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The Pulse: January 3, 2013

January PULSE

Happy New Year!  This is the first 2013 edition of The PULSE with a thorough review of the association’s activities and Legislative / Regulatory agenda over the last year as well as some last minute Lame Duck activity.  2013 will be no less hectic as the fiscal cliff and Medicare / Medicaid issues get spread throughout the year.  Stay tuned! 

The SOURCE will return mid-week on January 8th following the holiday schedule and then back to its normal Monday release there after.


The Fiscal Cliff

The U.S. Senate, making a rare appearance on New Years day starts 2013 off by overwhelmingly (89-8) passing H.R 8, the Job Protection and Recession Prevention Act of 2012.  Needing the support of the Senate, and not to be outdone, that body later Tuesday evening passed the measure by a vote of 257-167.  The President is expected to sign the legislation into law thereby averting the so called Fiscal Cliff.  The legislation addresses some key components but also pushes many issues down the road making 2013 look like a year of serial volatile fiscal bluffs! 

The immediate (GOOD) news for hospice and home care:

  • The implementation of the 2 percent across-the-board reduction associated with sequestration has been delayed until March 1, 2013.     
  • There are no cuts to Medicare home health services or hospice care benefits, payments, or payment rates. No home health copays are in this bill.
  • There are no Medicaid cuts affecting home care.
  • Protection against the Medicare outpatient therapy cap is continued through 12/31/13.
  • A 27 percent cut to Medicare reimbursement scheduled to hit physicians has been delayed for one year.  Fortunately, hospice was not included in      the $30 billion offset package for this provision.  The “doc fix” is paid for primarily through cuts to hospitals with nearly $15 billion in a combination of coding adjustments and DSH payment reductions. ESRD payments are also affected by a reduction of $4.9 billion.
  • The CLASS program established to help finance long term care services through a voluntary insurance approach under the Affordable Care Act is repealed under the Senate bill. The repeal has no financial consequence as CMS earlier indicated that it would not implement the CLASS program due to its inability to assure financial viability.
  • It is important to note that a provision in the Senate bill establishs a Long Term Care Commission that will be charged with the responsibility to develop a plan for meeting the needs of the growing population of Americans needing care in the home and in other settings. The Commission will have 15 members appointed by the President and Congressional leaders with representation of consumers, older adults, family caregivers, and care providers.
  • The bill extends tax rates for the vast majority of citizens along with a series of other tax-related extenders and unemployment benefits.

The deal also did not address the expiring debt ceiling limit.  This and the delay to sequestration puts Congress in a position that it will need to continue focusing on
large-scale economic issues throughout the next several months at the least. Medicare and Medicaid will also be part of the continuing dialog with an emphasis on entitlement reform this year.   Needless to say there is a persistent concern for the hospice and home heatlh community and the need to stay engaged on policy issues is critical. 


MCA End of Year Regulatory Review and Lame Duck Session Update

The 129th Ohio General Assembly returned after the general election to continue the work they had left undone after the general session. As expected, it was a busy lame duck session that concluded on Thursday, December 13th as planned.  Senate President Niehaus presided over his final session as he is term limited this year. Sen. Keith Faber (R-Celina) is the incoming Senate President for the 130th General Assembly, joining his leadership team are Senators Widener, Patton and Obhoff.  Speaker Batchelder will continue his leadership role in the Ohio House next General Assembly. Look for information on Committee assignments for both the 130th General Assembly in the New Year.

The following are of regulatory interest  to Midwest Care Alliance members:

Medicaid Reforms Activity
Comprehensive Medicaid reform continued developing throughout 2012 as it will in 2013.  Efforts are being undertaken to modernize processes like determining eligibility, improving technology, streamlining processes and to integrate care in a more seamless process for beneficiaries.  This major effort by the state places more than 1.6 million Medicaid beneficiaries under managed care, reducing the number of service regions from eight to three and combine coverage for families and children (CFC) and the aged, blind and disabled (ABD) populations.  Under this arrangement, Medicaid beneficiaries are expected to have more choices because larger service regions will support more plans per region and allow plans to spread administrative costs across more individuals. The state believes that this system will offer more choice for Ohioans, more competition among plans, and savings for Ohio taxpayers while allowing Medicaid to pay for value, not volume, in managed care.

