2015 National Nursing Home Change Package Released

The atom Alliance will be working with Indiana nursing facilities on the new NNHQCC change package that was recently released.  The change package, updated from its initial 2013 release, was created for nursing homes participating in the National Nursing Home Quality Care Collaborative led by the Centers for Medicare & Medicaid Services (CMS) and the Medicare Quality Innovation Net¬work-Quality Improvement Organizations (QIN-QIOs) like atom Alliance.

The Collaborative works actively to instill quality and performance improvement practices (QAPI), eliminate Healthcare-Acquired Conditions (HACs) and dramatically improve resident satisfaction by focusing on the systems that impact quality:

•    staffing
•    operations
•    communication
•    leadership
•    compliance
•    clinical models
•    quality of life indicators and specific
•    clinical outcomes

The change package, developed from a series of ten site visits to nursing homes across the country, focuses on the successful practices of high-performing nursing homes. The change package is a menu of strategies, change concepts, and specific actionable items that any nursing home can choose from to begin testing for purposes of improving residents’ quality of life and care.

Download your change package today! Go here to learn more about how atom Alliance is helping nursing homes in Alabama, Indiana, Kentucky, Mississippi and Tennesse implement these best practices.

Atom Alliance Announces CMS’ 2014 QIO Program Progress Report

atom Alliance is pleased to share the Centers for Medicare & Medicaid Services’ (CMS) 2014 QIO Program Progress Report, which highlights how Quality Innovation Network-QIOs (QIN-QIOs) nationwide are bringing together providers, partners and other stakeholders to achieve rapid improvements in health quality.

The report, which can be viewed at http://qioprogram.org/progress-report, features the following:

•    Information about the QIO Program’s new organizational structure, its goals and national partnerships;
•    Real-life examples of how healthcare providers like yours have addressed quality improvement challenges;
•    Takeaways from CMS’ 2014 QualityNet Conference, which was attended by providers, beneficiary advocacy groups, federal agencies, nationwide health care quality improvement organizations and others.

By participating in quality improvement initiatives with atom, your organization can benefit from our ability to help you make sense of key health quality data, improve your performance in Value-Based Purchasing programs and national quality ratings, and help publicize our joint successes in improving the quality of care for Medicare beneficiaries.

Congress Passes Permanent Fix for Physician Medicare Payments

With the Senate passage of the Medicare Access and CHIP Reauthorization Act of 2015 (also referred to as the SGR bill or the Doc Fix), certain risks related to the billing of Medicare Part B services will have been resolved.  The -21.2 percent rate adjustment that was to be applied for Part B procedures as of April 1, 2015, including therapy services, was eliminated. Provider fee schedule rates will remain unchanged until July 1, 2015 when a 0.5 percent rate adjustment will be applied.  The hard $1,940 Part B therapy cap without exceptions that would have applied for rehabilitation services as of April 1, 2015 was also eliminated. The process to request exceptions to the cap has been extended through December 31, 2017.  

AHCA sent a letter with FAQs and conducted member calls on March 30 to provide an update on the status of the SGR bill legislative delay that described two specific risks operators faced from April 1 until the date of enactment of the Doc Fix.  At the time, AHCA provided two specific recommendations to consider:  1) "Operators hold any Part B claims with dates of services on or after April 1 until it is clearer what will happen in the Senate" and 2) "Operators issue Advance Beneficiary Notices (ABNs) to beneficiaries needing Part B therapy services beyond the $1,940 threshold as of April 1, 2015." With the passage and enactment of the Doc Fix, these recommendations no longer apply.

AHCA is updating its recommendations to operators and encourages a return to normal operating procedures related to these two soon-to-be resolved risks:

1. AHCA recommends that operators submit claims on the usual schedule, as the Centers for Medicare and Medicaid Services (CMS) has indicated that Medicare Part B claims with dates of service on or after April 1, 2015 will be paid per the provisions of the SGR Bill. Note, however, that CMS has explained that "[w]hile the Medicare Administrative Contractors (MACs) have been instructed to implement the rates in the legislation, a small volume of claims will be processed at the reduced rate based on the negative update amount. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate."

2. AHCA recommends that it will no longer be appropriate for providers to issue advance beneficiary notices (ABNs) to beneficiaries receiving medically-necessary services above the $1,940 therapy caps since providers can use the exceptions process for therapy services above the threshold. More information about therapy cap related ABNs when exceptions apply can be found on the CMS website.

