HCAOA Analyzing How CMS’s Newly Proposed Rules Would Affect Home Care Industry

From HCAOA

Last week, the Centers for Medicare & Medicaid Services (CMS) unveiled two notices of proposed rulemaking (NPRMs), Ensuring Access to Medicaid Services (Access NPRM) and Managed Care Access, Finance, and Quality (Managed Care NPRM), that together address access to and quality of care across Medicaid programs.
 
HCAOA’s Policy Committee is currently reviewing the proposed rules and will provide additional information.

If adopted as proposed, the rules would attempt to establish national standards for access to care regardless of whether that care is provided through managed care plans or directly by states through fee-for-service (FFS). Specifically, they would establish access standards through Medicaid or CHIP managed care plans as well as transparency for Medicaid payment rates to providers.
 
Within the HCBS realm, the proposed rule seeks to:

• Establish a new strategy for oversight, monitoring, quality assurance, and quality improvement for HCBS programs;
• Strengthen person‑centered service planning and incident management systems in HCBS;
• Require states to establish grievance systems in FFS HCBS programs;
• Require that at least 80% of Medicaid payments for personal care, homemaker, and home health aide services be spent on compensation for the direct care workforce (as opposed to administrative overhead or profit);
• Require states to publish the average hourly rate paid to direct care workers delivering personal care, home health aide, and homemaker services;
• Require states to establish an advisory group for interested parties to advise and consult on provider payment rates and direct compensation for direct care workers;
• Require states to report on waiting lists in section 1915(c) waiver programs; service delivery timeliness for personal care, homemaker and home health aide services; and a standardized set of HCBS quality measures; and
• Promote public transparency related to the administration of Medicaid‑covered HCBS through public reporting of quality, performance, and compliance measures.

Medicare Advantage Enrollment Officially Crosses 50% of Beneficiaries: KFF

Fierce Healthcare / By Paige Minemyer
 
It's official: Medicare Advantage (MA) enrollment accounts for just over half of all Medicare beneficiaries, according to a new analysis from the Kaiser Family Foundation.
 
KFF researchers analyzed data from the Centers for Medicare & Medicaid Services and found that 30.19 million of the 59.82 million people enrolled in Medicare as of January 2023 were in an MA plan, the first time the program has crossed 50% of all Medicare enrollment.
 
Medicare Advantage has grown at a steady clip since its inception. Enrollment in private Medicare plans accounted for just 19% of the program in 2007, according to KFF. By 2019, enrollment had doubled to 39%.
 
"Enrollment in Medicare Advantage has increased dramatically in recent years," the KFF analysts wrote. "The growth in enrollment is due to a number of factors, including the attraction of extra benefits offered by most plans, such as vision, hearing, and dental services, and the potential for lower out-of-pocket spending, particularly compared to traditional Medicare without supplemental coverage."
 
In addition, MA coverage is attractive to many as it provides a one-stop shop for beneficiaries, since they will not need to shop separately for Part D coverage or supplemental plans, the researchers added.
 
The rapid growth has made MA a central focus for insurers, who generate significant profit in this space. Enrollment nationally is dominated by UnitedHealthcare and Humana.
 
That expansion has also led to far greater scrutiny on how insurers are managing the program along with concern that they're pocketing excessive dollars as MA grows. There is also a dearth of data on how MA compares to traditional Medicare in managing equity challenges and reaching underserved patient populations, the KFF researchers said.
 
Critics are also concerned about utilization management in the program, and the KFF report said that in 2021 alone MA members submitted 35 million requests for prior authorization.
 
"As the role of Medicare Advantage grows, so will interest in understanding how well the program serves the increasingly diverse group of enrollees who receive their Medicare coverage from private insurers," the KFF researchers said.

Nursing Shortages Show No Signs of Slowing, Survey Finds

Axios

Nearly a third of nurses nationwide say they will likely leave nursing for another career due to the pandemic, a new survey found.
 
Why it matters: Some sectors of the health care industry plagued by significant labor shortages during the pandemic appear to be rebounding, but the AMN Healthcare survey, published on Monday, suggests a shortage of nurses may continue to be a major challenge for health care providers for years to come. That reality is especially worrying for hospital leaders who are already relying on expensive contract labor to maintain services.

Details: For a decade, 80% to 85% of nurses said they were satisfied with their choice of becoming a nurse, according to AMN Healthcare. But in 2023, that percentage dropped to 71%, the survey of more than 18,200 nurses conducted in January found.

• Younger generations were less satisfied with their nursing career than older generations.
• The percentage of nurses who said they were satisfied with the quality of care they provide also decreased from 75% in 2021 to 64% in 2023.
• About 94% of those surveyed said there was a severe or moderate shortage of nurses in their area, with half saying the shortage was severe, per the survey.
• Nearly 9 in 10 nurses said the nursing shortage is worse than it was five years ago, the survey found. The vast majority (80%) believe the shortage will get much or somewhat worse over the next five years.

 What they're saying: The 2023 survey results show that a "crisis in nursing is upon us," Cole Edmonson, AMN Healthcare's chief clinical officer, wrote in a report about the survey results.

 "This extremity reverberates not only in the profession but throughout our nation’s healthcare system," he added.

The big picture: There are steps hospitals and other health care providers can take to better support nurses, the AMN Healthcare report said.

• The survey found that the top five strategies nurses said would reduce their stress included: increasing support staff, reducing patients per nurse, increasing salaries, creating a safer working environment, and including more nurse input into decision-making.
• Based on those results, AMN Healthcare recommended health care providers offer nurses mental health and wellness benefits and invest in technology to take away remedial tasks nurses don't need to perform. It also recommended regulatory changes and more investment in nursing programs to strengthen the nursing pipeline.

Methodology: The survey polled more than 800,000 Registered Nurses in the U.S. from Jan. 5 to Jan. 18, 2023, and received 18,226 completed questionnaires, of which 11,918 were from staff nurses with the rest identifying as travel, per diem or other types of nurses. The margin of error is 1% at a 99% confidence level, and the response rate is 2.5%.

Why Do We Lose Rational Behavior During Times of Intense Trauma?

By Barbara Karnes

I received a letter from a man who had been very ill. During some of that time he was delusional, confused, disoriented and agitated. His family has told him that during the time of his illness he was mean, uncooperative, a really nasty person. He is now puzzled by how he could possibly be that person they described. 

As people approach death in the weeks, days, and even hours they can experience the same behavior this gentleman described. It has the medical name of terminal agitation.

Why do we say and do what we say and do during times of intense trauma? I’m not a psychologist, but it seems to me that during these times (which can be from either illness or approaching death) we tend to lose touch with all the "conditioning" we have experienced in our life. Instructions on how to do and say the "correct things,'' how to be socially correct, are gone.

Our base nature comes out when we are in pain, other worldly, and on high doses of all kinds of medications.  We are unconsciously expressing the terrible situation we were in. Our everyday “manners” are of no importance here.

When a person is in an agitated state either in recovery or approaching death the "governor" is off. The training, thinking switch is off. The survival, get me out of here switch is on.

When the end of life is approaching, the line between this world, this reality and another reality, is thinned. The person has one foot in both worlds. I think with pain medications, intense physical pain, dehydration, the body malfunctions (even when death is not approaching or is approaching but is later reversed) we slip out of this world and into another. 

What we watchers consider rational behavior is generally gone. Unlike the movies, where the person says “I love you, take care of the children” closes their eyes and dies. In real life a dying person breathes strangely, talks about and to people we can’t see or hear, often shows fear, restlessness, agitation, and yes, may say angry, “mean” words. All of this is the normal, natural part of being very sick and possibly dying.