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News Roundup: April 15, 2016

Joint Replacement Bundles Create Showcase for Home Health

Published by Home Health Care News
By Mary Kate Nelson
April 15, 2016

The April 1 start of the Comprehensive Care for Joint Replacement (CJR) payment model could spell bad news for the 60% of participating hospitals that are likely to lose money.

But it’s also a “tremendous opportunity” for home health agencies, according to CareCentrix CEO John Driscoll.

Hartford, Connecticut-based CareCentrix acts as a partner for home health agencies and serves health plans in managing the post acute benefit. Currently, the company is seeking to help home health agencies understand, and maximize, their role in the new payment model.

The CJR initiative, first announced last July, represents a new approach to payment reform from the Centers for Medicare & Medicaid Services (CMS). As part of the plan, hospitals in affected regions will be responsible for Medicare spending on knee and hip replacement episodes of care, including hospital and post-hospital expenses. If spending exceeds specific thresholds—based on the hospitals’ past spending and that of its regional peers—Medicare penalties could ensue.

Essentially, the new CJR program means that hospitals must manage to a budget, Driscoll told Home Health Care News. Managing to a budget creates a huge opportunity for home health agencies, he said—as long as the home health agencies know how to manage care transitions. In these care transitions, they can demonstrate the best of what home health has to offer.

“We think the CJR is a tremendous opportunity for home health agencies to showcase the best of their work,” Driscoll said.

Simply put, CJR creates a strong economic incentive to keep home health agencies in the care loop earlier and longer, Driscoll said.

The new payment model also creates a fresh opportunity for home health agencies to do more with patients before and after the hospital, Driscoll said, citing physical and occupational therapy.

There’s no question that this payment change has come more quickly than expected, but home health agencies can—and should—assume a lead role in the process, Driscoll said.

“I strongly recommend that home health agencies create partnerships to optimize their role in the care loop,” he said. And that can be accomplished using data.

“Data is critical to be able to manage to the new budget standards,” Driscoll said. The availability of data and analytical tools allow for truly identifying the optimal clinical path, as well as the best combination of agencies and institutions that can get patients the best care at the lowest price, he said.

Medicare: 'House Calls' to Sickest Patients Saves Money

Published by Medpage Today
By Shannon Firth
April 15, 2016

WASHINGTON -- When the sickest of patients receive comprehensive, well-coordinated care through a home-based primary care model, Medicare sees savings, according to a physician who spoke at a briefing on Medicare payment reform.

The Independence at Home (IAH) demonstration project, which began in 2012, enables frail elderly Medicare beneficiaries, to receive care through a mobile interdisciplinary team that provides care across all settings, 24/7, explained Eric De Jonge, MD, director of geriatrics at the MedStar Washington Hospital Center and professor at John Hopkins University in Baltimore, at a recent forum hosted by the Alliance for Health Reform and the Kaiser Family Foundation.

Since the top 5% of the Medicare populations account for nearly half of all Medicare costs, "this is the population we focus on to have the greatest impact on costs," De Jonge explained.

The model has strict eligibility criteria, and identifying the right population is key to its effectiveness, De Jonge said. Patients must be frail, disabled, and have incurred high health costs in the past year.

In its first performance year, the IAH program garnered $25 million in savings, or approximately $3,070 per beneficiary, according to a 2015 press release from the Centers for Medicaid and Medicare Services (CMS).

De Jonge noted that CMS did not conduct the analysis of his institution's IAH program nor has it been verified or reviewed by the agency.
Cristina Boccuti, MPP, of the Kaiser Family Foundation said the IAH program showed "some promising savings." Bocutti is co-author of a recent report on payment and delivery system reform in Medicare.

But other primary-care medical home models, such as the Federally Qualified Health Center Advanced Primary Care Practice model, and the Comprehensive Primary Care (CPC) model, have, thus far, been less promising. "At this time, savings are not very high, but more results are coming," Boccuti stated.

De Jonge cited one example of a beneficiary involved in the IAH program as a success story.

Carolyn, a 69-year-old patient with heart and liver failure, liver cancer, depression and frequent falls, had been admitted to the hospital six times in 2011.

After moving to Washington, and enrolling in a home-based primary care IAH program, Carolyn received over 150 house calls. These involved services like home x-rays, ECGs, wound care, and urgent visits. Carolyn also learned from a MedStar gastrointestinal (GI) specialist, and after undergoing MRI testing, that she was misdiagnosed with liver cancer. However, she does have end-stage liver failure, due to Wilson disease.

