directly to home

• Outstanding Medicaid liabilities offsets:• Up to 70 percent of first distribution

• Up to 100 percent of subsequent distributions

• DOH will refund through the trustees any offsets for liabilities that have been paid

• Homes that elected to participate in the special appeals process were notified to submit documentation by May 20

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Medicaid Issues Update

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NH Medicaid Rate Dynamics

• 2016 is year 5 of pricing phase‐in (10% stop‐loss/gain)

• 2017 rates => no more stop‐loss/gain

• Direct price 2015 to 2016: +$0.51 / +$0.56

• Indirect price 2015 to 2016: +$0.26 / +$0.29

• 3 year MLTC NH benchmark rate clock started:• Feb. 2015 (NYC)

• April 2015 (Nassau, Suffolk, Westchester)

• July 2015 (ROS)

• Transportation

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Minimum Wage Increase

• Phases in $15 minimum wage

• Begins Jan. 2017

• Slower phase‐in than proposed by executive budget

• Roll‐out varies by region

• Safety valve provision starting 2019

• The agreement includes funds intended to cover the costs of the increase for health care providers

• $25.3 million in SFY 2016‐17

• $175.2 million in SFY 2017‐18

• $504.2 million in SFY 2018‐19

• Allows DOH to adjust the Medicaid Global Cap to account for the impact of the minimum wage increases discussed above

• DOH to work with associations to develop impact estimates

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• CMI Considerations

• Next census roster date (“picture date”) is Wednesday, July 27th

• Five percent cap on CMI change

• Homes should file an MDS with CMS for any resident that may be listed on

their case mix census roster, even if not required by regulations

• Managed long term care residents, including those in plans that integrate

Medicaid and Medicare such as PACE, FIDA and MAP, are counted in the

Medicaid CMI calculation

• Recent DOH alternative proposal

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Two‐percent Cut Restoration

• The cash receipts assessment continues at 6.8 percent (6 percent reimbursable 0.8 percent not reimbursable)

• DOH intends to supplement Medicaid rates by one percent retroactive to 4/1/14 to reinvest funds collected by the 0.8 percent assessment

In 2011, the State enacted a 0.8 percent increase in the cash receipts assessment on nursing homes in lieu of the two percent across‐the‐board cut imposed on most other Medicaid providers. While the two percent cut has expired, the 0.8 percent nursing home assessment continues. DOH has indicated that proceeds of the .8 percent assessment will be reinvested in nursing home care: a portion will help fund the Universal Settlement with the rest slated to fund an increase in the Medicaid operating rate.

In Sep. 2015 the State filed a Medicaid State Plan Amendment (SPA) with the Centers for Medicare and Medicaid Services (CMS) to make the reinvestment. When approved, the provision will fund an increase in nursing home Medicaid operating rates by approximately one percent retroactive to the time that the cut was repealed on April 1, 2014. Expected to be paid as an add‐on to April 2015 rates and forward.

The math (in rough numbers):

• State collects @$70M through .8 percent assessment

• Reinvests $35M into Universal Settlement (matched by federal funds)

• Reinvests $35M into NH rates (matched by federal funds)

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Listing Name Description Effective Dates NOTES

2015 July Case Mix Update

Updates the July 2015 rates to include the MDS Census Collection from January 2015.

07/01/2015 –12/31/2015

A number of facilities had data issues during the January 2015 data collection and these facilities are not updated herein. These facilities have had their data examined and corrected and will have a rate update processed shortly.

Facilities which have not certified the census data are likewise not processed. These facility will be processed upon receipt of the certification. (@100)

2016 January Case Mix Update

Updates the January 2016 rates to include the MDS Census Collection from July 2015.

01/01/2016 –06/30/2016

Data from the July 2015 Census collection has been updated and new data will be posted to the HCS for facilities which have not been processed.

Facilities which have not certified the census data are likewise not processed. These facility will be processed upon receipt of the certification. (@100)

July 2012 OMIG Audit Unwind

Reverses the inclusion of OMIG audit result before the audits themselves were final

07/01/2012 –12/31/2012

Facilities not impacted by an OMIG audit are not included in this rate set. Each facility audited by OMIG will see results after the audits are declared final by OMIG.

2013 January OMIG Audit Unwind


01/01/2013 –06/30/2013


2013 July OMIG Audits Unwind


07/01/2013 –12/31/2013


2014 January OMIGAudits Unwind


07/01/2014 –12/31/2014


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Medicaid Issues Update‐ Rate Sheet Postings

Outstanding Rate Issues

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www.health.ny.gov/facilities/medicaid_rate_inventory/

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Nursing Home Quality Initiative (NHQI)

• Rate adjustments on hold (2013, 2014 & 2015) pending resolution of legal challenge

• DOH issued 2016 NHQI methodology

• Replaces CMS 5‐star staffing hours measure with annualized staffing hours measure based on Medicaid cost report data

• Detailed 2013 and 2014 and 2015 scores are available to the public

• 2013 and 2014 amounts shown on the benchmark rate listings on the DOH Medicaid rate web page:

• the 2014 NHQI adjustment amounts are listed on the “January 2015 Nursing Home and Specialty Rates” document

• 2013 NHQI adjustment amounts appear on the July 2014 benchmark rate lists accessible by clicking on Historical Benchmark Rates

• DOH published an NHQI Honor Roll (in top quintile all three years)

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Test measures included in 2015 NHQIThe two measures described below appear on the 2015 NHQI score sheets for informational purposes only. Staffing measure will be incorporated in 2016.


