AHCANCAL 59th Annual Convention

1
AHCANCAL59th Annual Convention
ExpoRegulatory Update

• Peter Gruhn, Research
• Dianne De La Mare, Regulatory Affairs
• Sandra Fitzler, Regulatory Affairs
• Janice Zalen, Reimbursement
• Melissa Temkin, Membership

2
Trends and Medicare Update

• Peter Gruhn
• Director of Research
• 202/898-2819
• pgruhn_at_ahca.org

3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
CMS FY2009 SNF PPS Final Rule

• Final rule published August 8, 2008
• SNF market basket increase of 3.4
• No forecast error adjustment of 3.3
• 128 add-on which began on October 1, 2004 for
  HIV/AIDS patient remains
• No market basket forecast error correction
  because error less than new threshold
• The labor-related share will be 69.783 down from
  70.249 in FY 2008
• CMS Financial Impact 780 million (11 ppd)

8
SNF Reimbursement and FY 2010 Look Out

• The Deteriorating Federal Budget
• SNF PPS Forecast Error Adjustment
• The STRIVE project and SNF PPS Reform
• Other

9
The Deteriorating Budget
Source OMB. 2008 and 2009 estimates from
Presidents FY2009 budget
10
The Increase in Debt is Far Greater Than the 410
Billion Deficit
Source OMB, SBC.
11
Forecast Error Adjustment - Round 2

• In 2006, CMS refined the SNF PPS CMIs to better
  account for resource use of medically complex
  patients (RUG-53) using 2001 data
• CMS adjusted the nursing weights so that payments
  under RUG-44 and RUG 53 would be the same
• In the FY2009 SNF PPS NPRM, CMS reported that
  Medicare expenditures were higher under RUG-53
  than they would have been under RUG-44 based on
  actual 2006 data
• CMS proposed to recalibrate the nursing weights
  such that payments would be the same
• Payments for FY 2009 were estimated to decline by
  770 million

12
Forecast Error Adjustment (cont.)

• AHCA commented extensively on the NPRM, and
  lobbied actively against the proposed adjustment
• In the final rule, CMS
• Decided not to proceed with the proposed
  recalibration at this time pending further
  analysis
• Was confident that it employed the correct
  recalibration approach
• Would continue to evaluate the issue, and expects
  to implement an adjustment in the future (FY
  2010?)

13
STRIVE Project

• Conducted for CMS by the Iowa Foundation for
  Medical Care (IFMC).
• Purpose To determine the amount of time that
  nursing home staff spend caring for residents,
  and examine and evaluate changes to the SNF PPS
  RUG-III payment system.
• First national nursing home time study update
  since the establishment of the RUG-III case mix
  weights back in 1997.
• Data collected from over 10,000 residents in 205
  facilities in 15 states

14
STRIVE Project (cont.)

• CMS expected to update the nursing and therapy
  weights for FY 2010 using STRIVE data
• CMS is also reevaluating RUG-III and examine need
  for RUG-IV
• Examine lookback, examine special populations,
  reexamine rehab ext srv categories, analyze
  NTAS usage, adapt to MDS 3.0, etc.
• Phase 2 analytic report to be submitted to CMS in
  late 2008 / early 2009
• AHCA expects that the Phase 2 work will be the
  basis for a major refinement to the SNF PPS for
  the FY2010 SNF PPS proposed rule.

15
Workforce Fraud/Abuse

• Dianne De La Mare
• VP, Regulatory Affairs
• 202/898-2830
• ddmare_at_ahca.org

16
Workforce Report

• IOM Report, Retooling for an Aging America
  Building the Health Care Workforce.
  Recommendations include
• Annual report monitoring the supply crisis
• Encourage hospitals to train residents in all
  settings, including NFs, ALFs and home care
• All licensure and certification must include a
  show of competence in elder care
• Federal/State governments should increase the
  direct care staff minimum training standards
• Public/private organizations should provide
  funding/training opportunities for informal
  caregivers

17
Workforce Report (cont.)

• IOM Recommendations (cont.)
• Public/private should provide financial
  incentives to increase the number of geriatric
  specialists
• All payers should enhance reimbursement for a
  geriatric specialty in clinical certification
• Congress should authorize a Geriatric Academic
  Career Award
• Federal/State governments should institute loan
  forgiveness, scholarship and direct financial
  incentives for becoming a geriatric specialist
• State Medicaid programs should increase
  pay/fringe benefits to direct care workers.

