CMS issues proposed home health payment rule

The Centers for Medicare & Medicaid Services on July 30 proposed a net decrease of -0.86% in Medicare payments for home health agencies in calendar year 2010. This includes a 2.2% market basket update, which would be decreased by 2.75% as part of a four-year series of cuts that adjust for coding changes between 1999 and 2005. In addition, the rule states that CMS is considering additional coding reductions, based on further analysis of case mix change, that could lower 2010 payments by -4.90.

The proposed rule would also cap outlier payments at 10% per agency and limit total outlier payments to 2.5% of total HH PPS payments. The rule will be published in the Aug. 6 Federal Register with comments accepted through Sept. 28.

Home health agencies (HHAs) receive additional payments (outlier payments) for 60-day home health episodes of care that carry unusually high costs. CMS proposes to cap outlier payments at 10 percent per agency and target total aggregate outlier payments at 2.5 percent of total HH PPS payments. Currently, the target for outlier payment targets is 5 percent of total HH PPS payments. As such, CMS reduces home health rates by 5 percent to fund outlier payments. By lowering the total outlier payment target to 2.5 percent of total HH PPS payments, CMS would increase home health rates by 2.5 percent.

Read the full article.

Presidential Report Confirms Health Care Jobs On The Rise

We didn’t have to read the new jobs report from Obama’s Council of Economic Advisers to know that health care’s going to add a lot of jobs over the next several years.

But we were interested in the report’s finding that the biggest job growth of any category in the economy would come not for doctors, nurses, or nursing home workers, but for a broadly defined group called “other medical services and dentists.”

The report defines that group as “a broad category including the ever-expanding home health care, outpatient care, and medical and diagnostic laboratories subsectors,” and projects more than 2 million new jobs per year for the group, on average, between 2008 and 2016.

A separate projection looks at the growth of health-related jobs versus all other occupations between 2000 and 2016. The finding: 12% growth for “other occupations”; 35% growth for “health practitioners”; and 48% growth for “health care support.” Health care support includes physical therapists, physical therapist assistants, medical social workers and home health care aides, the report says.

Joint Commission Offers Seasonal Flu Immunization Strategies

Free Monograph Designed to Improve Health Care Worker Vaccination Rates

(OAKBROOK TERRACE, Ill. – June 24, 2009) Seasonal influenza in health care workers is a personal health threat, but also poses a significant risk to the patients in their care. In an effort to help health care organizations improve the rate of health care worker influenza vaccinations, The Joint Commission is releasing a monograph “Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination: Strategies from Research and Practice.”

The monograph, which was supported by an educational grant from sanofi pasteur, is the result of the project Strategies for Implementing Successful Influenza Immunization Programs for Health Care Personnel, a 10-month collaboration between The Joint Commission, the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), and the National Foundation for Infectious Diseases (NFID).

The monograph includes information about seasonal influenza and the influenza vaccine, barriers to successful programs and strategies for overcoming them, and examples of successful initiatives organizations have used to improve their influenza vaccination rates. The Joint Commission received more than 229 submissions from health care organizations and a subset of submissions was selected for a panel review. Ultimately, 28 submissions were selected for inclusion in the monograph.

The monograph incorporates evidence-based guidelines and published literature to highlight practical strategies and the tools submitted by health care organizations. Electronic copies of the monograph are available on The Joint Commission’s Web site at www.jointcommission.org, and can be downloaded free of charge.

“Health care worker flu vaccination rates have been less than optimal for years and the vaccination rate is still below 50 percent. Organizations are eager to find ways to encourage their employees to get vaccinated,” says Jerod M. Loeb, Ph.D., executive vice president, Division of Quality Measurement and Research, The Joint Commission. “The monograph includes strategies that organizations can employ and provides a foundation to improve vaccination rates.”

