Embed Size (px)
Citation preview
Finding the HorizonDeborah A. Randall, Esq.
Health Services and Telehealthwww.deborahrandallconsulting.com
Looking ahead will Homecare and Hospice be winning?
• Winning by trust
• Winning by team support
• Winning by having fans
• Winning by knowing the rules
• Winning by calling out foul play
• Winning by innovation
• Winning by using technology
• Winning by taking risks
• Winning over time
Where are we going?
With or without the full PPACA:
Concentrated Markets
Collaborations
Care management for chronic illness
Medicaid populations under tighter control
Experimentation in patient incentives
Physicians at the center [even when employed]
Distanced health delivery by telehealth
War zone with fraud and abuse enforcement
Accountable Care Organizations- ACOs
• ACOs are voluntary groups of physicians, hospitals, and other health care providers that are willing to assume responsibility for the care of a clearly defined population of Medicare beneficiaries attributed to them on the basis of patients' use of primary care services. If an ACO succeeds in both delivering high-quality care or improving care and reducing the cost of that care below what would otherwise have been expected, it will share in the savings it achieves for Medicare.
Changes toward ACO Rule
• 1200 comments about proposed ACO Rule• Preliminary prospective alignment • Retrospective reconciliation • Streamlining the metrics to focus on what
matters most; quality measures cut in half• Start-up ACO may choose “savings only”
track • “First dollar” share if ACO meaningful
savings• Federally qualified health centers and rural
health clinics
“Advanced” ACOs
• For established organizations with a track record of providing robust coordinated care, the CMS innovation center offered a “pioneer” ACO program, designed to encourage and support the next wave of innovation from vanguard organizations that are positioned to help realize the full potential of the ACO model.
Pioneer ACOs in CA, Dec.’11
• Brown and Toland Physicians, Bay Area
• Healthcare Partners Med’l Grp, LA /Orange
• Heritage California,Coastal,Central,SoCal
• Monarch Healthcare, Orange
• Primecare Med’l Network,San Bernadino and Riverside Cos.
• Sharp Healthcare, San Diego Co.
Additional ACOs April 2012
• AppleCare Medical ACO, Buena Park, CA
• Premier ACO Physician Network, Lakewood CA
What ACOs are Not
• Gate Keepers—not restraining specialty use at least directly
• A lock-in—so, not an old fashioned HMO
• But ACO is still held responsible financially and for quality
• “Big Medical Neighborhood” when a system’s patients have on average 12 physicians
How do Homecare and Hospice get to be Players....
• When they are not on the same block, fewer in the sandbox learning to play with others
• Is this the curse of holding ourselves “apart” and different [for example, on co-pays]
Lessons of a Successful ACO
• Ensuring the ACO “fits” mission
• ACO as a strategy to advance
◦ Integration
◦ Alignment
◦ Accountability
• Advancing readiness to take on risk and operate under a new model of care
• Strong assessment of partners
Lessons of an ACO, cont.
• Importance of organization-wide culture change
◦ Alignment, standardization, transparency
• Clinical integration strategy
• Engaging clinicians◦ Emphasize building “accountable care” into
organization, not just becoming an ACO
◦ Promote transparency, build trust in the data
◦ Employed physicians, built relationships
Eric Dishman, Visionary
“Coordinating care given by patients
themselves, family members and non
clinical community health workers will be
critical to sustainable models. We must
build a health IT infrastructure that facilitates
team-based care and real-time coordination
across specialties, locations and skill sets.”
The Money in Meaningful Use
• Outside the sandbox again.....
• But how are we doing in electronic records....
• Why are we not there as an industry, and is it always money that keeps us from our goals
• Organizing for what we want from vendors versus individualized action....a lesson from the Form 443 days.....
What is “Meaningful” in Aggregating
• Not document-centric stage
• Not data-centric stage
• But really patient-centric
• Need to move to “semantics” [format] of how data in many different systems can be understood
• Inter-operability issues in getting data out
• To “risk stratification” by ID’g persons who are likely to be passive or non-compliant
Community Care Physicians : The Electronic &Telehealth Highway
• Website to Guide Electronic Health Record Incentives Program Enrollment
https://www.cms.gov/EHRIncentivePrograms/56_DataAndReports.asp#TopOfPage
Other Programs and Grants
• Comprehensive primary care program
• Bundled payments for care improvement
• Community-based transitional care program with first grants issued in mid November 2011
• Major $1 Billion grant project from HHS Innovation Center for initiated in January 2012 with first proposals due out soon: innovation.cms.gov/initiatives/Innovation-Awards
LIFELONG MEDICAL CARECalifornia $1.1 Million
• Further integrate care, encourage healthy behavior, & reduce excessive ER and hospital visits among 9750 disabled, homeless, and mentally ill Medical/Medicare eligible.
• Train 60 disabled Medicaid and dually eligible beneficiaries to teach healthy behaviors to their peers; team of nurse care managers to facilitate.
• Savings = $1 million.
U.Chicago Urban Health Initiative $5.8 Million
• Develop the CommunityRx system, a continuously updated electronic database of community health resources that will be linked to the Electronic Health Records of local safety net providers.
• Create new worker, Community Health Information Experts (CHIEfs), assisting patients to use Health.eRx and community-based service providers to meaningfully use CommunityRx reports. Goal: ↑ compliance w meds and ↓ ER/hospitalizations.
Cooper Univ Hospital ,N.J. $2.78 Million
• Care management and care transition teams to work with 1200 people to reduce avoidable emergency room visits, inpatient hospital admissions, and hospital readmissions and improve their access to primary health care.
• Train 14 health care workers, including non-clinical staff, like AmeriCorps volunteers and community health workers, who will serve as part of multidisciplinary teams to support care coordination activities.