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Assessable Receipts

• Universal Settlement payments

• Advanced Training Initiative funding

• Medicaid Managed Long Term Care revenue

Unclear

• DSRIP‐related funding

No

• Medicare and Medicare Managed Care revenue

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Medicaid Issues UpdateCapital ProgramsHealth Care Facility Transformation ($200 million)

• Capital grants to replace inefficient and outdated facilities as part of a merger, consolidation, acquisition or other restructuring activity that is intended to create a financially sustainable system of care.

• Authorizes DASNY and DOH to make grants or loans to support debt restructuring and capital and non‐capital projects or purposes that support health care transformation and create a financially sustainable system of care

Non‐Profit Infrastructure Capital Investment Program ($100 million)

• Grants are intended to improve service quality, efficiency and accessibility. Eligible projects include renovations or expansions of space used for services; technology to support electronic records, data analysis and/or confidentiality; modifications to provide for sustainable, energy‐efficient spaces; and renovations to promote accessibility.

Capital Restructuring Financing Program ($1.2 billion)

• Capital Restructuring Financing Program that operates in tandem with the Delivery System Reform Incentive Payment (DSRIP) program to support improvements in the financial stability, quality and efficiency of health care providers

Oneida County Health Care Transformation Funding ($300 million)

• Supports capital projects that promote health care facility transformation in Oneida County

Brooklyn Health Care Transformation ($700 million)

• Supports capital projects that prmote health care facility transformation in Kings County.

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Advanced Training Initiative

• $46 million in SFY 2015‐16, $46 million for SFY 2016‐17

• Teach direct caregivers to detect changes in a resident’s status

that could lead to health declines and/or hospitalization

• Awardees encouraged to partner with designated training partners

(e.g., LeadingAge NY)

• 2015‐16 criteria: retention rate above statewide median (excluding

hospital‐based homes and VAP recipients)

• 2015‐16 payments made, use by March 2017

• 2016‐17 application criteria not yet certain

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Energy Efficiency • 2015‐16 State Budget authorized energy efficiency audits

• Goal: inform an energy efficiency program DOH would develop

• Candidates identified and educated; low participation

• DOH and NYSERDA proposing data‐mining based approach

• Workgroup process to be reestablished

“Signing this form authorizes the New York State Energy Research and Development Authority (NYSERDA), and its designated representatives, to access energy billing and consumption data for the property listed below”


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Managed Care Developments• Behavioral health services beneficiaries transitioning to HARPs in ROS (NYC done)

• New FIDA marketing and advertising campaign getting underway

• FIDA‐IDD plan operating in FIDA area (plus Rockland)

• The FIDA roll out for Region II –Enrollment in Suffolk and Westchester Counties for the FIDA model will not start until after mid‐2016

• MLTC Report provides profile of plan population as well as plan quality measure indicators

• VBP arrangement development

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Managed Long Term Care

• Transition of TBI/NHTDWaiver Participants into MLTC delayed until Jan 2018

• Rate Adequacy

• Subject to some Medicaid cuts‐ administrative actions

• Encounter data reporting penalties

• Contract Extensions‐Maximus and Mercer

• Uniform billing codes work

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NH and Medicaid Managed Care

• Crucial for providers to be familiar with each plan’s billing manual and procedures

• Plans facing new encounter reporting penalties• Definitive guidance in Benchmark Letter • Wealth of info in Frequently Asked Questions (FAQs)• Don’t assume plans know

• 2015 MLTC Report• Enrollee characteristics by plan• Quality indicators• Satisfaction survey data

http://www.health.ny.gov/facilities/long_term_care/reimbursement/nhr/benchmark/docs/jun2015_benchmark_letter.pdf


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NH and Medicaid Managed Care

Net Available Monthly Income (NAMI)

As part of the NH transition policy, the responsibility to collect NAMI amounts is being assumed by the plans. Plans may delegate the collection of NAMI to the NH, but this must be expressly agreed to by the provider in the participating provider contract. Monthly premium payments to the plans will reflect an offset for NAMI amounts.

If the plan retains responsibility to collect NAMI, it should pay the facility the full contract rate multiplied by the days of care provided. If the plan delegates NAMI collection to the facility, the NAMI amount should be deducted from payments to the NH for those time periods during which the NAMI is collected by the NH.

Source: June 2015 Benchmark Letter



Community First Choice Option (CFCO)

•DOH is moving forward with the operationalization of CFCO, which was approved on October 23, 2015, with a retro‐active effective date of July 1, 2015

•In April, Commissioners received letters informing them that New York State is participating in CFCO, which became available under the Affordable Care Act

•CFCO incorporates enhanced personal attendant services and supports into the Medicaid State Plan for eligible individuals who need help with everyday activities due to a physical, developmental or behavioral disability

•An Administrative Directive Memorandum (ADM) was drafted to outline the scope and procedures of CFCO services

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Value‐Based Payment (VBP) Arrangements

• DOH has convened a series of subcommittees to work out the operational details of implementing VBP in contracts between providers and Medicaid managed care plans.

• Updated Medicaid Value Based Payment Roadmap • LeadingAge NY dedicated web page with archived webinars and readiness scorecard

• By the end of year five, 80‐90 percent of payments to providers by Medicaid managed care plans must be made through a value based methodology other than fee‐for‐service

• Challenge of developing purely Medicaid VBP in long term care• DOH seeking VBP pilots• Medicare‐Medicaid alignment efforts

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Baseline Survey: Initial analysis indicates that approx. 27‐28% of PPS/MC spending is at VBP Levels 1‐3 and approx. 7% at Level 0 (quality bonus/withhold)

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Thank you!

Darius KirsteinDirector of Financial Policy & AnalysisLeadingAge NY13 British American Blvd., Suite 2Latham, NY 12110

518‐867‐8841

[email protected]

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