Official Testifies About HRSA’s Health Workforce Investments, Goals, Successes

On April 9, 2014, Rebecca Spitzgo, Associate Administrator of the Bureau of Health Professions in the Health Resources and Services Administration (HRSA), testified before a Senate Subcommittee on Primary Health and Aging regarding the nation’s primary care workforce needs and HRSA’s activities and in this area. In light of recent investments from the American Reinvestment Recovery Act of 2009 (ARRA) (P.L. 111-5) and the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), Spitzgo’s testimony focused on: (1) recent investments to strengthen the primary care workforce; (2) new efforts to build a primary care workforce; (3) diversity programs; and (4) training for comprehensive primary care.

HRSA’s Mission and Focus

An agency of HHS, HRSA is the primary federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. HRSA was created in 1982, when the Health Resources Administration and the Health Services Administration were merged. Its stated mission is to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. In its efforts to strengthen the health care workforce, HRSA’s workforce programs emphasize the training of the next generation of primary care providers, strengthening up the primary care training and development infrastructure, providing incentives for students to choose primary care and to practice where the Nation needs them most, and repaying loans for primary care providers willing to work in some of the Nation’s most underserved areas.

Recent Investments to Strengthen the Primary Care Workforce

In her testimony, Spitzgo stated that, to date, ACA and ARRA investments have resulted in:

  • the training of an additional 1,700 primary care providers, including physicians, advanced practice nurses, and physician assistants, as well as 200 behavioral health providers;
  • the doubling of the numbers of clinicians in the National Health Service Corps (NHSC) from 3,600 in 2008 to nearly 8,900 in 2013; and
  • nearly 1,600 advanced practice nurses in the NHSC and nearly 2,600 nurses in the NURSE Corps working in high need communities.

Spitzgo also noted that the ACA provides $230 million over five years to fund the Teaching Health Center Graduate Medical Education (GME) program, which has expanded residency training for primary care residents and dentists in community-based ambulatory patient care settings, including HRSA-funded health centers. According to Spitzgo, this program supported more than 300 primary care resident full-time equivalents (FTEs) in 21 states in academic year 2013-2014, and is expected to support nearly 600 FTEs in academic year 2014-2015.

New Efforts to Build a Primary Care Workforce

Spitzgo testified as to the several new programs and initiatives to build a better primary care workforce contained in the President’s FY 2015 Budget, including:

  • A workforce initiative to support the training of 13,000 new physicians by 2024 and grow NHSC clinicians from 8,900 in 2013 to 15,000 in by FY 2015.
  • A new residency program, the Targeted Support for GME program, will build on the Teaching Health Center GME program, focusing on residency training in ambulatory, preventive care delivered in team-based settings. This new program includes a $100 million set aside for children’s hospitals in FYs 2015-2016, to be distributed via formula that will continue to support the same types of disciplines currently funded through the Children’s Hospitals GME Payment program.
  • Continued support of the NHSC.
  • A new $10 million Clinical Training in Interprofessional Practice program, which will support community-based clinical training in interprofessional, team-based care setting.
  • $4 million for the Rural Physician Training Grant program to provide support for medical schools to recruit and train students interested in rural practice.

Diversity Programs

In her testimony, Spitzgo stressed HRSA’s success in facilitating a diverse healthcare workforce. She offered the following statistics:

  • Underrepresented minorities and individuals from disadvantaged backgrounds accounted for approximately 45 percent of those who completed HRSA’s health professions training and education programs during 2012-2013.
  • More than half of the nearly 1,100 NHSC scholars and residents in the pipeline are minorities.
  • In FY 2013, African American physicians represented 17.8 percent of the Corps physicians, which exceeds their 6.3 percent representation within the national physician workforce.
  • In FY 2013, Hispanic physicians represented 15.7 percent of the Corps physicians, exceeding their 5.5 percent representation in the national physician workforce.

Training for Comprehensive Primary Care

Spitzgo’s testimony focused on HRSA investments to support the behavioral health disciplines and the integration of oral health into primary care. With regard to behavioral health, she noted that:

  • NHSC providers (including health service psychologists, licensed clinical social workers, licensed professional counselors, marriage and family therapists, and psychiatric nurse specialists) have increased from 700 in 2008 to 2,440 in 2013.
  • If they count psychiatrists, psychiatric physician assistants, and psychiatric nurse practitioners, more than 2,800 out of nearly 8,900 clinicians in NHSC (as of September 30, 2013) provide behavioral health services.
  • A partnership between HRSA and the Substance Abuse and Mental Health Services Administration (SAMHSA) will train and provide placement assistance for approximately 1,800 additional behavioral health professionals and 1,700 behavioral health paraprofessionals.

Spitzgo further testified that HRSA funds several programs that support training and education necessary to improve the integration of dental care into primary care. Sptizgo also noted that approximately 75 percent of the more than 1,300 dentists and dental hygienists in NHSC work at health centers or health center look-alikes.

