New Rules, New Policies (And Old Time Hockey)…

CMS is expanding the Pioneer ACO model

Good morning, ProviderNation. I’m sure you’re anxious about the mixed results from last week’s most important news in the history of last week, but just calm yourself for 17 seconds. Further, it has been exciting to watch, no? And if this series doesn’t lead to a Constitutional amendment against dump-and-chase, well, then I weep for the future.

Pioneer Rules

In other news, the fine folks at CMS are clearly in a hurry to expand its Medicare Shared Savings program. Late last week, the agency published a final rule that the Obama administration hopes will “encourage the delivery of high-quality care for Medicare beneficiaries and build on the early successes of the program and of the Pioneer Accountable Care Organization (ACO) Model. This final rule is an effort to provide support for the care provider community in creating a delivery system with better care, smarter spending, and healthier people.”

Among other things, CMS is hoping that the final rule will create a new “Track 3” program, which attempts to Xerox the Pioneer model by offering higher rates of shared savings, prospective assignment of beneficiaries, and new care coordination tools. CMS says the rule will also “streamline” the flow of information between ACOs and the agency, refine some of the benchmarks to offer strong incentives to improve patient care and save money, and offer a waiver of the three-day rule for ACOs that join the Track 3 program, CMS says.

The last matter is likely to get the most attention from provider types. The American Health Care Association’s invaluable James Michel says the waiver may be “the most significant change” for post-acute care providers.

“Under the new rules,” Michel says, “ACOs who opt into the new ‘Track 3’ of the program will be able to submit an application to CMS requesting a waiver of the three-day stay requirement. ACOs must identify their desired SNF partners up front in the application, and the partner SNFs also must submit a letter of intent that must be included with the application.

“Additionally,” Michel adds, “SNFs will be eligible to apply for the waiver with the ACO only if they meet certain criteria, including having an overall rating of at least three stars on Nursing Home Compare.”

The new rules for the waiver take effect at the beginning of 2017, Michel says, “to give CMS enough time to issue additional sub-regulatory guidance outlining in more detail how to apply for and implement the waiver.” Stay tuned.

AGS, LGBT, You And Me

Speaking of new ways of thinking, you may have seen that the fine folks at the American Geriatric Society have published a new policy statement on the care of aging gay, lesbian, bisexual, and transgendered people. It urges provider types to take concrete steps to make sure that everyone is treated equally while under their care.

The statement itself is hardly revolutionary. But, rather like the dog walking on its hind legs, what matters is that it’s happening at all.

“All points covered aren’t groundbreaking, but it is great that they have taken an official stand,” says the Great Dayne Duvall, chief operating officer of the National Certification Board for Alzheimer Care. “I’m also glad that they cited studies and resources, especially the Joint Commission, CMS, and Institute of Medicine.”

The society’s policy statement is pushing on an open door as far as the National Center for Assisted Living’s board chair, Pat Giorgio, is concerned. “We long term care providers pride ourselves on person-centered care, and we must do all that we can to truly embody that effort,” she tells ProviderNation. “Each unique individual in our communities, regardless of sexual preference or orientation, is a person we are committed to serve.”

For all of that, Duvall says there is an unanswered question: What’s to be done about those elders who aren’t quite, um, on board with LGBT? (After all, it was barely a decade ago that a majority of voters in several states were showing up to ban gay marriage.)

Duvall nonetheless sees a paradox coming: If providers commit to person-centered care, doesn’t that mean that care has to be delivered equally to those who don’t share the majority’s view of equality? Putting it another way, what does a care center do when an orthodox Christian asks not to be cared for by an LGBT staffer?

“Does he have that right?” Duvall asks. “I really don’t know. But I know that we, as a profession, better start having that conversation.”

Bill Myers is Provider‘s senior editor. Email him at myers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

Through The Observation Stay Looking Glass…

The Senate Aging Committee admits that observation stays are a “crisis.”

