Medicaid Reimbursement Update and Financial/Operating Trends

Transcription

1 Medicaid Reimbursement Update and Financial/Operating Trends Christopher J. McCarthy, MBA, CPA Partner Health Care Leader Dorothea A. Russo, CPA Partner Health Care November 14, 2018

2 Agenda Current challenges Industry selected metrics Medicaid MLTC benchmark rates Update Statewide Pricing rates Medicaid rate changes Capital rates 2

3 Current Challenges Softening census Decline in quality mix (Medicare, Medicare Managed Care and Private) Ability to attract quality mix Operating margin dependent on one-time revenue inflows (e.g. a generous donation, Univ. Settlement, etc.) Increase in days in accounts receivable Increase in days in accounts payable Reduced current ratio Reduced days cash on hand Staff retention 3

4 Selected Industry Metrics Utilization, revenue and discharges Days in accounts receivable Net patient revenue divided by A/R = A/R Turnover Number of days in calendar year divided by A/R Turnover Bad debt expense per patient day Current ratio Current assets divided by current liabilities Operating margin Net operating income divided by total operating revenue 4

5 SNFs - 5 Years Facility Count Average Bed Size Occupancy Utilization Medicaid % 73.91% % 72.99% % 71.99% % 69.37% % 62.84% Medicaid Managed Care 1.21% 1.56% 2.06% 3.70% 9.58% Medicare 10.58% 10.88% 10.73% 11.21% 11.12% Medicare Managed Care 3.07% 3.44% 3.79% 4.08% 4.10% Private 8.15% 7.89% 8.10% 7.94% 8.04% Other 3.08% 3.24% 3.33% 3.70% 4.33% Revenue by Payor Medicaid 60.35% 59.33% 58.16% 56.01% 51.57% Medicaid Managed Care 0.69% 0.81% 1.10% 1.82% 4.48% Medicare 20.50% 21.23% 21.16% 21.92% 22.07% Medicare Managed Care 2.59% 2.87% 3.13% 3.30% 3.24% Private 13.02% 12.95% 13.02% 13.17% 14.45% Other 2.84% 2.82% 3.42% 3.79% 4.20% 5

6 SNFs - 5 Years Facility Count Average Bed Size Occupancy Discharges Total % 230, % 220, % 226, % 237, % 233,108 To Hospital 36.54% 35.89% 33.93% 33.30% 33.06% To Private Residence 44.77% 45.89% 48.09% 48.26% 48.78% To Another RHCF 3.56% 2.88% 2.78% 3.02% 2.85% To Adult Care Facility 2.09% 2.18% 2.02% 2.36% 2.40% Due to Death 11.75% 11.77% 11.79% 11.74% 11.67% To Other 1.29% 1.38% 1.39% 1.32% 1.24% 6

7 SNFs - 5 Years 37.00% Discharges to Hospital 36.00% 35.00% 34.00% 33.00% 32.00% 31.00%

8 SNFs - 5 Years Bad Debt Expense Per Patient Day Days in Accounts Receivable Current Ratio Operating Margin % -1.29% -0.31% 1.73% 1.19% 8

9 Medicaid MLTC Benchmark Rates Are currently posted on DOH website at: Included in 7/1/2018 Benchmark Rates: Casemix adjustment based on January 2018 CMI No Transition Adjustment (sunset with 2016 rates) Minimum Wage Adjustment, if applicable Case mix cap, if applicable Cash Receipts Assessment per diem (using 2016 rate) Does not include Quality Measures Does not include negative Transition Adjustment 9

10 Statewide Peer Group Prices: 2012-present HBF/300+ <300 Direct-No B Direct B&D Indirect Direct-No B Direct B&D Indirect Allowable cost per diem $ $ $ $ $ $ Ceiling application % % % % % % Ceiling cut (27.12) (26.76) (13.93) (24.91) (24.57) (12.35) Statewide price Ceiling application % % % % % % Statewide price Ceiling application % % % % % % Statewide Price Ceiling application % % % % % % Statewide Price Ceiling application % -9.89% -9.89% -9.89% -9.89% -9.89% Statewide Price Ceiling application % -9.48% -9.48% -9.48% -9.48% -9.48% Statewide Price & Forward Transportation Adjustment 7/1/2018 (0.18) (0.18) (0.08) (0.08) Statewide Price -7/1/18 & Forward

11 Statewide Peer Group Prices Effective 7/1/18 & Forward HB/300+ Beds <300 Beds Direct Indirect Direct Indirect 2007 Allowable cost per diem Ceiling application -9.48% -9.48% -9.48% -9.48% Ceiling adjustment (12.99) (6.76) (11.93) (5.99) 2007 Allowable cost per diem reduced by ceiling adjustment Transportation adjustment effective 7/1/2018 (0.18) N/A (0.08) N/A 2007 Allowable statewide price effective 7/1/18 & forward NO TREND (INFLATION) FACTOR 11