Readmission Rates from Post-Acute Care Facilities Similar to Hospitals

The last couple of years have seen lots of attention on the readmission rate of Medicare beneficiaries following a stay in a hospital.  But what about readmission rates from post-acute facilities?  Two recent studies have found that the readmission rate for residents of skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) is about the same as it is for  hospitals.  To reduce the rates of readmission, and hopefully improve care, the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) implemented payment reductions for hospitals that do not meet specific readmission rate targets, and will use hospital readmission rates for IRFs as a national quality indicator.

Readmissions After  SNF Discharges

The readmission rate of SNF residents in North and South Carolina was about 22 percent, according to a recent study reported in the Journal of the American Geriatrics Society.  The study found that “within 30 days of SNF discharge to home 10.3% (5,771 unique participants) had ED visits without hospitalization and 14.7 % (8,303 additional unique participants) were rehospitalized.”  During the period from  January 1, 2010 to August 31, 2011, 12, 349 visits were made to hospitals by SNF residents within 30 days of being discharged from a SNF; this number is slightly higher than the unique participant number because some residents had more than one hospital visit during the 30 days following discharge from the SNF.

The majority of hospital visits happened very soon after discharge from the SNF. The study found that 12 percent of SNF residents had a visit to a hospital’s emergency department or were rehospitalized within 10 days of  being discharged.  On an upbeat note, only 4,538  of the 55,980 Medicare beneficiaries studied  or 8.1 percent died within 90 days of being discharged from a SNF.

Residents of IRFs had a readmission rate of 18.8 percent during the 30 days following discharge, according to a second study reported in the Journal of the American Medical Association.   The study examined 736,536 Medicare beneficiaries who were discharged from 1,365 IRFs between 2006 and 2011.  Mirroring the finding of the SNF study, most readmission following discharge from an IRF happened soon after discharge. “Approximately 50 percent of patients hospitalized within the 30-day period were readmitted within 11 days of discharge,” the study found.

Readmissions After Hospital Discharge

The readmission rate to hospitals within 30 days of discharge has been in the 18 to 19 percent range since 2007.  The Kaiser Family Foundation reports that during the first 8 months of 2013 the hospital readmission rate fell below 18 percent.  In 2012, the readmission rate was 18.5 percent and from 2007 to 2011 it had been 19 percent each year.

The Hospital Readmission Reduction Program (HRRP) began assessing reductions in payments to hospitals that did not achieve their readmission goal beginning with payments for calendar year 2013.  In the first year of the program 2,213 hospitals were fined for not meeting their readmission rate goals.  In the second year of the program 2,225 hospitals were penalized for not meeting their goals.  Penalties in the first year could have been as high as 1 percent  and a 2 percent reduction was applied during the second year.  A reduction as much as 3 percent  could  apply during the third year of the program.  Only a small number of hospitals are receiving the full reduction. Of the 2,225  hospitals receiving a reduction in 2014, only 18 are received the full 2 percent reduction and another 154 will be receiving a 1 percent reduction. The majority of hospitals that are receiving a reduction in 2014 will be receiving a reduction of less than 1 percent. Kaiser said that the total reduction will result in a loss of $227 million to all hospitals in 2014.

CMS has stated that rehospitalization can be a sign of low-quality care and it has been taking action with hospitals to help drive down the rate of readmissions to a hospital.  These studies show that the post-acute care settings of SNFs and IRFs have a  readmission rate similar to hospitals, which might lead one to wonder if similar carrot and stick incentives will be applied to these facilities to drive down the rates of readmission to a hospital following discharge.

 

Avoidable Hospitalization and Therapy Services Discussed at SNF Open Door

CMS provided an overview of the Initiative to Reduce Avoidable Hospitalization Among Nursing Facility Residents during an open door forum for skilled nursing facilities (SNF) on January 16, 2014.  After the review of the initiative, providers asked questions on the use of the  change of therapy (COT) Other Medicare Required Assessment (OMRA), and the types of staff that can provide therapy for a resident who is on a maintenance plan.

Avoidable Hospitalizations 

The Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents was designed to help improve the quality of care for SNF residents while reducing costs to CMS at the same time.  During the open door forum, CMS reported that there are currently 1 million dual eligible beneficiaries in 15,000 SNFs across the country of which 45 percent will be admitted to a hospital.  CMS estimates that 314,000 of the 450,000 hospitalizations could be avoided, saving $2.6 billion in Medicare expenditures.

The initiative uses independent organizations known as  enhanced care and coordination providers (ECCPs) to implement interventions at SNFs to reduce hospitalizations. The ECCPs are testing several models of intervention. An ECCP must partner with at least 15 SNFs to be a part of the initiative. There are seven ECCPs currently working with 147 facilities in seven states, CMS reported.  These ECCPs are providing services to 16,000 dual eligible beneficiaries.

The demonstration began in 2012 and is to last for four years, until September 2016.  At that time a full evaluation of the various models being tested by the ECCPs will be conducted to determine the success of each model at reducing hospitalizations.  The two main models being tested are models that educate and train SNF staff to observe the signs of conditions that can be treated at the facility before hospitalization is required, and a model that uses nurse practitioners to provide additional hands-on care. In Nebraska, the ECCP is providing oral care to SNF residents, as better oral care has been linked to a reduction in pneumonia. During the open door forum CMS said that it has received significant anecdotal evidence of success in the reduction of hospitalizations for urinary tract infections and  medication management.