The Beacon Grants
• $12-15 million over 3 years for 17 grantees
• Regents of Univ. of San Diego winning proposal is focusing on cardiovascular health and admissions, readmissions and ER department use
• Grantees struggling with infrastructure issues, and Office of National Coordinator in Washington DC also struggling with administration of this program
• Regional Extension Centers as support
Medical Homes
• Slow to start
• Not all communities can be a Geisinger or Mayo type system
• John Muir health system in No. California doing and funding their own pilot on chronic disease education and management
=> 43% drop in hospitalizations and 10% drop in ER use in the two years
• A natural way to incorporate telehealth
Bundling
• Pilot projects and demonstrations
• The “private” bundling developments
• The forecast of a Medicare bundled post acute care model
• Once bundled, can it be “undone”?
“Independence at Home” Awards
• Sixteen provider collectives have been announced by HHS in late April 2012
• Physician-Nurse Practitioner entities
• Goals for increased quality, lower cost and innovative approaches to chronic disease management
• Use of technology and in particular, telehealth monitoring and communications
Community First Choice Final Rule, May 7, 2012= ↑6% FMAP• Individuals need institutional-level care
• Home attendants and supports for ADLs, IDLS and hands-on assistance, supervision cuing and many additional aides and items
• Self-directed and other models
• First year must = or ↑ prior 12 months $$
• Permanently waive the annual recertification requirement when improvement or significant change unlikely because of severity or degree of chronicity or impairment
“We agree with the commenters that
telemedicine could be a useful method
of providing backup systems or
supports. We are available to discuss a
State’s interest in using such technology
for this purpose....” 77 Federal Register 26828, at 26835 (5/7/12).
The Rise and Promise of Telehealth
• Research and challenges
• Expanding the repertoire
• Convincing the government
• Following the states’ leads; California’s new law
• Looking to the VA models, and to the new legislation undoing barriers
• Without physician endorsement......
• Movement in Europe
What We Know About Trust
• The reason care in the home and other non-institutional settings works
• The reason we can take the last journey at the end of our lives with less fear
• A partnering or supplementation of trusting relationships of family or loving friend
Rise of Major Marketing Fraud
• Pharma Cases still dominate the Headlines such as:
◦ Merck agreed to pay $950 million to resolve Vioxx promotion cases
◦ SmithKlineGlaxo announced $3 billion investigations of sales and marketing practices
◦ Abbott reserved $1.5 billion for DOJ cases
◦ Pfizer Inc. paid $2.3 billion in 2009
Home-based Care Fraud Cases Are Growing
• Maxim Healthcare Services paying $121 million plus interest in civil case and $20 million in criminal fines for false claims to Medicaid programs and Veteran’s Affairs => services not provided; not sufficiently documented; delivered from unlicensed offices.
Home Health Fraud Cases
• LHC Group civil settlement at $43 million
• Indictments in Florida, California, Michigan
• Substantial prison sentences
• Growing Medicaid fraud investigations
• ZPIC audits going ballistic; is this teeing up for a round of fraud overpayment cases
• Overpayments back 10 years to report?
Is it 60 days to investigate, post-investigation to report?
Dragnet: $452 Million
• Dept of Justice and Dept of Health and Human Services announced May 2, 2012
• Main cities in HEAT plus a few: Baton Rouge, Miami, Tampa, Houston, Detroit, Los Angeles, Chicago
• Variety of players, but includes home health
• How do we complain about unnecessary audits and enforcement actions in a time where these are the results of such actions
• Senate Letter about the ZPICs
In California...in the Dragnet
• Allegations that Great Care Home Health in Los Angeles billed for care that was not needed, for persons who were “well”
• In general, the home health cases in dragnet again are looking at illegal broker arrangements, and kickbacks in the community of physicians and others
Hospice Fraud Settlements
• Even when it’s a self reporting repayment, the penalties are stiff.
• Diakon Hospice Saint John, erroneously submitted $11 million in Medicare from Oct. 2004-2009 for patients ineligible for hospice benefits under Medicare/Caid regulations.
• Diakon’s voluntary disclosure to federal authorities allowed it to avoid prosecution under the False Claims Act and permitted it to negotiate a settlement.
AsaraCare and Odyssey Cases
• When does marketing become toxic
• When do employee incentives destroy trust
• What if clinicians are secondary to business
• What if internal or external Audits or Reports are ignored or buried
• Do incentives to potential patients or their families distort the medical justification for care or the intensity of care
• When internal alarms are disparaged
Moratorium on High Risk
• October 2011, Senators Grassley and Hatch wrote Secretary Sebelius:
“Explain why CMS has not imposed a temporary moratorium of ‘high’ or ‘moderate’ categorical risk providers/suppliers in HHS-OIG strike force cities or other high-risk areas.....”
Home Health Attacked by Congress October 2011
Congress goes after 4 large home health companies for “gaming” physical therapy
Time To Speak Out!
• If the homecare and hospice industries do not speak out with specifics about practices that cannot be tolerated and make that clear in the communities where they operate
=> They will miss the example set by the pharma and medical device industries
=> Mistrust of home-delivered services will deepen
=> Investigators’ accusations will increase
Winning for “Care in the Community”
• Winning by trust
• Winning by team support
• Winning by having fans
• Winning by knowing the rules
• Winning by calling out foul play
• Winning by innovation
• Winning by using technology
• Winning by taking risks
• Winning over time
Faculty Contact Info
Deborah A. Randall, Esq.Health Services & Telehealth Consultant
Law Office:237 9th St. SE, Washington, DC [email protected]
Consulting Office: Poinciana, [email protected]
202-257-7073www.deborahrandallconsulting.com