18
Workforce Report (cont.)

• IOM Recommendations (cont.)
• Payers should promote and reward new models of
  care for older individuals
• Congress/Foundations should increase support for
  research/demonstration programs that promote
  development of new models of care
• Disciplines/regulators/employers should expand
  the roles of individuals who care for the older
  population
• Federal agencies should provide support for the
  development/promulgation of technological
  advancements that enhance capacity to provide
  care for the elderly.

19
Workforce Report (cont.)

• MIV Report, 2007 National Survey of Consuemr and
  Workforce Satisfaction in NHs. Recommendations
  include
• Management must listen and care about direct
  caregivers
• Focus should be on hiring and ensuring that
  employees are adequately trained/supported
• Employers must determine how to retain older
  workers and attract younger workers.

20
Fraud/Abuse

• OIG Draft OIG Supplement Compliance Program
  Guidance for NFs released in April 2008, and the
  final supplement guidance expected in October
  2008.
• The final document will supplement the prior OIG
  guidance released in 2000, OIG Compliance Program
  Guidance for NFs.
• In the supplement, OIG focuses on quality of care
  issues, and mentions for the first time that an
  ALF may want to think about developing and
  implementing a compliance program.
• AHCA is meeting with OIG on a regular basis, and
  has launched an educational program for all
  AHCA/NCAL members.

21
Survey Life Safety

• Lyn Bentley
• Director of Survey/Certification/Enforcement
• 202/898-6304
• lbentley_at_ahca.org

22
Five Star Quality Program

• CMS presents this program as an improvement to
  NH Compare
• Rating system will include three components
• Survey Results
• Staffing
• Quality Measures

23
Five Star (cont.) - Quality Measures

• Subset of current NH Compare
• ADL change
• Mobility change
• Long-stay prevalence measures
• Pressure ulcers
• Physical restraints
• UTIs
• Long-term catheters
• Pain

• Short-stay prevalence measures
• Delirium
• Pain
• Pressure Ulcers

24
Five Star (cont.)

• Topic Expert Panel includes primarily
  researchers, one provider representative
• Abt is meeting with the panel for their ideas
  about development of Five Star
• Abt is developing the weighting formula will
  be complete in Oct. 2008
• First phase of Five Star will be live on CMS
  Web site in Dec. 2008

25
Five Star (cont.)

• Second phase of Five Star may include additional
  information
• Patient/family satisfaction scores
• Add new quality measures
• Include specific characteristics of nursing homes
  (e.g., specialty units languages spoken private
  rooms)
• Staffing data collected from payroll sources

26
Quality Indicator Survey

• Now (or soon to be) in
• OH KS LA CT FL MN NC NM WV
• Responses from members are still varied love
  it hate it positives out-weight the negatives
  still too soon to make a decision
• QIS no longer in CA resource issue per CMS
• CMS hopes to continue to roll out in 3 4
  states/year

27
Quality Indicator Survey (cont.)

• Second evaluation by Abt showed that QIS did NOT
  meet any of the CMS-defined goals for the program
• Improve consistency/accuracy of QOC/QOL problem
  identification using a more structured process
• More comprehensive review of facilities
• Enhanced documentation organize survey findings
  via computer
• Focus survey resources on facilities with largest
  number of quality concerns

28
Quality Indicator Survey (cont.)

• Caveats to the Abt report
• Not yet released by CMS (although it was complete
  in Dec. 2007)
• CMS committed to AHCA that they would release
  report w/CMS Action Plan to address concerns
  during summer 2008
• AHCA remains cautiously optimistic that this
  process could improve survey consistency

29
Surveyor Guidance Revisions Update

• F371 - Safe Food Handling- Mid 2008
• F325 - Nutritional Parameters - Mid 2008
• F309 Guidance for Pain Management 2008 or
  early 2009
• F441 - Infection Control Fall 2009
• F223 through F226 Abuse sometime in the
  future
• F309 Guidance for End-of-Life sometime in the
  future

