Legislative Update in Tumultuous Times Current State of Affairs - - PowerPoint PPT Presentation

Legislative Update in Tumultuous Times – Current State of Affairs &

Action Steps

Panelists Marsha Greenfield Richard Schwalberg Deborah Winn-Horvitz Molly Forrest

Federal Update

Marsha Greenfield

So – we know how that turned out…

What was in the ACA repeal bill that concerned LeadingAge and AJAS?

• Impact on older Americans?

– Age rating changed to 5:1 – Essential Health Benefits could be eliminated – Medicaid expansion effectively eliminated

• Impact on Medicare?

– Taxes on various industries repealed – Life of Trust Fund cut short

• Impact on Medicaid?

Comparing Medicaid Proposed Changes

Just a Reminder What’s at Stake

Estimates 1 TRILLION dollars decrease in Medicaid Funding

• ver 10 years

What Next? Are we out of the woods?

• CMS has the power…

– State waivers could include block grant (e.g., RI) – Other “experiments” possible – Medicaid expansion waivers will look like Indiana – Starve the exchanges

• Other Medicare bills in the works could see

poison pill amendments

What else are we working on?

• FY 2017 appropriations

– CR expires April 30 – Administration asks for $18B additional cuts – Appropriators negotiating – Complicated dance with defense/non-defense parity, administration defense increases, etc.

• FY 2018 appropriations

– Expect a budget resolution with reconciliation instructions for tax reform? – President’s “skinny budget” probably DOA but the battle between defense and non-defense will be fierce

• $54B cut to low income programs and PBS with corresponding

increase in defense

Housing

• Ongoing work on current fiscal year 2017

funding for HUD programs, given need for increases and securing RAD for PRAC authority.

• Analyzing skinny budget request seeking 13%

cut to HUD and a leaked non-final budget document suggesting HUD contemplating not asking to renew more than 23,000 Section 202 units in next fiscal year.

Medicare

• Observation Stay

– Legislation to count all nights in the hospital toward 3-day stay requirement reintroduced in House (H.R. 1421) and Senate (S. 568)

• Therapy Caps

– Legislation to repeal caps reintroduced in House (H.R. ) and Senate (S. ); exceptions process returns 12/31/17

• Value-Based Purchasing

– Unclear; expect last year’s legislation to be reintroduced

• Certified Nursing Assistant Training

– Proposing amendment to OBRA – discretionary rather than mandatory

Home Health and HCBS

• Professionals allowed to order home health

– Expands to include nurse practitioners, clinical nurse specialist, physician assistant (S. 445)

• Incorporating LTSS into Medicare Advantage

programs

– Medicare Advantage Community-Based Special Needs Plan demonstration reintroduced (S. 309)

Regulatory Relief

• Administration’s anti-

regulatory agenda

• Focus on nursing home

and home health requirements of participation, HCBS settings

• Congressional interest?
• CMS advocacy

Advocacy: New Administration, New Congress

• Organizational Letters to Congress and to the Administration

– LeadingAge – LCAO and other national organizations

• Grassroots Campaign

– Contact Congress letters (lots) – Member-generated letters (thousands!) – Call-ins (ours and other groups)

• Meetings

– AJAS/LeadingAge Ohio Delegation – In-district/state

• LeadingAge’s PEAK Conference

– 400 participants; 300 meetings – Follow-up at home and in DC

Importance of Grass Roots Advocacy – The Time is Now

Richard Schwalberg

Federal Advocacy Focus – March 9, 2017

Concerns About Medicaid Program Restructuring

• Changes to the Medicaid Program, both financing and structure,

will result in a federal reduction of Medicaid funding to states.

• Seniors who receive services covered by Medicaid are the frailest

and most financially vulnerable members of their communities. They have no other resources to cover the cost of critical services.

• Under Per Capita or block grants, states would receive a fixed

amount of federal Medicaid funding, as opposed to the increased federal allocation states receive when their own spending rises.

