Cynthia Morton, Executive Vice President
National Association for the Support of Long Term Care (NASL)
June 2012
 Whether
Medicaid expansion is coercive on states
 Constitutionality of individual mandate
 Decision expected last week of June, begin of July
 Possible outcomes:
o Entire ACA upheld (remains valid)
o Individual mandate unconstitutional but
o All or major parts of ACA declared
Sequestration 2% cut
Enormous pressure to cut
Pent-up frustration among conservatives about fiscal recklessness in Washington
Lame Duck Session–
o Doc “fix” past 12-31-12
o Therapy Cap Exceptions Extension, fatigue
o Reauthorization of Highway Trust Fund
o Alternative Minimum Tax (AMT)
o Research & Development Tax Credit
o Bush 2001 Tax Cuts
o National Health Service Corps Scholarship Program & F.
Edward Hebert Armed Forces Health Professions Scholarship
& Financial Assistance Program (Tax)
o 50% of cuts come from defense; 50% from domestic
2% across-the-board cuts to Medicare
Medicaid and CHIP exempt
Takes effect January 2013
Congress may exempt defense; may cut other
programs to offset defense cuts
Medicare is very vulnerable
No extensive policy changes this year in the payment
update (also called market basket).
FY 2013 SNF MB projection is 2.6%
o Subtract the productivity adjustment; estimated to be about 1%
o FY 2013 MB update: 1.6% +/- 0.2%
By statute, CMS must provide the full market basket and
could only be changed by Congress.
According to CMS:
• No current payment system for any individual provider type provides
both the quality and the cost efficiency that both CMS and Congress
believe can be achieved.
• Playing with payment system as a way to achieve better quality
savings for Medicare has been going on since the inpatient hospital
DRG system was introduced.
• None of the tinkering and the changes have succeeded.
• The provider types are silos with no real connection between them:
they lack team work, communication, beneficiary transition concern
• Utilization drives care: the more the merrier. Payment for overdoing
and unnecessary services.
of Care
Integrated CareJourneys not Fragments
Patient centered
Prevention Reduction of medical errors/
patient safety
Based on best science
Per Capita
Cost ReductionSpecifically NOT by
withholding or reducing care
Managed Care
Long Term
Home Health
Dual Care
Medical Homes
Bundled Payors
Managed Care
Care Coordination through Financial Alignment Demo
3 years; Enrolling January 2013
Integrates benefits and aligns financial incentives between
the two distinct and separate programs
Duals: 9.1 million of 97 million on Medicaid or Medicare
Sickest, most expensive, half have three or more chronic conditions and six in ten have
cognitive limitations
o Medicaid spends 69% of dollars on LTC (includes HCBS)
o Medicare spend 6% on SNF
CMS expects 26 states to participate
Tests Two Models:
o Capitated Model: Three-way contract among State, CMS and health plan to
provide comprehensive, coordinated care in a more cost-effective way.
o Managed FFS Model: Agreement between State and CMS under which
States would be eligible to benefit from savings resulting from initiatives to
reduce costs in both Medicaid and Medicare.
The challenges and the potential of this health reform
experiment are enormous
Combined data set-- individual state profiles that show the
demographics, utilization, and spending patterns and costs
of dually eligible individuals in each state
This is a very large demo.
Status: 26 States are actively
pursuing one or both of the models
(18 States capitated, 6 States managed
FFS and 2 States both)
State Draft Proposals:
26 States (AZ, CA, CO, CT, HI, ID, IA,
and WI) have posted their draft
proposals for public comment.
Official Proposal Submission to
Proposals can be found online:
Partnership for Patients: Public-private partnership to
improve the quality, safety and affordability of health care for
all Americans by reducing hospital readmission rates by 20%
by the end of 2013.
Community Care Transitions Program: Provides support
for high-risk Medicare beneficiaries following a hospital
discharge. 23 sites will work with CMS and local hospitals to
provide support for patients as they move from hospitals to
new settings, including skilled nursing facilities and home.
Independence at Home: Tests a new service delivery
model that utilizes physician and nurse practitioner directed
primary care teams to provide services to high cost,
chronically ill Medicare beneficiaries in their homes.
Launched in April 2011
“Take the Pledge”--More than 6,500 partners, including over
3,167 hospitals, 2,345 physician, nursing and pharmacy
organizations, 892 consumers and consumer groups, and 256
employers and unions.
Focus on physicians, nurses and other clinicians working in and
out of hospitals to make patient care safer and to support
effective transitions of patients from hospitals to other settings.
Two Concrete and Measurable Goals:
o Keep patients from getting injured or sicker. By the end of 2013,
preventable hospital-acquired conditions would decrease by 40%
compared to 2010.
o Help patients heal without complication. By the end of 2013,
preventable complications during a transition from one care setting to
another would be decreased so that all hospital readmissions would be
reduced by 20% compared to 2010.
Tests models for improving care transitions from the
hospital to other settings and reducing readmissions for
high-risk Medicare beneficiaries.
o Improve transitions of beneficiaries from the inpatient hospital
setting to other care settings, to improve quality of care,
o Reduce readmissions for high risk beneficiaries, and
o Document measurable savings to the Medicare program.