30
Fire and Life Safety

• CMS issued new regulation all nursing homes
  must be fully-sprinklered by August 13, 2013 (a
  five-year phase-in)
• AHCA continues to work with Congress to obtain
  grants or low-interest loans to assist providers
  who must install sprinklers

31
MDS, RAPs, PAC Demonstration Medication
Disposal

• Sandra Fitzler
• Sr. Dir. of Clinical Services
• 202/898-6307
• sfitzler_at_ahca.org

32
MDS 3.0

• Draft released in 1/08
• New tool shows excellent/very good reliability -
  MDS 3.0 out-performed 2.0
• Improved clinical relevance
• Takes less time to complete
• Improved tool technology, standardize terminology
  scales, link to STRIVE CARE

33
MDS 3.0 (cont.)

• Not all look-backs are 5-days
• Add self-report interview items more
  resident-centered
• Improved wording
• RUGs QMs - items retained
• Improved pressure ulcer assessment ends reverse
  staging coding for healing wounds allows
  identification of ulcers found on admission

34
MDS 3.0 (cont.)

• Expanded return to community section to better
  identify those who can benefit from Money Follows
  the Person
• Expanded section on Pain incorporated with
  assessment of health conditions
• Adds- definition of restraint to tool and
  anticoagulant to medication section
• Improves problematic coding elements no longer
  considers a resident with a catheter as being
  continent

35
RAPs

• No funds to update RAPs or to provide updates on
  a regular basis to ensure information is current
• Even if funding is available, not sure if
  updating a process that is poorly utilized is a
  wise investment

36
RAPs (cont.)

• In the fall of 2004, AHRQ pulled together a RAP
  workgroup, conducted a survey on RAP utilization
  and released a report
• Survey encompassed 1,835 AANAC, MDS Coordinators
  and 56 VA respondents
• 76 found RAPs are somewhat, rarely or never
  helpful
• RAP completion does not involve the
  interdisciplinary team as they are often
  completed separately by multiple individuals
  (30) or by individuals who do not participate in
  care (26) like MDS Coordinators having no
  clinical responsibility

37
RAPs (cont.)

• 31 saw RAPs as too time consuming
• 27 stated RAPs are done for paper compliance
• Physicians often uninvolved in the RAP and do not
  consider the care plan when making resident
  treatment decisions
• CNA work is not reflected in care plans

38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
RAPs (cont.)

• Do not update RAP Utilization Guidelines RAP
  Summary
• Go back to the basics for care planning use
  interdisciplinary team
• Consider retaining revising Trigger Legend
  renaming it Triggers for Analysis and Planning
  (TAP)
• Encourage the use of evidence-based practice
  guidelines information on clinical websites as
  resources for care planning

42
RAPs (cont.)

• Independent effort underway to develop an
  electronic decision tree for depression.
• There has been some discussion at CMS about the
  development of a RAP for Return to the Community

43
PAC Demonstration

• Boston, MA
• Seattle, WA (includes Portland, OR)
• Lincoln, NE (includes Omaha) ? Sioux Falls, SD
• Lakeland, FL
• San Francisco, CA
• Rochester, NY
• Chicago, IL
• Dallas, TX (includes Plano. Tyler, Fort Worth)
• Louisville, KY
• Columbia, MO
• Wilmington, NC (newest market)

44
PAC Demonstration/QIO Overlap

• All QIOs will strive to get 10 of providers to
  use the CARE tool
• This is a separate effort from the PAC
  demonstration exception NE
• Purpose To identify elements missing from the
  CARE tool needed to improve care transitions

45
PAC Demonstration (cont.)

• CMS collecting care transition literature
• 11/08, RTI plans to hold a TEP to start
  discussion on what additional items need to be
  added to the CARE tool
• QIOs will nominate people to the RTI TEP
• Concurrently, QIOs will be working on identifying
  transition of care items, needed on the tool, to
  improve care continuity

