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(1)

Critical Access Hospitals and

Health Care Reform

Health Care Reform

What’s in it for you? What s in it for you?

(2)

Patient Protection and

Affordable Care Act (ACA)

• Fundamental changes • Fundamental changes

– Moving Medicare from payment for services to payment for outcomes services to payment for outcomes – Expansion of Medicaid

Changes health insurance – Changes health insurance

(3)

ACA legislation

ACA legislation

• Clarifies 101% reimbursement for • Clarifies 101% reimbursement for

Method II outpatient billing

Method II is no longer an ann al election – Method II is no longer an annual election. – In effect until request for termination

M t tif MAC 30 d i t t t f – Must notify MAC 30 days prior to start of

cost reporting period for election or termination

(4)

ACA legislation

ACA legislation

• Extends Flex program to 2012 • Extends Flex program to 2012

• Additional grant funds to assist rural

h it l i l b d h i

hospitals in value-based purchasing, accountable care organization,

t b dli d th f

payment bundling and other reform programs

(5)

ACA legislation

ACA legislation

• Extends 340B discount program to • Extends 340B discount program to

CAHs for outpatient drugs

N kf t th i

• Numerous workforce strengthening and improvement provisions

(6)

Payment methodologies

Payment methodologies

• CAHs will be consulted regarding • CAHs will be consulted regarding

participation in Payment Bundling pilot

program (§3023)

program

• CAHs are exempt (for now) from

h it l d i i t

(§3023)

hospital readmissions payment reduction program

(7)

ACA legislation – CAH

challenges

• Independent Payment Advisory Board • Independent Payment Advisory Board • Changes to Medicare Advantage

• Medicaid DSH cuts

• Commercial health insurance changesg

• Payment cuts in related entities

– SNF HHA hospice physicians DME – SNF, HHA, hospice, physicians, DME,

(8)

Value based purchasing

Value based purchasing

• PPS hospital program begins 10/1/12 • PPS hospital program begins 10/1/12 • CAH program will start as a

d t ti

demonstration

– Begins 2012

(§3100 (b))

– Three year program

– Earliest implementation 2017

(9)

ACA legislation – CAH

challenges

• Quality reporting and payment • Quality reporting and payment

impacts

C li d f t

• Compliance and enforcement • Competition

– PPS hospitals in accountable care organizations

– FQHC increased funding – Physician recruitment

(10)

ACA legislation – CAH responses

ACA legislation CAH responses

• Report and monitor quality measures • Report and monitor quality measures • Improve revenue cycle processes

• Review staffing levels

– Hospital staff AND medical staff

• Evaluate profitable and unprofitable services

(11)

HCOs vs CAHs

HCOs vs. CAHs

(12)

Core Measure Composite Scores

for Georgia CAHs 2001 - 2009

(13)

Georgia CAH’s Gaining on

National CAH’s

(14)
(15)

CAH Hospitals are Improving!

CAH Hospitals are Improving!

(16)

Accountable Care

Organizations (ACO)

• Organization of health care providers • Organization of health care providers • Accountable for the quality, cost, and

ll f M di b fi i i

overall care of Medicare beneficiaries assigned to ACO

(17)

ACO - beneficiaries

ACO beneficiaries

• Assigned • Assigned

– beneficiaries for whom the professionals in the ACO provide the bulk of primary care the ACO provide the bulk of primary care services

• Assignment • Assignment

– invisible to the beneficiary

ill t ff t th i t d b fit – will not affect their guaranteed benefits or

(18)

ACO participants

ACO participants

• Group practice physicians/professionals Group practice physicians/professionals • Networks of physicians/professionals

• Partnerships or joint venture arrangements of Partnerships or joint venture arrangements of physicians/professionals and hospitals

• Hospitals employing physicians/professionals • Other forms that the Secretary of Health and

(19)

ACO requirements

ACO requirements

• Formal legal structure Formal legal structure

• Have a sufficient number of primary care professionals for the number of assigned

p g

beneficiaries (to be 5,000 at a minimum) • Participate for a minimum of three years

(20)

ACO benefits

ACO benefits

• Receives a share of savings each 12 • Receives a share of savings each 12

month period

Act al per capita e pendit res of – Actual per capita expenditures of

assigned Medicare beneficiaries compared to benchmark amount compared to benchmark amount

– Must meet quality performance standards to receive benefit

to receive benefit

(21)

ACO costs

ACO costs

• ACO participation is costly • ACO participation is costly. • Physician Group Practice

d t ti (GAO 08 65)

demonstration (GAO-08-65)

– Model for ACO program

– Average initiation costs were $489,000

– One year operating costs of $1.26 million – Eight of ten participants did not receive

(22)

Commercial involvement

Commercial involvement

• Although CAHs may be exempt from • Although CAHs may be exempt from

many of the ACA provisions,

commercial insurers are beginning commercial insurers are beginning adoption of accountable care

provisions provisions.

(23)
(24)
(25)
(26)

And finally

And finally . . .

• Community health needs assessments • Community health needs assessments • Financial assistance policies

Apply to 501(c)3 hospitals only

CHNA – must be performed between March 23, 2010 and March 31, 2013

FAP – in effect for fiscal years beginning after March 23, 2010

(27)

Healthcare Reform and CAHs

Healthcare Reform and CAHs

• Find a dance partner • Find a dance partner • Focus on quality

• Remember, patients have a CHOICE – give them reasons to choose your

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