12 Statewide Pricing Direct Component 2 Peer groups (<300 beds; => 300 beds or HB) Mean price computed using 2007 base year costs <300 beds => 300 beds or HB 7/1/18 & forward $ $ Peer group mean price adjusted by WEF ( Utica vs. Brooklyn ) WEF computed using 2009 salaries (primarily nursing) After WEF, the mean price is adjusted by the facility specific case mix CMI Changes the Direct Component (currently awaiting State s methodology for blending the April and July 2018 for 1/1/2019 rate) 12

13 Statewide Pricing Direct Component Medicaid Case Mix Analysis Medicaid rates Case mix data pulled for total and Medicaid-only Medicaid case mix by sponsorship Brief look at SNFs that changed ownership Other analysis 13

14 Nursing Facility Medicaid-Only Case Mix Index Benchmark Overview - New York State Medicaid-Only Case Mix Indices - January 2011 through July 2017 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 CMI 7.51% 2.29% 0.56% 3.21% 1.14% 0.15% 2.88% 2.99% 1.04% 1.53% 1.57% 1.03% Proprietary Facilities CMI 2.63% -0.25% 0.20% 4.40% 1.08% 0.07% 2.49% 2.77% 0.55% 0.72% 1.82% 1.72% Voluntary / Not-for-Profit Facilities Yr Avg NYS Proprietary and Voluntary/NFP Facilities Voluntary / NFP Proprietary 0.85 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 14

15 Nursing Facility Medicaid-Only Case Mix Index Benchmark Overview - Kings County Medicaid-Only Case Mix Indices - January 2011 through July 2017 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 CMI 11.28% 2.89% 0.00% 4.64% 1.18% 0.00% 2.75% 4.49% 0.41% 3.87% 2.74% 0.39% Proprietary Facilities CMI 4.02% 4.23% 0.52% 1.80% 1.34% 0.00% 2.83% 1.05% 0.39% -0.19% 1.43% 3.34% Voluntary / Not-for-Profit Facilities Yr Avg County Proprietary and Voluntary/NFP Facilities Voluntary / NFP Proprietary 0.85 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 15

16 Nursing Facility Medicaid-Only Case Mix Index Benchmark Overview - Erie County Medicaid-Only Case Mix Indices - January 2011 through July 2017 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 CMI 4.19% 1.53% 5.41% 4.14% 2.69% 0.00% -0.46% 1.78% 2.83% -0.28% 2.98% -1.79% Proprietary Facilities CMI 6.07% -5.43% 1.41% 2.76% 2.48% 0.00% 6.29% 9.34% 0.50% 0.21% 2.29% 1.68% Voluntary / Not-for-Profit Facilities Yr Avg County Proprietary and Voluntary/NFP Facilities Voluntary / NFP Proprietary 0.85 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 16

17 Medicaid Only Patient Mix PROPRIETARY FACILITIES MDS Categories Rehabilitation Low-Medium-High 34% 40% 43% 48% 48% 48% Very High 2% 2% 2% 3% 4% 5% Ultra High 3% 4% 6% 7% 11% 15% 40% 46% 52% 58% 63% 67% Behavioral 1% 0% 0% 0% 0% 0% Clinically Complex 27% 26% 23% 21% 19% 16% Extensive Services 4% 4% 3% 3% 3% 3% Impaired Cognition 6% 5% 4% 4% 3% 3% Special Care 8% 8% 7% 6% 5% 5% Reduced Physical Function 14% 11% 10% 8% 7% 6% 60% 54% 48% 42% 37% 33% Total 100% 100% 100% 100% 100% 100% Statewide July 1 MDS Submissions 17

18 Medicaid Only Patient Mix 70% 65% 60% 55% 50% 45% 40% 35% Proprietary Facilities 30% Rehab Non Rehab 18

19 Medicaid Only Patient Mix VOLUNTARY / NFP FACILITIES MDS Categories Rehabilitation Low-Medium-High 18% 23% 28% 31% 35% 40% Very High 1% 1% 1% 1% 1% 2% Ultra High 1% 1% 1% 1% 2% 2% 20% 25% 30% 33% 38% 45% Behavioral 1% 1% 0% 1% 0% 0% Clinically Complex 28% 28% 27% 25% 25% 21% Extensive Services 4% 4% 4% 5% 4% 4% Impaired Cognition 8% 7% 6% 6% 5% 5% Special Care 10% 9% 9% 10% 9% 8% Reduced Physical Function 30% 27% 23% 21% 19% 17% 80% 75% 70% 67% 62% 55% Total 100% 100% 100% 100% 100% 100% Statewide July 1 MDS Submissions 19

