February 13, 2017
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This week, leaders from all three major parties in Vermont announced a joint effort to respond to President Trump's Executive Order on immigration. Governor Phil Scott, Attorney General TJ Donovan, Lt. Governor David Zuckerman, House Speaker Mitzi Johnson, Senate President pro-tem Tim Ashe and other legislative leaders announced that companion bills will be introduced in the House ( H.228 ) and Senate ( S.79 ) titled "An act relating to freedom from compulsory collection of personal information."
Watching this process unfold, I was struck by the degree of civility in Vermont's political process. The leaders making the joint announcement have significant disagreements about a variety of other policy issues, including education spending and the Administration's proposal to combine the Department of Labor and the Agency of Commerce. Yet, because Vermont's political system is far less polarized than that of many other states and certainly Congress, those disagreements are often set aside when leaders share a common goal.
As someone whose approach to advocacy has always been to focus on policy and build consensus to the greatest extent possible, I am grateful to have built my government relations career here in Vermont and look forward to continuing my advocacy on your behalf.

Governor Announces Health Reform Initiative

This week, Governor Phil Scott and Agency of Human Services officials held a press conference in a room filled with health care reform stakeholders. It's a little unusual to see so many stakeholders pack a press conference. It seemed to reflect the uncertainty about health care reform that has prevailed in the transition from one administration to the next.

The initiative the Administration announced was not new to the health care community since it was initiated under the Shumlin Administration. It involves OneCare, an Accountable Care Organization (ACO), and four Vermont hospitals - UVM Medical Center, Porter Hospital, Central Vermont Medical Center, and Northwestern Medical Center. It's a year-long agreement between the state, the ACO and the hospitals to enter into a "risk" model for Medicaid enrollees. In a nutshell, if hospitals spend less than the agreement calls for, they can re-invest the savings into their organizations. If they spend more, the loss is theirs to absorb. It's a mechanism to move away from paying hospitals and doctors for what they do (tests, visits and procedures) toward paying them for the quality of care they provide.
While the program itself is not new, the announcement is significant. It was a clear signal that the Scott Administration is staying the course on the all-payer model agreement signed by the Shumlin Administration, but moving forward at a more deliberative pace. The absence of funding for "Medicaid transformation" in the Administration's budget proposal had left the health care community uncertain about the intentions of the new Governor.
The VNAs in the "risk communities" are already deeply engaged with the ACO and their local hospitals about the new initiative. VNAs are essential to the success of the model - hospitals can only reduce spending if more care happens in the community. VNAs also have the care management and prevention experience that hospitals will need to deploy. However, the agreement is silent about payment for community providers and the Administration's SFY2018 budget fails to fund even an inflationary rate increase for community providers. Shifting more care from the most expensive settings like hospitals to the least expensive settings like the home is the linchpin to reducing health care costs in Vermont. If VNAs are to have the staff in place to support this shift, ACOs, hospitals and the State will have to invest in community providers. 

Paid Family Leave Bill Released

Members of the House this week introduced
H.196, a bill that proposes to establish a paid family leave and medical fund at the Department of Labor. The funding mechanism is a 0.93 percent payroll tax, which would be split between employees and employers. The bill was referred to the House General, Housing, and Military Affairs Committee. Paid family leave advocates face a tough uphill battle. Governor Scott said last week that he would veto the bill if it would "raise taxes and fees."

Bills that impact VNAs in their role as employer place them in a challenging position. VNAs are mission-driven organizations with a strong commit ment to their workforce s . However , b ecause the individuals served by VNA s are almost all covered by Medicare and Medicaid, VNAs do not set their own prices . While some employers warn that such bills will force them to "pass costs along to consumers," VNAs do not have that lux ury. VNAs are lean organizations that have been managing Medicare and Medicaid losses for years. New requirements on VNAs in their capacity as employers must be accompanied by commensurate increases in Medicaid funding.
One-Year Delay Needed for Home Care Providers to Implement Biggest Changes to CoP Regulations in Nearly 30 Years

This article is adapted from a publication of the Home Care Association of New York State

On January 9, 2017, the U.S. Centers for Medicare and Medicaid Services (CMS) finalized the most substantial single set of regulatory changes and new operating requirements for home health agencies since 1989 - in nearly 30 years.
The changes include extensive amendments and additions to the Medicare Home Health Conditions of Participation (CoPs). The CoPs are a set of rules by which Home Health Agencies must abide by in order to participate in the Medicare program. These rules also impact state Medicaid program regulations.
Providers only have six months to understand and implement these sweeping new changes, which are slated to take effect on July 13, 2017.CMS estimates these changes will cost home health agencies $293 million nationally in the first year and $290 million in year two and thereafter. These costs will be incurred without any compensatory adjustments to Medicare and Medicaid rates for home care services.
The lengthy final CoP rule contains an array of new requirements and changes related to: nursing, therapy and aide services, supervision assessments, patients' rights, care planning, quality improvement, clinical records, agency structure, governance, management, and other CoPs that dictate the operation and function of HHAs certified by Medicare (and Medicaid).
These revisions affect all levels of a home care agency's operations - from the delivery of services, to the management of staff, to recordkeeping, to the overall structure of the organization. While some of the changes are merely technical or organizational in nature, others would have a significant impact on clinical and administrative functions. A comparison document from CMS shows more than 50 specific regulatory references that are being changed all at once, many of them far-reaching in scope.
Although well-intended and laudable, the CoP changes present serious concerns related to the cost and compressed timeline for implementation. This timeline not only strains providers but also state-level surveyors who are charged with enforcing the rules.
Thus far, CMS has yet to supply state surveyors with the Interpretive Guidance to assist in their enforcement of these CoPs. CMS's delay in releasing Interpretive Guidance has a downstream effect on providers subject to state-level surveillance activities, as all stakeholders need time to interpret, gain clarification, implement and plan for enforcement of the new rules.
The CoP changes were originally proposed in October 2014 but they were only just recently finalized. CMS allowed itself more than two years to finalize the changes, but has extended only six months for providers and state surveillance agencies to take on the massive task of implementation and enforcement.

Given the costs and severe implementation pressures, the VNAs of Vermont is joining with many other state associations in seeking a delay in the CoP effective date to no earlier than July of 2018.
We will be reaching out to Vermont's Congressional Delegation to help them understand our concerns and ask for their assistance.
VNAs of Vermont | 802-229-0579 | [email protected] | http://vnavt.com