Community organizations to partner with nursing homes
Apply on a rolling basis
$500 million available for 2011-2015
Targeting long stay resident
30 CCPT participants so far
Announced March 2012
Targeted to long stay dual eligible
o Reduce costly and avoidable hospitalizations
Funding organizations to partner with nursing homes
$128 million available
Propose your own evidence based intervention and
improvement strategy
Applications were due June 14th
ACA– Penalizes hospitals with greater-than-expected readmission
rates for specific conditions.
Payment reduction will be determined by an adjustment factor
based on an assessment of excess readmissions, with a
maximum payment reduction of 1 percent in 2013, 2 percent in
2014, and 3 percent in 2015 and beyond.
An excess readmissions ratio will be calculated based on
measures of readmissions currently used in the hospital
inpatient quality reporting (IQR) program.
Penalty applies to three conditions:
o acute myocardial infarction (AMI),
o heart failure
o pneumonia
Under Affordable Care Act Section 3022
Medicare Shared Savings Program
An organization whose primary care physicians are accountable
for coordinating care for at least 5,000 Medicare beneficiaries
o Having a hospital or specialist in the ACO is optional
o Secretary may include other providers
o At least 50% of the primary care physicians must be meaningful
electronic health record users by the start of the second reporting
Legal entity recognized under State law
o shared governance
o Participants have appropriate proportional control over decision making
Reimbursement & Care Delivery Bottom Line:
or not providers apply to become ACOs is
unknown, but payers and providers are preparing their
organizations for ACO-like changes in reimbursement and
care delivery.
A “bundled payment” is simply a single
payment for a package of services delivered
by a group of providers during a defined
episode of care.
The Secretary shall develop a pilot program for integrated care
during an episode of care provided to an applicable beneficiary
around a hospitalization
Implementation January 2013
Duration of pilot – 5 years
Secretary to submit plan for implementation of an expansion of
the pilot program no later than 01/2016
Model 2 – Acute and PAC bundle
Model 3 – PAC bundle only
Applications due June 28th, 2012
May expand the program nationwide after 01/2016 if it reduces
spending and either does not reduce quality of care or improves
quality of care.
According to CMS’ Request for Application…
• The ACO concept of capitated payment or shared
savings and a bundled episodic payment model both
create a framework that rewards providers for taking
accountability for the triple aim outcomes.
• Bundled episodic payment models support
accountability at the patient level while the ACO model
does so at the population level. This reduces
operational complexity at the provider level.
Quality measures are coming from CMS and others
Partnership to Improve Dementia Care -- reduce use of
antipsychotic drugs in nursing home residents by 15% by
end of 2012
o CMS data show that in 2010 more than 17 percent of nursing home
patients had daily doses exceeding recommended levels.
National Quality Forum’s MAP (Measures Application
Partnership)– contract with HHS to develop measures
across settings.
June 2012 Report – 26 measures sensitive to the unique
needs of dual eligible beneficiaries.
o detecting and treating depression
o screening older adults for fall risk
o unplanned hospital readmissions within 30 days of an initial stay as
a key measure of quality for the dual eligible population.
Includes a “starter set” of seven that are most ready for
immediate implementation in the field
Last year’s PPS rule and various OIG reports are telling us
that our stakeholders do not understand the value of the
amount of therapy we provide.
Working jointly with American Health Care Association
Developed a crosswalk to translate functional measures
used by some companies to the Modified Barthel Index as
used in the CARE tool project
Once validate the crosswalk, begin to examine QM’s.
Concern is that measures will be sensitive to change in the
patients we see
If we don’t do it, CMS will.
Growing recognition of the importance of HIT and the role of
LTC providers in ensuring smooth care transitions and
avoiding readmissions
Demonstrating “Meaningful Use” is how hospitals and
eligible professionals get the payments
LTPAC not included specifically in Stage 1 or 2 of
Meaningful Use (grant program from HiTECH)
LTPAC providers are forging ahead anyway
General Requirements That Must Be Met:
Certified EHR is used in a meaningful manner, including
electronic prescribing
Certified EHR is connected in a manner that allows for the
exchange of health information
Entity is capable of reporting on clinical quality measures
and such other measures as selected by the Secretary of
o Physician adoption of any EHR system has more than tripled since
2002, going from 17 percent to 57 percent in 2011 (NCHS Data Brief).
o The adoption of basic EHRs has doubled since 2008, going from 17% to
34% in 2011 (NCHS Data Brief).
o Adoption has grown significantly among important subgroups of
physicians including small practices and rural providers.
o Hospital adoption has more than doubled since 2009, increasing from
16% to 35%
Over 2,800 hospitals and more than 90,000 doctors have
received $5 billion in incentive payments for ensuring
meaningful use of health IT since the program inception
LTPAC Challenge Grants
 4 Challenge Grants to Massachusetts, Maryland,
Oklahoma, and Colorado through the state-based Health
Information Exchange (HIE) program
Focused on “improving long-term and post-acute care
 Written
and others in the
 http://www.ltpach
 State of play in
technology for our
Calm and Carry On!
Know that our landscape is
changing (when does it not?)
Your data is important to your
Advocacy is important
Cynthia Morton
Executive Vice President
202 803-2385