According to the CDC, vaccination coverage of health care personnel remains low despite the documented benefits on patient outcomes, staff absenteeism and reducing infections among staff. In addition, increased vaccination rates can reduce costs within health care organizations. Health care personnel can acquire seasonal influenza from patients and can also spread the disease to vulnerable patients or other staff. In 2007, The Joint Commission implemented a new standard in hospitals and long term care facilities requiring that influenza vaccinations be offered to staff and practitioners.

###

Founded in 1951, The Joint Commission seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits more than 16,000 health care organizations and programs in the United States, including more than 8,000 hospitals and home care organizations, and more than 6,200 other health care organizations that provide long term care, behavioral health care, laboratory and ambulatory care services. In addition, The Joint Commission also provides certification of more than 600 disease-specific care programs, primary stroke centers, and health care staffing services. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at www.jointcommission.org.

HCAF Show - Orlando, FL June 24 and 25 2009

Stop by and meet us at booth 25 in Orlando. We want to give you something!

Bring along one or two of the forms that you use in your home health care agency, in Microsoft Word or Microsoft Excel formats, on a CD or USB stick, and we will convert them to digitized forms while you wait - no charge!

While we convert your forms, we will show you home health care agencies are increasingly turning to point of care solutions to make it easier for caregivers to capture and deliver notes for their entire treatment schedule. This helps agencies submit their bills faster - no more searching for visit notes, no more transcribing of notes in to other systems.

Come and meet our team at booth 25, HCAF Show, Omni Orlando Resort at Championsgate, Orlando, Florida, 5:00pm to 7:30pm on June 24th, and 7:00am to 6:30pm on June 25th, 2009.

To call ahead to schedule an appointment, phone (305) 675-6704 and ask for Marc on extension 704.

ENSURE APPROPRIATE PAY FOR HEALTH SERVICES

ENSURE ADEQUATE AND APPROPRIATE PAYMENT
FOR MEDICARE HOME HEALTH SERVICES

ISSUE: The Centers for Medicare & Medicaid Services (CMS) administratively has promulgated a 2.75 percent across-the-board rate reduction for home health services for 2008, 2009, and 2010, as well as a 2.71 percent cut for 2011. The 2.75 percent cuts scheduled for 2008 and 2009 have been implemented. Over the next five years (2009- 2013) these cuts will reduce outlays for home health by $7.59 billion unless Congress blocks them. These reductions are based on an unfounded allegation by CMS that case mix weights have increased without attendant changes in patient characteristics, referred to by CMS as “case mix creep” or “upcoding.”

In its 2009 report to Congress, the Medicare Payment Advisory Commission(MedPAC) recommended that Congress eliminate the home health market basket update for 2010 and accelerate the application of the 2011 coding creep adjustment proposed for 2011 (2.71 percent) to 2010—reducing current rates in 2010 by 5.46 percent. MedPAC also recommended that Congress direct CMS to rebase home health payments in 2011, using 2007 costs as a base.

A 5 percent rural payment differential or “rural add-on” for home health services delivered in rural areas expired on December 31, 2006. This has resulted in rural home health agency closures and threatened access to home health care for beneficiaries living in rural areas.

In February 2009, the Obama Administration included MedPAC’s 2009 recommendations for deep cuts to home health as part of its proposed FY 2010 budget. Over five years these harmful cuts would take more than $13 billion from the Medicare home health program. The administration’s budget also calls for the bundling of hospital and post acute care payments beginning in 2013.

RECOMMENDATION: Congress should: 1) Reform the Medicare home health payment model to achieve a more reliable payment distribution that reflects varying resource uses and costs incurred in providing care to individual patients; 2) Reject any proposals to cut the home health market basket inflation update or impose additional rate reductions for home health agencies; 3) Reinstate the 5 percent add-on payment for home health services in rural areas; 4) Block the home health case mix rate reductions and reform the regulatory process for evaluating case mix changes; and 5) Reject proposals to bundle home health payments into hospital or other provider payments.