In early December, Ohio became the third state to reach an agreement with CMS on a memorandum of understanding to additionally launch the Integrated Care Delivery System (ICDS).  ICDS is a proposed three-year demonstration in 29 counties that the state believes will improve care for approximately 114,000 individuals who are eligible for Medicare and Medicaid. As with the broader Managed Care proposal above, the changes for ICDS should lead to greater efficiency and reduce costs.  The ICDS Memorandum of Understanding has been signed yet it lacks detail and leaves many areas vague and open for interpretation.  There are some aspects of the arrangement between CMS, the State, and Managed Care Organizations (MCO) that already appear to go against the dialog that providers were lead to believe, such as an all-inclusive, any willing provider provision for the first year.  Some members are being informed that there is no need to complete applications for participation, that certain particular MCO networks are full. 

Unfortunately, barriers for Medicare providers and the possibility of losing patients and payment may lead many providers to encourage Medicare beneficiaries to opt-out of the ICDS program in order to maintain uninterrupted Medicare services and choice of providers.  Of course, this also protects a level of payment for these providers which appears to be on the chopping block with the agenda the discussions the MCOs are having.  It may make sense for providers of both Medicaid and Medicare services to also market to its dual eligible patients to opt out of ICDS so these providers can maintain control of services and reimbursement on the Medicare side of the equation. 

Fight opiate abuse
Many state agencies have played a significant role in the Administration’s efforts to fight opiate abuse. Thanks in part to these efforts and the passage of HB 93, Ohio has closed pill mills and reduced the amount of pills prescribed to residents of targeted southern Ohio counties by as much as 15 percent.   The state has also created new Opiate Task Forces in 23 counties to provide community education and work toward prevention of opiate addiction and overdose deaths.

ODADAS and the Ohio Association of County Behavioral Health Authorities developed and launched the Don’t Get Me Started campaign to educate Ohioans about the dangers of opiate painkiller addiction and overdose. The campaign delivered more than 30,000 visits to its online ads and Website and 45 million social media impressions.

The Professional Education Workgroup of the Governor’s Cabinet Opiate Action Team, which is co-chaired by the Ohio Department of Health and the Ohio Department of Aging, adopted statewide prescribing guidelines for emergency departments and created a Website to provide promotional materials, including a pocket-size card, background documents and a guideline FAQ. The new guidelines and outreach materials will save lives and help reduce the scourge of opiate abuse.

Following a flurry of activity throughout the summer and fall, several state subcommittees that MCA was participating on, working to develop standardized language and a protocol for the general healthcare community in regards to treating chronic pain patients suddenly went silent.  At this point next steps are not known or anticipated.  At some point the Chronic pain rules will need updated.  Thus far, activities to protect the terminally ill community remain intact. 

Criminal Background Checks
Prompting from the Attorney General’s office, the administration and Office of Health Transformation identified gaps and inconsistencies in statutes and regulations governing criminal background checks and disqualifying criminal convictions for workers providing home health and waiver transportation services under the Medicaid program. HB 487 language and subsequent changes to administrative rules will close these gaps to protect individuals receiving home and community based services from harm.  While the majority of home and community based services now has a consistent set of rules across four state agencies, hospice at this time was spared any changes in their current rules.  Beginning in January 2013, the new rules governing home care and waiver providers mandate that each employee undergo a criminal background check once every five years within 30 days of their anniversary date. 

Additionally, the state, through the suggestion and support of MCA and other associations, is investigating the development of an electronic monitoring system that would provide real time criminal activitiy information and potentially be less costly to providers.  In December, MCA testified against the Attorney General’s open rule hearing on a suddenly proposed increase in CRC fees from $22 to $28.  This 27% increase in CRC fees was never part of the discussion during numerous meetings regarding the rule changes affecting the CRC.  This rule was pulled at a later date JCARR hearing.  MCA continues to monitor this situation as well as the possible expectation that hospice rules in the future may be suggested to mirror these most current changes. 

