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News Roundup: June 17, 2016

How Senior Living Providers Can Crash the Health Care Party

Published by Senior Housing News
Tim Mullaney
June 17, 2016

The U.S. health care system is changing in big ways, and senior living companies have much to contribute in the dawning era—but it hasn’t been easy for them so far. They have not been allowed to participate in some of the emerging models of care affecting their residents, and now is the time for senior living providers to invite themselves in and prove they belong, according to some industry leaders.

The new models were ushered in after the Affordable Care Act passed in 2010, and sometimes are lumped together under the term “pay for performance,” in which reimbursements through Medicare and similar programs are tied more to quality outcomes than simply to services performed.

In fact, the Centers for Medicare & Medicaid Services (CMS) put forth a goal of having 30% of Medicare payments tied to these new models, such as Accountable Care Organizations (ACOs), by the end of 2016. That goal already had been met as of March.

As the pendulum has swung toward these new models, senior living providers have seen skilled nursing facilities, home health agencies, hospitals, physician practices, and other parts of the senior care continuum start to form partnerships to better coordinate care, sharing in the potential financial rewards for doing so and the financial risks of failing. However, with independent living and assisted living being primarily private-pay rather than part of the Medicare ecosystem, this industry has been largely excluded from the new partnerships, at least in an official capacity.

That’s problematic, because many of the Medicare beneficiaries who are being cared for in these coordinated care models reside in senior housing communities, said Stephanie Handelson, president and COO of Benchmark Senior Living, at last week’s Post Acute Link Care Continuum Conference in Chicago. Based in Waltham, Massachusetts, Benchmark operates senior living communities in seven states, covering the full continuum of independent living through skilled nursing, as well as memory care.

Furthermore, because of the way assisted living has evolved in the last three decades, these residents have complex care needs that the senior living provider is addressing, making these companies important health care players as well as housing providers, she pointed out.

“They are highly acute, frail, need three to five ADLs [activities of daily living], average length-of-stay is 22 months,” she said of typical AL residents. “We’re caring for a very frail resident who was a custodial long-term care resident previously.”

In addition to providing care for these seniors, assisted living companies in many cases are acting as care coordinators, facilitating the movement of their residents through other settings as needs arise, pointed out Steven Littlehale, executive vice president and CCO of PointRight Inc., a predictive analytics platform for post-acute providers.

“We know you weren’t invited to the party, but it sounds like you want to crash the party,” Littlehale said to Handelson, who confirmed that she does want to play party crasher. And in some ways, Benchmark and other senior living companies already are playing that role.

Seizing the opportunity

In terms of what senior living companies can contribute in new coordinated care models, Handelson emphasized the role that they can play in reducing rehospitalizations. This is a primary concern in new care models, given that they often reduce Medicare reimbursements for hospitals and other providers if readmissions are too high.

If seniors have two or three days of oversight with 24-hour observation and medication management after leaving the hospital, the likelihood they will return decreases, Handelson said. Senior living providers potentially could play a larger part in providing this sort of post-acute care for all Medicare beneficiaries, but the most obvious opportunity is for those seniors who are returning to the senior housing community.

“We could have a better partnership between the hospital and home health and the hospice, and have everybody actually working together,” she said. “We’d have better outcomes.”

It’s a welcome message at least for home health providers, said Tracey Moorhead, president and CEO of the Visiting Nurse Associations of America (VNAA), a major association for the home-based care industry.

“My members need to hear that they have an opportunity to partner with organizations like yours, based on their quality scores and outcomes,” Moorhead said.

Benchmark has indeed formally partnered with home health agencies and physician practices at all 52 of its properties, after putting them through a rigorous vetting process, said Handelson.

“The way we pick our providers is unbelievably picky. It’s like getting married,” she said. “We’ve had people we’ve dated, and we ditched them because the way they provide the service is so critical to the health and wellness of our residents. If I couldn’t get home health to come quick enough if I needed an IV, I’m going ot have to send that resident out [to the hospital].”

Home Health Agencies Grapple With Prior Authorization Rule

Published by Home Health Care News
By Kourtney Liepelt
June 17, 2016

Home health providers and associations were quick to denounce a preauthorization requirement after the Centers for Medicare & Medicaid Services (CMS) revealed it will move forward with its formerly announced plans.

Across the board, industry officials expressed disappointment and concern with the CMS plans for prior authorization, now deemed the Pre-Claim Review Demonstration for Home Health Services. It will roll out in five states as announced in February, and aims to crack down on Medicare fraud and abuse.