She had one hospital admission 18 months ago, in which she received a life-saving radiological procedure -- transjugular intrahepatic portosystemic shunt was implanted to stop GI bleeding -- and a second admission more recently for an unrelated lower GI bleed. Overall, Carolyn has had two admissions in 4 years as opposed to six admissions in 1 year.

The core goals of the model are to improve the quality experience for patients and offer caregivers "peace of mind," De Jonge said, while the cost reduction for Medicare is "a happy side effect."

Unlike other home-based models, the model does not rely on monthly care management fees. "You only receive savings only after you've achieved 5% reduction in per capita Medicare costs," De Jonge explained.

He noted that payments must be linked to six quality metrics, and programs that meet all six quality metrics receive full payment -- "80% of savings beyond the first 5%" -- and sites that meet from three to five quality metrics receive a partial reward.

These metrics include fewer hospital readmissions within 30 days of a visit, follow-up from a provider within 48 hours of an admission, and a lower use of inpatient hospital stays for conditions such as diabetes, pneumonia, and high blood pressure.

CMS awarded $11.7 million to nine practices that met pre-set quality goals for the IAH program in the first year, and four of these nine sites met all six quality metrics. The program initially included 8,400 beneficiaries at 17 sites in the first performance year, but three sites have since left the program.

The advocacy team at the American Academy of Home Care Medicine and De Jonge are currently working with the Senate Finance Committee on a bill to expand the program to 500 sites. If 1 million patients are enrolled in the next 10 years, he estimates the Medicare program could save $3 billion per year.

Scale-up involves identifying the 5% of beneficiaries who are the most ill, building and training a workforce, and ensuring that they're properly compensated.

"If the financial payment isn't available, then it's not scalable," he said.

Mathematica Policy Research and RTI International, both policy research institutes, are currently conducting a second-year IAH performance review.

Medicare Help At Home

Published by Health Affairs Blog
By Karen Davis, Amber Willink, and Cathy Schoen
April 15, 2016

Nine million community-dwelling Medicare beneficiaries—about one-fifth of all beneficiaries—have serious physical or cognitive limitations and require long-term services and supports (LTSS) that are not covered by Medicare. Nearly all have chronic conditions that require ongoing medical attention, including three-fourths who have three or more chronic conditions and are high-need, high-risk users of Medicare covered services.

Gaps in Medicare coverage and the lack of integration of medical care and LTSS have serious consequences. Beneficiaries are exposed to potentially high out-of-pocket expenses. Medicaid covers LTSS for very low-income Medicare beneficiaries, but only one-fourth of Medicare beneficiaries with serious physical or cognitive limitations are covered by Medicaid.

Without personal home care, access to senior day care, or support for family care partners, older adults needing assistance are at risk of losing their ability to live independently and being institutionalized in a long-stay nursing facility, with costs eventually covered by Medicaid. The lack of integration and accountability for both medical care and LTSS also contributes to avoidable hospitalization and emergency room use, and hinders the substitution of less costly social services for high-cost medical care.

Covering Home Care Under Medicare
This blog presents a Medicare Help at Home policy proposal to add home and community-based services to Medicare to enhance financial protection for beneficiaries, provisions to ensure the quality and efficient use of services, and honor beneficiary preferences for independent living and care at home.

It has three elements:

A Medicare home and community-based benefit for those with two or more functional limitations, Alzheimer’s, or severe cognitive impairment, according to an individualized care plan based on beneficiary goals. This would cover up to 20 hours a week of personal service worker care or equivalent dollar amount for a range of home and community-based LTSS.
Creation of new Integrated Care Organizations (ICOs) accountable for the delivery and coordination of both medical care and LTSS that meet quality standards, honor beneficiary preferences, and support care partners.
Innovative models of health care delivery including a team approach to care in the home building on promising models of service delivery that improve patient outcomes, reduce emergency department use, prevent avoidable hospitalization, and delay or reduce long-term institutional care.
The benefit is financed by income-related cost-sharing, and a 25-75 mix of Medicare beneficiary premiums and an incremental payroll tax on employers and employees.

Medicare beneficiaries with serious physical and/or cognitive limitations, such as limitations in two or more activities of daily living, a diagnosis of Alzheimer’s, or severe cognitive impairment would be eligible. The benefit would be targeted towards those living at home or in community settings such as independent living in senior-life communities and group homes that retain patient autonomy and privacy. It is anticipated that those at the end of life experiencing a terminal illness will also qualify as their ability to function independently declines.

