Framework for Post-Acute Care: Current and Future Issues for Providers

Framework for Post-Acute Care: Current and Future Issues for Providers Alan G. Rosenbloom Alliance for Quality Nursing Home Care March 2012 Overview of Presentation Post-Acute Care: Background and Trends Impact of Health Reform Current Skilled Nursing Facility Marketplace Future Threats to Skilled Nursing Facility Providers 2 1

Post-Acute Care: Background and Trends 3 Distribution of Medicare PAC Care Long-Term Acute Care Hospitals (LTACHs) provide care to patients with clinically complex problems, such as patients on ventilators, that need hospital care for extended periods of time Inpatient Rehabilitation Facilities (IRFs) provide intensive inpatient rehabilitation services, such as physical, occupational, or speech therapy, after an illness, injury, or surgical care Skilled Nursing Facilities (SNFs) provide skilled nursing and/or rehabilitation services to patients on an inpatient basis Share of Medicare Hospital Post-Acute Discharges by Provider, 2009 37% 8% 3% 52% Nursing facilities Long-term acute care hospitals Inpatient rehabilitation facilities Home health care agencies Home Health Agencies (HHAs) provide skilled nursing and/or rehabilitation services to homebound patients on a part-time or intermittent basis Source: 2009 Medicare 100 Percent Standard Analytic File (SAF) claims data base from the Centers for Medicare and Medicaid Services. 4 2

Overview of PAC Providers LTACHs IRFs SNFs HHAs Admission Criteria LTACHs must have average stay > 25 days LTACHs cannot receive >25% of their patients from an individual hospital Intensive rehabilitation services (> 3 hours a day, 5 days a week) 60% of patients must have 1 of 13 diagnoses that require extended rehabilitation Requires 3-day hospital stay prior to admission Must require skilled services Beneficiary is homebound Beneficiary needs part-time skilled care Coverage and Payment Single payment, which covers up to 90 days per illness with a 60 day lifetime reserve Single payment, which covers up to 90 days per illness with a 60 day lifetime reserve Per day payment, which covers up to the first 100 days Per visit payment, which covers visits in 60-day episodes with no limit on number of episodes Beneficiary Cost sharing Deductible (if beneficiary admitted from community) and copayment beginning on day 61 Deductible (if beneficiary admitted from community) and copayment beginning on day 61 Sources: MedPAC, 2011 March Report to Congress. MedPAC, 2011 Payment Basics. Copayment beginning on day 21 of a SNF stay None 5 Growth in PAC Spending $70 $60 $50 $40 $30 $20 $10 $0 Medicare PAC Reimbursements By Provider Type (in billions) 2001 2003 2005 2007 2009 $57.2 $26.4 $19.3 $6.4 $5.1 All PAC Providers Skilled Nursing Facilities Home Health Agencies Inpatient Rehabilitation Facilities Long Term Acute Care Hospitals Source: MedPAC, June 2011 Data Book 6 3

Projected Demand for PAC Services 25,000 20,000 Projections of the Population by Selected Age Groups, 2010 2050 (in thousands of individuals) 15,000 10,000 65 69 years 70 74 years 75 79 years 80 84 years 85+ years 5,000 0 2010 2015 2020 2025 2030 2035 2040 2045 2050 Source: Census Bureau, National Population Projections Released 2009. Projections of the Population by Age and Sex for the United States: 2010 to 2050 http://www.census.gov/population/www/projections/2009hnmssumtabs.html 7 Impact of Health Reform 8 4