RATIONALE:
• MedPAC’s proposed freeze in home health payments, coupled with the CMS regulatory payment reductions and rebased payment rates, would reduce home health payments by $550 million in 2010, by 2.5 billion in 2011, and by $13 billion from 2010 through 2014. These cuts would come from a benefit that is about $15.5 billion per year ($2 billion less than in 1997) and under control in terms of expenditure growth.

• Currently, about one third of Medicare home health agencies (HHAs) have negative Medicare profit margins. The National Association for Home Care & Hospice (NAHC)as calculated that by 2011, nearly two-thirds of home health agencies will have negative Medicare profit margins if MedPAC’s proposed freeze, accelerated CMS regulatory cuts,and rebasing of payment rates are implemented.

• MedPAC fails to evaluate the impact on care access that occurs with the current wide ranging financial situation of HHAs. Regardless of average margins, there is a wide range in agency margins and thus a wide range in impact that the proposed across-the board cuts in payments would have. There is no evaluation to date of the completely reformed home health payment model put in place in 2008. In the event that the wide range in margins continues, a more sophisticated payment model connecting payments to resource use should be developed.

• MedPAC’s proposal to reduce home health payments is based on claims that home health agencies are making excessive profit margins on Medicare services. MedPAC’s financial analysis of Medicare HHAs, projecting a 12.2 percent margin for 2009, is unreliable. First, it does not include any consideration of the 1,626 agencies (21 percent)that are part of a hospital or skilled nursing facility. In some states, hospital-based HHAs make up the majority of the providers (ND 85.0 percent; SD 76.5 percent; MT 66.7 percent; OR 63.0 percent). Facility-based HHAs have an average Medicare profit margin of negative 6.19 percent. Second, the MedPAC analysis uses a weighted average,combining all HHAs into a single unit, rather than recognizing the individual existence and local nature of each provider. It sees a single national profit margin for freestanding agencies as representative of over 9,700 very diverse HHAs. When all agencies’ margins are included and given equal weight, the true Medicare margin would be closer to 5 percent. About one third of home health agencies currently have negative margins. Third, MedPAC margin data fails to recognize many agency costs, including the cost of telehealth equipment, increasing costs for labor, emergency and bioterrorism preparedness, and system changes to adapt to the new home health payment changes.

• Home health agencies are already in financial jeopardy as a result of Medicaid cuts and inadequate Medicare Advantage and private pay rates. Ongoing study of home health cost reports by the National Association for Home Care & Hospice indicates that the overall financial strength of Medicare home health agencies is weak. The average allpayor profit margin for freestanding HHAs is reduced to 4 percent when taking into account losses from non Medicare payors.

• Recent cost reports reveal that the average Medicare margin for rural agencies is negative 3.52 percent. The loss of the 5 percent rural add-on payment for home health services in rural areas has resulted in reductions in service areas, agency closures, and reports that some agencies had to turn away high resource use patients who are more expensive for agencies to serve. In many rural areas home health agencies can be the primary caregivers for homebound beneficiaries with limited access to transportation.

• The “case mix creep” adjustment ignores increases in patient acuity, particularly a significant increase in orthopedic and neurologically impaired patients requiring restorative therapy. These changes in patient characteristics are documented in a report from the Lewin Group and directly correlate with changes in case mix weights.

• CMS alleges that the entire change in the average case mix weights between 1999 and 2005 is the result of provider upcoding or factors unrelated to changes in patient characteristics. If this had occurred one would expect to see a big increase in Medicare home health expenditures. In fact, as the chart below indicates, Medicare home health expenditures are far lower than the Congressional Budget Office (CBO) had expected under the new Home Health Prospective Payment System and are $2 billion less than in 1997.

• Bundling home care payments into hospital or other provider payments would severely compromise both the quality and availability of home health care for Medicare beneficiaries. It would cause major disruption to the health care industry, be anticompetitive, increase the federal regulatory burden and erect a new and unnecessary barrier to beneficiaries’ access to quality care. Hospitals have no experience in the management of post acute care and no infrastructure to manage utilization review. Hospitals are the highest cost sector so this is not the place to locate efficiencies in post acute care. If bundled payments are considered, they should go to community-based providers that have a breadth of experience in providing post acute care and avoiding unnecessary hospitalizations.