20 Medicaid Only Patient Mix 85% 75% 65% 55% 45% 35% 25% Voluntary / Not-for-Profit Facilities 15% Rehab Non Rehab 20

21 Statewide July 1 st MDS Top 15 Rank

22 Nursing Facility Medicaid-Only Case Mix Index Benchmark Overview - Facilities that Transitioned from Voluntary to Proprietary Sponsorship* Medicaid-Only Case Mix Indices - January 2011 through July 2017 Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 CMI 4.72% 2.48% 1.21% 2.68% 2.79% 0.00% 9.75% 6.45% 2.21% 1.73% 1.67% 1.75% Count: 46 Facilities Sponsorship Proprietary Voluntary / Not-for-Profit Yr Avg NYS Facilities that Transitioned from Voluntary / NFP to Proprietary Jan-11 Jan-12 Jul-12 Jan-13 Jul-13 Jan-14 Jul-14 Jan-15 Jul-15 Jan-16 Jul-16 Jan-17 Jul-17 * Excludes facilities that closed in 2016 (2 facilities), hospital-based facilities (1 facility) and facilities that did not reflect MDS data for all periods (2 facilities). 22

23 Statewide July 1 st MDS Highest Score MDS Utilization Rehabilitation Low-Medium-High 18% 65% Very High 2% 6% Ultra High 60% 16% 81% 88% Non-Rehabilitation Clinically Complex 6% 4% Extensive Services 2% 4% Special Care 7% 2% Reduced Physical Function 4% 2% 19% 12% 23

24 24 Impact of Blended Casemix Direct Component at 1/1/2019 after WEF with January 2018 casemix (Line 5) $ Casemix Index January 2018 (per Schedule 4) 1.03 Value per point with Jan 2018 casemix $1.45

25 25 Impact of Blended Casemix (cont d) Value per point with Jan 2018 casemix Casemix Index January 2018 (per Schedule 4) With July 2018 casemix Casemix Index July With April 2018 casemix Blending Methodology $1.45 $1.45 $ Case Mix Index April Case Mix point change +2 pts - 6pts - 2 pts Impact of casemix change $2.90 ($8.70) ($2.90) Casemix impact $58,000 ($174,000) ($58,000) 1.01

26 Statewide Pricing Indirect Component 2 Peer groups (<300 beds; => 300 beds or HB) Mean price computed using 2007 base year costs <300 beds => 300 beds or HB 2017 & forward $57.18 $64.52 Peer group mean price adjusted by WEF ( Utica vs. Brooklyn ) WEF computed using 2009 salaries (primarily nursing) WEF is 50% regional & 50% facility specific Higher 2009 nursing wages, greater impact on WEF Higher the WEF, higher the indirect component 26

27 Non-Comparable & Capital Components Non-comparable component Based on facility specific 2007 non-comp costs No peer group, no need to apply WEF No change to non-comp unless new base year Capital component Generally, NFP s receive allowable mortgage interest & depreciation; Proprietary s receive mortgage interest & principal amortization Rate year ( real time ) for allowable mortgage expenses (Sch 17) 2 year lag for other capital items 27

28 Medicaid Rate Changes Timing Case mix updates twice annually (1/1 & 7/1) through rates effective 7/1/2018; subsequent casemix collection dates to be determined. 5% case mix cap adjustments will apply OMIG audit adjustments annually ; will release and reset 5% cap adjustments Cash receipts assessment (CRA) per diem reconciliations - annually 28

29 Medicaid Rate Changes Case Mix Rate Changes Effective Date Check Date Cycle # Reason for Rate Change 1/1/2013 2/24/ /2012 CMI w/5% cap 7/1/2013 3/10/ /2013 CMI w/5% cap 7/1 12/31/2012 & 1/1 6/30/2013 7/1 12/31/2013 & 1/1 6/30/ /14/ Result of OMIG audits of 1/2012 & 7/2012 MDS s 2/8/ Result of OMIG audits of 1/2013 & 7/2013 MDS s 7/1 12/31/2012 & 1/1 6/30/2013 7/1 12/31/2013 & 1/1 6/30/2014 7/1 12/31/2013 & 1/1 6/30/2014 7/1 12/31/2014 & 1/1 6/30/2015 4/ Unwind results of OMIG audits of 1/12 & 7/12 4/ Unwind results of OMIG audits of 1/13 & 7/13 12/ Final results of OMIG audits of 1/13 & 7/13 10/30/ Final results of OMIG audits of 1/14 & 7/14 29