• Therefore, care of the elderly who receive Medicaid services in

nursing home and community-based settings will be jeopardized.

• In summary, our request is twofold

– To maintain the current structure of the Medicaid Program – To not restructure Medicaid into block grant or per capita system

– To reduce regulations which will not impact quality and will save dollars

Impact of Federal Cuts on our Elderly

• Elaine Miller Letter: Ken Bravo
• The Hebrew Home at Riverdale: Dan Reingold

Innovative Programs that save the Government Money

• Jennings Center for Older Adults: Allison

Salopeck

• McGregor P.A.C.E: Tangi McCoy
• Montefiore: Mark Weiss
• Jewish Home Rockleigh: Sunni Herman

State Advocacy Visits March 22, 2017 Columbus, Ohio

Concerns About Governor Kasich’s Proposed Medicaid Budget: Mark Weiss

A. Do Not Cut Medicaid Services

• Negative impact on service provision for the frail and

sick elderly in Ohio’s nursing homes and in the community

• Financial Impact

B. Do Not Expand Managed Care in Ohio

• MyCare Ohio demonstration project
• Taking Ohio Medicaid into full managed care system

• Human Touch Impact
• Innovative Programs & Ways We

Save Medicaid Dollars

PPLG – Position Statement Questions

• What role we play in advocacy back home?
• How do we “educate” our legislators?

Packaging for Impact: How to present programs to legislators

Deborah Winn-Horvitz, President & CEO Jewish Association on Aging Pittsburgh, PA

In our experience….

Treat a legislator like a donor

• Give them both

– powerful data – individual stories of impact

Two programs making a difference

• HomeMeds℠
• AgeWell at Home, Care Navigator

HomeMeds℠ – What is it?

• Partners in Care Foundation
• Evidence-based, in-home, medication review and intervention

– Computerized risk assessment and alert process – Pharmacist review and recommendation

• Approved Disease Prevention and Health Promotion program
• Included in the National Registry

for Evidence-based Programs and Practices

• Strong evidence rating on the US

Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange

HomeMeds℠ – The Data

• 11,000+ older adults have had their medications

screened

– 40-50% of those screened had potential problems – 25% of all harmful adverse drug events caused by medication errors are preventable

• Adults 65+ are 2x as likely as others to go to the ED for

adverse drug events

– Potential savings associated with avoided ED visits due to prevented adverse drug events:

$1,485,000

HomeMeds℠ – The story

• f Norman
• 84 years old, residing alone in a low-income senior high-rise
• HomeMeds℠ assessment completed by our Nurse:

immediately noticed the name on the various medication bottle labels were not Norman’s name

– Norman was recently discharged from the hospital and was given prescriptions that were not for him/his conditions

• Norman cannot read so he was unaware he was taking incorrect

medications

– Blood pressure and cholesterol meds he did not need

– Nurse alerted the appropriate medical professionals

• Potential adverse health event avoided through

HomeMeds℠ assessment

• Norman remains independent today

AgeWell Pittsburgh

• Collaboration between Jewish Association on Aging,

Jewish Community Center of Greater Pittsburgh and Jewish Family & Children’s Service of Pittsburgh

• Mission: Helping older adults continue to live

independently in their own homes

• Goal: Identify seniors at risk of losing their

independence and help them connect to services

• 8,000+ clients served to date

AgeWell at Home – What is it?

• Care Navigator coordinates wrap around services:

– HomeMeds℠ – JAA Home Health – Home Safety Assessment – DPA/Options – Adult Day Services – DME – Private Duty – Veteran’s Services – Holocaust Benefits – AAA, JF&CS, JCC – Hospice – Meals on Wheels – Alert Systems – Transportation – Long-term Care Policy Assistance – Placement/Housing

AgeWell at Home – The Data

• Progression of hospitalization prevention
• Savings associated with avoided hospitalizations due

to AgeWell at Home:

$888,000

Cases Hospitalization Rate CY 2015 53 28.3% CY 2016 109 12.8% CY 2017 Annualized 152 5.3%