TAKE ACTION NOW:

http://www.congressweb.com/cweb4/index.cfm?orgcode=nahc

President Obama Makes Health Care Reform a Top Priority

March 03, 2009 - by Lynn Shapiro, Writer

The Senate is pitched for battle, having heard the details of President Obama's plans for health care reform, laid out in the speech he delivered to Americans last week.

It is a certainty that every vested interest will lobby against it, especially pharmaceutical companies, which stand to lose huge sums of money now that the Obama administration plans to spend $1.1 billion for new reviews of generic drugs. The move is based on several recent studies showing that generics sometimes work as well or better than newer, more expensive medicines. The budget also calls for negotiations with drug makers to lower their prices, as Canada and Western European countries now do.

This initiative is a radical departure from President George W. Bush's Prescription Drug Plan of 2003 for Medicare beneficiaries (Medicare Part D), which refused to require drug makers to negotiate their prices downward.

Unlike Bush, Obama appears unafraid of impinging on the fortunes of industry. Neither is he averse to taxing Americans in the highest income bracket. The President said that most workers are unduly constrained by health care costs and that to ease this burden, he would derive $318 billion by raising the taxes on the top 20 percent of tax filers who earn more than $250,000 a year. These individuals would pay 90 percent of all taxes.

Obama's proposal would also eliminate subsidies now given to the private plans that provide care to more than 10 million of the 44 million Medicare beneficiaries. By forcing these plans, known as Medicare Advantage, into a competitive bidding process, the administration says it can save $175 billion over the next 10 years.

The President is counting on the economy to be thriving by 2011. Then, his plan for hiking taxes on high-income payers would make it possible for him to keep his promise to halve the deficit by 2013.

Deficits of almost $1.8 trillion in 2009 and $1.2 trillion in 2010 are frightening. But while Obama wants to extend tax cuts for the middle class, much of the health care package is intended to save the economy and create jobs. So, the massive amount of red ink Americans face should be temporary, the budget assumes.

Deciding when to go from stimulus spending to deficit reduction is the trickiest part of the equation, but doing it is essential, analysts say.

Other Provisions

Another avenue for health care savings would come from slashing Medicare's home health care programs, said to be excessive. What's more, ending rebates from drug companies for medicines sold to Medicaid patients would save the U.S. healthcare system almost $20 billion.

The budget also includes more than $1 billion to help the FDA fortify its food safety program because of the salmonella outcry; $6 billion for cancer research and a program to send nurses to new mothers' homes to check on babies. Another $76.8 billion would go to the Health and Human Services Department to fund electronic medical records to end costly duplication of diagnostic tests and allow doctors to share patient histories. This provision is not only cost-effective but potentially beneficial to the patient, experts say. Obama promises to preserve patients' privacy, even while doctors share patients' records.

White House budget director Peter Orszag projected in commentary over the weekend that the proposed spending would save $1.8 billion in 2010, $16.2 billion in 2011 and increasing amounts annually to create a $633.8 billion fund to pay for health care reform by 2018. Congress has already provided $25 billion to help laid-off workers pay for COBRA.

What's more, Obama says that spending to get coverage for more of America's 46 million uninsured will save money, if preventive care helps patients avoid expensive and chronic diseases.

Money will be also be saved, Obama said, by finding and eliminating overpayments in Medicare. "The Government Accountability Office has labeled Medicare as 'high-risk' due to billions of dollars lost to overpayments and fraud each year," the budget reads.

Better Care, Not More

In conclusion, the budget says "about $26 billion can be saved over 10 years by using a combination of incentives and penalties to prevent avoidable expensive readmission when patients go back into the hospital within a month after treatment. Reforming the way doctors are paid will also reduce costs, by paying them to provide better care rather than more expensive care, such as imaging scans and surgery that may not be necessary." For example, since Obama took office, Medicare has announced it will stop covering virtual colonoscopies, deciding they're too expensive.

