Author: James Fuccione

WBUR Reports on Home Care Workforce Stuggles

Home care workforce struggles are being highlighted based on data collected by the Paraprofessional Healthcare Institute and reported by WBUR.

The data is staggering and all points to a theme that the New England states will struggle with attracting enough home care workers to meet demand. The six states in the region also have the lowest birthing rates in the country. Combined with a rapidly aging population, researchers conclude that the workforce has to come from outside the region and likely outside of the united States entirely. The story points out the following stats:

As of 2014, more than a quarter of the home health care workers in Massachusetts were foreign-born, according to census data compiled by the Paraprofessional Healthcare Institute. Forty-one percent of the nursing assistants in the state’s assisted living facilities were also born outside of the U.S. And these numbers likely miss immigrants who work part-time or who may be here illegally and working under the radar.

The WBUR story quotes Barry Bluestone, a professor of public policy at Northeastern University who’s run some of the jobs numbers, and predicts that in Massachusetts, “we’re going to need about 93,000 additional home care workers over the next 10 years, or almost 10,000 a year.”

Bluestone lays out that the enormous challenge is potentially compounded by the political landscape:

“These are overwhelmingly immigrant workers, and what I fear is if the current kind of political environment either shuts off immigration, or potential immigrants look at the United States and say this is not a very comfortable or safe place to be,” Bluestone says. “I don’t have any idea how we’re going to fill those 10,000 jobs each year.”

WBUR also had a follow-up piece on their “Morning Edition” show spoke only to 1199 Service Employees International Union as a “representative” of the home care industry and workforce.  SEIU shared national wage data and touted their work to achieve local raises to personal care attendants (PCA), leaving unaddressed the broader problem for home health aides, homemakers and other in-home caregivers related to rates and regulation. Recognizing the difficulty of covering a complex issue in a five-minute radio interview, the Home Care Alliance contacted WBUR with clarifying information and offered the organization’s expertise, along with that of member agencies.

For those looking, employers and job seekers in the home health industry may find career information through the New England Home Care Career Center, which is co-managed by the Home Care Alliance of Massachusetts.

 

Return to www.thinkhomecare.org.

 

State Budget Cuts Impact Home Health Care

The Home Care Alliance participated in several calls with MassHealth and Health and Human Services on planned budget cuts from Governor Baker’s administration. In total, the Governor announced $98 million in cuts from the $39.25 billion state budget.

Although there are reductions in home health, there are positive rates increases to report.

After years of advocacy by the Alliance and more recent efforts from a coalition of continuous skilled nursing providers as well as a family-based network called the Mass. Pediatric Nursing Campaign, MassHealth informed the HCA that payment rates for Continuous Skilled Nursing will increase by 2.6%. According to MassHealth, this equates to a $2.2 million bump in rates, which will become effective January 1st, 2017.

For the RN and LPN day and night rates, the increase hovers around a $1 boost in what those agencies currently receive. The Alliance, along with the provider coalition and family-based campaign, will continue to advocate for further adjustments to continuous skilled nursing rates in the upcoming FY18 state budget cycle.

As for home health skilled nursing rates outside of CSN, payment will be reorganized by the length of service of the MassHealth member. As of July 1, 2017, MassHealth is planning to break up the current skilled nursing rate for home health agencies into three separate tiers. The first tier will be for patients on services from day 1 through 30, which will be increased from $86.99 to $89.21. The second rate tier will be 31-180 days and the third rate tier is any home health service beyond 180 days.

MassHealth has indicated that the rates in the second tier will remain relatively static and the third tier will be decreased, but post 30-day rates as of 7/1/17 will be budget neutral from the changes taking effect on January 1st. An announcement from EOHHS will specifically outline the new tiered rates, but according to MassHealth, anything regarding rates that is seen before the New Year is not finalized and therefore subject to change.

The other notable decrease will take effect on January 1st when MassHealth plans to approximate the budget impact of those proposed second and third rate tiers into the current post 60-rate. The cut in the post 60-day rate from 1/1/17 to 7/1/17 will be a 6.75% reduction. This means the current post 60-day rate of $69.59 will be roughly $64.89 for the first six months of 2017. (This rate remains higher than the medication administration rate originally considered by MassHealth.)

