July 2018 Newsletter
Executive Director's Message
Jill and Governor Scott ride at Kingdom Trails with Vermont Mountain Bike Association
When I got my first job out of graduate school, my grandmother demanded that I provide her with a 3x5 index card explaining my job in a few bullet points. She pinned it to the wall next to her kitchen phone and referenced it proudly when sharing with friends and family what her middle granddaughter was doing with all that education. Nana has been gone for a while now, but I still have a mental index card I use when trying to explain to people outside my professional circle what it is that I do for a living. Statehouse advocacy is one of the easiest parts of my role to explain, so in the summer  -----      knowing the legislature has adjourned ------ people often ask me how I fill my time. 
There are many answers to that question, but in short, summer is regulatory season. After the session concludes, Administration officials in Vermont also spend less time in the Statehouse, so that's when most of the "rulemaking" takes place. At this writing, we expect to see a proposed home health designation rule -----    Vermont's criteria for deeming a home health and hospice agency qualified to provide services -----      any day now. The Vermont Department of Health is working on some revisions to the opioid prescription rule, which has an impact on our hospice patients. The Department of Vermont Health Access has released a home health payment rule outlining new documentation requirements (known as Medicaid Face-to-Face) imposed by their federal partners, and a telehealth rule that includes a section on telemonitoring. 
July is also the time of year when the federal Centers for Medicare and Medicaid Services (CMS) releases a draft home health prospective payment system (PPS) rule for public comment. This rule outlines how CMS plans to pay home health agencies, usually over the next two years, based on Congressional guidance and the relatively broad authority of the agency. It is the vehicle through which Medicare reimbursement to home health agencies has been slashed over the last decade or so. Needless to say, it's an important document. 
This year's proposed rule weighs in at about 600 pages. It lays out the schedule for phasing out the "rural add-on" payments that -----      while expected -----      is deeply worrisome. Our nurses, therapists and aides travel more miles than their more urban counterparts, and they cannot see as many patients in a single day. The rural add-on reflected these added costs and its planned phase-out was one of the biggest disappointments of the Bipartisan Budget Act of 2018. The rule also calls for a major overhaul of the entire home health payment system in 2020 -----      and the initial analysis by our national partners suggests that the overhaul will result in another Medicare cut overall. The VNAs of Vermont will be working closely with our national partners, members and regional financial experts to analyze the impact on Vermont's home health system. 
It's a lot to think about and I'm grateful to have hobbies that help me unwind and view the issues with a fresh perspective. For me, summer is also about mountain biking. I have a wonderful group of women with whom I ride one evening a week and my husband and teenage son are also avid riders, so that's how we usually fill our weekends. The picture above shows me on my bike posed with Governor Phil Scott. Through my participation in Vermont's statewide mountain bike association, I had the opportunity to join the Governor and some of his cabinet members last week as they explored Caledonia County's Kingdom Trails as part of their Capitol for a Day tour. Nana would be horrified by the bruises and scrapes I routinely sport at this time of year. But she'd have put that picture next to her phone. 

Jill Mazza Olson
Executive Director
Vermont Update
Over the next several weeks, the VNAs of Vermont will collaborate with experts from member agencies to develop comments on several proposed state regulations that impact home health agencies. These include:
  • The Rule Governing the Prescribing of Opioids for Pain -----The Controlled Substances and Pain Management Advisory Committee meets on July 31. With member input, the VNAs of Vermont has provided comments on a preliminary draft that is not yet available online.
  • Home Health Medicaid Payment Update (Medicaid Face-to-Face and other changes) -----Click HERE for an annotated version and HERE for a clean draft. Comments are due August 13, 2018.
  • Telehealth (including telemonitoring) - Click HERE for this proposed new rule. Comments are due August 13, 2018. The VNAs of Vermont will urge the Department of Vermont Health Access to expand telemonitoring to individuals beyond those with with Congestive Heart Failure.

Federal Update

Last week, the Centers for Medicare and Medicaid Services released the proposed calendar year  2019 Home Health Prospective Payment System Rule
Our partners at the National Association for Home Care have released an initial summary of the changes. As they deepen their analyses and develop comments, we will have more to report over the coming weeks. 
2019 Payment Model
  1. Overall 2.1% payment rate increase 
  2. The 2019 rural add-on depends on the region. For most eligible Vermont agencies, the 2019 rural add-on rate is 3%. It will drop to 2% in 2020, 1% in 2021 and be eliminated in 2022. One Vermont agency meets criteria that will mean a drop to 2% a year early, in 2019. Two agencies are not eligible at all .
  3. Outlier eligibility will be slightly tightened with the Fixed Dollar Loss ration dropping to 0.51% from 0.55%.
  4. The Low Utilization Payment Adjustment (LUPA) is unchanged. 
2020 Payment Model

CMS proposes a new payment model called Patient-Driven Groupings Model that has many of the same weaknesses as the Home Health Groupings Model proposed last year.  Probably most concerning is a cut. CMS proposes a "behavioral adjustment to base rates" of -6.425%. Other proposals include:
  1. A 30-day payment unit (instead of the current 60)
  2. The elimination of therapy thresholds for case-mix adjustment
  3. A new case-mix adjustment model (impact can vary depending on the people served by each agency)
  4. Combined care and non-routine medical supplies
  5. 30-day LUPA ranging from two to seven visits depending on case-mix category
  6. Possible elimination of the "Request for Anticipated Payment" program that improves cashflow by allowing agencies to receive partial payment for services at the beginning of an episode of care instead of waiting until the end 
Other Proposals
  1. New home infusion therapy benefit (21st Century Cures legislation created it)
  2. Elimination of the requirement that a certifying physician specifically state how much longer care will be needed
  3. Permitting of the incorporation of HHA records into the physician record including through the use of the Plan of Care
  4. Home health value-based purchasing demonstration refinements
  5. OASIS (patient assessment and data collection tool) refinements

OneCare Still Seeking Medicaid Representative

OneCare Vermont wants to understand issues and concerns from a consumer's perspective and is currently looking for volunteers who have Vermont Medicaid insurance to add their voices to its Board of Managers. The Consumer representatives from the three programs (Medicare, Medicaid, and Commercial programs) are part of a larger Board of Managers that works on ways to improve the health care system for all Vermonters.
All new members will receive training on OneCare programs and their responsibilities as Board Members. Part of each Board Member's role is to attend a board meeting on the third Tuesday of every month from 4:30 to 7 pm. These meetings rotate between OneCare Vermont offices in Colchester, Central Vermont Medical Center and Dartmouth Hitchcock Medical Center. There is an option to call into the meetings, but in-person attendance is encouraged as much as possible. 
If you are interested and has Vermont Medicaid insurance, please send a short description of yourself to Spenser Weppler at spenser.weppler@onecarevt.org

Upcoming Events
Third Thursdays beginning July 12
Hosted by VNAs of Vermont

August 29 | 1 p.m. to 2:30 p.m. 
Hosted by VNAs of Vermont

Second Thursdays beginning July 12
Hosted by VNAs of Vermont
11:30 a.m. to 1 p.m.

Upcoming Conference
VNAS of Vermont is proud to participate again in this year's Vermont Association of Hospitals and Health Systems conference. This year, we will lead a workshop, as will Judy Peterson, CEO of our member agency, VNA of Chittenden and Grand Isle Counties. We encourage health care professionals to join us at this worthwhile event.

VNAs of Vermont | www.vnavt.com | info@vnavt.org | 802-229-0579