None of this will be easy but one thing is for sure. President Obama has made health care reform a top priority.

Brought to you by Indura Systems.

House Call Physicians Ineligible for e-Prescribing Incentives

AAFP Efforts Fail to Reverse CMS Decision
By Sheri Porter 2/24/2009

The AAFP's efforts, in tandem with those of the American Academy of Home Care Physicians, or AAHCP, to correct an oversight in CMS' recently launched electronic-prescribing incentive program, recently resulted in a denial from the agency.

Rick Kellerman, M.D., of Wichita, Kan., an AAFP past president, is shown here checking on a nursing home patient.

In a Feb. 9 letter to CMS Acting Administrator Charlene Frizzera, AAFP Board Chair Jim King, M.D., of Selmer, Tenn., pointed out that, as currently implemented by CMS, Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 "precludes physicians who practice predominantly, if not exclusively, as house call physicians from participation in the e-prescribing incentive program." On Feb. 23, however, AAFP News Now learned from AAHCP Executive Director Constance Row that CMS had declined to make the changes recommended by the two organizations.

Relevant CPT Codes Overlooked

The issue lies with the agency's choice of CPT codes that appear in the denominator of the e-prescribing legislation. As King pointed out in his letter to CMS, those CPT codes include services provided in the areas of psychotherapy, general ophthalmological services, health and behavior assessment and intervention, office and outpatient visits, and office consultations. However, CMS failed to include codes typically used by physicians who focus their practices on house call services, said King.

Those codes also include care provided to patients living in nursing homes. King argued that many house call physicians were early adopters of health information technology and e-prescribing. He said patients served by home care physicians usually have multiple comorbidities that call for an array of prescriptions that would be more efficiently handled electronically.According to Row, however, "CMS has decided definitively not to add these codes to the 2009 electronic-prescribing incentive program." She added that the letter from CMS indicated the agency may "consider changes for 2010 or beyond."

Statistics Reinforce Call for Inclusion

Row said that statistics provided by CMS only reinforce the argument that home health care physicians and other eligible providers should have the opportunity to benefit financially from the e-prescribing bonus program. She cited figures from CMS' Physician Supplier Procedure Summary Master Record that details Part B claims paid by Medicare carriers in 2007.According to those data, all Medicare providers combined logged 2,194,083 total house calls and 1,696,411 total domiciliary visits (i.e., house calls to patients residing in assisted living facilities) in 2007.

Family physicians alone logged 410,582 house call visits and 286,521 domiciliary visits in 2007. In his letter, King called on CMS to add home services CPT codes 99341 to 99350 and domiciliary/rest home visit CPT codes 99324 to 99337 to the denominator for eligibility in the e-prescribing incentive program.Row said that in light of CMS' rejection of that suggestion, her organization would continue to work closely with the AAFP for possible resolution of the issue in 2010.

Brought to you by Indura Systems.

Kaiser Daily Health Policy Report

Health Care Marketplace Health Care Spending Will Account for One-Fifth of GDP in 2018; Federal Government Will Pay More Than 50% of Those Costs, According to CMS Report [Feb 24, 2009]

Overall U.S. health care spending will reach $2.5 trillion in 2009, a 5.5% increase from 2008, when health care spending increased by 6.1%, according to a CMS report published Tuesday in the journal Health Affairs, the Wall Street Journal reports (Zhang, Wall Street Journal, 2/24).

Total health care spending will account for 17.6% of the gross domestic product in 2009, a full percentage point higher than 2008, marking the largest one-year increase since CMS began tracking health care spending in 1960 (Dunham, Reuters/Boston Globe, 2/24). The rate of health care spending growth is expected to decline over the next five years in part because people will lose their jobs and health coverage as the recession continues, and they will forgo medical treatment; however, the economy will be shrinking and growing at a slower rate, which will increase health care spending's share of GDP (Young, The Hill, 2/24).