Shift to Reward Value over Volume Today New Models Rewards Volume Silos, Fee-for-Service Volume-based Rewards Limited Coordination ACA Driven Payment Reforms Reward Efficiency & Effectiveness Bundled Payments Pay-for-Performance ACOs, Medical Homes ACA: Affordable Care Act ACO: Accountable Care Organization 9 Key PAC Reforms in ACA Accountable Care Organizations Bundled Payments Value-Based Purchasing ACOs can form starting in 2012 Includes physicians and hospitals (PAC providers are optional) Accountable for all Part A and B spending for their assigned population ACOs are able to share in the savings achieved above a certain threshold ACA demonstration will begin in 2013 but CMS has created bundling pilot program that can begin earlier Includes varying combinations of physicians, hospitals, and PAC providers, depending on the model Includes spending for services provided during an episode of care (e.g., 30, 60, or 90 days) for patients with specified conditions Unclear how providers would share in the savings under the ACA bundling demonstration In the CMMI pilot, providers must provide CMS with discount before any shared savings CMS required to submit plan for SNF VBP; missed October 1, 2011 deadline in ACA. No implementation requirement. SNF VBP demonstrations are being conducted in 3 states (Arizona, New York and Wisconsin) Likely to include all spending by a specific provider type Likely that a shared savings pool will be created from reduced provider payments; savings will be distributed among high-quality providers or providers that have improved their quality of care substantially ACO: Accountable Care Organization PAC: Post Acute Care ACA: Affordable Care Act CMMI: Centers for Medicare & Medicaid Innovation VBP: Value Based Purchasing 10 5

Current Skilled Nursing Facility Marketplace 11 Medicare Cross-Subsidizes Medicaid Medicaid long stay patient days comprise almost 57 percent of total patient days but Medicaid payments represent only 33 percent of nursing facilities total revenue FY 2009 Patient Days CY 2009 Revenue Medicaid, 56.7% OOP, Private Insurance and Other, 29.7% Medicare, 13.6% OOP, Private Insurance and Other, 46.7% Medicare, 20.4% Medicaid, 32.8% Source: Patient revenues: 2009 National Health Expenditures data; Patient days: Analysis of 2009 Skilled Nursing Facility Centers for Medicare and Medicaid Services Cost Report Data 12 6

Average Medicaid PPD Payment Shortfall Continues to Increase Shortfall per Medicaid Resident Day, All States, 1999 2011 Source: Eljay, LLC. A Report on Shortfalls in Medicaid Funding for Nursing Home Care. American Health Care Association. 2011. *Notes: 2011 data are projected. The 2011 Medicaid shortfall is a projection based upon trending of the most recently available (2009 or 2010) cost reports to 2011 and comparing these trended costs to current rates No estimation could be made for 2010 because cost reports for 2010 were available in all but 10 states 13 Due to Freezes or Cuts to State Medicaid Nursing Facility Payment Rates SFY 2010 SFY 2011 SFY 2012 SFYs 2010 2012* Number of States Freezing Payments Number of States Cutting Payments 15 22 16 17 7 10 16 23 The number of states cutting Medicaid rates continues to increase. Note: The survey does not consider the impact of provider taxes, fees, and other policies apart from direct changes to payment rates. Sources: News sources, interviews with state affiliates of the American Health Care Association and interviews with state Medicaid departments. *For purposes of this column, a state that reduced payments in any of the three years counts as a cut state and a state that froze rates in any of the three years but did not cut rates in any of the three years counts as a freeze state. 14 7

States Imposing Freezes or Cuts to Medicaid Nursing Facility Reimbursement Rates, SFY 2010 - SFY 2012 WA ME CA OR AK AK NV ID AZ UT MT WY CO NM HI Sources: News sources, interviews with state affiliates of the American Health Care Association and interviews with state Medicaid departments. A state that reduced payments in any of the three years counts as a cut Confidential state and a state DRAFT that froze rates in any of the three years but did not cut rates in any of the three years counts as a freeze state. ND SD NE KS TX OK MN IA MO AR LA WI IL MS IN TN MI AL KY OH WV GA SC PA VA FL NY NC VT NH NJ MA CT DE MD D.C. RI Payments Delayed (for SFY12) Undecided (for SFY12) Instituted rate freeze Instituted rate cut Neither cut nor froze rate 15 Medicare Cuts Exacerbate Situation 10 Year Impact Reduction Percentage Cut (FY 2012 FY 2021) Forecast Error (Case Mix) Adjustment in FY 3.3% $16.8 billion 2010 Rule Productivity Adjustment (ACA mandated) Variable* $29.4 billion Forecast Error (Market Basket) Adjustment in 0.6% $2.6 billion FY 2011 Rule Total $48.8 billion** The FY 2012 SNF Final Rule included a NET payment reduction/correction of 11.1%, which will reduce SNF payments by an additional $60 billion** over 10 years. *Depends on the ten year average for nonfarm multi factor productivity; estimate assumes the productivity adjustment is 1 percent each year **Relative to payments that would have been made in the absence of the reductions 16 8