AgeWell at Home – The story of Marion

• Lives alone in a condo, socially isolated
• Frequent falls, was non compliant with medications

and nutrition

• Referred to Care Navigator by her Rabbi
• Care Navigator initiated the following:

– Established a trusting relationship with both Marion and her children – Provided an Elder Alert Emergency Response System – Reviewed Long-Term Care policy for coverage limitations, activated policy – Obtained Private Duty service – Obtained an order for JAA Home Health service

• Marion sees Care Navigator as her “go-to” contact for any changes

in condition/symptoms  Care Navigator assembles necessary resources to keep Marion safe in her home

Other ways to engage

• Include legislators and legislative staffers on your

E-news and other constituent communications

• Invite them to every public event you have
• Take (good) care of one of their parents/relatives
• Make sure they hear from you on important issues

Other ways to engage

• JAA Annual Event Host Committee

– U.S. Senator Bob and Terese Casey – U.S. Senator Pat and Kris Toomey – U.S. Congressman Mike and Susan Doyle – State Senator Jay and Roxanne Costa – State Representative Dan and Debbie Frankel – County Executive Rich and Cathy Fitzgerald – City Councilman Corey and Katie O'Connor – City Councilman Dan and Amanda Gilman

Transforming Senior Living and Services

2017 AJAS Conference

Molly Forrest, CEO President Los Angeles Jewish Home April 3, 2017

DHSS Secretary, Tom Price

Release ACA waivers & rule changes as administrative actions… Takes time & public comments

Undermine the ACA marketplace by actions such as:

• Change the requirement that

most Americans pay a penalty for not having insurance.

• End subsidies that insurers get

(could quickly cause the individual insurance markets to crater)

• Offering federal approval to state

proposals for Medicaid changes within their borders (i.e., setting

• f premiums, cost-sharing,

lifetime caps on benefits, offering subsidies to high-risk medical beneficiaries, establish high-risk pools ) Make administrative changes as key tools to change the health-care system

• Introduce work requirements for

Medicaid recipients, including poor & disabled

• Ease the coverage of certain

services, such as contraception

• Water down the ACA requirement

that most insurers provide a specific raft of benefits, such as maternity and mental-health care. *If insurers are allowed to offer less generous benefit packages, many believe this would lower premiums

Working Within the Continuum

Adapted from Greystone Communities’ Continuum of Care Chart

Subacute Rehab Skilled Memory Support Nursing Intermediate Nursing Respite Care Assisted Living Catered Living Senior Health & Wellness Center Geriatric Assessment/ Care Coordinator & Case Management Senior Center Services *Community Based Services Wellness Program Case Management Independent Living Adult Day Services Memory Support Assisted Living Home Health Care Skilled Nursing Hospice Acute Transitional Medicare *Transportation; Information/Referral; Counseling; Meals-on-Wheels; Integrated Day Care; Homemaker/Chore/Housekeeping; and Emergency Response System Communities’

Need Driven Preventative Hospital Long-term Care AACs Continuing Care Retirement Community Want Driven

New ACO Model Targets High-Cost Senior Care Population

December 18, 2016 by Amy Baxter

HOSPITALIZATION & EMERGENCY UTILIZATION RATES

65-74 75-84 85+ 7.7% 13.3% 20.4% 12.9% 21.3% 31.6% 65-74 85-84 85+ 46.6% 54.9% 62.9% 62.0% 71.4% 70.3%

ALL MEDICARE MEDICARE WITH ALZHEIMER’S & DEMENTIA

40% Of Seniors living in Senior Housing have Alzheimer’s Disease or other type of dementia The Alzheimer’s population is projected to rise from 5 million today to over 7 million by 2025