In particular, the home health sector criticized CMS for dismissing the comments and concerns from lawmakers and health care service providers, instead pushing forward the demonstration for home health care in Illinois, Florida, Texas, Michigan and Massachusetts. The first state, Illinois, will face the requirement no earlier than Aug. 1.

“This is a big deal,” William Dombi, vice president for law at the National Association for Home Care & Hospice (NAHC), tells Home Health Care News. “There are a lot of challenges, a lot of questions.”

Cause for Concern

Under the three-year demonstration, home health agencies in the five selected states will be required to submit documentation for review before processing claims for services. The requirement comes as a result of a 59% improper payment rate among home health claims in 2015, which largely stemmed from insufficient documentation, CMS stated. The pre-claim review demonstration aims to educate home health agencies on what documents are required and encourage correct submissions, while still allowing agencies to provide services prior to the preauthorization decision.

“CMS is testing whether pre-claim review helps reduce expenditures, while maintaining or improving quality of care,” the agency stated. “Additionally, CMS believes the demonstration will also help assure services are provided in compliance with applicable Medicare coverage and payment rules, thereby assisting in the prevention of fraud, waste and abuse.”

The issue with CMS’ reasoning on this front is that improper payments don’t necessarily equate to fraud, says Joy Cameron, vice president of policy and innovation for the Visiting Nurse Associations of America (VNAA). For the most part, home health agencies are providing the documentation they believe is correct in submitting claims, only to be rejected or face scrutiny over payments later on.

“We’re willing to sit down and talk [with CMS] about fraud, but this isn’t the way to do it,” Cameron says.

The pre-review demonstration would be similar to the Prior Authorization of Power Mobility Device Demonstration, which CMS implemented in 2012 and requires prior authorization for scooters and power wheelchairs within seven states with high population of fraud- and error-prone providers.

But equipment is very different from service, Dombi says. Home health remains an episodic benefit, begging the question of how something can be authorized if it’s apt to change by the time of the official claim. Cameron echoed that sentiment.

“[Home health] is not an item—it’s a very different animal,” she says. “This is an incorrect setting for this demonstration.”

Others worry about the administrative implications involved. The demonstration could impose even further documentation requirements on already burdened agencies, which might result in poor care transitions and more confusion among seniors seeking care, according to the Partnership for Quality Home Healthcare, a Washington, D.C.-based coalition of home health providers that works to improve the integrity, quality and efficiency of home health care.

“We appreciate the steps CMS has taken to protect beneficiary access to care in the revised demonstration, however, much more needs to be done,” Colin Roskey, executive vice president of the coalition, said in a statement. “We remain concerned that the demonstration does not go far enough to protect patients from potential harms inherent with pre-claim review, including confusion, delays and service interruptions in care for a vulnerable patient population. We are also concerned that CMS has not followed notice-and-comment standards for obtaining and responding to input from those immediately affected by the demonstration.”

Indeed, the proposed demonstration garnered pushback from the home health sector and lawmakers alike. Last month, 116 bipartisan House lawmakers wrote a letter to CMS expressing concerns that prior authorization could cause delays in care.

“That lobbying didn’t make as much of an impact as we were hoping,” says Rachel Hecox, RN, director of clinical services at Western Illinois Home Health Care. The family-owned and operated agency has been in business 35 years and covers 10 counties in west central Illinois, one of the selected states.

Further Confusion Ahead

As with any new procedure, home health agencies must prepare for what’s ahead.

“I think everybody needs to thoroughly understand what is included and required in this demonstration,” says Gina Mazza, director of regulations and compliance and partner at home care and hospice consulting firm Fazzi Associates. “That is priority No.1 [for agencies]. This is not something you leave up to chance. The agencies have to have a proficient working knowledge of what is required.”

That just might be the problem, according to Dombi. As it stands, CMS hasn’t clearly defined what documentation will be necessary to submit for review prior to a claim or how it should be submitted, and the agency needs to offer further guidance, he says.

During the pre-claim review process, Medicare will work closely with the agencies to explain what documentation is necessary and why a prior submission was insufficient, according to CMS. A home health agency will be able to resubmit the supporting documentation as often as necessary during the review. CMS will respond to the initial pre-review submission within 10 days,

“The communication piece, a timely response from the government, is a concern,” says Michele Berman, director of rehabilitation at BAYADA Home Health Care. “[Even if] we’d be getting a timely response, within the 10 days, [my concern is] how much of a burden it will be to ask for a reconsideration after a denial.”

