Legal & Policy Developments Impacting Long Term Care

Transcription

1 Legal & Policy Developments Impacting Long Term Care New York State Health Facilities Association Mid-Winter Education Conference Carla R. Williams, MPA Cornelius D. Murray, Esq. January 6, 2015

2 Jump to the Future 5 Years in the Future - How The Pieces Fit Together: MCO, PPS & HH MCO Other Providers PPSs HH#1 HH#2 PPS Provider Care Management for Health Home Eligibles Participation in Alternative Payment Systems Insurance Risk Management Payment Reform Hold PPS/Other Providers Accountable Data Analysis Member Communications Out of PPS Network Payments Manage Pharmacy Benefit Enrollment Assistance Utilization Management for Non-PPS Providers DISCO and Possibly RDA/MLTCP Maintains Care Coordination MMC/MLTC/FIDA Be held accountable for Patient Outcomes and Overall Health Care Cost Accept / Distribute Payments Share Data Provider Performance Data to Plans/State Explore Ways to Improve Public Health Capable to Accept Bundled and Risk-Based Payments

3 Moving Parts Managed Care: Medicaid; Medicare and Duals DSRIP: Medicaid and the Uninsured ACA: Increased Medicaid Enrollment; Parity; Bundling; ACOs and

4 Managed Care Nursing Home Transition Continues to be delayed FIDA Letters to NYC and Nassau out in December Nursing Home residents can voluntarily enroll Passive enrollments: Start April; August NH residents Medicare Advantage Continues to pick up enrollments

5 Managed Care Conflict Free Evaluations NY Medicaid Choice is performing the CFEEC activities, which include: Scheduling initial evaluations Staffing nurse evaluators to perform in-home evaluations (hospitals and nursing homes)

6 Managed Care Conflict Free Evaluations The CFEEC will evaluate consumer s eligibility for one of the four MLTC products: Partially Capitated Plans Program of All-Inclusive Care for the Elderly (PACE) Medicaid Advantage Plus (MAP) Fully Integrated Duals Advantage (FIDA) implemented January 2015) (To be

7 Managed Care - MLTC

8 Managed Care Current MLTC Leaders Plan Name County Total Enrollment GUILDNET NASSAU 1557 GUILDNET ARCHCARE COMMUNITY LIFE SUFFOLK 1474 WESTCHESTER 435 VNS CHOICE NEW YORK 15943

9 Nursing Home Transition Effective 1/1/2015 the Nursing Home Population in the FIDA region will begin to transition into Managed Care. The Transition will be limited to New NH Residents in need of long term placement. Anyone that was permanently placed in a nursing home prior to the effective date of the transition will remain in FFS and will not be mandatorily enrolled in Managed Care. Residents under 21 will be excluded from the first wave of Mandatory NH transition. 6 Months after Mandatory transition NH residents not mandatorily enrolled will be able to voluntarily enroll with a Managed Care plan.

10 Nursing Home Transition For 3 years after a county is deemed eligible for Mandatory NH transition Plans will be required to reimburse nursing homes as follows: Utilizing the Benchmark Rate including all scheduled rate changed OR Nursing Homes and Plan s can negotiate a payment arrangement that is mutually agreeable to the both the NH and the MC Plans

11 Nursing Home Transition NAMI is being offset from the from the Medicaid Premium paid to the managed care plan. Per the NH Transition Policy paper the collection of the NAMI falls on the Managed Care Plan. Plans have the Option to: Assume the responsibility to the Collect NAMI and administer the personal needs allowance or 2. Negotiate with the Nursing Homes leaving the responsibility to collect NAMI with the homes 1.

12 Nursing Home Transition DOH to continue to work with CMS on addressing all of the issues that were brought as Special Terms and Conditions (STC s) DOH to continue to work through Premium development MMC will have a rate cell structure MLTC will have a blended premium structure Effective 4/1/2016 Premiums must promote community integration including a blended Institutional / HCBS rate structure Rates must be fully risk adjusted

13 Nursing Home Transition DOH established a billing cash flow workgroup as a proactive way of addressing any cash flow implications as a result of the transition.