CMS Releases SNF PPS Proposed Rule

In mid-April the Centers for Medicare and Medicaid Services (CMS) released the Skilled Nursing Facility Prospective Payment System (SNF PPS) notice of proposed rulemaking (NPRM). The FY 2016 NPRM release is significantly earlier than its usual practice. While the projected market basket growth rate of 1.4 percent is less than the profession had hoped, the reimbursement provisions of the rule contain no unexpected proposals. Of note, however, the FY 2016 NPRM marks the first year in which the profession will begin to see value-based purchasing provisions, quality reporting requirements, and health information technology sections in its annual NPRM.

Specifically, the FY 2016 NPRM discusses CMS' proposed plans to implement:
•  Protecting Access to Medicare Act of 2014 (PAMA) SNF Rehospitalization Value-Based Purchasing Program;
•  Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) Quality Reporting Measures;
•  Preliminary IMPACT Act health information technology data interoperability proposals;  and
•  Finally, the NPRM discusses proposed new staff reporting requirements. 

AHCA has prepared a summary of the 150-plus page rule. To view the summary, which includes staff contacts by section, click here. Additionally, AHCA/NCAL has updated its SNF PPS Medicare rate calculator based on the FY 2016 NPRM. To view and utilize the calculator, please click here. 

We hope you find this information helpful and look forward to your comments and feedback as we begin developing our response to CMS.

Indiana Medicaid LTC Planning Process

Last month in the IHCA IMPACT we announced the creation of a dedicated page on the Member’s Only website that will house all information related to the Indiana Medicaid LTC planning process.  The challenge and request to create a plan and path forward on reforming nursing facility Medicaid reimbursement and policy was issued by current FSSA Secretary Dr. John Wernert in the fall of 2015.

New documents have been posted to that website since last month for the AL Workgroup and the Reimbursement Workgroup. To access the webpage, click here.

CMS Issues Memos Concerning Dementia Care Projects

On March 27, 2015, CMS issued a Survey & Certification Memorandum regarding the Final Report & 2015 Expansion for the Focused Dementia Care Survey Pilot.  The memo announces a final report that outlines the basis for the Focused Dementia Care Survey Pilot, the process utilized, conclusions gathered based upon post-pilot data analysis, as well as next steps for the future. CMS plans to expand upon the work of the focused survey pilot and has invited States to conduct such surveys in FY2015 on a voluntary basis. The expansion project will involve a more intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications, and broaden the opportunities for quality improvement among providers.  A conference call will be held in early summer for interested State Survey Agencies to further discuss this focused survey expansion effort.

In addition, on April 4, 2015, CMS issued another Survey & Certification Memorandum announcing a grant award to the Eden Alternative for the support and further expansion of the National Partnership to Improve Dementia Care in Nursing Homes. A grant, in the amount of $293,129.00, was awarded to The Eden Alternative for their project entitled, “Creating a Culture of Person-Directed Dementia Care.” The Eden Alternative plans to engage direct care staff from nursing homes across five states (Georgia, South Carolina, Kansas, Illinois, and Texas) in “Dementia Beyond Drugs” training.

Collection of Staffing Data for Long Term Care Facilities

On April 10, 2015, CMS issued a Survey & Certification Memorandum entitled Implementation of Section 6106 of the Affordable Care Act – Collection of Staffing Data for Long Term Care Facilities.  CMS has created a system for centers to submit staffing and census information and it is called the Payroll-Based Journal (PBJ). The PBJ is intended to meet the criteria outlined in the Affordable Care Act for electronic submission of direct care staffing information.  CMS intends to collect staffing and census data on a voluntary basis beginning October 1, 2015. All nursing centers will be required to submit staffing and census data using the PBJ beginning July 1, 2016.  The memorandum includes a link to access additional information about the system and information specifically for vendors or software developers. Additional information that is currently available for providers includes a Policy Manual for the PBJ. 

We encourage members to review the information on the PBJ website as well as the PBJ Policy Manual and send any questions or concerns directly to nhstaffing@cms.hhs.gov.  Please copy Zach Cattell (zcattell@ihca.org) or Lyn Bentley (lbentley@ahca.org) on any email you may send to CMS.