Reform Nursing Facility Payments
The budget bill completed the transition from a cost-based payment methodology for nursing homes to a price-based system with part of payment tied to quality measures.  The final budget reduced nursing facility rates 5.8 percent on average in 2012, providing a savings of $360 million that was invested in home and community based alternatives.  Furthermore, a subcommittee of the Unified Long-Term Care System Advisory Workgroup, chaired by the Office of Health Transformation, developed research-based quality measures and a methodology for linking almost $300 million of what Ohio pays nursing homes directly to practices that are proven to improve care for Ohio’s seniors and people with disabilities.

These recommendations, which were adopted by the General Assembly in SB 264, have increased the amount of nursing homes’ Medicaid reimbursement rate that is tied to quality from 1.7 percent to 9.7 percent beginning in July. The Office of the State Long-Term Care Ombudsman worked with experts to develop an online resource to help nursing facilities implement the quality incentives and give consumers the tools to expect excellence. A separate subcommittee is developing recommendations on reimbursement and capacity issues for consideration in the next budget.

The following are of legislative interest to Midwest Care Alliance members:

HB 27 Adult Guardianship
The Governor has signed into law HB 27 Adult Guardianship (Stautberg, Letson), which was brought forward by the Ohio Judicial Conference and the Ohio State Bar Association. It addresses the issue of jurisdiction over adult guardianships and other protective proceedings in interstate jurisdiction controversies. Adult guardianship issues commonly arise in situations involving snowbirds; transferred and long-distance caregiving arrangements; when families live within just miles of one another but in different states; interstate health markets; wandering; and even the occasional incidence of elderly kidnapping. The Ohio Council of the Alzheimer’s Association was also a proponent of the legislation. 

House Bill 27 ensures that only one state has adult guardianship jurisdiction of an incompetent person at any one time. It also specifies a procedure for transferring a guardianship to another state and for emergency situations. Under the act, a guardian is appointed by the probate court to make decisions regarding the person and/or property of an incompetent adult. The act contains specific guidelines to specify which court has jurisdiction to appoint a guardian for an incompetent adult by prioritizing the states which might claim jurisdiction. The state with primary jurisdiction, the "home state", will be defined as the state in which the adult has lived for at least six (6) consecutive months immediately before the beginning of the adult guardianship or protective proceeding. The state with secondary jurisdiction, the "significant connection state", will be broadly defined to include the location of the individual's family, a state where the individual may have lived for many years, or the state where the individual's property is located.

The act provides that once a probate court has jurisdiction, this jurisdiction continues until the proceeding is terminated or transferred to another state. Members of the House Judiciary accepted a sub bill that would allow a probate court to put a 72-hour freeze on the assets of someone reasonably believed to have been removed to another state in order to prevent significant financial harm to the individual.

The bill moved quickly through the Senate Judiciary Committee and passed the full Senate 33-0. By enacting the legislation, Ohio joins 35 other states that have already adopted the Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act.

HB 62 Assault of Health Care Workers (Gonzales) has been signed into law. This bill was introduced last year, but did not receive passage until lame duck session. When the bill was originally introduced it only included emergency room nurses and hospital nurses, but as the bill moved through the legislative process there was support to include additional health care workers of a hospital. The bill expands the penalty enhancement provisions in the offense of assault to include an enhanced penalty if the victim of the offense is a “health care professional” of a “hospital”, a “health care worker” of a hospital or a security officer of a hospital. It increases the penalty for assault to a fifth degree felony when the offender knows or has reasonable cause to know or the victim is engaged in the performance of the victim’s duties, and the hospital offers de-escalation or crisis intervention training for such professionals, workers and officers.