Laid out in another way, this will be how rates are currently planned to change:

January 1 – July 1:

Home health services post 60-day rate will be roughly $64.89 (6.75% reduction)

July 1:

Service days 1-30: $89.21

Service days 31-180: Rates will remain roughly the same, but are not yet finalized

Service days 180: Rates will be slightly reduced from the current post 60-day rate, but are not yet finalized.

MassHealth is also streamlining enrollment in the Independent Nursing program to cut their application process from 8 weeks down to one week.

The net state cut for home health is approximately $3.8 million out of $758 million in MassHealth spending on home health care services.

Most of the other cuts announced by the administration are restoring vetoes previously proposed by the Governor in the FY2017 budget, but that were overridden by the legislature. At that time, the Governor vetoed $255 million and the legislature overrode $231 million. Included in these cut overrides are certain hospital supplementary payments (particularly to pediatric and Western MA hospitals) as well as $1.1 million in cuts to public health hospitals.

Other impacted accounts include supplemental payments to nursing homes, which will be reduced by $2.8 million, as well as a $2.8 million cut to adult foster care (AFC).

The Pediatric Palliative Care account (4590-1503) is being reduced by $400,000.

The legislature has already announced their view that Governor Baker went too far with some of the announced cuts and they will be working on restoring some of the funding reductions.

HCA of MA has an upcoming meeting with MassHealth to review the Governor’s proposal.  Also on the agenda are issues with ICD-10 changes that are impacting agency billing and payment.

Return to www.thinkhomecare.org.

Advocacy Alert: Urge Congress to Delay Pre-Claim Review via the PUSH Act

With the election over, and Congress shifting slightly back to policy rather than politics, the Home Care Alliance is ramping up advocacy on an important piece of new legislation regarding CMS’ Pre-Claim Review Demonstration.

The Pre-Claim Undermines Seniors’ Health (PUSH) Act (H.R. 6226) offers relief from the demonstration, which has already created a chaotic and expensive mess in Illinois. Providers in that state initially experienced 60-80 percent denial rates and continue to struggle with “partial claim denials” that the Center for Medicare and Medicaid Services (CMS) does not count or recognizeU.S. Capitol Building. Pre-Claim Review also features a time-consuming new paperwork burden, an inefficient electronic system that cannot process documentation, and physician unfamiliarity with what is needed to be compliant due to poor education from CMS. These reasons have led to considerable cash flow problems at agencies, and at least one Illinois agency has closed its doors for good.

Massachusetts and three other states could soon be subject to the burdensome program if Congress does not act.

Please take a few minutes and send a message to your US representative urging repeal of the Pre-Claim Review Demonstration, sponsored by Rep. James P McGovern (D-MA) and Rep. Tom Price (R-GA). It only takes a minute to advocate and gaining support through congressional “co-sponsors” is critical.

Return to www.thinkhomecare.org.

 

CMS to Delay Expansion of Pre-Claim Review Demo

CMS announced yesterday afternoon that they are delaying the expansion of the Pre-Claim Review Demonstration for Home Health Services which began in Illinois on August 3, 2016.

According a notice on CMS’s website, based on early information from the problems encountered in Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, they will not move forward with initiating the demonstration in Florida in October.  This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.

According to the notice, CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states.   The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on this website prior to beginning in any state.  CMS continues to expect a staggered start, beginning with Florida.

The Alliance has been working closely with the state associations in the other demonstration states and national home health groups to advocate for major changes to the project.  Building off of this short-term victory, HCA will continue those efforts and is also briefing our Congressional delegation on the issue. HCA will, of course, keep members informed of any changes in the demonstration.

Return to www.thinkhomecare.org.

Proposed Changes Prep Mass. for Nurse Delegation

The Massachusetts Board of Registration in Nursing (BORN) has released proposed regulations that sets guidelines for, among other activities, delegation by nurses to “unlicensed personnel.” These guidelines are NOT a change in the nursing scope of practice around medication delegation, which requires a law  approved by the legislature and signed by the Governor.