The demonstration should not delay care to Medicare beneficiaries and doesn’t alter the Medicare home health benefit, CMS stated.

Mistakes could prove detrimental, though, especially when it comes to finances. Delays in submitting claims mean there will be continuous cash flow issues. If a provider submits a claim without going through the pre-claim review after the first three months of the demonstration, and the claim is determined payable, there will be a 25% reduction in the full claim amount.

“With trying to combat fraud in the home health industry that ultimately is putting such a strain on businesses to do the right thing, it may potentially damage the industry to a point where people go out of business,” Hecox says.

The financial aspect is crucial, even without considering potential deductions in Medicare payments, VNAA’s Cameron says. The administrative side of compliance could prove costly, and might take funds away from other critical aspects of business.

“Our concern is we don’t get to invest in the marketplace or in our staff, because we’re going to be paying for this,” she says.

One positive Dombi finds is that CMS views this as a way to help get to a point of compliance before submitting a claim, rather than having to review a claim after. Still, NAHC is “extraordinarily” concerned about implications, and wants to work with CMS to ensure that the demonstration becomes a positive rather than a negative, even if that takes some time.

“If we have a choice, Aug. 1 will not be the point when Illinois finds itself in this new system,” Dombi says.

Two experts square off on Part B pilot

Published by Politico Pulse
By Dan Diamond
June 17, 2016

Bill Gates wants genetically modified mosquitoes, and the man who was once favored to win the GOP nomination is instead closing out the AHIP conference today. But first: Inside the battle roiling Washington's health care community.

PULSE CHECK: Two experts square off on Part B. Medicare's planned Part B pilot is either a necessary fix for a broken drug payment system — or the first step to President Donald Trump dismantling the Affordable Care Act.

It all depends whom you ask. And for this week's POLITICO "Pulse Check" podcast, we asked both Peter Bach and Ted Okon — a high-profile proponent and opponent of Medicare's pilot, respectively — to make their case.

Why we need the pilot: Bach, a Memorial Sloan Kettering researcher, says that Medicare's planned pilot is a crucial effort to lower the nation's drug tab, and lobbyists have dramatically distorted the administration's goal of reducing physicians' incentives to prescribe high-cost drugs.

"This has been a highly coordinated effort to misinform the electorate, to frighten patients and to misinform policymakers about even the basic math," Bach said.

Why we don't: Okon, the executive director of the Community Oncology Alliance, countered that Medicare's pilot is a dramatic overreach that shortchanges doctors and could set precedent for a future president — say, Trump — to go around Congress when making changes to Obamacare.

"If this is not changed appreciably, the only recourse will … be to pursue legal action," Okon said. "There's too much riding [on it]. It's not just a reimbursement cut."

Listen to the podcast:
Read the story:

THANK GOODNESS IT'S FRIDAY PULSE — And thank goodness that the NBA Finals are moving to an epic Game 7, even if last night's game was more fixed than Crazy Glue. (Note: Crazy Glue was the name for our pet dog.) Tips and conspiracy theories to or @ddiamond on Twitter.

With help from Jen Haberkorn (@jenhab) and Brett Norman (@BrettNorman).


Anti-addiction advocates cheer CARA advance. “We’re feeling probably better than we have felt through this whole process.” So said Becky Vaughn, vice president of addictions at the National Council for Behavioral Health, after the Senate voted Thursday afternoon to go to conference with the House on the opioid legislation.

Committee staff in the two chambers have largely worked out the differences between their legislative responses to the epidemic and were just waiting for the Senate to move forward, she told Pro's Brett Norman. “Everybody seems to be on board and we’re hearing great talk about new money.” In particular, she said House Judiciary Chairman Bob Goodlatte told advocates that he wants to use additional discretionary money to fund opioid grant programs rather than redirect already appropriated money, as both the Senate and House bills would do.

The Senate also approved a nonbinding resolution Thursday instructing the conferees to seek new funding for the grant programs.

Portman asks for co-op clarity. Sen. Rob Portman is asking CMS to help 22,000 Ohioans who may lose their insurance coverage after the closure of state co-op InHealth Mutual.

"These families were encouraged by the Administration to enroll in the Obamacare marketplace and trust in its plan options, including a taxpayer-funded CO-OP,” Portman wrote in a letter to acting CMS administrator Andy Slavitt. “Now those same families are scrambling to evaluate new coverage options and understand the financial risks of continuing coverage under InHealth Mutual.”

