2019 Annual Report

Health Care Association of Michigan & Michigan Center for Assisted Living A division of HCAM

2019 Annual Report HCAM and Providers Fight Against Medicaid Cuts Michigan’s latest version of divided government started in 2019. The Republican-led legislature quickly disagreed with Governor Gretchen Whitmer on her proposed tax increase for road funding and other issues surrounding the budget. HCAM was successful in defeating a cut to Medicaid funding included in the governor’s proposed budget. When the legislature sent un-negotiated budget bills to the governor, however, nursing facilities were among the many casualties of Governor Whitmer’s vetoes and executive actions. Included in her actions was a Medicaid policy bulletin reducing the variable cost limit (VCL) from the 80th percentile to the 65th percentile.

After a more than two-month standoff, Governor Whitmer at the end of the year signed bills restoring some of the items that were cut by the line-item vetoes.

Although many of the executive actions, including rescinding the Medicaid bulletin lowering the VCL to the 65th percentile, are not addressed in these budget bills, we remain optimistic that the bulletin will be rescinded in the near future. Thank you for all your efforts advocating to stop this cut from taking effect. We continue to work with the administration and legislature to receive confirmation of the rescission of the bulletin, and we will notify membership as soon as action is taken.

Medicaid Process Bill Signed into Law Senate Bill 348 – which prohibits retroactive application of Medicaid policy reinterpretations – was signed by Governor Whitmer and assigned Public Act 178 of 2019. In 2018, Governor Snyder signed Senate Bill 1038, which placed timelines on the audit process for Medicaid cost reports.

As the department this year began implementing new procedures to meet these statutory requirements, SB 348 was imperative to ensure fairness in the process by prohibiting the Department of Health and Human Services (DHHS) from reinterpreting existing Medicaid policy, and applying the new interpretation retroactively to cost reports from previous years.

This law went into effect in December.

Follow us on Social Media!

2019 In Review 2019 brings the year and decade to an end. To say the past decade has been one of significant change would be an understatement. The world we operate in today is not the same world we operated in ten years ago. The greatest change came from the federal government in both regulatory oversight and reimbursement. The Requirements of Participation, Payroll Based Journal and the Patient Driven Payment Model are the most significant changes to our profession since OBRA, Medicare and Medicaid started!

On the state level Medicaid reimbursement remained stable over the last decade allowing Michigan to lead the nation in new builds and renovations of aging facilities. It also contributed to Michigan providers exceeding the national average on several key quality measures. Although, we end the decade facing significant challenges on the state level. In 2019 newly elected Governor Gretchen Whitmer proposed two separate cuts to nursing facility providers. Advocating for her priorities – including road funding, Governor Whitmer proposed numerous cuts across state government including nursing facilities. Fortunately, HCAM and our members were successful in stopping the cuts from taking effect. In addition, Michigan’s regulatory environment remains one of the most rigorous in the country, yet again Michigan providers demonstrate consistent positive outcomes.

And what will confront us as we start the next decade? Significant change will continue and likely intensify. Continued regulatory scrutiny from the Federal government is expected. Providers may find opportunity as they continue to operate under the Patient Driven Payment Model, we will face greater pressure on state Medicaid funding, in addition to health plans desire for managed longterm care services and supports in Michigan.

Despite the significant changes and challenges you are facing we are optimistic for the future. The association is strong – representing 360 nursing facilities and 227 assisted living communities.

Together we will take on these issues - we will help you fulfill your PURPOSE. We are grateful for the trust you have placed in us – the association team remains energized and ready to meet your needs in 2020!

The 2019 YEAR END REPORT details the major issues we have worked on throughout the past year - including provisions of our annual strategic plan approved by the board of directors.

Members and association staff attended the AHCA/NCAL Congressional Briefing in June.

Legal / Regulatory / Clinical The association, in collaboration with AHCA/NCAL, assisted providers to prepare and integrate for the waves of challenge and change during the year through communication, training and tools to weather the storms. HCAM remained an active participant in the BHCS LTC Stakeholders Workgroup, meeting with leaders in the Bureaus of Community and Health Systems and Professional Licensing to proactively work to improve care and relationships Senator Rick Outman visited with staff and residents at as well as to address concerns brought Schnepp Senior Care in July. forward by membership. It is important to note that despite the flurry of activity at the federal and state level, Michigan stands heads above the other states in quality and staffing, despite the day to day challenges we face. HCAM members average Quality Measures Star Rating is 4.04 compared to a national average of 3.60, and Staffing Star Rating is 3.50 compared to a national average of 2.87.

