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News Roundup: July 29, 2016

NAHC: Pre-Claim Review Makes No Sense, Goes Too Far

Published by Home Health Care News
By Amy Baxter
July 29, 2016

Days away from the start of the pre-claim review demonstration in Illinois, industry groups are pushing back yet again.

The National Association for Home Care & Hospice (NAHC) recently submitted harsh comments to the Office of Management and Budget (OMB) over the pre-claim pilot program by the Centers for Medicare & Medicaid Services (CMS). The demonstration is set to begin in five states—Illinois, Florida, Michigan, Texas, and Massachusetts—periodically over the next year, with Illinois beginning on August 1, 2016.

CMS has stated that the demonstration is aimed at reducing fraud. However, the downsides of the program to home health care companies are concerning for the industry, NAHC argued in its statements.

“The proposal is untargeted, with high administrative costs and operational burdens, is likely to create improper barriers to access to timely care, would not be effective against the fraud concerns in Medicare home health services, and would not aid in achieving a higher degree of compliance with the alleged claim documentation deficiencies,” NAHC wrote.

The industry backlash to the pre-claim demonstration has been strong since the proposal first appeared on the Federal Register at the beginning of 2016. Home health agencies argue the program will have too high an administrative burden, and have already challenged CMS officials on their ability to process the additional requirements in a timely manner and their own ability to secure proper documentation from physicians.

NAHC went even further by questioning the legality of such a demonstration program, citing that the nature of this demonstration does not comply with CMS’ authorities to investigate and prosecute fraud.

The association also expressed doubt at CMS’ estimated costs of the demonstration. While CMS maintains the project will cost nearly $300 million over three years, NAHC says the actual costs could exceed $1 billion if claims are submitted multiple times as allowed.

NAHC has recommended that OMB instructs CMS to withdraw the proposal for prior authorization altogether.

Hospitals will pivot to post-acute care to thrive under cardiac bundles

Published by Modern Healthcare
By Elizabeth Whitman
July 29, 2016

In the days and months after a heart attack, a patient has a long list of tasks to remember as they recover: Take medications, eat nutritious foods, go to physical therapy, to name just a few.

This kind of post-acute care has long been viewed as outside the purview of the hospitals that treated the patient in the first place. But a new set of rules for cardiac bundled payments and rehabilitation, proposed Monday by the CMS, is likely to drive hospitals to pay far more attention to post-acute care, a shift that could pose fresh challenges in a healthcare system that in many ways remains disjointed.

“In order for hospitals to win under the bundled payment programs, they have to take a more proactive role working with the surgeons … to plan the discharge of the patient a little bit more carefully,” said Francois de Brantes, the executive director of HCI3, a not-for-profit organization that focuses on improving healthcare. “The challenge of hospitals is making sure they've got good relationships with post-acute care providers,” de Brantes said.

Under a proposed demonstration program that would start July 1 next year in 98 randomly selected areas, Medicare would pay hospitals under a bundled-payment model for coronary bypass surgery and treatment for heart attacks. The hospitals would get a set amount per medical episode to cover the hospitalization and all of the related care for 90 days after the patient is discharged.

That puts hospitals at financial risk for managing the quality and efficiency of care delivered by a variety of post-acute providers, including skilled nursing and rehabilitation facilities and home health agencies.

“If you're responsible for the 90 days, you can't say, 'The patient is discharged, that's not my responsibility,'” said Dr. Gary Kalkut, senior vice president of network integration at NYU Langone, which participates in the voluntary Bundled Payments for Care Improvement (BPCI) initiative.

The hospital started with joint replacements under that program and later added cardiac valve and bypass surgeries. “It forces providers to have closer interactions and relationships about the care of the patient, with anyone who touches that patient over a 90-day period,” Kalkut said.

For NYU Langone, that meant creating new lines of communication—among physicians, nursing facilities, physical therapists, other providers—that hadn't previously existed. The hospital developed a transfer document that everyone reviewed regularly for status updates on a patient.

With better post-acute care, treatment costs could be slashed by anywhere from 10% to 20%, de Brantes said, adding that the structure of the CMS' proposed cardiac bundled payment would push hospitals and physicians to be proactive.

As bundled payment programs have expanded, major hospitals started to implement programs to track patients' discharge and recovery, said Josh Luke, a USC professor who also founded the National Readmission Prevention Collaborative and the National Bundled Payment Collaborative.

“Traditionally, once a patient went home from the hospital after a cardiac episode, anytime they showed fatigue or discomfort, you immediately would return them to the hospital,” Luke said. Now, he said, hospitals have an increasingly robust array of incentives to get serious about follow-up care.

But deeper involvement in post-acute care won't necessarily be easy or smooth for hospitals, however. They might be located in areas that have a dearth of high-quality post-acute care providers, for instance—although, de Brantes noted, those hospitals wouldn't bear disproportionate risk under those circumstances.

The new model mitigates such risk for hospitals by basing the target cost of a procedure in part on geography. The base payment for procedures will transition from a mix of hospital-specific data and regional historic data in the first years of the five-year program to only regional data, in the final two years.

The program could drive other structural changes in the industry, too, particularly in conjunction with the growing numbers of patients who need post-acute care.

In 2008, the Agency for Health Research and Quality found a 53% increase between 1997 and 2006 in the rate of patients discharged from hospitals who needed home healthcare. Over the same period, the rate of patients who went from hospital to nursing homes or rehabilitation facilities rose 30%, the agency found.

The accelerating transition to value-based payment models could “challenge revenue streams for post-acute providers in the near team” and “drive further vertical consolidation within the post-acute sector,” according to an equity research note from J.P. Morgan.

