THE IAH STORY AND OPPORTUNITIES FOR HOME BASED PRIMARY CARE UNDER HEALTH REFORM James C. Pyles Powers, Pyles, Sutter

1
THE IAH STORY ANDOPPORTUNITIES FOR HOME
BASEDPRIMARY CARE UNDER HEALTH REFORMJames C.
PylesPowers, Pyles, Sutter Verville, P.C.1501
M Street, N.W.Washington, D.C. 20005(202)
466-6550jim.pyles_at_ppsv.com

2
Where We Are Today

• The Independence at Home program has been
• enacted as part of the most sweeping health
  reform
• legislation in the history of the U.S.
•  
• Home Based Primary Care is poised to
• become the future of health care
•  
• The Academy of Home Care Physicians has become
• the most influential professional association for
  its size.
• How did we get here?

3
THE IAH STORYA 15-YEAR OVERNIGHT SUCCESS

• 1995-2000Moved home health care from cost
  reimbursement to prospective pay
• 2000GWU reportIf home health has a future, it
  is in chronic care coordination
•  
• 2002Johns Hopkins report5 of chronically ill
  account for 50 of costs
•  
• 2002The Farragut West Group develops IAH
  specs.-The importance of house calls
•  
• Dec. 2002White House signs on
•  
• 2003Voluntary Chronic Care Coordination Pilot
  enacted in MMA 03
•  
• 2004April 2004Disaster! VCCI pilot hijacked
•  
• 2006Suggested new IAH proposalcontact
  Congressman Markey
•  
• 2007-2008IAH Coalition assembled, IAH drafted
  and vetted

4

• Sept. 2008IAH introduced by Cong. Markey and
  Senator Wyden
•  
• Oct. 2008VCCI confirmed a failure
• May 2009IAH reintroduced in House and Senate
•  
• March 2010IAH enacted as sec. 3024 of PPACA33
  member IAH Coalition, more than 100 organizations
  interested in participating 

5

• Information That Will Drive Health
• Reform
• The number one fiscal problem facing the U.S. is
  the high and rising cost of Medicare nothing
  else even comes closePresident Obama
• 25 of Medicare beneficiaries account for 85 of
  costsCBO
• High cost Medicare beneficiaries suffer from
  multiple chronic illnesses and disabilities

6

• These beneficiaries get poor care and have poor
  outcomes under the Medicare FFS
• This is the fastest growing segment of the
  Medicare population
• Publics three greatest fears about chronic
  illness
• Not being able to pay for care
• Loss of independence
• Becoming a burden to family and friends
• Health reform criticized for doing little to
  reduce costs

7

• PPACA may make the problem worse
• Will add 34 million Americans to insurance rolls
• Expands coverage for mental health and preventive
  services
• Earlier diagnosis of chronic illness
• Recommended cuts by deficit reduction commission
  in early Dec. 2010
• Further reductions recommended by IMAB by 2014
• Spending will go up, not down-AP 9/9/10

8

• Medicare
• Payments will be cut 575 billion
• Home care cut by 40 billion
• Increase in documentation requirements
• for physicians to prescribe home health
• Increase in face-to-face meeting
• requirements

9

• Medicaid
• Broadened coverage, new services
• Increased FMAP
• But only for a limited time
• States cannot deficit spend

10

• Private Insurance and MA
• Medicare Advantage cut 147 billion
• Adding 34 million new insured individuals
• Providing free prevention and wellness services
• Cannot exclude for pre-existing condition
• Cannot rate based on illness
• Cannot rescind coverage
• Cannot have lifetime or annuals limits on
  payments
• Essential benefits must include prevention,
• wellness and chronic disease management
• Plans must cover and reimburse effective case
  management, care coordination, and chronic
  disease management

11

• Private Insurance and MA (cont)--Milliman
• While not explicitly in the law, cost
  effectiveness will be central. Health plans are
  revisiting risk-sharing methods as a way to help
  control costs and to create quality incentives
• Medicare Advantage plans will become less
  attractive to consumers and carriers. An effort
  to reduce MA payments will have a significant
  effect on the MA market, with plans facing
  difficult questions over efficiency and benefit
  mix

