BY RAE SZYMANSKI
ACOs, MLTCPs, FIDA plans, Health Homes, Health Exchanges, Care Transitions: these terms have already become commonplace in the home health care sector and can be confusing and overwhelming to those outside of the industry.
In today”™s ever-changing health care landscape, the alphabet soup of acronyms and new terminology is matched only by the complexity of the new systems of care it represents. Understanding the meaning and implications of these new programs is essential to choosing the best path of care for oneself or for a loved one.
Even for a seasoned administrator or expert in the field, it is challenging to keep up with changes that are under way and to anticipate those that are still to come. An increase in the number of patient care options means that individuals will rely more and more on the guidance of professionals to determine the best path of care for their condition.
The Visiting Nurse Association of Hudson Valley and organizations like ours have been making it part of their mission to help patients navigate the uncharted waters of these new health care models, so that they may access the best quality care available.
Although the whole health care industry has been affected, the home care sector in particular has experienced major changes in reimbursement and regulations at both the state and federal level.
New York state Medicaid has dramatically changed the way it manages patients and reimburses providers for long-term care services in the home and in skilled nursing facilities. Beginning in January 2013, Medicaid patients in Westchester were mandated to enroll in a managed long term care program, or MLTCP, which receives a capitated amount per person to manage, coordinate and provide long term care services at home or in a skilled nursing facility. As a result, patients enrolled in the program will only have access to the MLTCP”™s contracted providers.
New York has also been approved by the federal government to provide a demonstration program aimed at containing costs and at serving the needs of beneficiaries who are enrolled in both Medicare and Medicaid, known as “dual eligible.” This population is complex and challenging to serve, and a disproportionate amount of state funds go towards covering this group (more than twice the national average per individual). The proposed Fully Integrated Duals Advantage program, or FIDA, is a new managed care program that integrates all Medicare and Medicaid health care and long-term services. Enrolled “dual eligibles” will now need to ensure that their provider, hospital, and skilled nursing facility are providers under the FIDA plan and to understand what the changes mean for them if they are not.
The federal government”™s Affordable Care Act encourages whole patient population management through accountable care organizations, or ACOs, cost-sharing partnerships of health care providers, including medical groups, hospitals, skilled nursing facilities and home care providers. In this new model, the ACO is accountable for the quality, cost, and overall care of Medicare beneficiaries who enroll in the program. Its goal is to manage the health care needs of a quickly-growing aging population while ensuring the best possible outcomes at the lowest possible cost.
In an ACO, care management and coordination is critical, especially for members with chronic conditions who are considered high risk for frequent hospitalizations and emergency department visits. As ACOs mature and proliferate, it will become increasingly important to understand how care will be affected if one”™s medical provider is not part of the ACO.
In order to ensure continuity of care for our patients, the Visiting Nurse Association of Hudson Valley, and other agencies like ours, are adapting to the evolving environment by partnering with new providers, including MLTCPs and ACOs. Quality care and the patient will remain front and center of everything we do and we will continue to advocate for both.
Rae Szymanski is executive vice president and chief operating officer of Visiting Nurse Association of Hudson Valley in Tarrytown. She can be reached at rszymanski@vnahv.org or (914) 666-7616.