The benefit level is based on the degree of physical and cognitive limitation and an individualized care plan derived from beneficiary goals and preferences, or if incapacitated, their designated legal guardian’s preferences. The maximum benefit is based on the estimated cost of a maximum of 20 hours per week of personal service worker assistance. For modeling purposes, this is estimated at $15 per hour plus an additional 33 percent allowance for fringe benefits and overhead, or up to $400 per week, or $20,800 a year. Beneficiaries (or their legal guardians) could, however, elect to use a portion or all of their allowance on other approved home and community services including adult day care, home modifications, transportation, and respite care for unpaid care partners.

Beneficiary functional limitation would be assessed and individualized care plans developed by organizations designated by Medicare. Beneficiaries electing to receive paid personal care services could select their own paid personal service worker (“consumer-directed care”) including family members other than their legal guardian, modeled on the Medicaid Community First Choice program.

Beneficiary Financial Responsibility
Beneficiaries would be responsible for coinsurance of a portion of the cost of services based on income, ranging from 5 percent for beneficiaries with incomes below 150 percent of the federal poverty level (FPL), to 15 percent for incomes between 150-199 percent FPL, 25 percent between 200-399 percent FPL, and 50 percent for incomes 400 percent FPL or greater.

Estimated Cost And Financing
For modeling purposes, it is assumed that 75 percent of those eligible for the home care benefit who are not already on Medicaid would participate each year (5.0 million out of a total eligible of 6.7 million). Using the Medicare Current Beneficiary Survey, we estimated budget neutrality could be achieved with a Medicare beneficiary premium of under $35 a month covering one-fourth of the cost and a payroll tax estimated at around 0.3 percent of earnings on employers and employees (details available from authors) covering the remainder, sharing the costs across lifetimes and families.

Integrated Care Organizations
The second element of the Medicare Help at Home proposal is the creation of a new entity called an Integrated Care Organization (ICO). Beneficiaries would receive reduced cost-sharing on their Medicare Help at Home benefit if they enroll in an ICO. ICOs would meet the requirements for accountable care organizations (ACOs), but in addition ICOs would be accountable for the delivery and coordination of both medical care and LTSS, and receive incentives for reduced or delayed long-term institutional placement. ICOs would be responsible for supporting unpaid care partners including training, respite, and other support services (e.g. mental health services). ICOs would be required to meet quality standards including achieving patient goals and reporting on quality and other performance metrics.

Care Delivery Innovation
The third major element of the Medicare Help at Home policy proposal is to redesign care delivery to include innovative models emphasizing a team approach to care and to honor beneficiary preferences with regard to types of services and sites of care. ICOs would be encouraged to incorporate promising models of care in their delivery systems found to improve patient outcomes, and reduce use of emergency departments, hospitalizations, and long-term institutionalization.

For beneficiaries with limited mobility or cognitive functioning, an emphasis would be placed on delivering services in the home. Innovative models of home and community-based care that have been shown to improve patient and family satisfaction, quality of life, and health outcomes such as Independence at Home and Hospital at Home would also be candidates for adoption by ICOs. The Program of All-Inclusive Care for the Elderly (PACE), palliative care at home and in residential hospice settings, and congregate models of housing such as Green House would be in the ICO “toolbox” with options tailored to beneficiary preferences about where they live and receive care.

Impact On Beneficiaries
The proposal would benefit Medicare beneficiaries who face the challenge of serious physical or cognitive functioning. It could improve access to home and community long-term services and supports and reduce the financial burden of out-of-pocket costs. The proposal would also assist family care partners in providing support to maintain independent living longer, reduce health risks such as falls, pressure ulcers, and infections, and prevent avoidable hospitalization and emergency room use.

Covering home and community-based care under Medicare also has the potential to improve beneficiary health and well-being by honoring their preferences for site of care and living arrangement. Ensuring that such services meet quality standards and providing information on reliable, safe sources of personal care assistance would better inform choices.

It is not a comprehensive long-term care financing policy proposal, but an important first step that would support beneficiaries in their desire to enjoy quality of life in a familiar environment. The proposal would likely improve the supply of long-term services and supports, and more importantly, provide a mechanism for ensuring quality and availability of information that would help all families know where to obtain high-quality, reliable, safe care for family members with functional limitations.