SNF Occupancy at Record Low

• NIC Data: 82%

Occupancy

• Outflow exceeds

Inflow due to decreasing length of stay

KINDRED TO CEASE OWNING, OPERATING SKILLED NURSING FACILITIES

November 7, 2016

Navigating Asteroids: Skilled Nursing Moves with Technology

Skilled Nursing

VBP→ Readmission data gathering

CMS COPs Final IMPACT Act: 10.1.16

FHIR APIs

Mandatory Bundled Payments: CJR & Cardiac

ACOs

Pace of APM Increasing

INTERACT

Outcome Management → Analytics

QAPI

Transitions

• f Care

21st Century Cures Act Precision Medicine: Genotyping

Labor Shortage

VPB → reporting

• n NHC

VBP Penalties & Incentives begin IMPACT Act: 10.1.18 1) Med Rec 2) Transfer of information & Care preferences

2016 2017 2018

Regulatory Facility Operations ONC/Technology Market Forces

Acute Hospital

LTAC IRF SNF

Home Health

Hospice

RED are Post Acute Discharges Back to Hospital (readmissions) – average 18%

10%

9%

18% 22% 5%

BLUE Are Hospital Discharges To Post Acute Settings (PAC) 40% of Hospital Patients Transfer to PAC

1% 3% 17%

15%

2% 29% 57% 53% 2%

Post-Acute Services & Coordination Is Key to Managing HC Needs & Costs How the LA Jewish Home Can Meets the Need in 2016 & Beyond

BCSC or PACE & “a La Carte” Medical Home

Connections to Care – The One-Call Personal Counseling & Assistance

LA JH Provides

GREEN indicate transfers between PAC settings

Joyce Eisenberg Keefer Acute Psychiatric Hospital

The Los Angeles Jewish Home’s Connections to Care

Personalized Senior Case Management and Services

HOME- AND COMMUNITY- BASED SERVICES

GERIATRIC COMMUNITY CLINICS

• Primary & Special Medical Care

PACE / Brandman Centers for Senior Care (Supports Seniors In Their Own Home)

• PACE ‘Lite’—Self-Select PACE Services

CARE COORDINATION BRIDGE TO HOME PROGRAM HOME HEALTH AGENCY PERSONAL CARE SERVICES GERIATRIC CASE MANAGEMENT

• Medical Management

TRANSPORTATION SUPPORT GROUPS

• Memory Care
• Caregiver

L.A. CENTER FOR PALLIATIVE CARE (Management For Pain & Chronic Conditions) SKIRBALL HOSPICE INDEPENDENT SENIOR HOUSING

• Fountainview at Eisenberg Village
• Fountainview at Gonda Westside

RESIDENTIAL CARE w/Assisted Living *Newman Building *Polak Family Building *Bagno Towers SKILLED NURSING*

• General Skilled Nursing
• Memory Care
• Inpatient Hospice

SHORT TERM REHAB ACUTE GERIATRIC PSYCHIATRIC CARE JEWISH HOME PRIMARY CARE*

HOUSING & RESIDENTIAL SERVICES

BUILDING FOR TOMORROW’S HEALTHCARE NEEDS ANNENBERG SCHOOL OF NURSING

• Licensed Vocational Nurse (LVN)
• Personal Care Worker
• Home Health Aide
• Certified Nursing Assistant (CNA)
• Clinical Educational Partner for:

Registered Nurse (RN) Programs of Mount

• St. Mary’s And California State University of

Northridge EDUCATION & GERONTOLOGICAL RESEARCH ORGANIZATION

JHA NON-PROFIT PARENT ORGANIZATION PROGRAMS TO BUILD FOR TOMORROW

Toll Free: 1- 855-227-3745

Every Board and Leader Must have: A Truthful “Self-Examination” To Change How We Operate… Seeing different things…Doing things differently

Toot your Own Horn

KNOW YOUR BUSINESS…AND KNOW WHAT YOU DO VERY WELL? CAPTURE THE DATA, PRESENT IT & SEEK ALLIANCES

• Jennings Center for Older Adults: Allison

Salopeck

• McGregor P.A.C.E.: Tangi McCoy
• Montefiore: Mark Weiss
• Jewish Home Rockleigh: Sunni Herman
• Los Angeles Jewish Home: Molly Forrest

Innovative Programs that Save the Government Money

The average score of all JHA SNF Activities of Daily Living for Bed Mobility, Transfer, Toilet Use and Eating (Late Loss ADLs) used for RUG–IV rates. ADL scores are based on a maximum of 16 ADL points and impact reimbursement rates in the RUG- IV groups. Patients with higher ADL scores have a higher level of complexity/risk and indicate greater care is needed.