Residential Care Citation Update

The ISDH issued 4 Offense tags and 33 Deficiency tags to Residential Care Facilities in the month of March.  Ten citations were issued Tag 273 concerning maintenance of food preparation and service areas in accordance with state and local sanitation and food handling standards.  Tag 241 was cited 4 times for failure to have resident medications administered by licensed nursing personnel or QMAs.  Both of these citations are common and facilities should seek to prevent them.  Tag 217, cited with relative frequency lately, was cited 5 times in March.  Of the available survey reports, the tag continues to be cited primarily due to the lack of signature or date of signature on the service plan by the resident or resident’s legal representative.

Click here to review a summary of the March Residential Care citations.

ISDH IJ/SSQC Update

There was one event in March that resulted in and IJ citation that was also SSQC. F323 was cited for alleged failure of a facility to maintain resident transfer equipment in safe working condition and to utilize the equipment properly.  The 2567 indicated that each of the three sit to stand resident transfer slings were missing belt buckles to knee support straps. A buckle also appeared to be broken on one of the lift’s waist support belts.  The facility was notified from a prior employee concerning the condition of the lifts prior to the IJ being called and the Administrator scheduled a medical equipment professional to inspect and repair the lifts.  The medical equipment professional inspected the lifts and placed stickers on the lifts noting the inspection, which was taken by the facility as approval that the lifts were safe to use.  Email correspondence to the Administrator from the medical equipment professional, however, indicated that the missing buckles needed to be replaced. Follow-up phone interview with the medical equipment professional confirmed that the inspection resulted in recommendation to replace the buckles and the slings could not be used properly without the buckles.

Click here to review the March 2567 and a summary of 2015 IJ/SSQC citations.

CMS Approves Hoosier Care Connect – A New Indiana Medicaid Managed Care Program for the Aged, Blind and Disabled

On March 31, 2015 Indiana Health Coverage Programs sent out notice that CMS has approved implementation of Hoosier Care Connect (click here to see the notice).   A more detailed description of the program can be found here and at the Hoosier Care Connect website.  Hoosier Care Connect is a “coordinated care program for Hoosiers age 65 and over, or with blindness or a disability who live in the community and are not eligible for Medicare.”  The program excludes individuals enrolled in Medicare, and those residing in an institution or are receiving services through the Home and Community Based Services wavier.  Three Managed Care Entities, Anthem, MHS, and MD Wise are enrolling eligible persons and are responsible for coordinating the care with medical providers.   

Nursing facilities will be involved in the Hoosier Care Connect program as there are care coordination issues to address for Medicaid beneficiaries that transition between this new managed care program and traditional Medicaid for services within nursing facilities.  Indiana Medicaid has also published a lengthy FAQ document that can be accessed here or at the Hoosier Care Connect website.

US Supreme Court Rules - Providers Cannot Challenge Medicaid Reimbursement Rates

In a 5-4 decision, the US Supreme Court released an opinion today, holding private healthcare providers cannot sue the state over low reimbursement rates (Armstrong v Exceptional Child Center Inc.).  By way of background, in 2009, private healthcare providers delivering residential care to disabled patients in Idaho, sued the state alleging that it was illegally keeping Medicaid reimbursement rates at 2006 levels despite data showing that the cost of providing services had significantly increased. A Federal  District Court judge sided with the providers, holding that the Idaho Medicaid rates weren’t in line with the federal law’s requirements that states “assure that payments are consistent with efficiency, economy and quality of care and are sufficient to enlist enough providers” to ensure adequate access to care.  The District Court decision was upheld by the US Court of Appeals for the Ninth Circuit.  As a result of that ruling, Idaho was forced to pay an additional $12 million in 2013 reimbursements.  Idaho appealed the ruling to the US Supreme Court. 

On appeal to the US Supreme Court, healthcare providers argued that the courts are an important venue for challenging low reimbursement rates, which often are the only way to enforce federal payment requirements.  Furthermore, providers argued when reimbursement rates are too low, there is lower provider participation in the Medicaid program, which can lead to less access to care for Medicaid beneficiaries. The Idaho Medicaid officials countered those arguments asserting that Congress had not authorized lawsuits under the Medicaid Act, codified under Title XIX of the Social Security Act, and that allowing such a course of action would result in endless litigation.  The majority of the US Supreme Court Justices agreed with the state of Idaho, and concluded that a private cause of action is not permitted under the U.S. Constitution’s Supremacy Clause.  Further, Title XIX does not allow private parties to enforce the provision in the Medicaid Act that requires state plans to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . .care and services.” Rather, only CMS may scrutinize rate adequacy following its process for reviewing state plan amendments (SPA) pertaining to reimbursement.  CMS guidance on SPA review is located here in a State Medicaid Directors’ Letter. 