Payroll Tax Deal Worsens Environment Middle Class Tax Relief and Job Creation Act of 2012 includes a reduction in Medicare bad debt payments Medicare bad debt payments are payments made to nursing facilities and hospitals as reimbursement for unpaid deductibles and co payments owed by beneficiaries or state Medicaid programs Dual Medicare Medicaid eligibles are exempt from Medicare co payments and deductibles; Medicaid programs are generally required to make co payments on behalf of dual eligibles, but many states are able to avoid covering these copayments Current Reimbursement Level New Reimbursement Level Non-Duals 70 percent 65 percent Duals 100 percent 65 percent This cut has a disproportionate impact on nursing facilities, because approximately 90 percent of nursing facility bad debt is related to dual eligible beneficiaries. 17 Threats and Opportunities 18 9

Issues and Time Frames 2012 possibility of silo-specific cuts 2013 debt/deficit policy versus good health policy 19 Key Players Engaged in the Current Focus on Deficit Reduction Employer Interest Groups White House Centers for Medicare and Medicaid Services (CMS) Pharmaceutical interest Groups Insurance Interest Groups Provider Interest Groups Decisions Hill Committees of Jurisdiction Medicare Payment Advisory Commission (MedPAC) Hill Leadership 20 10

2012 Issues FY 2013 Federal Budget President s Proposed Budget PAC Specifics: market basket reductions; further bad debt payments; equalize hips & knees; SNF readmissions policy; home health co-payments; phase-down of provider tax House Republican Budget Likely Pre-election path ongoing Sturm-und-Drang through September resulting in Continuing Resolution 21 2012 Issues FY 2013 NPRM Late April/early May No major changes anticipated, but Possible revisit of sequestration Currently requires 2% across-the-board Medicare cut effective January 1, 2013 Some discussion of reshaping likely to mean winners and losers Doc Fix/Medicare extenders Lame Duck 22 11

2013 and Beyond Likely dominance of debt and deficit reduction Entitlement programs in cross-hairs Provider cuts v. radical reforms (personal responsibility) Outcome of elections will drive approaches, but can t avoid issue 23 2013 and Beyond: Implications for PAC Policy ACOs Bundling Episodic Payment Systems Site-Neutral Payment Systems 24 12

Because the Cost of Providing Care Varies Substantially by PAC Provider Top Five Conditions with Hospital Major Severity of Illness (SOI 3) Discharged to PAC Settings* Comparison of Mean Medicare PAC Payment for Top PAC Conditions MS-DRG, SOI Level 3 Long Term Acute Care Hospitals Inpatient Rehabilitation Facilities Skilled Nursing Facilities Home Health Agencies 291: Heart Failure and Shock with MCC $26,372 $15,564 $8,114 $3,354 871: Septicemia or Severe Sepsis w/o mechanical ventilation, with MCC $29,987 $16,540 $8,946 $3,430 683: Renal Failure with CC $28,095 $15,486 $9,214 $3,499 193: Simple Pneumonia and Pleurisy with MCC $29,280 $16,896 $9,760 $3,804 064: Intracranial Hemorrhage or Cerebral Infarction W MCC $25,744 $15,570 $8,588 $3,261 Source: Analysis of 2009 Medicare 100 Percent Standard Analytic File (SAF) claims data base from the Centers for Medicare and Medicaid Services (CMS) for SNFs, LTACHS, IRFs, HHAs, and Inpatient Hospitals. CC indicates complications or comorbidities; MCC indicates major complications or comorbidities.; * Extreme severity (SOI 4) was not chosen due to sample size 25 Proposals to Equalize Payments Across Post- Acute Care Providers Are Under Consideration Current Silo ed Medicare Post Acute Care Payment System* Long Term Acute Care Hospital Skilled Nursing Facility Inpatient Rehabilitation Facility Home Health Agency *Circles Adjusted to Represent the Difference in Payments by Site of Care Equalizing Payment New Site Neutral Payment System LTACH IRF SNF HHA The President s FY 2013 Budget included a proposal to equalize SNF and IRF payments for certain conditions such as hip and knee replacements. 26 13