HB 303 Nursing (Schuring) has been signed into law by the Governor. It addresses pertinent regulatory issues and requirements for licensees in a common sense manner and provides greater clarity regarding its law to licensees and the public. The bill encompasses the entire Nurse Practices Act (NPA) and revises statutory law to conform to current practice.  The bill was proposed by the Ohio Board of Nursing and received input from stakeholders. The bill provides necessary updates to laws pertaining to various aspects of the Board's primary responsibilities to license and discipline. It streamlines certain Board practices and data collection requirements; changes to certain grounds for discipline; conforms laws governing dialysis technicians and interns to federal requirements; refers to Advanced Practice Registered Nurses, the nationally accepted term now used to refer to registered nurses who have attained this degree of licensing and certification; requires out-of-state applicants to complete a two hour course on Ohio laws and rules; specifies that a person licensed by the Board make a report on an employer's behalf regarding misconduct by a licensee; requires the Board's Supervising Member to be responsible for various decision making involving the Board's chemical dependency monitoring program; and rescinds language for programs no longer functioning at the board. The Ohio Board of Nursing supports House Bill 303, a comprehensive revision and update of the NPA.

In addition, “Sarah’s Law” regarding the licensure of pediatric respite care programs is now included in this bill.  Under this provision, the Department of Health is required to regulate pediatric respite care programs, which are programs that provide services to patients under age 27 who have been diagnosed before age 18 with life-threatening diseases or conditions that shorten life expectancy.  The bill establishes a licensing process for pediatric respite care programs that is similar to the Department's existing licensure process for hospice care programs.

HB 284 Physician Assistants (Gonzales) has been signed into law. It allows PAs to make pronouncements of death, insert and remove chest tubes and prescribe physical and occupational therapy, and prescribe Schedule II drugs; exempt out-of-state PAs from the prescriptive provisional period if authorized by another jurisdiction; improve the process for amending the PA formulary; clarify PA authority to provide emergency services and direct emergency providers; include PA practices as part of Ohio’s new patient-centered medical home model; and allow PAs to write “do not resuscitate” (DNR) orders.

The bill was amended in Senate Health to harmonize advance practice nurses pronouncement with physician assistants’ pronouncement provisions. In addition, an amendment was accepted that expands pronouncement authority to registered nurse practitioners in hospice care programs or palliative care, but only if the individual’s respiratory and circulatory functions are not being artificially sustained. 

Pronouncement authority was also expanded to certified nurse practitioner or clinical nurse specialist, but only if the individual’s respiratory an circulatory functions are not being artificially sustained and if the individual is receiving care in one of the following: a nursing home, a residential care facility or home for the aging, a county home or a residential facility licensed under section 5123, hospice or palliative care program.

Wheelchair Unbundling Amendment Stalls In Conference Committee.  House and Senate members were unable to reach an agreement on Wednesday, Dec. 12, over an amendment to SB287 for "unbundling" Medicaid reimbursement of services for custom wheelchairs.

In an effort to reverse service bundling enacted in former Gov. Ted Strickland's FY10-11 budget, the House Health and Aging Committee recently added the amendment to SB287. Senators Cafaro and LaRose agreed that the amendment has merit, but decided it should be included as part of a broader discussion of unbundling services during a full debate on Medicaid in the upcoming FY14-15 budget.

Rep. Wachtmann said bundling has been "a disaster" for people in need of custom wheelchairs, and Rep. Sears argued that bundling leads to disparate treatment of patients in nursing facilities compared to those who aren't. Sears said wheelchair services have enough distinct issues to warrant separate consideration apart from a broader unbundling discussion.  Additionally, House Speaker William Batchelder said his members want the wheelchair unbundling issue to be addressed in the next budget.

Governor Kasich Looks Back at 2012, Previews 2013

Gov. John Kasich began his 2012 year-in-review session Wednesday by saying Ohio is in a period of transformation while reflecting on the issues his administration and the General Assembly tackled over the last year.

The Governor provided a preview for his next budget but did not reveal details, telling reporters at a Statehouse event that tax reform and school funding will play heavily in his early plans.

Among that tax reform will be the severance tax on the oil and gas industry. He emphasized that lowering the income tax will play a part, and the plan will also focus on lowering taxes for small businesses.

Kasich hinted at what his education reform will look like, saying the basis will be that every child will be able to compete with any other child in the state no matter where they live or what his or her background is. He said some of it will be programs that should be viewed positively and will have opportunities for schools to change and innovate.