12

• Essential features of any successful health
  reform model
• It must reduce costs
• It must be able to show the savings
• Primary care will be the coordinator
• It will be patient-centeredAdministrator Berwick
• It must reduce institutionalizations

13

• Home health not viewed as answer
• MedPAC March reporthome health payments need to
  be significantly reduced
• Wyatt Matas report (April 12, 2010)must evolve
  from basic home healthcare to true chronic care
  management
• Wall Street Journal (April 27, 2010)the number
  of in-home therapy visits tracks Medicare
  financial incentives

14

• May 12 letter from Senate Finance Committee--WSJ
  findings suggest that HHAs are basing the number
  of therapy visits they provide on how much
  Medicare will pay them instead of what is in the
  best interest of the patients. Illustrates that
  Congress is feeling the heat for lack of cost
  reduction
• DOJ/OIG Medicare fraud bust involving home care
  7/16/10
• 2011 prospective pay cut 900 million
• Rebased prospective pay 3/1/11

15

• Between 1997-2008
• Spending on home health declined by 1 billion
  (6) to 17 billion
• Number of beneficiaries declined by 400,000 (11)
  to 3.2 million
• Medicare spending grew by 259 billion (123)
• Spending on hospital care grew by 90 billion
  (73)
• Spending on SNFs grew by 16 billion (162)

16

• New Opportunities for Home-based primary care
• Preventive care and screening services
• -- 500 million--2 billion annually
• -- 100 Medicare coverage of personalized
  prevention plan1/1/11
• -- 100 health plan coverage 9/23/10
• -- 100 Medicaid coverage 1/1/13-incentives

17

• Independence at Home Demo-
• -- Health care of the future Sen. Aging
  Committee--4/22/10
• -- PPAC, Title III section 3024
• -- Unanimous bipartisan support
• -- Adds new chronic care coordination benefit
  across all treatment settings
• -- Funded entirely from savings

18

• -- Targets the highest cost Medicare
  beneficiaries with specific multiple chronic
  conditions, and functional disabilities
  including--chronic heart failure, diabetes,
  chronic obstructive pulmonary disease, ischemic
  heart disease, peripheral arterial disease,
  stroke, Alzheimers Disease and other dementias,
  pressure ulcers, hypertension, and
  neurodegenerative diseases
• -- Holds providers and practitioners accountable
  for minimum savings of 5, good outcomes and
  patient/caregiver satisfaction

19

• -- Splits savings beyond 5 on an 80/20
  basiscreates source for reinvestment in
  technology
• -- Allows chronically ill beneficiaries to
  receive primary care at home and avoid
  hospitalizations, ER visits and nursing home
  admissions
• -- Provides relief for sandwich generation
• -- Preserves beneficiary choicebenefits and
  providers
• -- Allows participation by home health providers
• -- Implemented no later than Jan. 1, 2012

20

• IAH is the ONLY Health Reform Proposal That
• -- Requires any savings
• -- Targets the highest cost Medicare
  beneficiaries
• -- Provides a new chronic care coordination
  benefit and is based on hundreds of similar
  programs across the country that have proven
  successful in reducing costs and improving
  outcomes for high cost chronically ill

21

• The VA Home-Based Primary Care Program
• -- Reduced hospital days 62
• -- Reduced nursing home days 88
• -- Reduced total VA costs 24
• -- Reduced Medicare costs 10.8
• -- While increasing home care visits by 264 and
  home care spending by 460

22

• Shared Savings Program (ACOs)
• Sec. 3022
• -- HHS can enter into 3-year agreements with
  groups of hospitals, physicians and physician
  groups which after a mechanism for shared
  governance
• -- No mention of home health providers or DME
  suppliers but Secretary may add other groups of
  providers and suppliers as appropriate
• -- ACO must be willing to become accountable for
  the quality, cost, and overall care of Medicare
  fee-for-service beneficiaries assigned to it

