Harmony Healthcare Blog

2017 AHCA Provider Lounge Series: State of Medicaid in the State of New Jersey

Posted by Kris Mastrangelo on Fri, Jan 05, 2018


Reviewed by Kris Mastrangelo

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency


Interview with Loretta Kaes, Director of Quality Improvement and Clinical Services of the Health Care Association of New Jersey Health Care

Kris Mastrangelo, President of Harmony Healthcare International (HHI) interviews Loretta Kaes, Director of Quality Improvement and Clinical Services of the Health Care Association of New Jersey Health Care (HCANJ), in the 2017 AHCA Provider Lounge.  Loretta discusses the impact recent regulatory changes, along with ACOs, have had on reimbursement, in particular Medicaid reimbursement, in the state of New Jersey.  (Audio transcription below).

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Transcribed Audio:

Kris Mastrangelo: Welcome to the Provider Lounge at the 68th Annual AHCA/NCAL Annual Convention in Las Vegas, Nevada. Today we're here with Loretta Kaes she is the Director of Quality Improvement and Clinical Services at New Jersey Health Care, an affiliate of American Health Care. Loretta, thank you so much for coming today. We are super interested to hear what's happening in the state of New Jersey and things that you've been working on - in particularly with all the reimbursement and regulatory changes, what's keeping you up at night?

Loretta Kaes: Well New Jersey is really really active in the ACO. New Jersey is home to the second largest ACO in in the nation - the Atlantic ACO and many of our long-term care members belong to that.  So, there's a definite emphasis on collecting and analyzing data for the ACO and for their own analysis of what has to be done in their own facilities.  A very concerning trend is that in New Jersey the Medicaid payment is very very delayed and is a serious impact now on the reimbursement issue for long-term care providers. On the assisted-living front they're gearing up for the higher acuity resident which they already are taking care of, while trying to maintain the social setting but the social setting is definitely the benefit, …but they also have to provide care for chronic medical diseases so they're gearing up to work with the bundled payment systems in the orthopedic and cardiac care or ready by waiver from the state regulations. We are starting IVs, we are treating short-term antibiotic IV treatment along with dehydration and some assisted livings are moving up to step-down cardiac care, cardiac rehabilitation.  So, in that way we differ from the rest of the nation we're kind of trend setting by necessity. And I will say that our regulations especially on the assisted-living side lend to that flexibility where most states do not so we're at an advantage there.  The rules of participation of course is my biggest challenge right now. I can't imagine what it is to the facilities to implement all these rules and regulations in a short period of time while some of them are really really good - definitely a change was necessary, they haven't been updated in 21 years so we saw that coming.  And I would tell you probably one of the most advantageous is the person-centered care aspect that I think is long overdue and I think we've got a great head start on that. Definitely, need to implement it. The facility assessment part is giving a lot of people a lot of heartache as much as a headache too, so we're working to educate on that and we're all working uncharted courses here.

Kris: Yes. It’s new. Change is stressful.  A lot of stress associated with it.  Backup. When you mentioned about Medicaid and you said the payment is delayed…are you saying that the funding is not being delivered timely, like a cash flow thing, or is it the rules?

Loretta: I'm not sure that it's such a cash flow thing. I think it's more of a bureaucratic thing and maybe staffing wise on the Medicaid side.

Kris: Is New Jersey case-mix on the Medicaid side?

Loretta: No.  They receive especially by waiver in the assisted living. They have one set fee for no matter what the acuity and that's difficult.   That’s difficult because the acuity is high no matter what or who the payment source is and on the long-term care side it's just receiving the payment.  You know, it could be a combination of cash flow.

Kris: So, when I say case-mix - is the rate for New Jersey Medicaid driven by the MDS or is it a flat cost based?

Loretta: No, it’s a flat per day.

Kris: Is New Jersey looking into case-mix, meaning MDS driven? Is it one of the states…or maybe not, I thought I heard it was…

Loretta: I don't think so, I haven't heard any information…but one really good thing that happened with the Medicaid in New Jersey on the long-term care side is that it's privatized now. It's privatized to HMO and we had the opportunity, when I say we, the New Jersey Health Care Association, had the opportunity meet with the Medicaid Management and the Insurance Brokers and instead of using five-star as a willing provider we were able to convince them to use quality measures because a five-star can be heavily weighted on your survey.  Speaking about the five-star I think in some ways it does focus on quality but I think its downside is that it's too heavily weighted on the survey because it's one moment in time and you could be a five-star today doing everything right and having great outcomes and then tomorrow because of a single serious infraction - and maybe not even - you're down, you're down to a three or two.

Kris: Well thank you so much for your insight and just to clarify for those that don't know the ACO, the Accountable Care Organization, in your state you have this hybrid in which in the Medicaid system they're also using an ACO type model, which some states don't do that so I want the viewers that are watching to know that. But thank you so much Loretta it was a great day and we've got some nuggets of information from you.  We look forward to seeing you soon.

Loretta: Thank you very much.


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