He went over his accomplishments of the past year, discussing the capital bill that he said transformed the higher education system; K-12 reform that included Teach for America, teacher evaluation, the A-F grade card and the Cleveland Schools Plan, disability services, the backpack program for poorer school children; criminal sentencing reform; new rules on oil and gas drilling that he said are among the toughest and clearest in the nation; his Mid-Biennium Review; OARnet; human trafficking; and the financial institutions tax.

He discussed his plan to sell bonds against the Ohio Turnpike and higher education reform among his priorities.

Joining the Governor were Lt. Gov. Mary Taylor, who outlined the successes of the administration’s Common Sense Reform (CSI) over its first year of operation, outgoing Senate President Tom Niehaus (R-New Richmond) and House Speaker William Batchelder (R-Medina).

Niehaus noted pension reform, which he said is a politically sensitive topic that still managed to pass in a politically divisive climate. He said he hoped to pass a few priorities on to his replacement, Sen. Keith Faber (R-Celina) and Batchelder, including ethics reform and redistricting reform.

Batchelder remarked that the General Assembly and the administration have had an “atmosphere of reform that is truly remarkable.”

“What is common in this administration is the desire to actually reform things in a long-term way, not cosmetic, not pro forma, but to get things fixed and fixed for the long term,” he said. He listed human trafficking, criminal sentencing, and Cleveland school reform among accomplishments.

The Governor would not say if he would support or oppose a ballot issue on right to work, saying that he continues to be focused on his agenda which he believes is moving Ohio in the right direction.

Kasich was asked if he will be doing anything new with mental health in the wake of the school shooting in Connecticut and if he would support arming school employees in response to school shootings, Kasich said there are experts who will be looking at the issue and making recommendations. He said it is an issue where ideas need to be on the table and then determine what makes the most sense.

He also touted his plan for the Ohio Turnpike, saying there is an appropriate amount of debt that can be added to an asset to unlock its value, and said some projects would be delayed 20 to 25 years if they didn’t move forward with the plan.

Story originally published in The Hannah Report on December 19, 2012. Copyright 2012 Hannah News Service, Inc.


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Invite Legislators To Visit Your Facility in 2013

Midwest Care Alliance reminds its members that the beginning of this New Year is a great time to invite your Ohio State Representative or Ohio State Senator to visit your campus. Hosting a legislative visit gives Midwest Care Alliance members an opportunity to highlight the important services they provide at a critical time. This month, the biennial budget will be under consideration and it is more important than ever that home, hospice, and palliative care providers communicate their needs to the legislature.

To find and contact your Senator or Representative, please visit or

Charities Hit the Hill to Save Tax Deduction

With both Democrats and Republicans expressing some willingness to cap deductions for higher-income households, hundreds of nonprofit professionals came to Washington Dec. 5 to urge Congress not to take away a powerful incentive for charitable giving.

Members of the Charitable Giving Coalition, including ASAE, believe that capping the charitable tax deduction could have a profound impact on private donations that support thousands of worthy causes all over the world. Independent Sector, which helped organize the legislative fly-in this week, has estimated that annual giving could drop by as much as 36 percent if the deduction were eliminated. Capping the value of the deduction at 28 percent for households with income above $250,000 a year, as proposed by the White House, could reduce giving by as much as $7 billion a year.

Coalition advocates’ message to the Hill was focused less on incentives for higher-income donors and more on the impact the proposal would have on nonprofit groups that are serving millions of people in need. The coalition has estimated that for every $1 subject to the charitable deduction, communities reap up to $3 in benefits.

President Obama this week told business leaders that concerns over charitable giving are partly driving the administration’s push to let the Bush-era tax cuts expire for higher-income earners. Speaking about the tax deal offered by Republicans earlier this week, Obama said it’s not possible to raise the amount of revenue needed just by closing deductions and loopholes, unless the charitable deduction were eliminated.

Obama said charities are the “glue that holds our communities together. So the notion that somehow we’re going to just eliminate charitable deductions is unlikely."