8.45 8.44 8.09

2.00 4.00 6.00 8.00 10.00 12.00

MEDICARE MEDI-CAL & PRIVATE ALL PAYERS Activities of Daily Living Score

Activities of Daily Living by Payer Fourth Quarter 2016

Low (0-5) Moderate (6-10)

Complex (11-16)

This is for all payers: Medicare, Medi-Cal and private pay. There were 893 residents with 0 admissions. 171 residents with 1

• admission. 38 residents with 2 admissions and 13 residents with 3 or more admissions.

80.09% 15.34% 3.41% 1.17%

2016 Inpatient Admission Rates for SNF Residents

0 Admissions 1 Admission 2 Admission

This is for all LAJH SNF facilities. The average inpatient admission among nursing home residents is 25% according to a 2011 study conducted by the U.S. Office of the Inspector General.

90.40% 3.66% 3.32% 2.62%

SNF Medicare Part A 2016 Hospital Usage Rates

No Hospital Usage ED Visit Inpatient Admission Observation

3.67% of all Grancell Village Short Stay Medicare Part A residents had a hospital inpatient admission in 2016. In comparison, according to a 2013 OIG (Office of the Inspector General) report 25% of Medicare nursing home residents experienced hospitalizations in 2011 and Medicare spent $14.3 billion on these hospitalizations.

89.76% 3.41% 3.67% 3.15%

Grancell Village Short Stay Medicare Part A 2016 Hospital Usage Rates

No Hospital Usage ED Visit Inpatient Admission Observation

CDC (Center for Disease Control) 2012 data shows nursing home depression at 48.5%. According to the Kaiser Foundation, 31% of nursing home residents had psychiatric conditions such as schizophrenia or mood disorder.

26% 18% 40% 13% 24% 41% 15% 6% 41% 25% 17%

Percentage of Residents

Grancell Village SNF Resident Breakdown by Diagnosis January 12, 2017

Atrial Fibrillation Cerebral Vascular Accident (and associated diagnoses) Chronic Kidney Disease Chronic Obstructive Pulmonary Disease Congestive Heart Failure Heart Disease Diabetes Mellitus Parkinson's Disease Depression Psychiatric Diagnosis (excluding Depression) Other Diagnoses

Potential Transformative Arenas

SNF Care Reimagined Life Plan communities expand and reposition Memory care explodes PACE and PACE-lite Population Health Health Systems/hospitals create elder support networks Home care comes in 36 Flavors INSURANCE PLANS NEED PARTNERS!!!!!!

1 2 3 4 5 6 7

Affiliation, Mergers & Sponsorship Transition Activity

• Pace of consolidation activity is dramatic, both in

the for-profit and not-for-profit space

• Multi-site organizations recognizing that growth

through sponsorship transition can accelerate pace and is costs less than new campus development

• Single-site providers wanting to benefit from greater

scale and sophistication of larger organizations

• Increasingly a consideration when looking to replace

a CEO vacancy or plan for succession SOURCE: Zeigler CT Market Trends, July

2015

Areas of Focus Today ….

• Continue All Staff Focus on HCC Adjusted Risk Scores
• Continue Evolution of Data Analytics for C2C
• Contracts with “Duals” Plans, MCOs, MA, Hospitals

Bundled Payments Share in Risk Share in PMPM

• Independent Physician Association - IPA

 Implementation of HCC Adjusted Risk Scores = Revenue Sharing with Partner