WSHPCO Annual Conference, Session 5C 1. 2 3 Payer20132012 Medicare Hospice Benefit87.2%83.7% Managed...

1

Where the Money Comes Fromand Where it Goes:

How to Help Your Staff Understand the Financial Realities of your

Program

-A Panel DiscussionGary Castillo, Tri-Cities Chaplaincy

Chris McFaul, Horizon HospiceMark Rake-Marona, Franciscan Hospice & Palliative CareWSHPCO Annual Conference, Session

5C

2

Session Overview• The Factors Behind Our Revenue• How Revenue Will Work in the Future – Big Changes Coming!• How Expenses Work• Q&A

2014 NHPCO Facts and Figures on Hospice Care 4

Percentage of Patients Served by Payer

Payer 2013 2012

Medicare Hospice Benefit 87.2% 83.7%

Managed Care or Private Insurance

6.2% 7.6%

Medicaid Hospice Benefit 3.8% 5.5%

Uncompensated or Charity Care

0.9% 1.2%

Self Pay 0.8% 0.9%

Other Payment Source 1.2% 1.2%

2014 NHPCO Facts and Figures on Hospice Care 5

Percentage of Patient Care Days by Payer

Payer 2013 2012

Medicare Hospice Benefit 91.2% 89.0%

Managed Care or Private Insurance

4.0% 4.4%

Medicaid Hospice Benefit 3.1% 4.3%

Uncompensated or Charity Care

0.6% 0.8%

Self Pay 0.5% 0.6%

Other Payment Source 0.6% 0.9%

www.HospiceAnalytics.com 6

2013 Demographics & Hospice Utilization

Washington National

Total Deaths 51,052 2,529,792

Medicare Beneficiary Deaths 41,560 2,081,847

Medicare Hospice Beneficiary Admissions

24,02158% of Medicare

deaths

1,304,99463% of Medicare

deaths

Medicare Hospice Beneficiary Deaths17,961

43.2% of Medicare deaths

946,01745.4% of Medicare

deaths

Medicare Hospice Total Days of Care 1,385,256 days 91,044,459 days

Medicare Hospice Mean Days/BeneficiaryMedicare Hospice Median Days/Beneficiary

58 days23 days

70 days24 days

Medicare Hospice Total PaymentsMedicare Hospice Mean Payment/Beneficiary

$240,695,096$10,021

$14,917,921,218$11,444

2013 Hospice Utilization(Medicare Hospice Deaths / Total Medicare Deaths)


Arizon

a 1

Utah 2

Florida

3

Iowa

4

Delaware

5

Oregon

6

Rhode

Islan

d 7

Ohio 8

Colorad

o 9

Michiga

n 10

Texas

11

Georgi

a 12

Wiscon

sin 1

3

Idaho

14

South

Carolina

15

Nebras

ka 1

6

Kansa

s 17

Missou

ri 18

New M

exico

19

Minnes

ota 2

0

Oklaho

ma 21

Penns

ylvan

ia 22

Louis

iana

23

Nevad

a 24

North C

arolina

25

Nation

al

Illinois

26

Alabam

a 27

Arkans

as 2

8

Indian

a 29

New H

amps

hire

30

Washin

gton

31

Conne

cticu

t 32

Maine

33

Massa

chus

etts

34

Californ

ia 35

Marylan

d 36

New Je

rsey

37

Virginia

38

Hawaii

39

Montan

a 40

Tenne

ssee

41

West V

irginia

42

Kentuc

ky 4

3

Mississ

ippi 4

4

South

Dakota

45

Distric

t of C

olumbia