30 Medicaid Rate Changes (cont.) Case Mix Rate Changes (cont.) Effective Date Check Date Cycle # Reason for Rate Change 1/1/2014 7/23/ /2013 CMI w/5% cap 7/1/ /10/ /2014 CMI w/5% cap 1/1/2015 3/09/ /2014 CMI w/5% cap 1/1/2015 9/09/ /2014 CMI w/5% cap 7/1/2015 3/07/ /2015 CMI w/5% cap 1/1/2016 2/22/ /2015 CMI w/5% cap 7/1/ /2/ /2016 CMI w/5% cap 1/1/2017 2/22/ /2016 CMI w/5% cap 7/1/2017 8/17/ /2017 CMI w/5% cap 1/1/2018 4/23/ /2017 CMI w/5% cap 7/1/2018 7/09/ /2018 CMI w/5% cap 30

31 31 Medicaid Rate Changes (cont.) Cash Receipts Assessment Rate Changes Effective Date Check Date Cycle # 1/1-12/31/2011 7/30/ /1-12/31/2012 (rolled rate into 2015 in error for some facilities) 3/9/ /1/2013 current (correction of error from cycle #1959) 4/13/ /1-12/31/2013 8/26/ /1-12/31/2014 2/22/ /1-12/31/2016 updated w/ 2014 rate 7/25/ /1-12/31/2015 3/15/ /1-12/31/2016 1/1/ /1-12/31/2018 updated w/ 2016 rate 6/25/

32 Outstanding Reimbursement Issues 1% Restoration retroactive to 4/1/2014 Quality Measures (NHQI) (retroactive) OMIG MDS audit results 2015, 2016, 2017 Release of 5% Casemix adjustments based on completion of above OMIG audits 1.5% ATB adjustment effective November 1, 2018 Shared Savings appeals Cash Receipt Assessment reconciliation for CY 2017 (vs. 2014) Elimination of hospital bedhold effective 4/1/

33 Capital Per Diem Important RHCF schedules: Schedule Q Facility Reported Capital Part II and Part III (if applicable), Schedule 9 Part II and Part III (if applicable), Schedule 10 & 11 Part II and Part III (if applicable), Schedule 15 Part II and Part III (if applicable), Schedule 17 Part II, Schedule 8, 8A & 8D Part IV, Exhibit A & B Part IV, Exhibit E Part IV, Exhibit I Part I-3 33

34 Capital Per Diem (con t) Part II and Part III (if applicable), Schedule 9 Depreciation and Amortization on Bldg & Mov Equip Must be supported by Schedules 10 & 11 Mortgage related costs Details must be on Schedule 17 for current debt If refinanced after 2015 provide details in Notepad Movable Equipment (ME) Operating Rentals Details must be on Schedule 15 ME Capital leases Details must be on Schedule 9A 34

35 Capital Per Diem (con t) Basis for the 2019 Schedule VI is 2017 RHCF 2017 RHCF, Schedule Q Facility Reported Capital Should reflect actual reimbursable capital Issue regarding traceback percentages Apply allowable mortgage percentages Apply threshold for WCI, etc. 35

36 January 1, 2019 Rate Attestation Process Facility involvement before rates are promulgated DOH involvement will be reduced with reliance upon a facility s attestations OMIG will be more involved resulting in quicker and more numerous capital audits Significant reduction in the number of capital appeals Should result in more accurate and timely capital reimbursement 36

37 January 1, 2019 Rate (con t) Timeline 8/8/18 DAL requesting providers to confirm or make changes to the state s mortgage database by COB 8/31/18 9/21/2018 DAL - Preview 2019 capital rate posted using automated system and adjusted for known issues 10/12/2018 Attestations for corrections were due 11/1/2018 DAL 2019 Notice rates posted - many DO NOT have capital corrections requested through Attestation process Includes 1.5% ATB adjustment on Miscellaneous Adjustments line along with Minimum Wage Adj January 2019 (est) Publish 2019 rate including capital with operatorcertified changes 37

38 Contact Information Dorothea Russo Partner PKF O Connor Davies Offices: Christopher J. McCarthy Healthcare Leader cmccarthy@pkfod.com Keith Solomon Partner ksolomon@pkfod.com Bethesda, MD 2 Bethesda Metro Center Suite 420 Bethesda, MD Cranford, NJ 20 Commerce Drive Suite 301 Cranford, NJ Harrison, NY 500 Mamaroneck Avenue Harrison, NY Livingston, NJ 293 Eisenhower Pkwy Suite 270 Livingston, NJ New York, NY 665 Fifth Avenue New York, NY Newburgh, NY 32 Fostertown Rd Newburgh, NY Stamford, CT 3001 Summer Street 5 th Floor East Stamford, CT Wethersfield, CT 100 Great Meadow Road Wethersfield, CT Woodcliff Lake, NJ 300 Tice Boulevard Suite 315 Woodcliff Lake, NJ