Portman, whose Permanent Subcommittee on Investigations held an oversight hearing on co-ops this year, is asking for clarity from HHS on whether people who choose to remain in their InHealth plans – with the known risk that the insurer is liquidating – would also be at risk of the individual mandate’s penalty.

** A message from PhRMA: Biopharmaceutical research and development is transforming medical discovery and there are no signs of slowing down. Learn more about how America’s biopharmaceutical researchers and scientists are advancing the science of hope here. **


234 pregnant women in U.S. now suspected to have Zika. That's according to CDC's latest count, released Thursday. CDC also flagged another 189 pregnant women with suspected cases of Zika in the territories.

The agency also announced on Thursday that three babies in the United States have already been born with severe, Zika-related birth defects and three pregnancies with evidence of birth defects were lost.

Bill Gates wants genetically altered mosquitoes. The billionaire philanthropist told Bloomberg's Caroline Chen that he's in favor of using "gene drives" to make them more resistant to carrying Zika, malaria and other mosquito-borne diseases. However, he acknowledged that scientists and ethicists are still wrestling over the implications.

“My basic belief is that children dying of malaria is a bad thing, and that we should be able to meet these objections,” Gates said. “But there’s still a fair bit of work to be done. Nothing is ready to be deployed today.” More.


CDC says key efforts to reduce tobacco use are 'stuck in neutral.' The agency specifically flags a lack of progress on smoke-free laws and cigarette excise taxes.

• While 26 states have implemented comprehensive laws that ban smoking at work and in restaurants, 25 of those states did so between 2000 and 2010.
• And while 46 states imposed cigarette excise taxes before 2010, most of those states have since failed to raise the tax. More.

Senators push HHS on clarifying language in health law. The Affordable Care Act's recommendations for insurers on covering tobacco cessation need to be clearer, according to a letter led by Sens. Patty Murray and Tom Carper and co-signed by 12 other Democrats.

"It has come to our attention that not all insurance carriers are covering these services due at least in part to a lack of clear guidelines," the senators write in the letter going out this morning. "Updated and clear guidance from the Administration is necessary to give carriers clear direction that all seven FDA-approved cessation medications and all forms of counseling must be covered without cost sharing."

Read the letter:


More medical groups want movement on gun violence research. "It is time for Congress to fund Centers for Disease Control research into the causes and prevention of gun violence," said John Becher, president of the American Osteopathic Association, said in a statement. He also called on his how organization's board "to use its resources to sponsor objective research that will help our nation address the epidemic of gun violence."

Congressman pushes legislation to relax blood donor rules. Rep. Mike Honda on Thursday announced a bill calling on the HHS secretary to allow for more flexibility when screening blood donors during an emergency. The bill, known as the Deliver for Our Nation At Times of Emergency (DONATE) Act, follows outrage in the wake of Sunday's shooting at a gay nightclub, given that many gay men were unable to donate blood because the FDA bars men from donating blood if they had sex with other men in the past year.

“It was a horrific irony that gay and bisexual men could not donate in a time of local need,” Honda said in a statement. "This is not a problem of science; it’s a problem of morality.”


Obama names six well-known researchers to cancer board. The researchers — Francis Ali-Osman, Lawrence Gostin, Scott Hiebert, Electra D. Paskett, Nancy Raab-Traub and Margaret R. Spitz —will join the National Cancer Advisory Board and help advise on the White House's cancer moonshot initiative, among other priorities. More.

Home health group touts new data on bundled payment program. The Alliance for Home Health Quality and Innovation released analysis that found savings of about $5,000 when patients entered home health care after a common type of major joint replacement. More.

Four groups unhappy that Senate Appropriations bill cuts funding for assistance program. The Center for Medicare Advocacy, Medicare Rights Center, National Committee to Preserve Social Security and Medicare and National Council on Aging are warning that the appropriations bill cuts the Medicare State Health Insurance Assistance Program’s $52 million in funding. The groups say the program is essential to help beneficiaries navigate Medicare’s complexity. More.

The Better Medicare Alliance hosts 12:30 p.m. briefing on community partnerships. The Medicare Advantage advocacy organization will discuss the value of community-based initiatives to boost outcomes for beneficiaries. More.


Who's addressing AHIP today? Jeb! The former Republican presidential candidate and ex-Florida governor is giving the closing keynote at the association's annual conference in Las Vegas. More.