46

Vermon

t 47

Wyoming

48

New York

49

North D

akota

50

Alaska

51

0%

10%

20%

30%

40%

50%

60%

70%58

.7%

56.1

%55

.8%

54.3

%53

.7%

53.3

%52

.3%

52.1

%51

.5%

51.1

%49

.3%

48.8

%48

.8%

47.6

%47

.6%

47.3

%47

.0%

47.0

%46

.9%

46.7

%45

.7%

45.7

%45

.5%

45.5

%45

.4%

45.4

%44

.9%

43.9

%43

.6%

43.3

%43

.3%

43.2

%42

.8%

42.6

%42

.5%

42.1

%42

.1%

41.8

%40

.9%

40.4

%40

.2%

40.1

%38

.1%

37.7

%37

.5%

34.8

%32

.1%

31.5

%30

.2%

29.7

%28

.4%

25.1

%

National:45.4%

WA #31:43.2%

Alabam

a 1

Idaho

2

South

Carolina

3

Mississ

ippi

4

Georgi

a 5

Utah 6

Oklaho

ma 7

Texas

8

Nevad

a 9

New M

exico

10

Louis

iana

11

Arizon

a 12

Missou

ri 13

Ohio 1

4

Distric

t of C

olumbia

15

Californ

ia 16

Colorad

o 17

Florida

18

Nation

al

North C

arolina

19

Delaware

20

Wiscon

sin 2

1

Virginia

22

Tenne

ssee

23

Hawaii

24

West V

irginia

25

Kansa

s 26

Massa

chus

etts

27

Penns

ylvan

ia 28

Michiga

n 29

Indian

a 30

New Je

rsey

31

Minnes

ota 3

2

Illinois

33

Arkans

as 3

4

Montan

a 35

Nebras

ka 3

6

Vermon

t 37

Rhode

Islan

d 38

Oregon

39

Washin

gton

40

New H

amps

hire

41

Iowa

42

Maine

43

Marylan

d 44

Kentuc

ky 4

5

North D

akota

46

New York

47

Alaska

48

South

Dakota

49

Conne

cticu

t 50

Wyoming

51

-

10

20

30

40

50

60

70

80

90

100

91 90 9087 85 85 84 82 82 82 80 79

73 71 71 71 71 70 70 69 69 68 67 67 67 67 65 65 64 64 64 63 63 61 61 61 61 60 59 58 58 57 57 57 56 56 54 52 51 51 50 48

2013 Medicare HospiceMean Days of Care / Beneficiary

WA #40:58

National:70


Idaho

1

Alabam

a 2

South

Carolina

3

Utah 4

Mississ

ippi

5

Georgi

a 6

Arizon

a 7

Oklaho

ma 8

Nevad

a 9

New M

exico

10

Distric

t of C

olumbia

11

Louis

iana

12

Texas

13

Californ

ia 14

Missou

ri 15

Colorad

o 16

Hawaii

17

Massa

chus

etts

18

North C

arolina

19

Virginia

20

Wiscon

sin 2

1

Minnes

ota 2

2

Delaware

23

Oregon

24

Vermon

t 25

West V

irginia

26

Nation

al

Montan

a 27

Washin

gton

28

Kansa

s 29

Maine

30

Ohio 3

1

Tenne

ssee

32

Nebras

ka 3

3

New H

amps

hire

34

Penns

ylvan

ia 35

Florida

36

Indian

a 37

Michiga

n 38

Iowa

39

New Je

rsey

40

North D

akota

41

South

Dakota

42

Marylan

d 43

Alaska

44

Illinois

45

Kentuc

ky 4

6

New York

47

Arkans

as 4

8

Rhode

Islan

d 49

Wyoming

50

Conne

cticu

t 51

-

5

10

15

20

25

30

35

40

45

50

44 4340 40 39

33 32 3129 29 29 28 28 27 27 26 25 25 25 25 25 25 24 24 24 24 24 23 23 22 22 22 22 21 21 21 20 20 20 19 19 19 19 18 18 17 17 17 16 16 15 14

