Late-March 2018 Newsletter
Executive Director's Message
Confessions of a Policy Wonk
If there's one thing we health care policy wonks have in common, it's our natural tendency to make interesting and important work sound boring and incomprehensible to everyone else. Partly this is a function of the reality that health care policy is complex, fragmented and counter-intuitive.  Medicare is the health care plan for people 65 and over ----    until they need long term care, which isn't considered "health care" at all.  Medicare and Medicaid health care payments are based on lengthy regulations that change every year ----     and the changes often center on arcane issues like the length of an "episode" of care. And of course, there are the endless acronyms and short-hand terms that have no obvious plain-language meaning.

I started thinking about this issue while putting together the Federal Update section below. One significant change we report is that that " CMS has posted a notice  for the revised Outcome and Assessment Information Set (OASIS-D)." To home health industry leaders, these words have meaning. And yet, that sentence fails to convey the importance of that tool to policymakers, the individuals we serve and their families. If I wrote that "OASIS is a comprehensive patient assessment," would that help? I don't really think so.

But what if I told you that when new patients are referred for home health care, nurses and therapists spend a few hours making sense of how the patients are doing living on their own, after spending time with them and their families in their homes.

They consider the things that the adult children of parents who are becoming more frail think about every day. Can they get themselves to the bathroom alone safely? Do they seem anxious or depressed? Are they starting to have trouble remembering things? Do they seem alert and oriented? Did they get a flu shot this year? Are they eating ---- and can they still prepare a meal or feed themselves? What is in all those pill bottles ----   which ones are they taking and is that really what their physicians intended? Are they likely to fall ----   and are there changes that can be made in their home to reduce the chance that they will?

It's this kind of work that home health agencies view as part of their role as a vital "extension" of primary care. Some of these things can be assessed in a physician office, but so much more is revealed when individuals are assessed in the context of their homes and their families. 

And ----   back to the policy wonk language ----   this is the kind of work that we need to do a lot more of in the context of health care reform and Vermont's all-payer model. Under existing payment regulations, home health agencies can only care for those individuals who have immediate and acute need for home health services. Under Medicare, they also must be considered "homebound" according to detailed criteria. All too soon, the "episode" comes to an end and the visits end. The next time a home health nurse or therapist sees the individual is after the next hospitalization or trip to the emergency department.

Under Vermont's all-payer model, we hope to develop new programs that will allow home visits to happen with a focus on prevention, rather than having to wait for the next crisis. Not only will this save dollars for the health care system as a whole; it will keep more Vermonters healthier and happier ----   the true goal of health care reform.

Think Spring!

Jill Mazza Olson
Executive Director
State Update
The VNAs of Vermont are deeply grateful to the members of the House Appropriations Committee for their unanimous support of a 2 percent Medicaid payment rate increase for home health, hospice and long-term care services (Choices for Care) in the House budget. The budget bill passed the House this week with the increase intact. This support is critical to the Vermonters we serve. Medicaid rates have grown well below the rate of inflation for more than a decade, even as the needs of the people we serve have become more complex. In addition, Medicare reduced its payment rates consistently over the same period. The focus of our advocacy now moves to the Senate.

Federal Update
Rural Add-on Implementation 2018
The Centers for Medicare & Medicaid Services (CMS) has issued  Change Request  10531, which provides instructions to the Medicare Administrative Contractors (MACs) to reprocess home health claims eligible for the 3 percent rural add-on pursuant to the Bipartisan Budget Act of 2018. Most Vermont agencies are eligible for the rural add-on.
Some claims require reprocessing because Congress didn't reauthorize the 3 percent 2019 rural add-on until February 9, 2018 as part of the Bipartisan Budget Act of 2018. The rural add-on expired on December 31, 2017.
According to CMS, the MAC will initiate the adjustments and agencies will not need to take any action.
The rural add-on will be reduced to 2 percent on January 1, 2019.
OASIS Update
CMS has posted a notice  for the revised Outcome and Assessment Information Set (OASIS-D) that goes into effect January 2019. Comments on the revised OASIS assessment instrument are due May 11, 2018 and can be submitted HERE .
The revised OASIS and supporting documentation is posted  HERE . CMS removed 33 data items to make room for new items that will be phased in over the next few years.
The most significant additions include extensive mobility and self-care assessments that are rated on a six-level rating scale ranging from "6" "Independent" to "1" dependent. Our national partners predict that agencies will need time to adjust to the mobility and self-care items, which are time-consuming and will require staff training.
If CMS follows the typical public comment process, it will be several months before the OASIS changes are official.
MedPAC Recommends Payment Cuts ----   As Usual
The  latest report  to Congress from the Medicare Payment Advisory Commission (MedPAC) recommends a 5 percent payment rate cut to home health care for 2019. The purpose of MedPAC is to monitor the Medicare program and provide advice to the US Congress on payments to private health plans participating in Medicare and health providers serving Medicare beneficiaries.

This proposal is frustrating, but not surprising. MedPAC has previously called for payment rate cuts to home health care despite its cost-effectiveness relative to the rest of the health care system - and the reality that home is where most people prefer to receive their care. Congress is under no obligation to follow MedPAC recommendations and in the past, home health rate cuts have been considerably more restrained than suggested by MedPAC. 

Upcoming Events
March 26 | 5:30 to 7:30 p.m. ET
Hosted by OneCare Vermont
In-person event
March 27  | 1:30 p.m. ET
Hosted by CMS

March 28 | 2:00 p.m. ET
Hosted by CMS
April 12, May 10, June 14  | 3 to 4 p.m.
Hosted by VNAs of Vermont

May 1, 15, 29   | 9 a.m. to 5 p.m.
Hosted by VNAs of Vermont
May 9  | 1 to 2:30 p.m.
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Learn About Targeted Probe & Educate and Medicare Documentation Requirements 
April 4, Concord, New Hampshire

Postponed: OneCare Provider Panel
Please note that the OneCare Provider Panel that we listed in our last newsletter has been postponed due to Statehouse scheduling issues.

Upcoming Conferences
J6/JK Home Health and Hospice Medicare Summit 2018:
Maintaining a Healthy Compliance Program
hosted by National Government Services
September 19 & 20 | The Orleans, Las Vegas, NV 
Save the Date! Registration opens in February.
VNAs of Vermont | | | 802-229-0579