14 FIDA Individuals residing in nursing homes prior to January 1, 2015 will not be passively enrolled into FIDA. Individuals new to custodial status in nursing homes as of January 1, 2015 will be passively enrolled into FIDA on or after August 1, 2015

15 FIDA - Enrollment Region I NYC and Nassau: No earlier than April 1, 2015, NYSDOH will passively enroll community based: Eligible Individuals Medicaid Eligibility Authorization that are due for renewal Eligible Individuals who do not undergo annual Medicaid Renewal and have a birthday within the months of January, February and March 2015 Each month new cohort based on MEA or DOB until August of 2015 Region II Suffolk and Westchester: All community based eligible individuals will be passively enrolled July 1, 2015

16 FIDA - Enrollment There are two types of enrollment: Opt-in Enrollment, which is initiated by an individual. January 1, 2015, effective date for individuals in Region I (New York City and Nassau County). April 1, 2015, effective date for individuals in Region II (Suffolk and Westchester). Passive Enrollment, enrollment by the State, which the individual can decline by opting out. April 1, 2015, effective date for individuals who are Passively Enrolled in Region I. Passive Enrollment will occur over a five-month period. July 1, 2015, effective date for individuals who are Passively Enrolled in Region II.

17 FIDA - Enrollment All enrollments (Opt-in and Passive) will be through NY Medicaid Choice, which will provide counseling and assistance. Plans cannot perform enrollments into FIDA. FIDA eligible individuals enrolled in a Managed Long Term Care (MLTC) plan will convert to their Plan s FIDA product, unless they choose another FIDA plan. Individuals may disenroll from FIDA at any time.

18 FIDA - Enrollment The FIDA Program Announcement Letter marks the start of potential Opt-in Enrollments. Participants will also receive a 90-day, a 60-day and a 30-day Passive Enrollment reminder notice. (First letters sent to NYC and Nassau 12/1/14)

19 FIDA Transitions of Care The FIDA Plan will manage transitions of care and continuity of care for participants moving from an institutional setting to a community living arrangement Health Promotion and Wellness: Plan will offer expansive set of health education Plan will identify regional community health education opportunities ; including classes, support groups and workshops related to heart attack and stroke prevention, asthma, etc. Includes annual reminders to caregivers Flu Prevention

20 FIDA FIDA Plans are required to provide medically necessary covered items and services. FIDA offers the most robust service package available in New York s Managed Care Program.

21 FIDA FIDA coverage includes items and services currently covered by: Medicare Medicaid Long Term Care Behavioral Health Wellness Programs Prescription Drugs Home and Community Based Waiver Services

22 FIDA The FIDA Plan will be required to develop a plan for a fully integrated payment system through which Participating Providers would no longer be paid on a traditional fee-forservice basis but would instead be paid on an alternative basis (e.g., pay for performance, bundled payment).

23 FIDA Approved Plans PLAN Name Approximate Current Enrollment in FIDA Region VNS Choice 22,000 Guildnet, Inc. 15,000 Managed Health, Inc. 200 Elderplan, Inc. 11,000 Elderserve Health, Inc. 10,000 Centerlight Healthcare, Inc NYS Catholic Health Plan, Inc. 490,000 Wellcare of New York, Inc. 186,000 Health Insurance of Greater New York 245,000 Independence Care System, Inc. Agewell New York, LLC Amerigroup New York, LLC Village Senior Services Corporation PLAN Name Approximate Current Enrollment in FIDA Region Aetna Better Health, Inc Catholic Managed Long Term Care, Inc. 400 Integra, MLTC 1950 Centers Plan for Healthy Living, LLC 2000 North Shore-LIJ Health Plan, Inc Senior Whole Health of New York 1500 Metroplus Health Plan, Inc. 419, Alphacare of New York, Inc Montefiore HMO, LLC ,

24 Medicare Advantage 14 NY Counties have greater than 50% Medicare Advantage Penetration Rates (most are Upstate) Participation is expected to grow: baby boomers familiar with managed care lower cost to beneficiary Impacts on referrals based on Network partners

25 Medicare Advantage May represent a private pay opportunity Even in counties like Livingston, Ontario and Genesee, more than 50 percent of Medicare-eligible beneficiaries are enrolled in MA plans.

26 Medicare Advantage COUNTY ELIGIBLES ENROLLED PENETRATION RATE ALBANY 54,493 20, % NASSAU 241, , % SUFFOLK 263, , % WESTCHESTER 161,135 82, % NEW YORK 1,181, , % ERIE 183,758 44, %

27 What is DSRIP and Why Now? Delivery System Reform Incentive Payments or DSRIP is the process by which the State of New York and CMS have agreed to allow savings generated by the Medicaid Redesign efforts to be used to reform the delivery of health care to Medicaid recipients.

28 What is DSRIP and Why Now? DSRIP is a demonstration and the State is subject to all the requirements for reporting and evaluation The continuation after the 5 year period will be dependent on the success of the demonstration and any additional requirements negotiated with CMS in the future.

29 What is DSRIP and Why Now? Statewide Accountability: PPS funds received may be reduced for missed milestones statewide The reduction is applied proportionately to all PPSs High Performance Fund payments are not subject to the reduction.

