1. Hospital Public Image Michigan Revenue Cycle Conference
Laura Appel,
senior vice president, chief innovation officer
Hospital Public Image
Ruthanne Sudderth Vice President, Public Affairs

2. Congress – What’s was next…
Raising debt ceiling and Hurricane relief
Tax reform—use Medicaid cuts as pay-for
Timing on additional activity around the Repeal and Replace efforts
Nothing set in stone at this point
Bi-partisan governor’s still working on a plan led by Govs. Kasich (OH) and Hickenlooper (CO)
Smaller conversations continue in Senate, 9/30 reconciliation deadline
Renew CHIP (Children’s Health Insurance Program) funding and Rural Extenders

3. Rural Hospital Access Act of 2017
A.K.A. Rural Extenders
Address the Medicare Dependent Hospital (MDH) and Low Volume Adjustment (LVA) rural Medicare programs that expire Oct. 1
These rural health programs were enacted to minimize disparities in reimbursement between rural and urban providers
These programs are important to rural communities because:
MDH: provides an additional measure of protection for small and rural hospitals serving a disproportionate Medicare caseload of greater than 60%
LVA: recognizes that certain hospitals are more isolated and have lower volume, but critical to the community they serve
Activity on Rural Hospital Access Act is expected in September

4. ACA Repeal/Replace/Repair
Graham-Cassidy
Eliminates subsidies for private insurance and ends the Medicaid expansion
The health insurance marketplaces would no longer exist
Federal government would convert some of that spending into a lump-sum payment of block grants
States could choose to spend this money on providing insurance or to fund high-risk pools
States have to pay a small percentage themselves, starting at 3% in 2020 and increasing to 5% by 2025
Michigan loses as much as $8 billion through 2026

5. Graham-Cassidy

6. Michigan Legislative Big Picture
Desire for income tax reduction set aside, MPSERS reform first major objective completed
Failure of AHCA at federal level eliminated any legislative desire to change the HMP in FY 2018
Despite different objectives, legislative leaders prove they can get something done
Snyder – Legacy mode (leave state in better shape than he found it)
Meekhof – Legacy mode (leave Senate in better shape than he found it)
Leonard – Campaign mode (potential statewide run)
A House (Republican caucus) still divided
So-called Gang of 12 formed, remains relevant beyond income tax issue
Auto no-fault reform efforts on the horizon

7. Auto No-fault Appearing Now
House takes the lead this session, to roll out major reform bill this fall
House floor remains battleground
Effort to pass assigned claims package failed to date
Mayor Duggan made deal with Speaker Leonard and insurers, abandoning Detroit-specific reform
Campaign issue: Duggan wants to deliver insurance rate relief
Mayor engaging SE MI business leaders to push for statewide reform
Covenant ruling has potential to change MHA strategy regarding ANF reform

8. Covenant Medical Center vs. State Farm
Ruling states that healthcare providers can’t sue insurers for payment for services rendered to patients in auto accidents
Opinion leaves “door open” to potentially allow patients to assign right to sue to providers
Hospitals should update patient admission forms to include assignment of claims language
Insurers have already begun fighting against this effort, will be adjudicated in courts
Legislative fix is only way to mitigate the negative impact of the ruling
Politics, composition of the legislature will be major hurdles to achieve
Providers will have to “give” on something, to get a fix

9. Auto No-fault: Key Components of Reform
Cap on benefits
Anti-fraud authority
Fee schedule
Attendant care
MCCC (catastrophic fund)
Assigned claims facility reforms
August Board decision — too soon to “trade” against the potential negative impact of the Covenant ruling. Too many unknowns about Covenant impact.

10. Leonard/Duggan Bill Medicare rates.
For emergency services and the inpatient services immediately following 125% of present day Medicare rates.
Rates are in effect until January 1, After that, the director may order the rates for PIP payment updated.
There is no requirement that provider reimbursement rates are ever updated.

11. Leonard/Duggan Bill
By rendering treatment to anyone covered by personal injury protection benefits after the effective date of the act, any provider (including hospitals) is considered to have agreed to submit extensive claim information to the auto insurer, the Michigan Catastrophic Claims Association (MCCA), and DIFS including the average amount accepted for the care rendered, notes of physicians and nurses, progress, psychiatric, or other notes, patient history and physical reports, reports and records relating to autopsies, operations, recovery room activities, incident, triage and pharmacy reports, etc.

12. Benefit Levels
$225,000 for emergency services and inpatient services immediately following, plus $25,000
$500,000 for personal injury protection benefits
No maximum limit for personal injury protection benefits
People over age 62 who have guaranteed retirement benefits may opt out of the personal injury protection benefit

13. Catastrophic Claims Association
There is a provision for refunding future surpluses of the MCCA. The reserves for existing claims, including any surplus, are not eligible for refunding.
Drivers/insureds who chose the lower PIP levels and qualify for lifetime benefits are required to pay into the MCCA if there is a deficit assessment for pre- existing MCCA claims.