2013 Medicare HospiceMedian Days of Care / Beneficiary

National:24

WA #28:23


2013 Medicare Hospice BeneficiariesLevels of Care (days)

Compare: Washington Compare: National90%

92%

94%

96%

98%

100%

98.5%

97.6%

1.2%

1.8%

0.3%0.3%

0.0% 0.3%

Cont. Home Care

Respite Care

General Inpt

Routine Home Care


2013 Mean Medicare Hospice Payments/Beneficiary

Nev

ada

1Ar

izon

a 2

Cal

iforn

ia

3So

uth

Car

olin

a 4

Geo

rgia

5

Idah

o 6

Flor

ida

7N

ew M

exic

o 8

Texa

s 9

Uta

h 1

0Al

abam

a 1

1D

elaw

are

12

Dis

trict

of C

olum

bia

13

Mis

siss

ippi

14

Okl

ahom

a 1

5C

olor

ado

16

Haw

aii

17Lo

uisi

ana

18

Nat

iona

l

Mas

sach

uset

ts 1

9O

hio

20

Nor

th C

arol

ina

21

New

Jer

sey

22

Wis

cons

in 2

3M

isso

uri

24R

hode

Isla

nd 2

5Vi

rgin

ia 2

6Ill

inoi

s 2

7M

inne

sota

28

Penn

sylv

ania

29

Con

nect

icut

30

Was

hing

ton

31

Mic

higa

n 3

2O

rego

n 3

3N

ew Y

ork

34

New

Ham

pshi

re 3

5Ka

nsas

36

Indi

ana

37

Wes

t Virg

inia

38

Tenn

esse

e 3

9Ve

rmon

t 40

Mar

ylan

d 4

1Ar

kans

as 4

2N

ebra

ska

43

Mai

ne 4

4Al

aska

45

Mon

tana

46

Kent

ucky

47

Iow

a 4

8So

uth

Dak

ota

49

Wyo

min

g 5

0N

orth

Dak

ota

51

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

15,1

5113

,648

13,6

4813

,458

13,3

3613

,073

12,8

1412

,807

12,7

0812

,623

12,5

8912

,191

12,1

7512

,175

11,8

2611

,818

11,6

9011

,613

11,4

4411

,443

11,4

2511

,136

11,0

4210

,858

10,6

1010

,602

10,3

2310

,264

10,1

4010

,097

10,0

6810

,021

9,90

09,

890

9,83

19,

802

9,76

39,

756

9,75

59,

735

9,70

59,

530

9,24

89,

117

9,06

78,

988

8,87

78,

794

8,67

87,

600

7,49

07,

322

WA #31:$10,021

National:$11,444


12

Medicare Reimbursement Changes

BNAF

10-1-2014

2009-2016

2017

ACA Prod

Adjustment

Sequestratio

n

Quality Reporti

ng

Penalty

2 Tier R

HC + SIA

10-1-2009 1-2013…2024

1.1.201610-1-2012

MEDICARE PAYMENT: HISTORICAL REVIEW

FY2008 (ac-tual)

FY2009 (actual) FY2010 (actual) FY2011(actual)

FY2012(actual)

FY2013(actual)

FY2014(actual)

FY2015(actual)

Published national rate 135.11 139.97 143.42 146.63 151.03 153.45 156.06 159.34

Net increase after reductions 135 139.97 142.34949 146.2884 150.14912 151.03 139.6395 148.257

$137.50

$142.50

$147.50

$152.50

$157.50

RHC Rates After Rate Reductions - 2008 through 2015

Published national rate

Net increase after reductions

How reimbursements works in the future

Show me the money…


8/6/15: http://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf

http://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-19033.pdf


Changes to RHC Starting 1/1/16

• Higher RHC rates days 1-60: $186.84• Versus $159.34 through September 30, 2015• Versus $161.89 October first through December 31, 2015

• Lower RHC rates days greater than or equal to 61: $146.83• Versus $159.34 through September 30, 2015• Versus $161.89 October first through December 31, 2015

• Wage Index Adjustments

17

FY2017(estimate)

FY2018(estimate)

FY2019(estimate)

FY2020(estimate)

FY2021(estimate)

FY2022(estimate)

FY2023(estimate)

Published na-tional rate

191.32416 195.91593984 200.61792239616

205.432752533668

210.363138594476

215.411853920743

220.581738414841

Net increase after reduc-tions

$183.67 $188.08 $192.59 $197.22 $201.95 $206.80 $211.76

$185.00

$195.00

$205.00

$215.00

$225.00

$183.67

$188.08

$192.59

$197.22

$201.95

$206.80

$211.76

Estimated RHC High Rates After Rate Reductions 2017 through 2023

Published national rateNet increase after reductions

MEDICARE PAYMENT


“Days follow the Patient”• Example One: Live discharge on RHC day 45• Less than 60 days later, patient reenrolls (any hospice)• That reenrollment day is day 46 and $186.84 is daily rate• 15 days later (day 61), the lower $146.83 rate starts

