Summary Parts 1-3

The Affordable Care Act (ACA), now found constitutional by the Supreme Court, continues to have significant impact on the nation’s health system presently and will have tremendous impact in the future.

In June and July Select Data ezine articles parts 1-3, we have discussed the ACA impact on

• New Health Care Delivery Models such as Accountable Care Organizations (ACO) and Patient Centered Medical Models (PCMM)   www.CMS.HHS.gov/PCMM
• Bundled payments for hospital stays, physicians, and post-acute providers

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PCPricer/HH.html

• Value-based Purchasing

http://innovations.cms.gov/initiatives/Bundled-Payments/index.html

• Shared savings Programs (SSP)

http://www.ofr.gov/inspection.asp

• Electronic Health records

www.CMS.HHS.gov/EHR

The ACA has even expanded the RAC requiring, in 2012, the audits of Medicare Part C and Part D as well as Medicaid.  See www.cms.gov/medicaid/racs

It seems as if the reach of the ACA is everywhere in healthcare.

In this article, we will briefly discuss the ACA and its impact on hospital admissions and the Continuity of Care.

ACOs and significant payment reform encourage home health agencies partnering with physicians and hospitals to improve care transitions of patients through acute and post acute levels of care as well as reducing inpatient readmissions. Home health agencies may choose to investigate Guided Care and the evidenced-based guidelines for managing chronic conditions. Agencies need to develop innovative programs and should consider those based on the effective principles of case management, disease management, self management, and caregiver support models. Investigate the Guided Care Model, so your agency is prepared to interact with physician groups that adopt this model.

In the Patient Protection and Affordable Care Act (PPACA) commonly referred to as the ACA, Congress designed numerous provisions including the Hospital Readmissions Reduction Program (HRRP) which requires payments to applicable hospitals to be adjusted downward if the hospitals have excess readmissions.

CMS views operationally, three stages related to readmissions:

• Inpatient care processes
• Effective Discharge (soon to be termed transitional level planning)
• Post Discharge or transitional care

CMS and the OIG are reviewing transfer processes, rates of adverse events, and preventable hospital readmissions.  Presently, the OIG are focusing on SNFs, IRFs, and Long Term Hospitals. Throughout this year and next year, the OIG will be focusing on these sites ostensibly seeking innovative ways to deliver care that aids in preventing readmissions. Here is where the innovative home health agency can shine. Start looking at stages two and three and how your agency can impact those processes.

In addition, beginning in FY2013, hospitals with specific risk-adjusted readmission rates for 30 days post discharge will receive reduced Medicare payments (up to 1%). By 2015, it can increase to 3%. Hospitals will be motivated to work with the creative home health agency.

Root cause analysis should be utilized to discover why each and every hospital readmission occurred. Agencies should analyze why home health care plans were ineffective in that area. Take them apart. Dissect by section. Look for weak areas so future plans might be strengthened. This is a new era for quality improvement team evaluation. Sharing data and establishing reasons for the readmission will assist both levels of care seek improved interventions.

Preventing hospital readmissions with innovative programs will position agencies to negotiate positive agreements with hospitals for ongoing referrals. Hospitals will be motivated to work with agencies with proven positive care methods that reduce acute care readmissions. The same old same old manner of delivering care may be seen as lacking.

It will be the home health agencies that focus on excellent care interventions in specialized programs that will be able to negotiate with acute care providers for future referrals. Care transitions means transitioning care from level to level. It means providing excellent care that meets an individual’s care needs in the least restrictive environment.

As part of the ACA; the Accountable Care Organization (ACO) and the EHR but first let’s look at the Supreme Court Comments.

Impacting News: The Supreme Court has upheld all of the Patient Protection/ Affordable Care Act.

On June 28, 2012, Chief Justice John Roberts became the swing vote, joining four justices appointed by Democratic presidents in sustaining the Affordable Care Act. In doing so, it appears the Supreme Court has upheld ALL of the Patient Protection and Affordable Care Act (PPACA)

The core provision of the law is the individual mandate, which requires all Americans to buy or pay a penalty. Justice Roberts led the justice majority in arguing that the provision was a federal taxing power.

For home health agencies, Face to Face encounters, ACOs, and Care Transitions remain intact. Home health agencies will need to structure their agencies to provide meaningful alignment capabilities. Besides ACO creation, the Affordable Care Act includes increased Medicaid eligibility in the states, thus increasing the number of Medicaid-eligible individuals, as well as the government’s ability to impose stricter anti-health care fraud measures, including moratoriums.

