If there is one word to describe the agenda for the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) and its members for 2019, it is “more.” 

Mark Parkinson, president and chief executive officer of AHCA/NCAL, tells Provider more is exactly what is in store for the new year as the association sets an aggressive agenda to unsettle the status quo in the battle to make the profession more financially viable. 

Facing the critical challenges of nearly nonexistent operating margins, a decline in occupancy, and a historically tight labor market, the long term and post-acute care (LT/PAC) profession requires AHCA/NCAL advocacy efforts not only in the nation’s capital, but at the state level, where warranted, he says. 

There are also major new educational programs underway, led by the PDPM (Patient-Driven Payment Model) Academy, which allows providers to prepare for the sector’s new payment system going into effect on Oct. 1. Parkinson says the approach taps AHCA/NCAL’s expertise for members to learn everything they need to know both in person and via online resources.

The response to the PDPM outreach has been excellent, he says, noting strong attendance at information sessions at the most recent AHCA/NCAL national convention this past October in San Diego, and bigger-than-expected interest for state PDPM Academy sessions being conducted in the first half of 2019 for any state requesting one.

Branching Out for 2019

In discussing the group’s broad goals for 2019, Parkinson says AHCA/NCAL will not lose its focus on what it normally does, such as fighting for positive results from the Medicare market basket rate update. This effort helped yield a 2.4 percent increase in payments beginning on Oct. 1, 2018. In addition, the association will advocate for the elimination of unnecessary regulations, notably through proposed changes to the Requirements of Participation.

“We are going to be working with CMS [Centers for Medicare & Medicaid Services] to improve our regulatory environment, and I feel confident we are going to be able to succeed in all of those areas,” Parkinson says. “But what we have learned from the crisis the sector has been in over the last three years is that winning those [Medicare and CMS issues] is not enough. It is not enough just to hold our own and keep our margins where they are. Our margins are too low.”

From this thought comes a new strategy to get involved in specific state initiatives. The AHCA Board of Governors decided that breaking with tradition and getting more involved at the state level would require that a state affiliate first ask for such assistance and that the issue has a good chance of succeeding with national-level help. The issue must also reap a large enough financial benefit for members to be worth AHCA/NCAL’s time and expense.

Thus far, Parkinson says, this strategy has seen AHCA/NCAL get involved in Texas on a provider tax effort, in Oklahoma to rework an archaic Medicaid payment system, and in Illinois to bring litigation to accelerate the state processing of pending Medicaid applications. 

“We have succeeded in Illinois, and a $400,000 investment has resulted in over a $300 million court award,” he says. “We are hopeful that we will succeed in Oklahoma and Texas, and we are actively looking for other issues in states where AHCA involvement will be helpful.”

Parkinson says in a perfect world there would be no need for the association to be so active in the states, but there are important, life-and-death issues at stake, such as Medicaid funding and the aforementioned legal and tax issues that are in play.

“I would love to get to the point where we have an army of lobbyists going around the country, but we are not there yet,” he says. “Part of these early efforts will determine how it goes and what our long-term goal will be.”

Fighting Back in the Managed Care Space

Moving to a new subject affecting LT/PAC providers’ bottom lines, Parkinson does not hesitate to declare the new AHCA/NCAL Population Health Management Council an area that can bring real opportunity for members looking to enter the private Medicare Advantage (MA) marketplace as Institutional-Special Needs Plans (SNPs) and/or Dual Eligible-SNPs.

For nearly a decade, the rollout of managed care programs has impacted LT/PAC providers in a negative fashion, he says. In the Medicare program, the growth of MA plans has proven popular with consumers, with some 35 percent of beneficiaries in a private plan versus traditional Medicare. At the same time, this movement to MA has cut down on lengths of stay in facilities and reduced reimbursement, pitting the economic gains of private insurers against providers’ margins and occupancy levels, Parkinson says. 

Now, however, the managed care story is not all about private health insurers and their demands on providers, but instead on the new trend for LT/PAC providers to become insurers themselves, mainly as I-SNPs. And, through that comes population health management, which encompasses the prevention of disease, promotion of good health, and generating positive outcomes through the total coordinated care of a resident.

“Population health management allows us to get back control of our residents and their lives,” he says. By becoming an insurance company, a provider has to meet state regulations to do so but can benefit financially by receiving MA payment for each enrolled resident from CMS for their care. This in turns raises the stakes in a good way by allowing the LT/PAC provider to benefit from the good health and outcomes of their care for their residents under the rules of managed care, including reimbursement above traditional Medicare rates, Parkinson says.

Providers Get Active 

Thus far, AHCA/NCAL counts some 28 long term care member providers that have started their own managed care plans. “And, what we are doing is defending their right to do that,” he says, which entails making sure large insurance companies do not attempt to curtail the CMS rules allowing for providers to be in managed care.

And, through the new Population Health Management Council, AHCA/NCAL wants to lead its members in this new space by knowing more about managed care than anyone else.

“The thing makes me excited about it is I think it is a real financial opportunity for our members because it is a way they can make money. But the second and more important reason is that it completely aligns the interest of our members and their residents,” Parkinson says.

Beyond being an I-SNP, which requires the Medicare beneficiary to be receiving nursing facility care in order to enroll, providers can also seek to become D-SNPs, which is for people not quite as infirm and who may be living outside an LT/PAC community.