The BORN is merely aiming to establish a nurse delegation framework inclusive of much more specificity in areas such as training, supervision and documentation should nurse delegation practices become allowable in Massachusetts.

The proposed regulations also protect nurses by setting criteria for delegation that includes the following:

  • Ensuring that the delegating nurse would not bear any responsibility for any deviation by the unlicensed personnel from the nursing directive, instruction, or plan of care.
  • Formalizes the nurse’s role in knowing what is within the ability of the unlicensed personnel to carry out and what can be delegated that would not require judgment or assessment by the unlicensed personnel.
  • The final decision to delegate is made by the nurse and not the employing healthcare provider.
  • The employing healthcare provider must have the competencies of the unlicensed personnel documented for each nursing activity along with periodic validation of those abilities.
  • The nurse can determine at any time that an activity can no longer be delegated based on the health status of the patient, the unlicensed personnel’s performance of the activity, or any other reason the nurse believes would jeopardize the health and safety of the patient.

The proposed regulation follows years of discussion and a BORN subcommittee report on the state’s readiness for potential changes to nursing practice.

One of the possible changes is a longstanding policy priority of the Home Care Alliance, which is to allow home health care nurses to delegate certain medication administration tasks to a trained and certified home health aide. The HCA has dubbed the proposed policy as the “Nurse Delegation Bill.”

This bill will not pass in the current legislative session that ends with the New Year in 2017, but the HCA plans to continue pursuing a change that would allow – not mandate – that home health and home care agencies can implement proper training and procedures to maximize the efficiency of their direct care staff.

It should be noted that this bill includes protections, such as the fact that delegation is limited to medications which are NOT controlled substances and are administered in the following methods:

  • Oral
  • Ophthalmic
  • Otic
  • Topical
  • Internasal
  • Transdermal
  • Suppository
  • prefilled auto-injectables designed for self-administration
  • Products which are administered by inhalation.

The legislation states that “delegation of intramuscular, subcutaneous, intradermal, intraosseous or intravenous administration of medication shall not be permitted.”

Although the Alliance has comments and suggestions for the BORN’s proposed regulations, HCA fully supports the move to ensure the state is prepared for laws that promote nurses practicing at the top of their licenses. The Alliance appreciates the BORN’s thoughtful approach that further solidifies the importance of nurses in healthcare delivery.

The BORN will hold a public hearing on October 4th and will accept written comments until October 11th.

Return to www.thinkhomecare.org.

Home Care’s Part in the CMS Bundled Payment Program for Cardiac Care

Though no final announcements on participants have been made, several areas of Massachusetts were declared “eligible” by CMS for random selection of nearly 100 metropolitan statistical areas (MSA) across the country for a new innovation initiative that offers bundled payment for cardiac care.

CMS released the proposed rule on July 25th where the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.

As with many similar alternative payment programs, established quality metrics would help determine whether the hospital would be required to pay Medicare for poor performance or receive reward payments for higher-quality care. CMS chose July 2017 to March 2018 as the “performance year” and then a gradual increase in the gains and downside risk for hospitals beginning at 5 percent in 2018 and capped at 20 percent in 2020-2021.

CMS is encouraging collaboration with other providers, including home health care and other post-acute providers. Equally important are a list of waivers this program will grant relative to the provision of post-acute care. Some notable highlights are listed below, with explanatory excerpts from the proposed rule, but the full list of waivers can be found in the proposed rule under “Subpart G” on page 885.

  • Waiver of direct supervision requirement for certain post-discharge home visits:
    • “CMS waives the requirement in  § 410.26(b)(5) of this chapter that services and supplies furnished incident to a physician’s service must be furnished under the direct supervision of the physician (or other practitioner) to permit home visits as specified in this section.  The services furnished under this waiver are not considered to be “hospital services,” even when furnished by the clinical staff of the hospital.”
  • Waiver of certain telehealth requirements:
    • “Except for the geographic site requirements for a face – to – face encounter for home health certification, CMS waives the  geographic site requirements of sec tion 1834(m)(4)(C)(i)(I) through (III) of the Act for episodes  being tested in an EPM, but only for services that  (1)  May be furnished via telehealth under existing requirements; and (2)  Are included in the episode in accordance with  § 512.210”
    • The Alliance is researching whether this is restricted to physicians performing telehealth or whether home health agencies would be allowed to engage in remote patient monitoring.
  • Waiver of the SNF 3-day rule
    • Only applies to the AMI (Acute Myocardial Infarction) model.