The study found that in 2009, government health care spending is expected to increase by 7.4% to $1.19 trillion, while private health spending is expected to increase by 3.9% to $1.32 trillion (Wall Street Journal, 2/24). CMS projects that in 2018 overall U.S. health care spending will reach $4.35 trillion, accounting for 20.3% of the GDP (The Hill, 2/24). The study estimates that health care costs will average $8,160 per U.S. resident in 2009, up $356 from 2008, and will reach $13,100 per U.S. resident by 2018 (Alonso-Zaldivar, AP/Boston Globe, 2/24).

The report forecasts that the government will pay for more than 50% of total health care spending by 2016 and 51.3% by 2018, as Medicaid enrollment increases and baby boomers start enrolling in Medicare (Pugh, McClatchy/St. Paul Pioneer Press, 2/24). According to the study, Medicaid spending will increase from $352 billion in 2008 to $801 billion by 2018. The report estimates that Medicare enrollment increases will drive up the spending growth rate in the program from 6.2% in 2011 to 8.6% in 2018.

CMS predicts that final Medicare figures will show spending of $466 billion for 2008, 8.1% higher than in 2007 (Reichard, CQ HealthBeat, 2/24). According to the report, Medicare's hospital trust fund could become insolvent by 2016 -- three years earlier than previous estimates -- because of lower tax revenue caused by the recession (AP/Boston Globe, 2/24).

Additional Findings The study predicts that private health insurance enrollment will drop from 195.5 million in 2008 to 189.5 million in 2010 (CQ HealthBeat, 2/24). Private health spending is expected to increase as the economy improves, growing to 4.2% in 2010 and reaching 6.1% by 2018 (Reuters/Boston Globe, 2/24). The report also estimates spending growth rates for overall health spending in 2008 of 7.2% for hospitals, 6.2% for physician and clinical services, 9.1% for home health care, and 4.6% for nursing homes (CQ HealthBeat, 2/24). The rate of prescription drug spending increased by 3.5% in 2008, down from 4.9% in 2007, which study co-author Andrea Sisko attributes to U.S. residents' being more willing to use generics and less inclined to fill prescriptions as the economy declines.

The report projects that the recession would begin to improve in 2010 and health spending growth would surge again in 2011 (Reuters/Boston Globe, 2/24). The study did not examine the impact of the recently enacted stimulus package, which includes $87 billion in increased Medicaid aid, nor did the report take into account the expansion of CHIP (Wall Street Journal, 2/24). The estimate includes a scheduled 21% cut to Medicare physician payment rates, but Congress and President Obama are expected to block the cuts. The Congressional Budget Office has estimated that blocking the cut will cost at least $100 billion over 10 years (The Hill, 2/24).

The study is available online.

Brought to you by Indura Systems.

Obama releases $15 billion in Medicaid funding to states

President Obama, meeting with the nation's governors in Washington, D.C., this morning, announced a quick release to the states of $15 billion of federal Medicaid relief funding to help them cope with the rising health care costs brought on by the economic crisis. According to a White House press release, the money will be available in 48 hours--on Wednesday--in special Treasury accounts set up for the states to access.

"That means that by the time most of you get home," said President Obama, "money will be waiting to help 20 million vulnerable Americans in your states keep their health coverage. Children with asthma will be able to breathe easier, seniors won’t need to fear losing their doctors, and pregnant women with limited means won’t need to worry about the health of their babies.”

The funding is part of the designated moneys from the American Recovery and Reinvestment Act, and the temporary increase will be administered by the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS). The federal agency will coordinate with states to ensure they are properly meeting regulations and requirements about Medicaid.

The announcement of the funding release was made as President Obama and Vice President Biden hosted members of the National Governors Association at the White House.

A state-by-state grant award summary for the program can be found here.

SusanG@dailykos.com

Brought to you by Indura Systems.

Care Givers on Bikes!

Brought to you by Indura Systems.