The initiative is being overseen by the Medicare-Medicaid Coordination Office, which was created by section 2602 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Its purpose is to improve the quality of care received by dual eligible beneficiaries by eliminating regulatory conflicts between Medicare and Medicaid, improving the continuity of care between the two programs, eliminating cost shifting, and improving the quality of performance of providers and suppliers.

Questions on Therapy Services

CMS clarified that assistants can provide physical therapy to SNF residents who are on a maintenance program following the agreement reached in the Jimmo v Sebelius case.  For a short period of time, the SNF provider manual said that assistants could not provide the therapy. For home health agencies and outpatient rehabilitation facilities (ORFs) this is the case, and CMS applied the rule to  SNFs in an effort to be consistent.  Upon further review, it was discovered that the SNF regulations specifically allow for assistants to provide physical therapy,  although the regulations governing in home health  care or at ORFs do not. CMS has recently corrected the SNF manual to be consistent with the regulations.

Several providers had questions about the use of a COT OMRA.  A COT OMRA  is required if a resident does not receive the therapy as indicated by the  resource utilization group (RUG-IV) classification level provided by the patient’s last assessment.  Particularly providers had questions about when to complete a COT OMRA for a resident who simply took a break from therapy for any number of reasons. A resident can be reclassified back into rehabilitation group prior to the discontinuation of therapy services by using a COT OMRA, CMS said.  Prior to fiscal year 2012 SNFs would have to wait until the next scheduled comprehensive assessment to get a resident back into the level of therapy from which they took a break.

The next SNF open door forum is scheduled for March 6, 2014.

Changes to Hospital and SNF Payment Systems Considered by MedPAC

At its meeting on December 12th and 13th, the Medicare Payment Advisory Commission (MedPAC) discussed  draft recommendations that would increase hospital inpatient and outpatient payments by 3.2 percent.  The draft recommendations, however, would make dramatic cuts to payments to long-term care hospitals (LTCH) and reduce payments for 66 services provided at hospital outpatient departments.  The net result would be an increase in payments of $500 million dollars in 2015.  MedPAC recommended no increase in payments to skilled nursing facilities (SNFs) in 2015 and discussed a draft recommendation that would reduce payments by 4 percent in 2016. By law, each year MedPAC is required to assess the adequacy of hospital payments and recommend payment updates for hospital inpatient and outpatient services as well as for long-term care facilities.

Hospital Payments

The 3.2 percent increase in payments for services provided under the inpatient prospective payment system (IPPS) that MedPAC is recommending would result in an additional $2.5 billion in payments during the 2015 rate year. However, the recommended $2.0 billion reductions in payments under the LTCH and outpatient prospective payment systems (OPPS) would result in a net increase in spending on hospital services of $500 million.

Equalization of Payments for Outpatient Services

MedPAC’s draft proposal would reduce the payment for 66 services under the OPPS to the  level of payment that would be made to a physician’s office for the same services.   MedPAC hopes this payment adjustment would slow or stop the shift of services from free-standing practices to more expensive outpatient departments.   MedPAC estimates that this shift from outpatient departments to free-standing practices would reduce a hospital’s  revenue by  0.6 percent.  In addition the shift would result in beneficiaries paying $1.1 billion less in copayments and deductibles.

LTCH Payment Rates

  Payment rates for patients in LTCHs who are not chronically, critically ill (CCI) would be the same as for patients in IPPS.  CCI patients would be defined as patients who had a stay of eight days or more in an intensive care unit  immediately preceding an IPPS or LTCH stay. MedPAC estimates that this change will decrease spending on LTCHs by roughly $2 billion.  The money saved by this reduction would  be used for additional outlier payments for CCI patients in IPPS hospitals.  Joanna Hiatt Kim, vice-president of payment policy for the American Hospital Association  (AHA) said, “we are deeply disturbed by the Commission’s draft recommendation to cut payments to 64 percent of the LTCH cases.”  This recommendation is being made as an alternative to ending the LTCH prospective payment system altogether, which was an option considered but never adopted.

SNFs

MedPAC is recommending no increase in payments to SNFs for 2015 and a reduction of 4 percent in 2016. The recommendation was made because the operating margins,  or profits,  for SNFs are estimated to be 12 percent in 2014 and have been above 10 percent each year since 2000. MedPAC made the same recommendation in 2012.

Earlier in 2013, the Office of Inspector General  (OIG) reported that Medicare paid $5.1 billion for SNF stays that failed to meet the quality of care requirements. In 37 percent of the SNF stays, the facilities failed to develop plans of care that met requirements or failed to provide care that was consistent with a patient’s plan of care.  In 31 percent of stays, the SNFs failed to meet discharge planning requirements.  These figures are based on the OIG’s review of Part A SNF stays from calendar year 2009. The combination of high margins and questions about the quality of care have led to questions about SNF payment levels.

MedPAC will make its final recommendations when it formally adopts its report to Congress at a later meeting.