14. Rate Relief?
The “average 40% reduction per vehicle” is only applied to the personal injury protection portion of the auto insurance premium
Credit for the reduction may include the elimination of the MCCA assessment for those drivers who do not chose the lifetime benefit
For many drivers outside of Southeast Michigan, simply not paying most of the MCCA assessment will meet most of the premium reduction requirement

15. Rate Relief
The dramatically lower provider reimbursement rates and the anti-fraud mechanism included in the legislation will apply to drivers who choose the lifetime benefit…but no premium reduction is required to be filed for those policyholders.

16. Opioid Abuse Issue
Gov. Snyder’s Michigan Prescription Drug & Opioid Abuse Task Force
MHA was a task force member
Mission: examine recent trends in prescription drug and opioid abuse and develop a statewide action plan
10th nationally in per capita prescribing rate of opioid pain relievers
19% of overdose deaths in Michigan were opioid related
ED visits doubled to 20% per 10,000
Opioid Bill Package
Total of 13 bills
4 of the 13 came from the task force recommendations
Regulation based
Bills unfocused
Update MAPS System - Done
Task force formed in June 2015 and released recommendations in Oct. 2015
Chaired by Lt. Gov. Calley
Sub Chair: Schuette & Nick Lyon
21 members (lawmakers, court officials, law enforcement, medical professionals)
Prevention, treatment, regulation and enforcement

17. Senate Bill 270 Sen. Steve Bieda (D-Warren) House Health Policy
Recommended by opioid task force
Prohibits physicians from prescribing Schedule II-V controlled substance to a patient unless they are in a “bona fide prescriber-patient relationship”
Bona fide prescriber-patient relationship
Reviewed medical records and history
Created and maintained records of medical condition
Provide follow up care or refer patient to another prescriber
MHA Position: Support
Worked with Bieda’s office to get amendments that brought us to supportive and worked to support recs from taskforce

18. House Bill 4404 Rep. Sam Singh (D-East Lansing) House Floor
Recommended by opioid task force
Define and allow licensure of pain management clinics by LARA
Pain management facility does not include hospital or facility owned and operated by a hospital
MHA Position: Support

19. Senate Bills 166 and 274
SB 166: Sen. Tonya Schuitmaker (R-Lawton), passed Senate & awaiting House action
Recommended by opioid task force
Require running a MAPS report before prescribing or dispensing schedule II-V controlled substances to a patient beginning Jan. 1, 2020
Inpatient exemption from running the report
MHA Position: Neutral
SB 274: Sen. Marty Knollenberg (R-Troy), passed Senate & awaiting House action
Not recommended by opioid task force
Limit the amount of opioids a prescriber can prescribe for a patient being treated for acute pain to seven days
Chronic pain (cancer, palliative care, hospice) are not limited in the bill
-State pays for electronic medical record integration with maps
-LPP voted to be neutral on this bill
-originally talked about morphine milligram equivalents
-amendment that removed chronic pain

20. Certified Registered Nurse Anesthetists (CRNA)
Issue
Limited access to anesthesiologists in rural areas has lead to multiple member requests that MHA advocate for special CMS opt-out provision from federal supervision requirements for CRNA’s
Problem
Shortage/availability of anesthesiologists
Surgeon unwillingness to provide supervision of CRNA’s
Cost of anesthesiologist vs. volume of care need in rural areas
Option
Governor attestation to CMS that in consultation with Boards of Medicine and Nursing, the best interest of the citizens is to opt-out of physician supervision requirement, consistent with state law
Flexibility allowed for individual facilities to continue to require physician supervision of CRNA’s

21. CRNA Physician Supervision Opt-out – Last Session
MHA Board of Trustees supported opt-out
Governor’s letter alone not sufficient in Michigan
Attorney General opinion #6567 (1989), anesthesia may be delegated, but only under the supervision of a physician
MHA and Michigan Association of Nurse Anesthetists pursued legislative fix
Passage of legislation necessary; Michigan Public Health Code regarding CRNA scope of practice must change
Senate Bill 1019 introduced by Senate Majority Floor Leader Mike Kowall (R- White Lake) which passed the Senate but stalled in House Health Policy Committee
Why? Time constraints and political complications were key factors

22. How Medicaid Expansion Matters to Michigan
680,000 covered lives
HMP QAAP─ $580 million net to hospitals in FY 16
$4 billion appropriated
30,000 jobs
$2.3 billion economic activity
$150 million state tax revenue
$235 million state general fund savings absorbed by Healthy Michigan Plan

23. Healthy Michigan Plan and Traditional Medicaid

24. Why Medicaid Population isn’t Shrinking

25. General Fund Revenue: Flat Since 2000

26. Laura Appel