46
PAC Demonstration Key Contacts

• Barbara Gage, Project Director RTI
  bgage_at_rti.org
• Laura Coots, RTI lcoots_at_rti.org
• Judy Abbate, RTI jabbate_at_rti.org
• CMS staff involved in PAC demo Doug Brown, Tracy
  Archibald Judy Tobin
• CMS involved in QIO efforts Debbie Terkay

47
Disposal of Unused Drugs

• No federal law only guidelines on the disposal
  of controlled substances
• Some states have implemented laws for drug
  disposal and/or redistribution
• DEA will be releasing proposed regulation
• EPA concerned about unused drugs in ground water
• EPA survey for healthcare leading to potential
  regulation

48
Disaster Planning Medicaid

• Janice Zalen
• Sr. Director of Special Programs
• 202/898-2831
• jzalen_at_ahca.org

49
Disaster Planning

• Dept. of Health and Human Services (HHS)
• Office of the Assistant Secretary for
  Preparedness and Response (ASPR)
• Center for Disease Control and Preparedness (CDC)
• Center for Medicare and Medicaid Services (CMS)
• Department of Homeland Security
• Federal Emergency Management Administration
  (FEMA)
• Department of Labor
• Occupational Safety and Health Administration
  (OSHA)

50
CDC/Influenza Pandemic

• Challenging questions
• Who receives the first vaccines from a limited
  supply?
• Who receives the limited supply of antivirals?
• Who should be responsible for stockpiling medical
  countermeasures, e.g., facemasks, respirators,
  antiviral medications?
• Decisions made with limited information.

51
CDC/Pandemic Influenza Vaccine

• Draft CDC Guidance released late 2007 for
  discussion
• Tier 1(top priority) 25 of LTC facilities
  direct care workforce
• Tier 5 (out of 6) residents of LTC facilities
• AHCA/NCAL attended several stakeholder meetings
  and sent written comments
• Results of 2008 stakeholders meetings and
  comment letters (not yet released)
• Tier 1 75 of LTC facilities direct care
  workforce
• Tier 5 Residents of LTC facilities

52
CDC/Antiviral Drug Use and Stockpiling (cont.)

• Stakeholder meetings in late 2007 and early 2008,
  including conference call with AHCA/NCAL members
  and survey
• To determine who gets doses from national
  strategic stockpile
• To identify barriers to employers purchasing
  their own stockpiles
• Initial guidance containment and early
  treatment limited doses

53
CDC/Antiviral Drug Use and Stockpiling (cont.)

• CDC released 2 guidance in 2008
• Proposed Guidance on Antiviral Drug Use During
  an Influenza Pandemic
• Considerations for Antiviral Drug Stockpiling by
  Employers in Preparation for an Influenza
  Pandemic
• Reflect increased manufacturing capacity
• Recognizes potential value of prophylaxis (Px) to
  maintain healthcare and other critical services
• Front-line HCWsoutbreak Px (12 weeks)
• Other HCWsPost-exposure Px (10 days)
• ResidentsPost-exposure Px
• HHS recommends shared responsibility, i.e.,
  employer buys and stores their own
• AHCA commented on both guidances
• To date, no final guidances released

54
LTC Facilities

• Ought to be planning for an influenza pandemic
• CDC (AHCA/NCAL vetted) checklist
  http//www.pandemicflu.gov/plan/healthcare/longter
  mcarechecklist.html
• Pandemic Influenza Workbook for LTC (California
  Association of Health Facilities)
  www.cahf.org/public/dpp
• Disaster Planning Booth Exhibit

55
CMS/During an Emergency

• HHS issued more than one public health emergency
  declaration in 2008
• Allows certain waivers, e.g. waive the 3-day
  hospital stay requirement
• CMS provides FAQs to help answer questions
  relating to the emergency
• These FAQs are becoming consistent so in effect,
  we have CMS disaster policy
• http//www.cms.hhs.gov/Emergency/Downloads/Medicar
  eFFS_Policy_Gustav_09102008.pdf (Medicare)
• http//www.cms.hhs.gov/SurveyCertEmergPrep/Downloa
  ds/AllHazardsFAQs.pdf (Survey Certification)