AHCA/NCAL Advocacy To-Date
AHCA/NCAL submitted an amicus brief in support of the Idaho providers in Armstrong v Exceptional Child Center Inc., and the Association is greatly disappointed in the US Supreme Court decision released today.  As you know, AHCA has ample data demonstrating nursing facility Medicaid rates do not cover  allowable costs.  To view the 2015 Medicaid Shortfall Report, click here.  As a result of this decision, providers with insufficient Medicaid rates may continue to address rate complaints to the Single State Medicaid Agency (SSMA) as under current state practice but now have little hope of judicial relief. 

Advocacy Next Steps
In the last year, recognizing existing challenges with court action related to rate adequacy, the Association opened a dialogue with CMS and the National Association of Medicaid Directors (NAMD) on a revised Medicaid SPA process which would allow providers and other stakeholders to engage in a standardized and CMS-regulated rate development and SPA submission process.   AHCA has developed and vetted through the Legal Committee, Finance Committee and State Executives a preliminary SPA approach which has been shared both with CMS and the National Association of Medicaid Directors (NAMD).  Next week, AHCA/NCAL staff are meeting with the Acting Deputy Administrator for the Center for Medicaid and CHIP Services (CMCS), Tim Hill, to review our proposed framework and highlight Medicaid rate issues including the annual Shortfall Report and news articles indicating physician and hospital withdrawal from the Medicaid program due to inadequate reimbursement.  The goal is to accelerate and influence CMS promulgation of key parts of is long languishing proposed “Equal Access Rule” which includes helpful provisions on rate development and related SPA submission.  Click here to view the proposed rule.  In the upcoming months, AHCA’s Legal Committee will review the US Supreme Court opinion carefully and will work with the Finance Committee, Reimbursement Cabinet and State Executives to develop other strategic action steps.   If you have questions, suggestions or concerns, please contact Dianne De La Mare at ddmare@AHCA.org. 

Indiana Medicaid Begins Examining Assisted Living Options

As part of the 5-8 year Long Term Care planning process, Indiana Medicaid has named four workgroups to start on the detailed work for the plan.  One of those workgroups is the Assisted Living Workgroup and the first meeting of that group occurred on March 30, 2015.  Indiana Medicaid staffer Chris Fletcher is organizing the meetings and content for all of the workgroups, and distributed a document to describe the AL Workgroup’s charge. (Click here to access the document.)  The workgroup will meet monthly this year with a  goal of producing recommendations by the end of this September.  The other three workgroups will have similar time-frames.

The main goal of the AL Workgroup are to explore expansion of AL within the Indiana Medicaid program.  A primary assumption is that expanding care in the AL setting may be less expensive and less restrictive than care in a nursing facility.  Whether that is true remains to be seen.  Federal and state regulatory requirements concerning licensed and unlicensed AL, Medicaid waiver and Medicaid state plan options, and the new CMS Home and Community Based Services regulations will all be considered as this part of the plan is developed.

IHCA is part of all of the workgroups and will continue to participate. IHCA will be reaching out to members to participate in the planning process once more defined goals are determined.  If you have questions or comments, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.

Congress Considers Permanent Fix to Medicare Physician Funding Formula

On March 24th, 2015, the House Ways and Means Committee introduced a bipartisan permanent fix to the Sustainable Growth Rate (SGR). The bill, H.R. 2, would remove the perennial threat of providers paying for a "doc fix" and inject much-needed stability for the long term and post-acute care sector.

You may have already read about this legislation. You may even know that it contains a cut for skilled nursing. That is the case – but we believe this legislation does much more good than harm. The promise of payment stability in the sector, as well as much-needed therapy reforms, means this is landmark legislation for our membership. AHCA’s Board of Governors endorses this effort to permanently fix the SGR.

What’s in it?

•    Stability – A permanent fix to the annual SGR battle. The doc-fix limped along year-to-year for a total of 17 patches. We estimate that skilled nursing has been cut by more than $27 billion to pay for short-term SGR fixes.

