Includes provisions for high-cost cases in the form of additional outlier reimbursement. Outlierthresholds were modified based on the recommendations of the Home Care Reform Work Group toprovide greater reimbursement for high-acuity cases.
Enhanced care management and service capability.
Fosters provider fiscal stability and planning.
Redirects Medicaid spending from New York City (where over-utilization of CHHA services has drivenrapid increases in per-patient costs) to other areas of the State where additional resources can be usedto meet staffing needs.
Opportunity to enhance patient access and quality of care.
Concerns with Proposal:
Provider limits may provide agencies an incentive to "cherry pick" patients by serving only those withlower acuity and less intense needs. However, the Case Mix adjustment component of the providercaps and the transition to Episodic Pricing should mitigate this incentive.
Providers have expressed concern that the grouper employed to determine Case Mix may notadequately reflect all aspects of patient need, including chronic illness, psycho-social factors, andspecial needs populations. To address these issues, the Department designed a new grouperspecifically for New York State Medicaid patients, and made significant changes to the clinical andfunctional scoring mechanisms to better reflect the needs of this population.
Provider groups have expressed concern about the time required to implement Episodic Pricing. Toaddress this concern, the Department has pushed back the proposed effective date to April 1, 2012.
The proposal does not include funding for rewarding provider quality and performance. However,alternatives for providing financial incentives to meet clearly defined quality standards were presentedto the Home Care Reform Work Group and can be implemented in the future.
Providers Based on the most recent available Medicaid paid claims data for 2009 and a savings assumption of $200million annually, the provider per-patient limits would impact only 23 of 139 CHHAs. These 23 agencies billed acombined average of $33,421 per patient during calendar year 2009 or $17,851 more than the statewideaverage. The $192 million impact on New York City providers represents about one-third of the $575 millionincrease in CHHA spending in New York City from 2003 to 2009.
Provider Limits: Gross FiscalImpact by RegionNew YorkCityOtherDownstateUpstateTotal($ millions)
Negative Impact ($ millions) -$192.3 -$2.1 -$5.6 -$200.0Negative Impact: # of providers 16 4 3 23
No Impact: # of providers 13 27 76 116Total # of providers 29 31 79 139
Under the Episodic pricing proposal, which reflects the continued shift of patients to Managed Care, Medicaidspending outside New York City would increase by more than $20 million.
Page 3 of 234