56
CMS/Survey and Certification

• No new regulations (yet)
• Favors all hazards planning
• Stakeholder group reviewing documents for past
  two years
• http//www.cms.hhs.gov/SurveyCertEmergPrep/
• AHCA role--To stress voluntary nature of the
  documents
• Checklists
• After Action Plans
• Recommendations

57
Medicaid Reform/Rebalancing

• Definition Take away institutional bias, i.e.,
  serve more people in the community
• Result More Medicaid dollars to HCBS and more
  acute residents in NFs
• Reason Cost containment changing personal
  preferences
• Vehicles 1915(c) and 1115 waivers, real choice
  systems change grants, aging and disability
  resource centers, DRA, MFP Demonstration Grants

58
Medicaid Reform (cont.)

• Section 1115 waiver RI Application
• State contribution would be capped at 23 of the
  state's general fund budget
• Annual federal block grant
• NF care only for highest need level
• DRA In 08 CMS issued proposed rules for
• Self-directed personal assistance services
• Benchmark benefits provision
• HCBS state plan services

59
AHCA/NCAL/Alliance LTC Finance Reform Proposal

• Goal Help shape the future towards a
  sustainable array of quality LTC services
• Currently Medicare Medicaid pay almost 70 of
  LTC and post acute care costs
• LTC Finance Reform Proposal Highlights
• Infuses private funding into LTC system
• New Personal responsibility expectation federal
  catastrophic LTC coverage for Medicare eligibles
  major federal education campaign improved
  financial products to help prepare for LTC needs
• Exemption for low income individuals
• Benefits NF, ALF, HCBS, Medicare Advantage

60
LTC Finance Reform Proposal (cont.)

• Post-Acute Care Highlights
• Site neutral prospective payment system
• National post-acute patient assessment tool
• Status of Proposal
• Released in January response favorable
• Some common ground with other proposals
• Bob Van Dyk presented to health innovations
  breakfast at the Republican Convention

61
LTC Finance Reform Proposal (cont.)

• Next Steps
• Contract to score the proposal
• Estimate the budgetary effects of the proposal
• To be completed late January
• Continue to give presentations and to publicize
  the plan
• Questions
• http//www.ahcancal.org/advocacy/Documents/AHCA-Al
  lianceJointHighlights.pdf
• jzalen_at_ahca.org

62
OSHA, Hospice, VA DD

• Melissa Temkin
• Director of Membership and Regulatory Relations
• 202/898-2822
• mtemkin_at_ahca.org

63
OSHA/SST Inspections

• Applies to NFs, ICFs/MR and ALFs.
• For 2008 SST DART greater than/equals 11,
  DAFWII greater than/equals 9.
• OSHA will randomly select and inspect about 175
  workplaces (with 100 or more employees and in
  industries that had higher than the national
  DART/DAFWII rates) that reported low injury and
  illness rates to review their actual degree of
  compliance.

64
OSHA/New Items

• PPE final rule
• Wicker rider defeated Enforcement of
  respirator fit testing for TB.
• Safe patient handling legislation in New Jersey
  passed.

65
OSHA/PPE Final Rule

• Final released on November 15, 2007 8 years
  after rule proposed.
• Items for patient safety and health (rather than
  for employee safety and health) do not have to be
  paid for by employer.
• E.g., plastic /rubber gloves, self-sheathing
  needles, etc.
• Infection control items are still required for
  CMS compliance.

66
OSHA/Wicker Rider

• Prohibits OSHA spending on enforcement of annual
  respirator fit testing requirements for TB
  protection in healthcare settings.
• Wicker Amendment not included in FY08
  Appropriations bill.
• If score low on CDC risk assessment, OSHA fit
  testing requirements do not apply.

67
New Jersey Safe Patient Handling Legislation

• Applies to NFs, general/specialty hospitals and
  county psychiatric hospitals.
• Patients can refuse mechanical lifting,
  facilities cannot retaliate against employees.
• Recommends three year capital plan.
• January 2011 mandate to establish program.

