At the end of March, Health and Human Services (HHS) and the Centers for Medicare & Medicare Services (CMS) released accountable care regulations, estimated to save Medicare hundreds of millions of dollars over the next three years.

An ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

• ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements.
• Networks of individual practices of ACO professionals.
• Partnerships or joint ventures arrangements between hospitals and ACO professionals.
• Hospitals employing ACO professionals.
• Other Medicare providers and suppliers as determined by the Secretary.

Under the proposed rule, an ACO refers to a group of providers and suppliers of services that will work together to coordinate care for the Medicare fee-for-service beneficiaries they serve. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

ACOs would be separate organizations with their own tax identification numbers. Each ACO would establish a governing body representing ACO providers of services and suppliers and Medicare beneficiaries. Interestingly, regulations propose that a beneficiary (read patient) be represented in the ACO's governing body

To participate in a Shared Savings Program, the proposed rule would require an ACO to complete an application providing the information requested by CMS, including how the ACO plans to deliver high quality care at lower costs for the beneficiaries it serves.

• An ACO must agree to accept responsibility for at least 5,000 beneficiaries.


• If approved, the ACO must sign an agreement with CMS to participate in the Shared Savings Program for a period of three years. Two models of ACOs are proposed. The first would allow an organization to share in savings only for the first two years and share in savings and losses in the third year. The second would allow an ACO to join and have a sharing of savings and losses for all three years, which would leverage more risk with more potential benefit.


• An ACO must meet the program's quality performance standards to be eligible to receive a share of the savings it generates below a specific expenditure set by HHS. Conversely, ACOs would be accountable to repay Medicare for a portion of losses (expenditures above its benchmark).


• New quality indicators fall under the areas of patient/caregiver experience of care, care coordination, patient safety, preventive health and at-risk population/frail elderly health. There are 65 measures among those five areas.


• ACOs would report quality measures to CMS and give timely feedback to providers.


• ACOs would also need to publicly report certain aspects of their performance and operations.

Under the proposed rule, Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems.

Being Held Accountable

• The proposed rule outlines a monitoring plan that includes analyzing claims and specific financial and quality data as well as the quarterly and annual aggregated reports, performing site visits, and performing beneficiary surveys.


• There are a number of circumstances under which CMS may terminate the agreement with an ACO, including avoidance of at risk beneficiaries and failure to meet the quality performance standards.


• The ACO would to have in place procedures and processes to promote evidence-based medicine and beneficiary engagement in their care.

"ACOs will flip the value chain on its head," said Dr. Jeff Gruen, the director of Health Care Services, PRTM to McKnight's. "There is a big opportunity for long-term care to partner with physicians and hospitals in ways they haven't in the past. It will improve the care experience."

It will be interesting given that fee-for-service is not eliminated entirely to see how providers balance that mentality against working with other ACO components to share in cost savings. Will fee for service billing still be more lucrative than the share in savings? That is one vague part I would like to learn more about.

As I have been writing about, long-term care providers do have a part in this discussion. But not all providers. Frankly, high quality, patient-centered, efficient providers will have the leg-up.

Learn more ~ or join the conversation!

_{NEWSLETTER | FORUM | TWITTER | FACEBOOK | CONNECT}

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Iowa Gov. Terry Branstad (R) recently cut 10 of the state's 38 nursing home inspector positions. The surveyor group monitors Iowa's 442 nursing homes covering 30,000 residents.

Rod Roberts, who leads the state's inspections department, cited Iowa's financial challenges as the reason for the reduction. He noted that other staffers in the Inspections and Appeals department could be trained to fill in the gaps left by the inspectors. Red flag that!

Branstad's move came under fire by state legislators. The cuts also concern advocates for the elderly, because a shortage of inspectors already puts Iowa at risk of failing to meet minimum federal standards for overseeing nursing homes. And with MDS 3.0, the need for robust inspections increases.

While campaigning for governor, Branstad said state inspectors often fine Iowa nursing homes unfairly. There may be some truth to the just the opposite.

According to the Government Accountability Office's (GOA) report Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment up to 20 percent of state inspectors surveyed in Iowa report a state agency practice that surveyors not cite certain deficiencies. So a bad situation can only get worse.

State governments oversee the licensing of nursing homes. In addition, States have a contract with the Centers for Medicare and Medicaid Services (CMS) to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries.

CMS contracts with each State to conduct onsite inspections that determine whether its nursing homes meet the minimum Medicare and Medicaid quality and performance standards. The State conducts inspections of each nursing home that participates in Medicare and/or Medicaid on average about once a year. If the nursing home is performing poorly, however, the State inspectors may go in more frequently. The State also investigates complaints about nursing home care.

The inspection team consists of trained inspectors, including at least one registered nurse. This team evaluates whether the nursing home meets individual resident needs. In addition, fire safety specialists evaluate whether a nursing home meets standards for safe construction. When an inspection team finds that a home does not meet a specific regulation, it issues a deficiency citation. There are over 150 regulatory standards that nursing homes must meet at all times.

No doubt that the nursing home industry is one of the most highly regulated industries within and outside of healthcare. And it is also true that regulations are continually increasing. At the same time, states are hard pressed to enforce the regulations because budgets are shrinking.

I truly believe that the majority of care facilities want to provide good care. And yes there are some bad apples too. But in the absence of state enforcement, providers must police themselves. And in addition consumer now more than ever need to do their homework. And they will hear about the bad apples. So the lack of state enforcement will not deter people from finding and sifting out bad places when choosing care for mom and dad. And as simple as it sounds it comes down to this - do the right thing.

Learn more ~ or join the conversation!