HHS touts Minnesota program for dual Medicare-Medicaid eligibles. Beneficiaries that participated in the integrated program between 2010 and 2012 were 48 percent less likely to have a hospital stay than their counterparts outside the program, among other positive results. "The evidence is stronger than ever: integrated care is improving outcomes," write CMS's Sean Cavanaugh, Tim Engelhardt and Vikki Wachino. More.

Doctors represented by AFT reach deal with Oregon hospital. A labor union at PeaceHealth Sacred Heart Medical Center — the first group of hospitalists to be represented by the American Federation of Teachers — has reached a tentative agreement with the hospital system. More.


Price transparency was supposed to reform health care and lower costs, or so its advocates claimed. It hasn't.

The Supreme Court's decision on Thursday made health care fraud cases more complicated, Noah Feldman writes at Bloomberg View.

Why local doctors are increasingly selling out to national chains.

The pace of Zika cases in Florida is rising; state officials reported seven cases on Tuesday alone.

Your doctor may have a history of abuse or drinking on the job — and not have to tell you about it, Casey Leins reports for U.S. News & World Report.

** A message from PhRMA: Researching and developing innovative medicines is a challenging undertaking – and the science is only getting harder. America’s biopharmaceutical researchers and scientists are tireless in their pursuit of new treatments and cures for patients. With over 7,000 new medicines currently in development, patients today have more hope for a better quality of life. Learn more about how America’s biopharmaceutical companies are driving innovation, collaborating and helping to translate new findings into hope for America’s patients. **

Home Health Shown to Cut Costs in Joint Replacement Patients

Published by Home Health Care News
By Kourtney Liepelt
June 17, 2016

The use of home health services after a major joint repair surgery for Medicare patients results in cost-effective care and lower readmission rates, according to data newly released Thursday.

The data analysis, conducted by Dobson | DaVanzo & Associates and released by the Alliance for Home Health Quality and Innovation, comes just more than two months after Centers for Medicare & Medicaid Services (CMS) launched a bundled payment system for joint replacements through the mandatory Comprehensive Care for Joint Replacement (CJR) model in 67 regions. It examines the distribution of discharges between October 2011 and September 2014 for patients from the hospital to various post-acute care settings, the average Medicare payment per episode by first setting, and the average readmission rate for related conditions within the CJR model.

“The data analysis points to the value of home health care in the context of the CJR model,” Teresa Lee, executive director of the Alliance, tells Home Health Care News.

Under the model, hospitals in the select regions are responsible for Medicare spending on hip and knee replacement episodes of care, including hospital and post-hospitals of costs. If spending exceeds certain thresholds—based on the hospitals’ past spending and that of its regional peers—it could be dinged with Medicare penalties.

Generally, when home health is the first post-acute setting after a hospital discharge, patients have lower Medicare episode payments and lower readmission rates than facility-based settings, according to the data. For example, across all settings, 8% of episodes included in the data contain a readmission, while that rate is lower among home health agency episodes, at an average of 5%. Meanwhile, readmission rates range between 12% to 15% for patients receiving rehabilitation in facility-based settings.

The data also indicates significant savings for the Medicare program when patients turn to home health after a hospital stay. The average Medicare episode payment for knee or hip replacements without major complications is $24,900, but that number drops to about $19,900 when home health is the first post-acute setting for the patient.

“However, HHA first setting episodes had slightly higher Medicare payments and readmission rates compared to Community care, which includes physician and outpatient therapy services,” according to the data analysis. “Higher Medicare payments for HHA episodes are likely attributed to the higher clinical severity compared to patients who are discharged home with no formal post-acute care.”

Additionally, patients who go on to receive home health care initially are far less likely to undergo fractures following surgery. The average hip fracture rate for those who received home health services as the first post-acute setting was 2.5%, as compared to 30.9% at inpatient rehabilitation facilities and 20.5% at skilled nursing facilities.

“Fracture rates are critical not only in understanding differences in Medicare payment and readmissions across different settings, but in understanding significant variation across regions, due to the potential impact fractures have on payment and readmission rates,” the analysis states.

While this data won’t impact payment bundles, it’s a good indicator of what’s to come and how crucial agreements between home health agencies and hospitals will be moving forward, according to Lee.

“This is data that shows the importance of partnerships and the use of home health in the context of caring for patients after they’ve received major joint replacements, particularly in the areas included in the CJR model,” Lee says. “It’s critically important for home health agencies to reach out with hospitals in those areas.”