•    Therapy reforms – The bill includes a 33-month extension of the therapy cap exceptions process (through December 31, 2017). This allows providers to continue delivering therapy above the current $1,940 threshold as long as supporting coding and documentation show the services were medically necessary.

The legislation also mandates a new therapy review process to take the place of current manual  medical review (MMR). The new structure will be in place within 90 days of enactment of the bill. It will target providers with high denial rates and outlier billing patterns as well as new providers, certain medical conditions, and certain group practices.

The new system is limited to $10 million in funding across all provider settings for FY 2015-2016, which will substantially limit the regulatory burden on skilled nursing therapy services.

•    1 Percent Market-Basket Update – Skilled nursing is part of the pay-for in this bill. AHCA/NCAL staff worked closely with Congressional leadership to ensure that this cut is not an unbearable burden for our members.

Under the proposal, skilled nursing providers will receive a 1 percent market basket increase, net of other adjustments, in FY 2018. We had assurances from members of Congress that this increase would take into account the productivity adjustment within the Affordable Care Act. Our current assessment of the legislation is in line with that promise.

The two-year delay of this pay-for allows AHCA/NCAL time to work with Congress on our payment reform proposal as an alternative to the market basket cuts. AHCA’s payment reform proposal is part of our effort to seek quality solutions as an alternative to across-the-board payment cuts.

Where does it go now?

We expect this legislation to reach the House floor for passage as early as Thursday. Right now, we believe there is enough bipartisan support to send it to the Senate. Speaker of the House John Boehner released a statement today applauding the effort to permanently fix the SGR. He also stated the House would not attempt to pass another short-term patch, ratcheting up the pressure on the other chamber to take what the House has approved.

This creates a very tight deadline in the Senate. The Senate must pass a budget on Thursday night in an hours-long affair known as the "vote-o-rama." This is a time-consuming and tiring process for all involved. The Senate would then have to vote on an SGR repeal early Friday morning before a two-week-long holiday recess.

Because of these timing issues, it is significantly less likely the Senate will be able to send this legislation to the president’s desk this week. We still believe there is a chance they will. If they do not, however, they will either have to vote on a short-term fix to send to the House or allow CMS to hold claims while they recess.

What can you do?

If you have a strong relationship with your Representative, contact them and tell them to support H.R. 2.

AHCA/NCAL has developed talking points to help with your outreach. Time is of the essence and we need your support.

Following Thursday’s anticipated House vote, AHCA will provide additional information regarding continued outreach to your Senators.  

This is a bill the profession can get behind. The legislation the House will consider this week meets the criteria we laid out early in the process. A permanent repeal of SGR will mean a new level of certainty and stability for care providers across the country. And the needed reforms and extensions to therapy will go a long way in helping tens of thousands of patients who rely on these therapies to return to their communities.

CMS Withdraws Memo Concerning Blood Glucose Monitoring System and Provides New Draft Guidance

On November 21, 2014 CMS issued S&C 15-11 concerning the direction on off-label/modified use of waived blood glucose monitoring systems (BGMS) and attendant CLIA regulations concerning use of such systems.  The memo is being withdrawn in order to obtain more feedback on the use of waived BGMS and to provide more education on CLIA requirements.  The withdrawn memo are accompanied by new draft guidance, in red, that may be added to a future, re-issued memo.  In addition, CMS released two Q&A documents concerning CLIA and waived BGMS.  Click here for the S&C Memo, the first Q&A, and the second Q&A.

FSSA Issues RFI to Expand Research on Community Transitions for ID and DD Populations

The Indiana Family and Social Services Administration (FSSA) released an RFI to solicit response from entities that can assist the state with performing research and assessment on what barriers exist which prevent the ID/DD populations from transitioning from nursing homes to community-based settings.  This RFI follows a multi-year project led by the Arc of Indiana to move individuals with an ID or DD from nursing facilities into a community-based setting.  The Bureau of Developmental Disabilities Services currently provides supports to approximately 1,340 individuals with disabilities in nursing facilities and has worked with the Arc to move individuals from the nursing facilities into community based settings.  While the existing program has identified large numbers of individuals interested in moving to a community-based setting, the number of those that have transitioned remains low.

Through this RFI the State is interested in assessing and researching what barriers currently exist that are preventing fluid movement of the ID/DD population from nursing facilities into community-based settings.  The assessment and research shall focus on individual communities to identify barriers that are unique to certain environments, and also draw larger systemic statewide conclusions.  To read the RFI, click here.