Michigan providers have much to be proud of in the care that is delivered to our residents every single day of the year!

CMS Focus On Regulatory Oversight Throughout the course of 2019, CMS Administrator Seema Verma released commentary and directives related to her Five Step Approach to Ensuring Safety & Quality in Nursing Homes. This strategy focuses on critical areas of 1) strengthening oversight, 2) enhancing enforcement, 3) increasing transparency, 4) improving quality, and 5) putting patients over paperwork. The resulting impact includes changes to our survey process, quality measures, and proposed changes to requirements of participation. In addition, CMS reorganized to include all Regional Offices now reporting to the Central Office in an effort to improve consistency in the application and enforcement of regulations. Much of this work has been the result of added scrutiny from the Office of Inspector General (OIG) and US Government Accountability Office (GAO) following on the heels of the Senate Finance Committee’s Hearing on Abuse in Nursing Homes.

Changes to Nursing Home Compare Reporting 2019 saw the addition of the Abuse Icon to Nursing Home Compare. This icon was added for nursing facilities receiving citations related to F600 Free from abuse & neglect, F602 Free from misappropriation/exploitation, and F603 Free from involuntary seclusion. AHCA and HCAM continue to push back against this change and advocate for fairness at both the federal and state level.

Michigan Rolls Out MI-FRI Portal Early in 2019, Michigan finalized the work to make updates and changes to the Facility Reported Incident (FRI) process recommended by the FRI LTC Stakeholder Workgroup. The site was launched in the Spring and in addition to collecting more complete information with initial reports, offers providers reporting and tracking functions for FRI reports.

Health Facilities Rules Work continued through the year on revisions to the health facility state rule set. This initiative began late in 2017 with a workgroup including HCAM & MCAL, and focused on combining the current rule sets for four individual health facilities including hospitals, hospice, nursing facilities, and outpatient surgical centers, into one combined rule set. These revisions will eliminate a number of outdated nursing facilities rules and create parity with other settings once implemented. At the end of 2019 the rules have been submitted to the Joint Robinwood Landing was the winner of the Commission on Administrative Rules (JCAR) for final MCAL Halloween photo contest. approval and are anticipated to be released in early 2020. Home for the Aged administrative rules are not currently addressed in this process, however we anticipate they will come under review in the future.

Nurse Aide Rules HCAM and several of our members have been active participants in the current work to develop an administrative rule set to cover nurse aides. Once completed, these administrative rules will provide guidance on nurse aide training & certification, the nurse aide registry, complaints and investigations, and enforcement, hearing and disciplinary action. We anticipate this work to develop the rule set will continue throughout 2020. Once implemented, these rules will affect certified nurse aides working in skilled and AL settings.

Core Dementia Care Civil Monetary Penalties (CMP) Grant HCAM in partnership with The Starling Center received a three year CMP Nursing Facility Enrichment Program Grant. The project will offer in-person advanced training for facility staff to effectively modify care strategies, with the primary aim to discover what contributes to helping a resident with dementia feel content, engaged, and enriched in everyday life. The approach adopted, through training, encourages staff to take active steps to prevent or avoid unnecessary pain and suffering for the dementia resident.

Exemption from HFA License Sunset Date When Public Act 167 of 2017 went into effect it included a sunset date for the HFA Exemption from licensure opportunity in certain circumstances (Sec. 21311a) MCAL supported numerous members to accomplish their goal of exemption in time to meet the December 31, 2019 sunset date.

Public Policy

In May, testimony was given before the House Health Policy Committee on legislation creating a medication aide registry.

The first year of divided government in nearly a decade brought with it a number of challenges in 2019. Throughout the year, HCAM monitored, tracked, and engaged in a number of bills impacting long term care. As issues arise, HCAM/MCAL staff, board members, and facility employees met with legislators and testified in legislative committee hearings to address concerns. The association advances our initiatives and supports many bills, but also prevents advancement of bills having negative consequences for the profession. The following highlights major legislation from 2019.