30 What is DSRIP and Why Now? As part of the agreement between New York and CMS, New York is required to take steps to ensure DSRIP investments will be recognized and supported by the state s managed care plans. New York must submit a roadmap in Spring 2015 detailing how contract terms will be amended and provider capacities and efficiencies in managed care rate-setting will be reflected.

31 Performing Provider Systems Responsibilities of Performing Provider System (PPS) must include: Community health care needs assessment based on multi-stakeholder input and objective data. Building and implementing a DSRIP Project Plan based upon the needs assessment in alignment with DSRIP strategies. (Due December 22,2014) Meeting and reporting on DSRIP Project Plan process and outcome milestones. 43 PPS statewide; 25 in Metro NY every major hospital system

32 Project Goals and Focus The goals of DSRIP are: Transformation of the health care safety net at both the system and state level. Reducing avoidable hospital use and improve other health and public health measures at both the system and state level. Ensure delivery system transformation continues beyond the waiver period through leveraging managed care payment reform. Near term financial support for vital safety net providers at immediate risk of closure.

33 Project Goals and Focus Key focus on reducing avoidable hospitalizations by 25% over five years. Statewide initiative open to large public hospital systems and a wide array of safety net providers. Payments are based on performance on process and outcome milestones.

34 Project Goals and Focus Providers must develop projects based upon a selection of CMS approved projects. Key theme is collaboration. Communities of eligible providers will be required to work together to develop DSRIP project proposals.

35 Funds Flow Amounts received will be determined based on performance of the providers engaged on each approved project and the PPS s overall performance in achieving project goals. This can result in significant reductions in payments, even during the first year of DSRIP missing 1 out of 5 milestones, for example, could lead to 20% reduction in funding for that year.

36 Funds Flow Each PPS may also receive additional funds from the High Performance Fund if high performance levels are met. Tier 1 is met when the PPS closes the gap in their DSRIP project plan by 20% between current and high performance levels as defined by DOH Tier 2 is met when the PPS s performance meets or exceeds the 90thpercentile of statewide performance for a specific measure NOTE: Funds can be used to offset losses in revenue due to shift in services.

37 Capital Restructuring Financing Program $1.2 billion over six years for capital projects that will enhance the quality, financial viability and efficiency of the NYS health care delivery system. Apply through one PPS lead; PPS Lead submits Proposal to DOH PPS lead must rank projects in order of priority

38 Capital Restructuring Financing Program Eligible applicants: hospitals; PCPs; home care providers; entities with operating certificates issued by DOH, OMG, OPWDD, OASAS, OMH; assisted living providers; residential health care facilities; licensed clinics Not-for-profit and/or proprietary applicants are eligible Preference will be given to applicants committing matching funds, demonstrate transformational change and/or demonstrate significant financial need

39 Capital Restructuring Financing Program Focus is on projects that support development of primary care, benefit Medicaid and uninsured, and are closely related to DSRIP program goals Funding is available for capital expenditures related to: Planning or design of changes to a fixed asset, including plans/specs/engineering Construction and renovation Asset acquisitions Equipment, including HIT

40 Capital Restructuring Financing Program Funding is not available for expenditures related to: Personnel, supplies, utilities, or other operating costs, or working capital

41 Capital Restructuring Financing Program Capital projects viewed most favorably will: create or expand primary care capacity promote care coordination among providers (for example, development of tele-health infrastructure, medical villages, co-located primary, specialty and behavioral outpatient services) promote patient-centered care (medical and health homes) reduce avoidable hospital & nursing home admissions, ER visits benefit the largest # Medicaid beneficiaries and uninsured individuals

42 Capital Restructuring Financing Program Capital projects viewed most favorably will: include as much funding as possible from other funding sources and represent a significant investment beyond CRFP funding result in a reduction of inpatient beds and the continuation or expansion of ambulatory care and emergency services in a community

43 Capital Restructuring Financing Program Timeframes: Many PPS want letters of intent prior to December 22nd DSRIP Plan submission Applications due to State on February 20, 2015 Many PPS due dates likely to be by mid to late January.

44 ACA Increased Medicaid Enrollment Parity Bundling ACOs

45 Increased Medicaid Enrollment New York State of Health Exchange New York picked up the Medicaid Expansion option The Medicaid population expanding due to effort; each year will continue to increase.

46 Increased Medicaid Enrollment NYS of Health Data April 2014 Total Enrolled in Eligible for Coverage Assistance Medicaid/CHP Eligible Number Selected a Plan 960, , , ,769

47 Parity The largest expansions of mental health and substance use disorder coverage in a generation. In 2014 all new small group and individual market plans will be required to cover ten Essential Health Benefit categories, including mental health and substance use disorder services, and will be required to cover them at parity with medical and surgical benefits.