• Example Two: Live discharge on day 77 (lower rate in effect)• At least 60 Days without hospice care• Patient reenrolls (even on day 61)• Higher daily rate is paid• The 60 day clock begins again


Service Intensity Add-On• Optional, as-needed additional rate for high-intensity

service during last seven days of life: up to four hours total per day paid at CHC rate ($39.37 per hour*).• $0-$1,100/beneficiary who dies on service• Day must be billed as RHC day.• Day occurs during last seven days of beneficiary’s life (and

beneficiary’s dc deceased).• Direct patient care provided by RN or SW (i.e., in person).• The proposed rule excluded SIA payments if the beneficiary

was being served in a SNF or NF – the final rule includes SNF/NF.

20

Changes to Other RatesType of Care New Rate Versus

Continuous Home Care (CHC)

$944.79 $929.91

Inpatient Respite Care (IRC) $167.45 $164.81

General Inpatient Care (GIP)

$720.11 $708.77

• Wage Index Adjustments• Market Basket Increase 1.6%• Final Year BNAF Phase Out• Adjustment Factor 1.018%• -2% for Hospice Agencies that DO NOT Submit

Required Quality Data

Revenue Modeling

Dec. 2015 January 2016

100 * 161.89 * 31 Days 1-60 60 +

$501,859.00 10 186.8 90 146.8 $467,576.10

20 186.8 80 146.8 $479,979.20

30 186.8 70 146.8 $492,382.30

Census = 100 40 186.8 60 146.8 $504,785.40

50 186.8 50 146.8 $517,188.50

60 186.8 40 146.8 $529,591.60

70 186.8 30 146.8 $541,994.70

27 Deaths SIA: 2 hrs x 2 days 4252



Revenue Modeling

Dec-15 January 2016- $34,283

100 * 161.89 * 31 Days 1-60 60 +

$501,859.00 10 186.8 90 146.8 $467,576.10

20 186.8 80 146.8 $479,979.20

30 186.8 70 146.8 $492,382.30

40 186.8 60 146.8 $504,785.40Census = 100

50 186.8 50 146.8 $517,188.50

60 186.8 40 146.8 $529,591.60

70 186.8 30 146.8 $541,994.70




Revenue Modeling

Dec-15 January 2016

100 * 161.89 * 31 Days 1-60 60 +

$501,859.00 10 186.8 90 146.8 $467,576.10

20 186.8 80 146.8 $479,979.20

30 186.8 70 146.8 $492,382.30

40 186.8 60 146.8 $504,785.40

Census = 100 50 186.8 50 146.8 $517,188.50

60 186.8 40 146.8 $529,591.60

70 186.8 30 146.8 $541,994.70

27 Deaths SIA: 2 hrs x 2 days 4252 + $40,00030 Deaths SIA: 3 hrs x 3 days 10630


Revenue Modeling

Dec-15 January 2016

100 * 161.89 * 31 Days 1-60 60 +

$501,859.00 10 186.8 90 146.8 $467,576.10

20 186.8 80 146.8 $479,979.20

30 186.8 70 146.8 $492,382.30

Census = 100 40 186.8 60 146.8 $504,785.40

50 186.8 50 146.8 $517,188.50

60 186.8 40 146.8 $529,591.60

70 186.8 30 146.8 $541,994.70




Summary of the 8/6/15Hospice Final Rule


Oregon

1

Washin

gton

2

Vermon

t 3

Alaska

4

North D

akota

5

Maine

6

Minnes

ota 7

New H

amps

hire

8

Wyoming

9

Montan

a 10

South

Dakota

11

Distric

t of C

olumbia

12

Massa

chus

etts

13

Californ

ia 14

Virginia

15

Utah 1

6

New York

17

Hawaii

18

Iowa

19

Nebras

ka 2

0

Marylan

d 21

Colorad

o 22

Kansa

s 23

Wiscon

sin 2

4

Arizon

a 25

Mississ

ippi 2

6

North C

arolina

27

Alabam

a 28

Idaho

29

West V

irginia

30

Missou

ri 31

Kentuc

ky 3

2

Penns

ylvan

ia 33

Nation

al

South

Carolina

34

Delaware

35

New Je

rsey

36

Conne

cticu

t 37

Indian

a 38

Michiga

n 39

Tenne

ssee

40

Oklaho

ma 41

Rhode

Islan

d 42

Georgi

a 43

Louis

iana

44

Illinois

45

Nevad

a 46

Ohio 4

7

Arkans

as 4

8

New M

exico

49

Florida

50

Texas

51

$0

$100

$200

$300

$400