23

• -- Groups of providers and suppliers in an ACO
  may work together to manage and coordinate care
  for FFS Medicare beneficiaries
• -- ACOs will have a minimum of 5,000
  beneficiaries assigned to it by CMS from patients
  receiving services from primary care physicians
  in the ACO
• -- Providers and suppliers in an ACO continue to
  receive all FFS payments plus some share of
  savings, IF ANY

24

• -- ACOs can receive a percentage of savings
  (specified by the Secretary), after a threshold
  percentage (specified by the Secretary) up to a
  cap (specified by the Secretary)
• -- Savings are computed by comparing the
  estimated per capita average costs in a year with
  the estimated benchmark costs per capita for
  those beneficiaries over the most recent 3 years
  for which data are available
• -- Reimbursement can also be partial
  capitation or any other method selected by the
  Secretary

25

• -- Program must be established not later than
  January 1, 2012
• -- ACO program is a permanent new part of
  Medicarenot a pilot or demonstration project

26

• CMS Innovation Center, Sec. 3021to test
  innovative payment and service delivery models to
  reduce program expenditures while preserving or
  enhancing quality preference for models that
  improve coordination, quality and efficiency
  shall select models where there is evidence they
  address a defined population with deficits in
  care leading to poor clinical outcomes,
  potentially avoidable expenditures

27

• 18 Models May Be Tested Including the
  Following
• Funding home health providers who offer chronic
  care management in cooperation with
  interdisciplinary teams
• Patient-centered medical home for high-need
  individuals
• Establishing community-based health teams to
  support small practice medical homes
• Contracting directly with groups of providers and
  suppliers under risk-based comprehensive payment
  or salary-based payment

28

• Using geriatric assessments and care plans to
  coordinate care of individuals with multiple
  chronic conditions and an inability to perform 2
  or more ADLs and cognitive impairment
• Care coordination that moves providers from FFS
  reimbursement to salary-based payment
• Care coordination for chronically-ill
  beneficiaries at high risk of hospitalization
  through HIT enabled provider network that
  includes care coordinators, a chronic disease
  registry, and home telehealth

29

• Paying providers and suppliers for using patient
  decision-support tools
• Payment incentives for using evidence-based
  guidelines or cancer care and follow-up care
  planning
• Paying for home health care in continuing care
  hospitals and 30 days following discharge
• Allowing outpatient services, including
  outpatient physical therapy to be provided
  without a referral from a physician if permitted
  by state law

30

• CMS Innovation Center programs can be extended or
  expanded if CMS Actuary determines they would
  reduce program spending
• Center must begin carrying out its duties not
  later than January 1, 2011

31

• Hospital Readmission Reduction Program, Sec. 3025
• Hospital payments reduced for excess
  readmissions
• Beginning fiscal years Oct. 1, 2012
• Community-Based Care Transitions Program, Sec.
  3026
• Additional funding for hospitals with high
  readmission rates
• For high-risk Medicare beneficiaries with
  multiple chronic conditions
• Begins January 1, 2011

32

• National Pilot on Payment Bundling, Sec. 3023
• -- Group of hospitals, physician practices
  nursing homes and home health agencies receive
  single payment for all services 3 days prior to
  hospitalization to 30 days after
• -- Not later than Jan. 1, 2013
• Community First Option, Sec. 2401
• -- States may amend Medicaid plans to offer
  medical assistance for home and community-based
  attendant services and supports
• -- Beginning Oct. 1, 2011

33

• Removal of Barriers to Home and CommunityBased
  Services,
• Sec. 2402
• -- Secretary to issue regulations requiring
  states to allocate resources to meet the needs
  and choice of individuals who want to receive
  services outside of an institution and maintain
  their independence
• -- States may expand HCB programs to individuals
  at 300 of SSI income benefit rate
• -- Plan amendments can be made April 1, 2010

34

• Health Home Medicaid Option for Chronic
  Conditions
• States can amend plans to provide chronically ill
  beneficiaries comprehensive care management, care
  coordination, health promotion and transitional
  care
• Can be provided by designated providers
  (including HHAs), team of health care
  professionals, or a health care team
• 90 federal funding for 2 years
• Effective 1/1/11