The agency also proposed a model creating financial incentives for hospitals in 45 other geographic areas to put patients in cardiac rehabilitation programs.

Just 15% of heart attack patients use these services, which have been found to reduce the risk of a second heart attack or death, the CMS said. Under this initiative, Medicare would pay hospitals $25 per service for a maximum of 11 services.

The proposals are designed to emphasize health over treating a disease, Dr. Patrick Conway, acting principal deputy administrator and chief medical officer for CMS, said in a call with reporters Monday.

Top Policy Recommendations for Aging in Place

Published by Home Health Care News
By Amy Baxter
July 29, 2016

Nearly all Americans want to age in place, but policies and payment mechanisms often get in the way of seniors getting the care they need at home. Between burdensome regulations and limitations on payments for certain types of care, there are a number of policy changes that would better enable seniors to receive care at home.

Leaders across the care spectrum agree that policy updates are necessary for aging Americans to receive necessary care.

“The current care delivery models, infrastructure and reimbursement systems will need to evolve if we want patients to benefit from access to affordable and high-quality health care,” said Tom DeRosa, CEO and director of senior housing real estate investment trust (REIT) Welltower Inc., speaking at the 2016 Executive Summit in New York City. Welltower (NYSE: HCN) is a major real estate owner of senior housing care facilities across the country.

While the home health care industry has seen an onslaught of new regulations over the past few years, not all of these are helpful to expanding care to more Americans at home. Here are the top regulatory recommendations that would better enable home care, according to a white paper from that summarizes major takeaways from the summit:

1. Renovate the regulatory system

Executives agreed that instead of piecing together different regulations, legislative changes could be more focused on getting rid of outdated systems and even standardizing licensing requirements across state lines. Current regulatory changes are making the home health space more complex and even adding costs.

“The gradual accumulation of disparate regulations adds complexity and cost while deterring agile development to meet changing needs,” according to the white paper.

Modern systems will help simplify procedures for all, executives said, including patients, providers, payers and vendors.

2. Reform health care payments

As the health system shifts from fee-for-service reimbursements to value-based purchasing, new metrics and technology need to keep up, experts argue. In addition to paying for home health care services, Medicare should expand to cover telemedicine as more Americans receive health care at home.

“Telemedicine reimbursement (by Medicare). I cannot think of anything more important,” Tom Daschle, a former Senator from South Dakota, founder and CEO of The Daschle Group and a member of the 2016 Advisory Board, said at the summit. “[It is] the most important catalyst by far to bring about home care for individuals with chronic conditions. …[It] has extraordinary potential for transforming home health care and chronic illness management.”

Currently, Medicare fee-for-service does not cover telemedicine, though some private insurers are expanding coverage in this space, according to

3. Foster interoperability

Currently, between care settings, interoperability is virtually nonexistent. Greater access to medical records, along with telemedicine could encourage more timely care and implementation of payments and penalties. Free-flowing information will likely result in higher quality care. Encouraging wider use of electronic medical records (EMRs) could also boost interoperability, experts said.

4. Tackle the social determinants of health

Access to high quality care is often blocked by social determinants, such as a person’s ability to transport themselves to a physician’s office or have good quality food available to them. These factors can influence the cost of care as well. Supporting access to these other factors of health can improve patient outcomes and reduce overall health care costs.

“The new administration should look to support improvements in such factors, whether by guidance calling on health plans to get Medicaid patients on food assistance or accelerated implementation of rural high-speed Internet access to facilitate connected living and telehealth,” the paper urges.

5. Encourage planning and engagement

Overall, Americans will be better off to age if they are well prepared for their retirement needs. Not only should Americans have better retirement plans in terms of their finances, but family members and other informal caregivers who help provide care at home could be better engaged and informed with better policies.

These Are the Best Cities in the US for Seniors

Published by Home Health Care News
By Alana Stramowski
July 29, 2016

Based in part on the lower costs for home health care, a list of the top 10 best cities for seniors was compiled, and Oklahoma City came in at number one.

Oklahoma City has average home health care costs of $46,057 per year, according to SeniorAdvice’s SeniorScore, which is the first comprehensive data-driven scoring system specifically designed to identify and measure the livability for seniors for any location in the United States.

In addition to having a very high number of Medicare registered physicians in the city, Oklahoma City also was found to have an abundance of hospitals in the city and lower than average property taxes. Also, the city rated high in the quality of life category due to low levels of rainfall each year, mild temperatures in the four seasons and very good water quality.

The cities on the list with the lowest costs for home health care were Louisville, Kentucky, Fort Worth, Texas and Richmond, Virginia. They each came in with an average annual cost of $43,472, which is lower than the national average.

Austin, Texas, and Pittsburgh came in second and third, respectively. They both have well over 100 senior living facilities close to the city. Austin, Texas, was also found to have a very high quality of life ranking due to the low levels of rainfall each year, the very mild winters and very warm summers.

Surprisingly, less than half of the cities on the top 10 list are in warmer climates. Warm climates included Austin, Texas, Louisville, Kentucky, Ft. Worth, Texas, and San Antonio.

The top 10 best cities for seniors were:

1. Oklahoma City

2. Austin, Texas

3. Pittsburgh

4. Louisville, Kentucky

5. Ft. Worth, Texas

6. Richmond, Virginia

7. St. Louis

8. Omaha, Nebraska

9. Cincinnati

10. San Antonio

These findings follow the top 10 most livable states list, also determined by SeniorAdvice. Of the top 10 states list, only four cities in those states were found on this list. Those states were Oklahoma, Virginia, Nebraska, and Texas.