Impact On Care Delivery
By offering a home and community care benefit combined with delivery system reforms, acute care and LTSS could be better coordinated. A team approach to care using a wide range of personnel whose services are not now covered by Medicare offers the opportunity to shift resources to the types of care preferred by beneficiaries and to reduce costly avoidable hospitalization and long-stay nursing home care.

In addition, by intervening before beneficiaries become impoverished by the costs of home and community services, it shows great promise of maintaining independent living longer and avoiding costly long-term institutionalization and exhaustion of resources that result in Medicaid eligibility. These offsetting savings would reduce the current cost of Medicare and Medicaid to the federal government and state governments.

Creating integrated care organizations (ICOs) accountable for both acute care and long-term services and supports for this high-need population has several potential advantages. Such organizations would be an extension of Accountable Care Organizations that share in savings in Medicare services to also share savings from reduced or delayed long-term nursing facility care and be accountable for overall quality of care.

It would provide the incentive and the flexibility to adopt innovative acute care delivery models such as Independence at Home and Hospital at Home that bring physician and inpatient hospital care into the home. Care at home for those with mobility limitations can reduce the difficulty of arranging transportation, navigating stairs, and coping with unfamiliar environments. Hospitalization of this vulnerable population entails the risk of delirium and deconditioning, falls, infections, and pressure ulcers. Without palliative care in the home, the only recourse in an emergency may be to call 911, seek care from emergency departments, and wind up in intensive hospital care units at the end of life.

ICOs could also adopt innovative long-term services and supports such as CAPABLE and Mind at Home that show promise of improving functioning, and delaying or eliminating long-stay nursing facility placement by substituting low-cost personal care and supervision for more costly medical care. ICOs could be charged with providing support to care partners, whether training in administering medications, avoiding falls and pressure ulcers, or providing respite.

Meeting The Needs Of An Aging Population
The boomer generation began reaching the age of Medicare eligibility in 2011. Five years later they are entering their 70s, watching family members and friends encounter declines in their health and functioning, and hoping for a better old age for themselves. Yet, the Medicare program which recently celebrated its 50th birthday was not designed to support their preferences for independent living and functioning.

Medicaid is the nation’s safety net for low-income families, the disabled, and elderly people. Given the expense of long-term care services and support, it is also the safety net for middle-class elderly Americans who require assistance with their daily care. It began with coverage for institutional care, and has only recently moved to expand home and community-based services. Yet, it reaches only a fourth of Medicare beneficiaries with complex care needs.

Moving forward, adoption of a home and community based benefit in Medicare would constitute an important first step to helping beneficiaries afford the services and support they need to continue living independently. Adoption of innovative models of care emphasizing care at home or in independent living settings would reduce the difficulty and risk of obtaining services in traditional health care settings such as physician offices and hospitals. It would also reduce beneficiary reliance on Medicaid’s safety-net coverage of institutional care. It is a policy proposal worthy of serious consideration as the nation grapples with Medicare redesign to meet the needs of an aging population.

Home Health Job Growth Outpaces All Other Health Care Settings

Published by Home Health Care News
By Mary Kate Nelson
April 15, 2016

Home health care—an industry that knows staff turnover all too well—is adding jobs at a faster pace than any other health care employment setting, new data show.

Over the past 12 months, home health care added 74,900 jobs for a growth rate of 5.8%, according to an analysis of U.S. Bureau of Labor Statistics data by the Altarum Institute, a 501(c)(3) nonprofit health care research and consulting organization based in Ann Arbor, Michigan.

That’s higher than outpatient care centers’ job growth rate of 4.2%, hospital jobs’ growth rate of 3.7%, and nursing and residential care’s job growth rate of 1.2% over the past 12 months.

The home health care industry added 30,000 jobs in the first quarter of 2016, the analysis reveals. Specifically, home health care added about 10,000 jobs in each month of 2016’s first quarter, higher than the 12-month average of 7,000 jobs.

The findings support widespread predictions that home health will be among the fastest-growing employment sectors as the population ages.

Additionally, in March 2016, home health care services accounted for about 9% of health care employment. And although nursing and residential care facilities accounted for approximately 21% of health care employment that month, there may be more turnover trouble brewing in that job market, the data show.

Lately, residential care facilities seem to be having greater success than skilled nursing facilities when it comes to attracting employees. In the first quarter of 2016, residential care facilities gained 13,000 jobs and skilled nursing facilities lost 12,000 jobs. The shift resulted in job growth in nursing and residential care slowing to 1,000 new jobs in the first quarter of 2016, down from 4,000 new jobs in the fourth quarter of 2015.