Good morning, ProviderNation. Hope you’re recovered from your careful attention to the week’s most important news in history. Beyond the great news from Anaheim, the better news is that the next news will come from Chicago. Even if you don’t care for what one poet called “this combination of ballet and murder,” you owe it to yourself to watch the national anthem. It is an experience like no other. Trust your reporter: you’ll thank me later.

In other news, provider advocates are increasingly confident that there is (finally) momentum behind efforts to close Medicare’s observation stays loophole. In case you missed it, the Senate Aging committee on Wednesday took testimony from executive branch types on what the committee itself is calling a “crisis.”

“The financial consequences of these stays can be devastating for these patients and their families,” Aging Chair Sen. Susan Collins, R-Maine, said in her opening statement. “Many of these patients find themselves in a Medicare twilight zone.”

The hearing itself was something of a victory for advocates, who’ve been working for years to raise awareness of the thousands of people who are being denied Medicare benefits because of a loophole that allows hospitals to classify patients as being “under observation” instead of as, um, patients.  More than a few patients have found themselves through the looking glass here. (“‘When I use a word,’ Humpty Dumpty said in a rather scornful tone, ‘it means just what I choose it to mean—neither more nor less.’”)

On Wednesday, AHCA/NCAL’s Clif Porter II said he was glad to see the Senate committee focused on an ongoing (and growing) problem. “Millions are at risk for getting stuck with thousands of dollars in medical bills because of their classification status in the hospital,” he said in a statement.

The hearing comes just a week after the NOTICE Act, which would require hospitals at least to tell patients when they’re under observation, was introduced into the Senate. Collins is one of several senators who’ve signed on to additional bills that would count observation stays toward a patient’s skilled nursing benefit.

Beyond the hearing, though, advocates are feeling confident that Congress is inching closer to fixing the problem.

“We’re pleased the Senate recognizes the scale of the problem and appears poised to move on it,” says Neill Pruitt Jr., chairman and chief executive officer of UHS-Pruitt and a member of the congressionally appointed Long Term Care Commission. “We’re hopeful that movement comes quickly, and we’re ready to help in any way we can.”

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

Please the Court…

ACHA/NCAL is wading into a legal challenge of Medicare’s observation stay policies.

Good morning, ProviderNation.

The legal eagles at AHCA/NCAL are soaring into a potential class-action suit challenging federal observation stay rules. Here’s the background: 14 Medicare patients sued the government alleging that their due process rights were violated when they were put on observation status. Last September, a federal District Court in Connecticut dismissed the case, saying that a previous decision by the 2^nd Circuit Court of Appeals means that when Kathleen Sibelius uses a word, it means just what she chooses it to mean—neither more nor less.

The plaintiffs here are appealing their dismissal (back with their old friends in the 2^nd Circuit). The plaintiffs are arguing that the feds should be required to give written notice when they’re placed on observation status, what it will cost, and whether they can challenge the status. The plaintiffs are also arguing that they should have the right to appeal observation status administratively under the Medicare statute.

In an Amicus brief filed to the circuit, AHCA lawyer Mark G. Arnold says that the current rules are expensive and dangerous for Medicare patients.

“The private interest here is clear: the ability to obtain necessary, often life-saving, medical treatment in a timely fashion,” Arnold says in the brief. “Of at least equal importance is the prospect that the absence of full Medicare benefits prevents the beneficiary from obtaining necessary medical care at all. One of the named plaintiffs … had to depart from the [skilled nursing center] despite her need for such services because she could not afford its costs.”

Given that the 2^nd Circuit has already ruled on the matter the odds against the plaintiffs seem long. But, after all, one only gets what one negotiates for.

Santa Baby…

Good morning, ProviderNation.

U.S. Rep. Tom Latham, R-Iowa, is calling it a Congressional career.

“It is never a perfect time or a right time to step aside,” Latham said Tuesday.  “But for me, this is the time.”