$500

$600

$517

$503

$494

$486

$476

$472

$465

$464

$462

$462

$458

$448

$446

$429

$426

$422

$422

$419

$419

$416

$412

$409

$406

$405

$403

$401

$397

$397

$397

$394

$390

$388

$387

$381

$380

$380

$376

$376

$375

$371

$364

$348

$345

$342

$338

$335

$326

$322

$319

$319

$316

$313

National:+$381

Hospice Reimbursement Modeling(based on levels of care only, no SIA or wage index adjustment)



Quality Reporting• Submit HIS-Admission and HIS-Discharge record for each

patient admission or face 2% rate reduction.• No new quality measures proposed for FY2017; some

changes to timeline, requirements for new hospice agencies.• Public reporting timeline not yet set, but coming!• Areas for future quality measure development:

• Patient/proxy reported pain outcome.• Claims-based measures looking at skilled visits in last days of life,

burdensome transitions in/out of hospice, rates of live discharge.• Responsiveness of hospice to patient /family needs.• Hospice team coordination/communication.


A Final Thought…We are concerned that some hospices are making determinations of hospice coverage based solely on cost and reimbursement. It was very clear throughout the development, and years after the implementation, of the Medicare hospice benefit that hospices were expected to make good on their promise to do a better job in the provision and coordination of care than conventional Medicare services for those who were at the end of life. However, if hospices are not making good on that promise, it results in increased burden on hospice beneficiaries and their families – both clinically and financially – and is not in keeping with the intent of the Medicare hospice benefit as originally developed and implemented in 1983.

~CMS2016 Hospice Proposed Final Rule

30

How the Expenses Work

31

Routine Home CareMileage, 2%

Other Levels Loss, 1%Ambulance, 1%

Comfort Therapy, 1%

Treatments, Labs, Diagnostics, 3%

Pharmacy, 9%

Equipment, 3%

Supplies, 3%

Clinical Staff Benefits, 12%

CHI/FHS Overhead, 6%FHPC Overhead, 11%

Nursing Home Room and Board, 1%

Clinical Staff Salaries, 47%

32

Medicare Cost Reports5 Cost Reporting Period (mm/dd/yyyy) From: 01/01/2013 To: 12/31/2013

6 Provider Identification Number

6 National Provider Identifier (NPI) Number

7 Type of Control (see instructions) 1

PART II

Title XVIII Title XIX Title XVIII Title XIX

Unduplicated Unduplicated

Enrollment Days Unduplicated Unduplicated Skilled Nursing Nursing Other Total

Medicare Days Medicaid Days Facility Days Facility Days Unduplicated Unduplicated Days

1 2 3 4 5 6

8 Continuous Home Care 27 27

9 Routine Home Care 144,054 5,229 27,075 17,946 167,229

10 Inpatient Respite Care 126 14 126 8 148

11 Inpatient General Care 404 91 150 645

12 Total Hospice Days 144,584 5,334 27,201 18,131 168,049

PART III

Title XVIII Title XIX

Skilled Nursing Nursing

Title XVIII Title XIX Facility Facility Other Total

1 2 3 4 5 6

13 Number of Patients Receiving Hospice Care1811

109 327 341 2,773

Total Number of Unduplicated Countinuous

14 Care Hours Billable to Medicare

15 Average Length of Stay 63 48 60 46 60

16 Unduplicated Census Count 1874 157 387 387 2,633

33

Cost Reports - Continued CON- RECLAS-

EMPLOYEE TRACTED SIFICATION

SALARIES BENEFITS TRANSPOR- SERVICES (Increase/

COST CENTER DESCRIPTIONS (From (From TATION (From TOTAL Decrease)