48 Parity Estimated 32.1 million will gain access to coverage that includes mental health and/or substance use disorder benefits. Estimated additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections.

49 Parity Individuals who will gain mental health, substance use disorder, or both benefits under the Affordable Care Act, including federal parity protections Individuals with existing mental health and substance use disorder benefits who will benefit from federal parity protections Total individuals who will benefit from federal parity protections as a result of the Affordable Care Act Individuals currently in individual plans 3.9 million 7.1 million 11 million Individuals currently in small group plans 1.2 million 23.3 million 24.5 million Individuals currently uninsured 27 million n/a 27 million Total 32.1 million 30.4 million 62.5 million

50 Bundling Bundled Payments for Care Improvement (BPCI) initiative is comprised of four broadly defined models of care, which link payments for multiple services during an episode of care. Organizations enter into payment arrangements that include financial and performance accountability for episodes of care

51 Bundling In Model 2, the episode of care includes the inpatient stay in the acute care hospital and all related services during the episode. The episode ends either 30, 60, or 90 days after hospital discharge 596 participants, including 76 conveners of health care organizations, representing 1,964 providers are currently in Phase 1 of BPCI Model 2 has 60 Awardees, including 24 conveners of health care organizations, representing 112 providers actively testing the model in Phase 2

52 ACO Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

53 ACO When an ACO succeeds it will share in the savings it achieves for the Medicare program. Medicare offers several ACO programs: Medicare Shared Savings Program a program that helps a Medicare fee-for-service program providers become an ACO. Advance Payment ACO Model a supplementary incentive program for selected participants in the Shared Savings Program. Pioneer ACO Model a program designed for early adopters of coordinated care. No longer accepting applications.

54 ACO Before an ACO can share in any savings generated, it must demonstrate that it met the quality performance standard for that year 33 quality measures, which span four quality domains: Patient / Caregiver Experience Care Coordination / Patient Safety Preventive Health At-Risk Population

55 ACO Approximately 25 Shared Savings ACOs in New York State No Advance Payment Models One Pioneer Model (Montefiore)

56 ACO CMS is projecting that within a three-year period there will be ACOs coordinating care for 1.5 million to 4 million Medicare beneficiaries nationwide. The Congressional Budget Office estimates that the savings to Medicare over 10 years will be $4.9 billion.

57 ACO A large portion of the savings from the program are expected to come from reduced hospital admissions although the results of prior CMS demonstrations also indicate the potential for significant savings in outpatient services.

58 ACO ACOs had higher quality and better patient experience than published benchmarks compared to previous year performance, the ACOs improved significantly for almost all of the quality and patient experience measures. ACOs in the Pioneer ACO Model and Medicare Shared Shavings Program (Shared Savings Program) also generated over $417 million in savings for Medicare.

59 ACO ACOs qualified for shared savings payments of $460 million. Preliminary quality and financial results from the second year of performance based on 23 Pioneer ACOs and the first year of performance for 220 Shared Savings Program ACOs

60 Internal Scan Identify the processes, trends & other factors driving performance Intake processes follow thru to billing Documentation: regulations, accuracy, completeness & timeliness Billing routines, timeliness & completeness Payer mix Software systems Clinical & billing personnel performance Process & personnel accountability

61 Internal Scan Reviewing contracts from all perspectives: Administration Type of contract; scope of opportunity; network Finance Rates: Can you identify your unit costs? Volume does not make up for below cost rates! Clinical Service definitions; supervision; assessments; training

62 Internal Scan Quality CMS Style Effectiveness: providing care processes and achieving outcomes as supported by scientific evidence. Efficiency: maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used. Equity: providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care.

63 Internal Scan Quality CMS Style Patient Centeredness: meeting patients' needs and preferences and providing education and support. Safety: actual or potential bodily harm. Timeliness: obtaining needed care while minimizing delays.

64 Internal Scan Quality Best practices Outcome measurement Electronic communications Using technology Patient and family involvement Training of patient and family Staff training, engagement

65 Opportunities Building Broader Geographic Relationships Expanding footprint: outpatient care; community based supports; behavioral health Access to capital Learn about value based payments get prepared and find good partners Look for partners IPAs; shared services; ACOs

66 Opportunities Higher degree of interdependence: MDs, Hospitals, community; are MDs in ACOs? Quality of Care and Data

67 Questions? Need assistance? Contact Us: Carla Williams: Neil Murray: