hcap update - ohio hospital assoc · hcap 2019 2019 oha annual meeting june 3, 2019 16 • data...

HCAP UPDATE

June 3, 2019

2019 OHA Annual Meeting

Ohio Hospital Association | ohiohospitals.org |

AGENDA

I. Welcome/Introductions

II. HCAP 2018 Refresher

III. HCAP 2019 Introduction

IV. Data Trends/Analysis

V. DSH Audits

VI. Federal DSH Cuts

VII.Q/A

VIII.Adjourn

June 3, 20192019 OHA Annual Meeting 2

HCAP UPDATE – OHA ANNUAL MEETING


HCAP 2018 REFRESHER




HCAP 2018 – A REFRESHER


Pot 1 Pot 2 Pot 3A Pot 3B Pot 4 Pot 5 Pot 6Total

Distribution

High DSH Pot OBRA Cap Pot CAH Pot Rural Pot Closed Pot Children’s

Hospital PotState Residual

Distributed

Based On:

Medicaid Costs (inc.

MCP)

For hospitals with

Medicaid utilization

ratio greater than

28.38%

“Room” left under

OBRA caps.

“Room” left

under OBRA

caps.

“Room” left

under OBRA

caps.

UC Below

FPL Costs

“Room” left

under

Children’s

hospital OBRA

caps.

“Room” left

under OBRA

caps.

---

SFY 2017

Data

Inputs for

Each Pot:

High DSH Medicaid

f-f-s Costs

+

Medicaid MCP

Costs

=

Total Medicaid

Costs

OBRA Cap total:

UCC<100% FPL w/o

ins. +

Medicaid Shortfall

+

UCC>100% FPLw/o

=

OBRA Cap Total

OBRA Room

for Critical

Access

hospitals

OBRA Room

for hospitals in

rural counties

Remaining

hospitals in

Stark,

Mahoning, and

Montgomery

County:

UC Below

100% Costs

OBRA Room

for Children’s

hospitals

OBRA Room for

All Hospitals---

Distributed

To:

High DSH hospitals

if within OBRA

caps

(16 qualify to

receive $ in Pot 1)

All hospitals

(if within OBRA cap)

Designated

Critical

Access

Hospitals

Rural hospitals

(if within

OBRA cap)

Hospitals in

Stark,

Mahoning, or

Montgomery

Counties (if

within OBRA

cap)

Children’s

hospitals

(5 eligible)

All hospitals

(if within OBRA

cap)

---

Total Funds

Distributed

(in millions):

$76.1 $489.8 $21.6 $34 $1.2 $12.6 $.890 $633.9


HCAP 2019 INTRODUCTION




HCAP DATA -

REFRESHER

FFY 2019 HCAP:

• Uses SFY 2018

Medicaid Cost Reports

• Hospital FYEs

between July, 2017

and June, 2018

• Majority CY 2017

Data



HCAP 2019 – PRELIMINARY MODEL


Pot 1 Pot 2 Pot 3A Pot 3B Pot 4 Pot 5 Pot 6Total

Distribution

High DSH Pot OBRA Cap Pot CAH Pot Rural Pot Closed Pot Children’s

Hospital PotState Residual

Distributed

Based On:

Medicaid Costs (inc.

MCP)

For hospitals with

Medicaid utilization

ratio greater than

29.58%

“Room” left under

OBRA caps.

“Room” left

under OBRA

caps.

“Room” left

under OBRA

caps.

UC Below

FPL Costs

“Room” left

under

Children’s

hospital OBRA

caps.

“Room” left

under OBRA

caps.

---

SFY 2018

Data

Inputs for

Each Pot:

High DSH Medicaid

f-f-s Costs

+

Medicaid MCP

Costs

=

Total Medicaid

Costs

OBRA Cap total:

UCC<100% FPL w/o

ins. +

Medicaid Shortfall

+

UCC>100% FPLw/o

=

OBRA Cap Total

OBRA Room

for Critical

Access

hospitals

OBRA Room

for hospitals in

rural counties

Remaining

hospitals in

Stark,

Mahoning,

Montgomery,

Belmont, and

Geauga

Counties:

UC Below

100% Costs

OBRA Room

for Children’s

hospitals

OBRA Room for

All Hospitals---

Distributed

To:

High DSH hospitals

if within OBRA

caps

(16 qualify to

receive $ in Pot 1)

All hospitals

(if within OBRA cap)

Designated

Critical

Access

Hospitals

Rural hospitals

(if within

OBRA cap)

Hospitals in

Stark,

Mahoning,

Montgomery,

Belmont,

Geauga

Counties (if

within OBRA

cap)

Children’s

hospitals

(5 eligible)

All hospitals

(if within OBRA

cap)

---

Total Funds

Distributed

(in millions):

$81.6 $525.4 $23.1 $36.5 $7.1 $13.5 $3.5 $680.1


HCAP 2019

2019 OHA Annual Meeting June 3, 2019 8

POT 1 – “High DSH”

Medicaid inpatient

utilization rate (MIUR)

of at least 29.58%

$81.6M(12.00% of total)

Medicaid costs

($2.7B)

FUNDING

ELIGIBILITYDISTRIBUTION

METRIC


HCAP 2019


POT 2 – “OBRA”

OBRA space

(i.e., room under DSH

limit)

$525.4M(77.26% of total)

Remaining “zeroed”

OBRA

($1.51B)

FUNDING


METRIC


HCAP 2019


POT 3A – “CAH”

CAH status &

OBRA space

$23.1M(3.40% of total)


OBRA for CAHs

($48.6M)

FUNDING


METRIC


HCAP 2019


POT 3B – “Rural”

Rural status &

OBRA space

$36.5M(5.36% of total)

Remaining OBRA for

non-CAH rurals

($121.4M)

FUNDING


METRIC


HCAP 2019


POT 4 – “Closed Hospital”

Open hospitals in Stark, Montgomery, Mahoning,

Belmont, or Geauga counties with OBRA space

$7.1M

UC<100% FPL

FUNDING


METRIC


HCAP 2019


POT 5 – “Children’s Hospital”

Children’s hospital with

OBRA space

$13.5M(1.98% of total)


OBRA

($162.1M)

FUNDING


METRIC


HCAP 2019


POT 6 – “Statewide Residual”

All hospitals with

OBRA space

$3.5M


OBRA

($886.5M)

FUNDING


METRIC


HCAP 2019 DATA TRENDS &

ANALYSIS




HCAP 2019


• Data Trends:• DSH OBRA caps are up 14.4% statewide from the 2018 model; about $209 million.

• The statewide “misery index” is 3.52%, meaning that uncompensated care and

Medicaid losses, when offset by HCAP net gains, represent 3.52% of total hospital

operating expenses, on average. This is a moderate increase over last year’s 3.17%.

• For comparison:• In 2012 model, the statewide misery index was 5.5%.

• Medicaid expansion—along with the delays in the Medicaid DSH cuts at the federal

level—means, on average, an additional two percentage points to Ohio hospitals’

operating margins.

• Regional Trends:• Of the five largest CBSAs, only Columbus has not seen an increase in misery index

from the 2018 model.

• Misery index levels of all CBSAs remain below pre-expansion levels.


HCAP 2019 – PEER GROUP

SNAPSHOT


Peer Group

Net HCAP Index -

Preliminary

2019 OBRA Cap -

Preliminary

OBRA Cap

Change from

2018

2019 Preliminary

Net Gain

Net Gain Change

from 2018

Children's 4.80% $280,289,757 $13,100,549 $112,872,374 ($644,003)

Other 4.14% $356,372,577 $24,435,321 $65,390,600 $286,996

Adult DSH 4.10% $310,657,116 $107,599,540 $98,607,176 $31,018,355

CAH 3.65% $71,450,724 $7,959,645 $39,007,303 $2,503,687

Statewide 3.52% $1,654,033,739 $208,535,004 $428,714,557 $31,100,892

Rural 3.21% $172,477,946 ($11,074,068) $65,586,180 ($7,137,460)

Teaching 2.88% $462,152,884 $62,409,182 $51,843,586 $5,398,453

LTACH 0.86% $486,893 $4,031,285 ($3,090,609) $235,278

Rehab 0.83% $145,843 $73,549 ($1,502,054) ($560,413)


HCAP 2019 – PEER GROUP

SNAPSHOT


OBRA Cap Profiles by Peer Group (% of total OBRA)

Peer Group Medicaid ShortfallUncompensated

Care >100% FPL

Uncompensated

Care <100% FPL

Adult DSH 68% 26% 6%

Children's 89% 10% 1%

Critical Access 81% 18% 2%

Other 78% 19% 3%

Rural 79% 19% 2%

Teaching 67% 27% 6%

Statewide 75% 21% 4%


HCAP TRENDS BY CBSA


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

$350,000,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Cincinnati CBSA Misery Index 2009-2019

Net Gain OBRA Cap Misery Index


HCAP TRENDS BY CBSA


0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

$350,000,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Cleveland CBSA Misery Index 2009-2019



HCAP TRENDS BY CBSA


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

$350,000,000

$400,000,000

$450,000,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Columbus CBSA Misery Index 2009-2019



HCAP TRENDS BY CBSA


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Dayton CBSA Misery Index 2009-2019



HCAP TRENDS BY CBSA


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Toledo CBSA Misery Index 2009-2019



HCAP TRENDS BY CBSA


0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

$350,000,000

$400,000,000

$450,000,000

$500,000,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Rural "CBSA" Misery Index 2009-2019



HCAP 2019


$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$1,800

$2,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Millions

Ohio Hospital Uncompensated Care Costs & Medicaid Losses vs. HCAP Federal Funding 2001-2019

Uncompensated Care Costs HCAP Federal Funds


HCAP 2019


• Hospital gainers/net contributors:• 51 hospitals lose a combined $33.1M in the preliminary model;

• 44 have $0 OBRA Caps/DSH Limits—42 of those fail to meet OB requirement;

• 146 hospitals gain a combined $461.8M;

• 94 hospitals see a higher net gain in 2019 vs. 2018; 99 see a lower net gain.• 32 hospitals with a lower net gain had $0 OBRA Caps, so the lower net gain was a result of a

higher assessment.

• Closed hospital implications:• Affinity Medical Center, Good Samaritan (Dayton), Heather Hill Care Communities, and

Steward Northside closed prior to program year;

• Belmont Community Hospital closed during the program year, but are eligible to receive a payment for the time they were open;

• Remaining open hospitals in Belmont, Geauga, Mahoning, Montgomery, and Stark counties split net gain that would have gone to these hospitals during the time they were closed;

• 10 hospitals with OBRA room by Pot 4 split $7,072,927;

• Creates need for statewide residual pot.

• Rising OBRA Caps:• Both Medicaid shortfall and uncompensated care increased in 2019;

• Statewide Medicaid shortfalls have increased 15% from 2018 and 133% from 2016. Uncompensated care has increased 17% from 2018 and decreased 2% from 2016.


DSH AUDITS




DSH AUDITS


• Myers and Stauffer will re-run the DSH

audits for 2012-2015 after CMS withdrew

FAQs 33 and 34.

– Payments associated with dual-eligible patients

will come out of data; associated costs will not.

– All third-party payments will come out of HCAP

data

• Process to re-run audits will begin after 2016

audit is closed. Audit re-runs will start with

2012 and 2013.


FEDERAL DSH CUTS




FEDERAL DSH CUTS

Updated with BiBA - 2018 Federal DSH Savings Target

Nat'l Average

Allotment Cut

Percentage Current Estimate - Ohio Cut Percentage

2014 $0 0.0% 0.0%

2015 $0 0.0% 0.0%

2016 $0 0.0% 0.0%

2017 $0 0.0% 0.0%

2018 $0 0.0% 0.0%

2019 $0 0.0% 0.0%

2020 $4,000,000,000 31.5% 38.5%

2021 $8,000,000,000 62% 69%

2022 $8,000,000,000 61.1% 68.1%

2023 $8,000,000,000 60.2% 67.2%

2024 $8,000,000,000 59.3% 66.3%

2025 $8,000,000,000 58.4% 65.4%

2018-25 Total $44,000,000,000

Cuts legislated in Bipartisan Budget Act of 2018

2019 OHA Annual Meeting 30June 3, 2019


QUESTIONS?



OHA collaborates with member hospitals

and health systems to ensure a healthy Ohio

—

Ohio Hospital Association

155 E. Broad St., Suite 301

Columbus, OH 43215-3640

T 614-221-7614

ohiohospitals.org

—

HelpingOhioHospitals

@OhioHospitals

www.youtube.com/user/OHA1915

Ryan Biles, Executive Vice President

Daniel Vielhaber, Manager, Health Economics & Policy

[email protected]

[email protected]

hcap update - ohio hospital assoc · hcap 2019 2019 oha annual meeting june 3, 2019 16 • data...

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