There is a 60-day public comment period and it is unlikely that the participating MSAs will be revealed before the final rule, but the “eligible” areas in Massachusetts are included below:

  • Barnstable Town, MA
  • Boston-Cambridge-Newton, MA-NH
  • Providence-Warwick, RI-MA

Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.

Return to www.thinkhomecare.org.

 

MassHealth Announces Home Health Agency Audit Results

Though a statement published in a Boston Globe online article, MassHealth revealed that their first round of home health agency audits uncovered $22.5 million in improper billing.

Nine home health agencies were involved in the initial audits conducted in response to steep spending growth in the MassHealth home health program. As the Globe article points out, the majority of that spending growth is driven by 62 companies that have come online since 2013.

In response, the Home Care Alliance is making its statement on the audits available. The full text of the statement is copied below:

Home Care Alliance of MA Statement on MassHealth Audits

BOSTON, MA – MassHealth announced today that audits of home health providers have uncovered more than $22 million in improper payments. The audits were initiated in an effort to identify the sources of recent dramatic spending growth on MassHealth home health services.

The Home Care Alliance of Massachusetts, a nonprofit trade association representing home health and home care providers, has been working side-by-side with the state Medicaid office staff since these audits were announced. The Alliance supported and continues to support MassHealth’s efforts to ensure appropriate services are being provided. This includes a temporary moratorium on new providers, and a prior authorization process for approving home health care services. In the months since the latter measure was put in place, both sides are in constant communication to relay concerns and suggestions. After years of lax oversight, Governor Baker’s administration has put a long-overdue emphasis on program accountability to assure that only eligible MassHealth members receive the in-home services they need to preserve their health and well-being.

“Massachusetts is fortunate in having some the best home health providers in the country and we support MassHealth in these efforts because we want to preserve the high standards of quality that patients and their families should expect,” said Patricia Kelleher, Executive Director of the Home Care Alliance of MA. “These audits only help to prove what our organization has been saying for years: There needs to be better state oversight as well as a higher bar of entry into the market.”

“Many of the MassHealth enrollees that our member agencies see have severe and persistent mental illnesses, and the multiple medications that they take can cause additional medical problems that require ongoing medical attention,” added Kelleher. “The agencies who do this work feel that they are a huge part of the health care safety net, providing valuable services to patients and families who otherwise would be placed in costlier care settings and/or become a detriment or even threat to their communities.”

The decision to add new management controls was driven by growth in utilization of the benefit particularly between FY 2013 and FY 2015. At present approximately 32,000 MassHealth enrollees are using home health services on an annual basis. Of these approximately 7,000 are receiving home health to assist in managing a mental or behavioral health condition, 4,000 are under age 21 and 9,300 are over age 61.

“Although MassHealth has not shared the specific audit results with us, we will continue to push for better standards and support program integrity efforts on behalf of all agencies that are playing by the rules and providing great care,” said Kelleher.

Return to www.thinkhomecare.org.

Moratorium on Home Health Agencies Extended by CMS, MassHealth

Both the state and federal governments are extending moratoria on new home health providers.

MassHealth will be extending the six-month moratorium on new home health providers, which will become effective on August 12 for an additional six months, according to MassHealth. The Home Care Alliance has been supportive of the measure and has collaborated with the state Medicaid office on program integrity efforts, but attempts to kick-start a state oversight policy for home care agencies have been unsuccessful.

In a letter requesting the initial stoppage on new providers from Massachusetts Health and Human Services Secretary Marylou Sudders to federal HHS Secretary Sylvia Mathews Burwell, it was noted that home health spending under MassHealth increased 41% from fiscal years 2014 to 2015. The letter continued to explain that 85% of that growth was driven by providers that were new to the MassHealth program since 2013.