Medication Aide Legislation – Goal for Passage in 2020 House Bill 4098 began to move through the legislative process this year as the bill was reported from the House Health Policy Committee. The legislation closely mirrors the statutory framework in place for nurse aides to establish a medication aide registry. Responsibilities of medication aides would include administering regularly scheduled medication under the supervision of a registered nurse.

Medication aides may be used to supplement staff to help provide residents with the care they need while offering MediLodge of Plymouth hosted a nurse aides with the opportunity to advance their careers. carnival in June.

HCAM continues to work with bill sponsor Representative Ben Frederick and legislative leadership with the goal of sending the bill to the governor in 2020.

Attorney General Dana Nessel’s Elder Abuse Task Force In her first year as Michigan’s Attorney General, Dana Nessel turned her focus to issues surrounding elder abuse and exploitation, forming a task force to explore policies to prevent these crimes.

HCAM/MCAL was invited to join the task force, and has actively participated to offer the provider perspective. It is expected legislation will be pushed by the AG in 2020, and the association will continue to engage to make certain any new policies do not adversely impact providers and the seniors we serve.

Government Advocacy Educating Legislators on the Quality Care Provided by Michigan Nursing Facilities HCAM continues to spend considerable time advocating against policies detrimental to the profession. The governor proposed a cut of nearly $40 million from Medicaid, the AG aggressively charged nurse aides with elder abuse, and a number of bills were introduced by legislators that hinder the ability of facilities to effectively provide care. These policies clearly show a lack of understanding of the profession and the way it is regulated and funded.

In an effort to educate policy makers, HCAM launched a Quality Care Campaign in the spring of 2019. This campaign focused on the high-quality care offered by providers to change the negative perception that often leads to adverse legislation and policies. The campaign included billboards on the highways used by legislators in route to Lansing from their districts. There was also a robust social media effort targeted in Lansing, with links to a website, minursingandrehab.com, that provided information on quality care and quality initiatives.

In the fall of 2019, we again engaged in a social media “like” campaign, to increase our online presence and connect with policy makers. We will also be releasing a quality report, highlighting the quality measures that Michigan providers perform better than the national average.

HCAM launched a quality care marketing campaign highlighting caregivers and residents.

A Senior Olympics was held in June featuring many Jackson-area members.

Members Host 37 Legislators in 2019 Perhaps most important to our advocacy efforts, members hosted 37 elected officials to facilities in 2019. We set a goal of three visits each quarter from a legislator to a member facility in 2019. Thanks to your efforts we were able to far surpass that goal. These visits promote a positive reputation of the profession, allow elected officials to learn more about the profession, and allow residents and staff to meet with their representatives. Hosting a legislator helps you to establish a relationship with them that will be helpful as we navigate the budget and legislative process.

2019 HCAM PAC Campaign Thank you to everyone who contributed to the 2019 HCAM PAC Campaign. Association members generously donated nearly $90,000, allowing us to play an active role in fundraisers and events this year. With a competitive election for the House of Representatives coming in the fall, we hope that 2020 is our strongest campaign to date, with a goal of $100,000 in contributions.

Reimbursement and Managed Care In 2019 major changes were implemented for Medicare Part A payments. Medicare changed the payment system from Resource Utilization Groups (RUGs) to Patient Driven Payment Model (PDPM). This moved the focus from primarily therapy services to an overall view of the patient’s total medical needs. PDPM in its first year is a test to see if it is a better system, so far it appears to be better for the patient. Managed care has grown in its enrollment of beneficiaries for Medicare Advantage plans with low or no co-pays. The Medicaid programs across the states turns over the management of care to health plans with the vision of saving money and better coordination of care.

Michigan is requesting to continue the MI Health Link program for an additional three years even though evaluations show little results of savings or coordination. The upcoming year will bring many challenges to how skilled nursing facilities get reimbursed.

Medicare and Medicaid Reimbursement HCAM provided members with the latest information on the changes in Medicare fee for service (FFS) rates and coverage. The American Health Care Association provided HCAM members with the Medicare FSS Part B rates. Medicare and Medicaid policy changes were shared with members throughout the year in the newsletter and member alerts, and at the Reimbursement/Managed Care

Committee meetings. Medicaid changes in 2019 included audit and settlement process changes in accordance with Public Act 612, Quality Measure Initiative (QMI) updates, Veteran Homes Medicaid rates switched to PDPM methodology and numerous ongoing upgrades to the Community Health Automated Medicaid Processing System (CHAMPS).