68
Hospice CoPs

• June 5, 2008 CMS released final rule on Hospice
  CoPs goes into effect on Dec. 2.
• Hospices must formally contract with the facility
  in which their patients reside. Minimum
  requirements of the contract include
• Hospice responsible to determine appropriate
  course of care.
• Identification of services the hospice will
  provide, including medical direction and patient
  management, drugs for palliation, etc.
• Hospice may use the SNF/NF or ICF/MR nursing
  personnel to assist as hospice would routinely
  use a patients family to implement the plan of
  care.

69
AHCA 2007 Hospice Survey

• 423 respondents, mostly NF administrators and
  DONs, a few hospice professionals.
• Surveyors questions to NF staff regarding
  hospice
• How is NF/hospice patient care coordinated?
• Why are some patients on hospice for 6 months?
• What are the differences between NF services for
  hospice patients and hospice contractor
  services?
• If NF versus hospice services are not that
  different, why are hospice contractors needed at
  all? (F-490)

70
Shared Survey Results with NHPCO

• Most Immediate Needs-- Educational Tools,
  In-Services
• Differences in NF hospice staff services.
• NF/ hospice care coordination.
• Appropriate care planning.
• Longer Term Needs
• Appropriate expectations of patient outcomes.
• Acknowledge unique, valuable skills and roles of
  NF and hospice staff.
• Hospice and LTC staff work together, not against
  each other!

71
VA/CNH Agreement

• AHCA is working with VA to revise the Community
  Nursing Home (CNH) provider agreement.
• Negotiated items
• VA agrees that CNHs are exempt from requirements
  in the Service Contract Act and E.O. 11246 (e.g.,
  prevailing wage rate, affirmative action plans,
  etc.)
• Allow compliance with CMS version of the LSC with
  full sprinklering of facilities.
• HIPAA is adequate to protect PHI business
  associate agreements not required.
• New 10 VA RUG system must be used in conjunction
  with agreement.

72
Proposed VA Rate Setting Methodology

• Combine 53 RUGs into 10 V/A RUGs.
• Use therapy intensity and nursing CMI to define
  the 10 V/A RUGs.
• Calculate weighted rates for each VA RUG using
• PPS Rates and Local Wage Indexes published by CMS
• Distribution of Medicare Days by RUG-53 for a
  sample of multi-facility operators

73
Next Steps

• VA to reiterate the availability and benefits of
  new agreement to VA Medical Centers (VAMCs)
  nationwide.
• VA will work closely with VAMCs that have
  expressed interest in the agreement.
• CNHs interested in serving VA patients can also
  contact their VAMCs.

74
DD Proposed Rule

• Clarifies and proposes new requirements to
  implement the DD Act, which establishes
• State Councils on DD.
• Protection and Advocacy (PA) systems in states.
• University Centers for Excellence in DD.
• Funding for national initiatives.

75
DD Proposed Rule (cont.)

• Rule could affect all LTC providers as
  individuals with DD reside in multiple settings.
• Revised definitions in the rule do not
  appropriately identify thresholds used to define
  them.
• Aspects of the rule dont recognize rights of
  individuals with DD to reside in ICFs/MR ICFs/MR
  are left vulnerable to closure.
• Proposes inappropriate access by State PAs to
  individuals with DD, their records and service
  providers.
• Service providers are not guaranteed the right to
  be parties at hearings that address allegations
  of poor care to individuals with DD.

76
AHCA Recommends

• PAs should have to notify ICF/MR residents,
  families, legal guardians or representatives
  before filing a class action lawsuit against an
  ICF/MR.
• PAs should give residents and representatives
  the right to opt out of the lawsuit.
• Revise the definition of complaint so that
  residential placement alone (e.g., residing in an
  ICF/MR), if not related to quality issues, does
  not constitute a complaint issue.
• Recommend further revisions to abuse, neglect
  and probable cause definitions to identify
  reasonable thresholds .

77
Recommendations (cont.)

• Records accessed by PA should relate directly to
  allegation of sub-optimal care.
• PA access to providers must be based on
  substantiated allegations of wrongdoing and only
  involve individuals with DD that are the subject
  of wrongdoing.
• Parties addressed in a hearing should be
  guaranteed admission, as well as the right to
  testify on their own behalf.

78

• QUESTIONS??