_{NEWSLETTER | FORUM | TWITTER | FACEBOOK | CONNECT}

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Stockbyte©Getty Images

PHI, an organization that works to improve the lives of people who need home or residential care by improving the lives of the workers who provide that care, have released a profile of direct care workers that providers should find interesting. Here are some of the findings.

Direct-care workers constitute one of the largest and fastest-growing workforces in the country. They provide an estimated 70 to 80 percent of the paid hands-on long-term care and personal assistance received by Americans who are elderly or living with disabilities or other chronic conditions.

Direct-care workers fall into three main categories tracked by the U.S. Bureau of Labor Statistics (BLS): Nursing Assistants (usually known as Certified Nursing Assistants or CNAs), Home Health Aides, and Personal Care Aides.

• Nursing Assistants or Nursing Aides generally work in nursing homes, although some work in assisted living facilities, other community-based settings, or hospitals. They assist residents with activities of daily living (ADLs) and can erform clinical tasks such as range-of- motion exercises and blood pressure readings.
• Home Health Aides provide essentially the same in homes or community settings under the supervision of a nurse or therapist. They may also perform light housekeeping tasks.
• Personal Care Aides work in either private or group homes. They have many titles, including personal care attendant, home care worker, homemaker. In addition to providing assistance with ADLs, these aides often help with housekeeping chores, meal preparation, and medication management. They also help individuals go to work and remain engaged in their communities.

According to PHI, the federal government requires training only for nursing assistants and home health aides who work in Medicare- and Medicaid-certified nursing homes and home health agencies. However, states and individual employers may require training and/or certification for other types of direct-care workers.

In 2008, over 3 million direct-care workers were employed in the three occupations: Nursing Aides, Orderlies and Attendants (1,470,000); Home Health Aides (922,000); and Personal Care Aides (817,000). Home and community-based jobs dominate direct-care employment. By 2018, home and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.

In 2009, the median hourly wage for all direct-care workers was $10.58. This was significantly less than the median wage for all U.S. workers ($15.95). Both Personal Care Aides and Home Health Aides earned under $10 per hour ($9.46 and $9.85, respectively); Nursing Aides, Orderlies, and Attendants earned $11.56. Part-time hours reduce overall earnings; thus in 2009, median annual earnings for direct-care workers were $16,800.

One in every four nursing home workers and more than a third of aides working in agency-based home care lacked health coverage. About 45 percent of direct-care workers live in households earning below 200 percent of the federal poverty level income, making them eligible for most state and federal public assistance programs. Nearly half of all direct-care workers (46 percent) live in households that receive one or more public benefits such as food stamps; Medicaid; or housing, child care, or energy assistance.

At 4.3 million, in 2018, the direct-care workforce will reach historic proportions, exceeding kindergarten teachers, law enforcement and public safety workers, fast food and counter workers, registered nurses and all child care workers and preschool teachers.

What disturbs me is that the people who are caring for our elders are struggling to care for themselves. That is no reflection on them personally but it is a reflection of how they are valued. If you look at what they are paid and the benefits they receive as a determination of value, well, that would indicate they are not very valued. But when you look at what they provide to our elders, their value is enormous. And while it is easy to blame employers for not paying more or providing benefits, often their hands are tied because of the sorry state of the reimbursement system. That is the root cause that needs to be fixed.

Sources

U.S. Department of Labor

U.S. Census Bureau

PHI National

Learn more ~ or join the conversation!

_{NEWSLETTER | FORUM | TWITTER | FACEBOOK | CONNECT}

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Andrew Bret Wallis©Getty Images

According to Bloomberg News, the long-term care industry would be harshly impacted if state Medicaid funding is converted into block grants.

Bloomberg finds that converting Medicaid money into block grants could translate into billions of dollars worth of cuts to long-term care programs. It could lead to $53 billion to $154 billion in reduced overall Medicaid spending between 2012 and 2019 and long-term care facilities would lose between $8 billion and $23 billion.

A block grant is a large sum of money granted by the national government to a regional government with only general provisions as to the way it is to be spent. They allow regional governments to experiment with different ways of spending money.

According to the General Accounting Office, from 1980 to 2001 the number of federal block grant programs went from 450 to 700. The grants are aimed at a wide range of activities from education to healthcare, transportation, housing and counterterrorism.

My guess is that because block grants only have general provisions attached to how they are sepant, it gives states great latitude to "put the screws" to healthcare organizations and use the funding for other purposes. OK, so that is my crude interpretation. Maybe some of the policy wonks can expand on this by commenting.

Major criticisms of block grants are that:

• the award process can be manipulated so that grants can be distributed to reward the federal administration's own party.
• the same sort of partisan favoritism may occur at a local level when the state distributes the funds to local government units.
• dispersing the funds through state or local governments makes federal oversight of their proper use very difficult.

Republicans have been talking about converting Medicaid funding into block grants for states as a potential cost-saving option. Managed care plans would be the hardest hit, losing between $15 billion and $45 billion, followed by hospitals, which could lose between $11 billion and $33 billion.

American Health Care Association and National Center for Assisted Living President and CEO Mark Parkinson was quoted expressing the balance between maintaining the crucial role of Medicaid in protecting those who require care and services the most, while still addressing state budget crises. "We understand the need for states to balance their budgets, but oppose any block-grant proposal that balances those budgets on the backs of the frail and elderly," said Parkinson in the article.

Not to belabor a point but issues like this require those working in elder care services to get involved in the legislative process. So please re-read our primer on that (you did read it the first time right?!) and get involved in your local and state associations to make sure your funding source do not dry up.

Learn more ~ or join the conversation!

_{NEWSLETTER | FORUM | TWITTER | FACEBOOK | CONNECT}

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

©Getty Images