Meanwhile, the Centers for Medicare and Medicaid Services (CMS) announced that they will be not only  extending their temporary moratoria on enrollment of specific locations within Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, but will also be broadening moratorium across each of those states.

Below is an excerpt from the Federal Register with CMS’ reasoning in announcing the extension and expansion:

CMS has determined that the factors initially evaluated to implement the temporary moratoria show that a high risk of fraud, waste, and abuse exists beyond the current moratoria areas, which may suggest that a high risk of fraud, waste, or abuse exists due largely to circumvention of the moratoria by some providers and suppliers.

The primary means of circumvention includes enrolling a new practice location outside of a moratorium area and servicing beneficiaries within the moratorium area. Additionally, CMS has continued to see areas of saturation that exceed the national average in the moratoria states. As a result, CMS, in consultation with the OIG, has determined that it is necessary to expand the temporary moratoria on a statewide basis, by implementing temporary moratoria on all newly enrolling HHAs in the remaining counties in Florida, Illinois, Michigan, and Texas, and on all newly enrolling Part B non-emergency ground ambulance suppliers in the remaining counties in Texas, New Jersey, and Pennsylvania, in order to combat fraud, waste, or abuse in those states.

Return to www.thinkhomecare.org.

One Care Program Extended Through 2018

MassHealth announced that the One Care Program for individuals dually eligible for Medicare and MassHealth and between the ages of 21 and 64 has been extended through 2018.

Part of this new agreement with the Centers for Medicare and Medicaid Services (CMS) is that MassHealth will be accepting letters of intent (LOI) from entities interested in becoming One Care Plans effective January 1, 2018.

Beginning in 2013, the One Care program included several plans that were whittled down to what is now Commonwealth Care Alliance and Tufts Health Plan, which began participation in the initiative as Network Health. Funding issues were at the center of why other plans could not sustain covering One Care enrollees, although adjustments have been worked out that are intended to help plans better predict costs and assess financial risk. Fallon Total Care was the latest to drop their participation in June 2015.

Out of 103,041 eligible individuals, MassHealth reports that 13,038 are covered by the two One Care Plans. Commonwealth Care Alliance covers the bulk of that total with 10,050 enrollees as of June 1, 2016. According to the latest enrollment report, more than 30,000 individuals have “opted out” of the One Care Program.

Return to www.thinkhomecare.org.

What the Senate’s Economic Development Bill did for Home Care

Late Thursday night, the Senate wrapped up debate on more than 200 amendments to legislation promoting economic and workforce development and the Home Care Alliance was active on several issues.

Senate Bill 2423, “An Act relative to job creation, workforce development and infrastructure investment,” created a a special commission to investigate and report on barriers to meeting labor market demands in the commonwealth. The commission’s report can include a broad range of industries, but according to the legislation, it must consist of cyber-security, high technology and biotechnology, early education and care, home care and home health. Despite this focus, the “labor commission,” as it was labeled, did not have a member that represented the home care industry.

Working together with the Home Care Aide Council, and Senator Patricia D. Jehlen’s office, an amendment was adopted to get a home care agency representative on that commission. If the Senate’s legislation advances and is passed, this commission will be shining a light on home care workforce issues on a level of importance that places it with other industries.

The other amendment, which was of great concern, was an effort that would have created a publicly-available registry with the personal information of home care workers. It was the same provision that showed up in legislation and FY17 budget amendments – all of which were defeated.

In this particular iteration, the result was a redrafted amendment to create a registry of home care workers that does NOT include personal information, but rather certifications and whether that worker has ever committed abuse, mistreatment or neglect of an elderly patient or consumer.

The Alliance thanks the many agencies that weighed in quickly with their state senator by phone and email on both of these matters.

The Senate’s legislation now must pass a conference committee process where differences between S.2423 and the House’s version of the bill must be worked out.

Further updates will be shared when they become available.

Return to www.thinkhome.care.

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