Some political types were surprised by the announcement because Latham, 65, was being pressed to run for Senate to replace retiring Democrat Tom Harkin next year.  Nevertheless, the tributes have come pouring in.

Among the most fulsome are long term care providers, for whom Latham was a reliable ally.

“Rep. Latham was a champion for long term care and those we serve,” AHCA leader Mark Parkinson says. “From introducing legislation to ensure access to skilled nursing care, to shepherding Congressional coalitions against drastic cuts, Rep. Latham understood the value nursing centers provide to our nation’s seniors and individuals with disabilities. Such a committed public servant will be sorely missed, but we wish him all the best in his future endeavors.”

Among other things, Latham was a champion of closing the observation stay loophole.

“To Iowans across the state, Rep. Latham has served as an effective voice for the issues that matter most to us,” says AHCA Board Member and NCAL Chair Pat Giorgio. “His work on behalf of the assisted living
and long term care communities will not soon be forgotten.  We will miss his graciousness in service as well as that Iowa hospitality he offered everyone who entered his door.”

Fare thee well, and all that…

Speaking on Parkinson: I have it on good authority that there’s a picture somewhere in AHCA world headquarters of leader Mark Parkinson palling around with a colleague who is dressed as Santa. Some wag has captioned the photo, “All I want for Christmas is a permanent doc fix.”

Santa, baby: Parkinson must have been a good boy this year. Because it looks like Congress is serious about the doc fix. Parkinson tells us that it’s going to be his top priority in the New Year.

Alzheimer’s Dirty Joke….

Good morning, ProviderNation.

The group formerly known as the American Medical Directors Association (and now known as “AMDA—Dedicated to Long Term Care Medicine”) says it has some thoughts on improving quality. AMDA is teaming up with the ABIM Foundation’s Choosing Wisely campaign and urging docs, patients, and “other health care stakeholders” to rethink tests and “procedures” that AMDA says “may be unnecessary or even cause harm.”

To wit:

• Keeping feeding tubes out of those suffering from late-stage dementia and instead offering oral assisted feedings;
• Avoid Sliding Scale Insulin for residents with diabetes in nursing centers;
• Don’t “obtain a urine culture unless there are clear signs and symptoms that localize to the urinary tract;”
• Avoid antipsychotic meds “without an assessment for an underlying cause of the behavior;” and
• Cut down on the use of lipid-lowering meds for patients who have “a limited life expectancy.”

In other news, NPR and the Kaiser Foundation are taking a look at observation stays, the British journal Age and Ageing finds a correlation between stress and falls in elderly men, and some Alzheimer’s researchers wonder if we’re too clean for our own good.

Holding Out for a Hero…

Good morning, ProviderNation.

The Department of Health and Human Services’ Inspector General is urging the Obama administration to count observation stays toward Medicare patients’ skilled nursing benefits. In a new report released today (and props to the folks at Kaiser for getting an advanced copy), the IG says that there isn’t a lot of rhyme or reason to the observation stay system.

Tuesday’s report won’t be much  news to long term care advocates, but it’s a big deal because it’s a federal watchdog agency adopting advocates’ long-standing recommendations. Stay tuned…

Meanwhile,  the fine folks at National Center for Assisted Living need a hero. NCAL is kicking off its “Quality Initiative Recognition Program” for members who are getting it done.

Members have to meet one or more of four goals to be recognized in New Orleans next year:

• Cut readmissions by 15 percent;
• Keep turnover below 30 percent;
• Score at least 90 percent on customer satisfaction surveys; and
• Cut off-label antipsychotics by 15 percent…

In other news, an awful story from the Chicago suburbs: a 95-year-old nursing home resident died after being tasered by police.

And, Slate’s inestimable David Weigel says that conservative Republicans’ fixation with Obamacare may mean there is no “grand bargain” over entitlement cuts this fall. You’ll recall that AHCA leader Mark Parkinson predicted that there might be some more brinksmanship this fall…