Wkst A-1) Wkst A-2) (See inst.) Wkst A-3) OTHER (col. 1-5) (Fr Wkst A-6) SUBTOTAL

1 2 3 4 5 6 7 8

GENERAL SERVICE COST CENTERS

1 0100 Capital Related Costs-Bldg and Fixtures 691,567 691,567 691,567

2 0200 Capital Related Costs-Movable Equipment 235,254 235,254 235,254

3 0300 Plant Operation and Maintenance 17,204 17,204 17,204

4 0400 Transportation - Staff

5 0500 Volunteer Service Coordination 125,146 56,492 1,296 66,334 249,268 249,268

6 0600 Administrative and General 1,232,703 556,455 6,001 2,962,351 2,847,510 7,605,020 7,605,020

INPATIENT CARE SERVICE

10 1000 Inpatient - General Care

11 1100 Inpatient - Respite Care

VISITING SERVICES

15 1500 Physician Services 116,714 52,686 355,663 525,063 525,063

16 1600 Nursing Care 7,474,477 3,374,055 516,333 87,970 256,553 11,709,388 -2,079,185 9,630,203

#### 1620Nursing Care -- Continuous Home Care

17 1700 Physical Therapy

18 1800 Occupational Therapy 213,929 213,929

19 1900 Speech/ Language Pathology

20 2000 Medical Social Services 1,340,082 1,340,082

21 2100 Spiritual Counseling 525,174 525,174

22 2200 Dietary Counseling

23 2300 Counseling - Other 152,146 68,680 10,882 1,862 564 234,134 234,134

24 2400 Home Health Aide and Homemaker 476,637 215,159 27,143 35,034 55,581 809,554 809,554

#### 2420HH Aide & Homemaker -- Cont Home Care

25 Other 36,758 36,758 36,758

34

Cost Reports – Continued CONT- RECLAS-

EMPLOYEE RACTED SIFICATION

SALARIES BENEFITS TRANSPOR- SERVICES (Increase/

COST CENTER DESCRIPTIONS (From (From TATION (From TOTAL Decrease)

Wkst A-1) Wkst A-2) (See inst.) Wkst A-3) OTHER (col. 1-5) (Fr Wkst A-6) SUBTOTAL

1 2 3 4 5 6 7 8

OTHER HOSPICE SERVICE COSTS

30 3000 Drugs, Biological and Infusion Therapy 1,411,342 1,411,342 1,411,342

#### 3030Analgesics

#### 3031Sedatives / Hypnotics

#### 3032Other -- Specify

31 3100 Durable Medical Equipment/Oxygen 1,429,230 1,429,230 1,429,230

32 3200 Patient Transportation

33 3300 Imaging Services 3,448 3,448 3,448

34 3400 Labs and Diagnostics 23,109 23,109 23,109

35 3500 Medical Supplies 202,627 202,627 202,627

36 3600 Outpatient Services (incl. E/R Dept.) 722,344 722,344 722,344

37 3700 Radiation Therapy

38 3800 Chemotherapy

39 Other

HOSPICE NONREIMBURSABLE SERV.

50 5000 Bereavement Program Costs 487,292 219,969 17,721 165 48,890 774,037 774,037

51 5100 Volunteer Program Costs

52 5200 Fundraising

53 Other Program Costs 209,888 94,746 3,702 182,388 490,724 490,724

100 Total 11,309,601 5,105,270 583,078 3,443,045 8,230,703 28,671,697 28,671,697

35

Questions…..Discussion?

WSHPCO Annual Conference, Session 5C 1. 2 3 Payer20132012 Medicare Hospice Benefit87.2%83.7% Managed...

Documents

Transcript of WSHPCO Annual Conference, Session 5C 1. 2 3 Payer20132012 Medicare Hospice Benefit87.2%83.7% Managed...