However, the court seemed to give the states the option to choose whether or not to participate in the Medicaid expansions. Those states that refuse to do so may not be excluded from the entire Medicaid program, stated the court opinion. This puts the states in the position to make the decision of accepting or not accepting the federal dollars that would pay for many of the expansions.

The PPACA also includes $40 billion in reimbursement cuts and calls for rebasing of home health reimbursement rates. Now that the PPACA also called the Affordable Care Act has been upheld by the highest court in the nation, the federal government and states will proceed with implementation of health care reform. It will be a time of change with a focus on quality care outcomes and access to care.

Follow up to Part 2 re the Affordable Care Act and Home Health..the EHR

The last article regarding the Affordable Care Act generated several comments concerning the impact of the Act specifically regarding home health. With ACO numbers pushing toward 50 established or planned, Section 3022 of the Affordable Care Act Shared Savings Program is well underway. CMS expects ACOS to save Medicare up to $940 Million in the first four years of implementation.

Early adopters have received incentives and agreed to participate for three years. The CMS reported that, as of April 1, 2012, over 1.1 million beneficiaries are receiving care through ACO Shared Savings Programs.  Expect rapid growth , because though Accountable Care Organizations take up only 7 pages of the 2000+ page health care law, it is one the most discussed provisions.

Regulation states the ACO must include hospitals, physicians, rehab facilities, and long term care facilities to provide patient and provider partnered patient-centered care. To be certain the care is patient centered and quality centered, CMS proposes specific measures of quality care that will include:

• Surveys and measure reporting of the patient experience
• Defined Care Coordination processes
• Patient safety indicators and care intervention
• Preventive health that focuses on preventing illness and early intervention
• Specific programs for at-risk populations such as older frail individuals
• Providers are required to alert their patients that they can choose another doctor if that makes them feel more comfortable in participating in the ACO

CMS is linking these measures with Electronic Health Records (EHR) and Physician Quality Reporting Systems (PQRS). Successful reporting of quality measures under the Shared Savings Program will allow eligibility for a PQRS bonus, thus incentivizing physicians.

Since ACOs must define processes promoting evidenced based medicine, home health agencies needs to define care in that manner. Home health agencies must have care that will positively impact on quality and cost measures and be clearly promoting those positive impacts. Otherwise, the home health agency will not be attractive to ACOs.

Physician based ACOs will seek home health agencies utilizing evidenced based processes that are efficient and effective in relation to patient and financial outcomes. In addition, the agencies must have easily acquired data that validates the value and the positive outcomes.

Achieving those goals may include blended technology that includes significant scalability, potential tele-monitoring at the acute stage and phone interactions at the less acute stage.

Remember, under the Affordable Care Act, consumers are expected to manage their health, providers are to manage cost and care better, hospitals must reduce volume of patients and improve outcomes of those acute and subacute patients, purchasers must redesign benefit packages and health plans are expected to change payment structures and have contracted with providers who are driven to improve outcomes and decrease cost.

One of the key needs to achieve those goals is to have an Electronic Health Record. This too, has been an incentivized program.  Eligible hospitals have received payments that began with a base $2 million, after meeting specific factors, to adopt and demonstrate meaningful use of certified EHR technology.  Payments begin to decrease for hospitals beginning the project in 2014 and later. Home Health agencies should be planning now for an EMR/EHR.

CMS is driving care integration of preventive, acute, primary care, and home health care. CMS sees the disconnect between the various levels of care and believes there is a communication core design flaw. Enter the EHR for easier access to patient information. This communication would allow the focus to be on the patient and will be very different from the present health care delivery where statistics show that presently integration is frequently absent and patients often falter and have decline in their healthcare transition from one level to another.

The EHR is one of six requirements expected to increase success of the ACO.

Besides that EHR information continuity, the other requirements include care coordination /care transitions including managed transitions of all levels of care, system accountability which will include shared revenue generation based on population outcomes, peer review to potentially include reviewing each ACO members care delivery and outcomes, ongoing innovation that promotes high value creative care, and finally, easy access to this care.

To be certain that the creativity continues, the hospital directed ACOs are required to conduct a community health needs assessment (CHNA) every three years. Failing to conduct such an assessment could lead to a potential $50,000 excise tax, which for health care systems, could result in the tax application to each facility member of the system. Obviously, home health agencies want to be in a position to offer creative new programs with a strong data matrix to support outcomes so the agency can assume a role in this community needs assessment.

In the next article (article 4) in this Affordable Care Act series, we will explore the Readmissions Reduction program and the role home health can play.