Court Upholds CON Commission’s Addition of New Nursing Facility Beds The Certificate of Need (CON) Commission, during their September 19 meeting, adopted an updated bed need report, resulting in the addition of 2,813 nursing home beds to current inventory statewide.

The Commission did so despite the warnings from HCAM and other long-term care stakeholders that the state is already over bedded, and the addition of the unnecessary beds will have significant detrimental impact on providers and the state Medicaid program.

In light of the Commission's decision, the HCAM Board of Directors approved filing a lawsuit against the Michigan Department of Health and Human Services and the CON Commission seeking injunctive relief to prevent the department from publishing the additional beds, and from accepting, processing or granting any certificate of need applications for these new beds. Unfortunately, the court denied our motion for injunctive relief, which means the new bed need numbers will be published and may be applied for at the next comparative review period February 1, 2020.

HCAM is working with the Standard Advisory Committee (SAC) and commission members to update the bed need methodology to reflect today's long-term care environment and take into account current occupancy rates. The first SAC meeting took place on Thursday, December 19, with monthly meetings planned through June of 2020.

Quality Measure Initiative The Michigan Department of Health and Human Services (MDHHS) Medicaid Quality Measure Initiative (QMI) continued for the second year. The QMI provides a net of approximately $30 million dollars to Michigan Medicaid nursing facilities based on the 5-Star Quality Measures criteria, as established by CMS. QMI is a pay-for-performance program that provides each Medicaid nursing facility an incentive to provide the highest quality of care as measured by the CMS criteria. The program pays a pre-set monthly amount based on the QMI criteria for payment. HCAM presented this program to MDHHS and gained initial legislative approval in A staff member and resident at WellBridge of Pinckney the State FY 17-18 budget. The QMI enjoyed National Skilled Nursing Care Week activities. program is ongoing as we enter its third year, State FY 19-20.

Medicare Patient Driven Payment Model The Centers for Medicare and Medicaid Services (CMS) implemented for Medicare Part A Skilled Nursing services the Patient Driven Payment Model (PDPM).

PDPM focuses on the overall health issues of the beneficiary with less focus on therapy services. The American Health Care Association (AHCA) continues to work with CMS to fix any implementation

issues in this new system. AHCA has numerous webinars and resource material on PDPM which are available to members free or at reduced cost. This change took effect October 1, 2019 and seems to be well received by facilities. This first full year will be interesting and may see changes proposed by CMS in PDPM payment rates.

MI Health Link (MHL) Extended Michigan Medicaid has operated an Kith Haven staff enjoyed dressing up for National integrated care duals pilot since 2015 Skilled Nursing Care Week activities. called MI Health Link (MHL). MHL is in four regions of the state ranging from the entire Upper Peninsula to specific counties in both southwest and southeast Michigan, and enrollment is voluntary. The program integrates the services and funding streams from both the Medicare and Medicaid programs under a managed care health plan arrangement called Integrated Care Organization (ICO). MHL was due to end December 2020 but MDHHS has requested an extension for three more years to 2023. This extension may or may not include a larger geographic area, that decision is pending. Since the inception of MHL less than 2,000 individuals residing in nursing facilities have participated in the MHL ICO’s. As in the initial years ongoing operational concerns continued regarding timely and accurate payments for services. The experience with MHL has not been positive for nursing facility residents or nursing facility providers. The claims of savings and better coordination of care have not materialized.

MI Choice Home and Community Based Waiver (HCBW) Michigan’s MI Choice HCBW program began in 1992 and is funded as an 1915 (b) (c) waiver program as approved by CMS. In 2014, CMS put forth a number of changes to the waiver program and Michigan was required to submit a transition plan for these changes. Final approval for the transition plan was extended by CMS until March 17, 2019. The changes will need to be implemented by March 17, 2022 which include new guidelines for residential settings that will impact assisted living waiver providers. MCAL members will be meeting with Michigan’s MI Choice Director in January of 2020 to become better acquainted with the changes and receive assistance in following guidelines for change and compliance.

Education The association offered more than 40 opportunities for educational involvement in 2019. Education programs developed by the association saw an increase in participation in 2019. Our convention was the highest attended in recent years. An increase in exhibitors at convention was also noted.

Thank you HCAM and MCAL board and committee members for all of your work throughout 2019!