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Public Policy Committee: CMS Update


Posted on: 7/11/2016

By Patricia Velky, RN, BSN, MS, MBA, CPHQ, FAACM, FABC, ACM

The Centers for Medicare and Medicaid Services (CMS) continues to pursue a proactive stance to protect both the Medicare trust fund and improve outcomes for beneficiaries. CMS recently held a second Open Door Forum (ODF) call to provide additional details regarding a three-year Medicare pre-claim review demonstration for home health services set to begin in the states of Illinois, Florida, and Texas in 2016, and in the states of Michigan and Massachusetts beginning in 2017.

As noted on the website “CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits. Additionally, CMS is also testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.”

CMS representatives assured callers that the pre-claim review process does not create new documentation requirements, would not delay access to care or alter the Home Health benefit. A key component of the demonstration project is that the documentation to support payment will be submitted earlier in the process. Direct feedback will be provided to the agency on deficiencies in the submitted documentation thus avoiding improper payments to and potential appeals from the Home Health agencies. Specific turnaround times are spelled out in the Operational guide and CMS stressed that this pre-claim review process should not be a barrier to the start of care for any Medicare beneficiary.

For more information, visit CMS.gov or click the link to the fact sheet below: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Downloads/Pre_Claim_Review_Fact_Sheet.pdf

Additionally, on July 6, 2016, CMS released the Calendar Year (CY) 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1656-P). Among other things it has key language to implement Section 603 of the Bipartisan Budget Act of 2015, which impacts the way Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider. This is often referred to as “site neutral payment.”

Another key component receiving media attention is the proposed removal of the Pain Management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of the Hospital Value Based Purchasing Program. Changes to the incentive program for EHRs and changes to definitions/documentation requirements for organ procurement agencies are outlined. As always the annual update to the Medicare Inpatient Only (IPO) List (addendum E) is included. For CY 2017, CMS is proposing to remove six procedures from the IPO list. The procedures include four spine procedures as well as two laryngoplasty procedures. The proposed rule also includes for the second year in a row a comment solicitation regarding whether total knee arthroplasty (TKA) should be removed from the IPO list in a subsequent year.

For more information, visit CMS.gov or click the link to the fact sheet below: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html


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Public Policy Committee Update: ACMA goes to Washington

Bills would count observation toward SNF benefit, reform the RAC, and aid highest risk patients

Posted on: 10/8/2014

By: Steven J. Meyerson, M.D.

On September 30, a cadre of 15 case management professionals, including members of ACMA’s Public Policy Committee, descended upon Washington, DC for two days to promote three specific pieces of legislation. Since Congress had taken an earlier than expected recess to go home and campaign for the upcoming midterm elections, ACMA representatives were happy to meet with the legislative assistants who specialized in healthcare issues in the offices of their respective Congressmen and Senators. This “trek to Washington” is an annual event for ACMA and serves to educate legislators on issues important to Medicare beneficiaries and hospitals and urge lawmakers to support key pieces of legislation. The delegation reported that the Congressional aides were uniformly well-informed, engaged, and receptive to their message regardless of their political party. The meetings clearly stimulated interest in the targeted legislation, and ACMA members will follow-up with Congressional staff regarding their specific requests related to the following bills:

Improving Access to Medicare Coverage Act would count observation toward SNF benefit
The first bill to get ACMA support was the Improving Access to Medicare Coverage Act1 (HR-1179 in the House where it has 159 bipartisan cosponsors and S-569 in the Senate where there are 27 cosponsors). This bill, which was first introduced in an earlier session, would count nights in an outpatient hospital bed (such as a night in observation) toward the three inpatient nights that are required to qualify a beneficiary for the skilled nursing facility (SNF) Medicare benefit. This reform is needed because many Medicare beneficiaries spend the first night in the hospital in observation and this night does not count toward the SNF benefit. As a result, a Medicare patient with a night in observation requires three more nights as an inpatient and many of these patients are ready for transfer to a lower level of care after the third night of hospital care, which is only the second inpatient night, and does not qualify for Medicare coverage at the SNF. Counting the initial observation night toward the SNF benefit would allow more Medicare beneficiaries to access this important benefit. The question of paying for additional skilled nursing care of course came up early in the discussions. While no price tag has been placed on this proposal, the increased cost for skilled nursing facilities would at least in part be balanced by fewer hospital readmissions. Since the difference between observation and inpatient admission is the anticipated length of stay, not the patient’s clinical condition or the hospital services they require, the initial night in observation does not distinguish between patients for whom skilled nursing care in a SNF would be appropriate from those who would not benefit.

The Medicare Audit Improvement Act would provide RAC transparency and accountability
The second bill, the Medicare Audit Improvement Act2 (HR-1250 in the House where there are 231 cosponsors and S-1012 which has 16 cosponsors in the Senate) would reform the Medicare Recovery Audit (RAC) program by increasing transparency and accountability. The bill calls for public reporting of each contractor’s denial rate as well as the rate at which its denials are overturned in the appeal process. It would impose penalties on the recovery auditors for overturned denials and for failing to meet prescribed timelines. The bill would cap the number of additional documentation requests to 500 per 45 days or 2% of Medicare claims and would require physician validation of denials, which are currently at the discretion of nurse reviewers.

The Better Care, Lower Cost Act would provide just that for the chronically ill
The third bill has a name which is hard to argue with; it’s the Better Care, Lower-Cost Act3 (HR-3890 and S-1932). This new bill has only one cosponsor in each house and would establish a novel integrated chronic care delivery system designed for Medicare beneficiaries with multiple comorbidities. These Medicare patients, who consume a disproportionate share of Medicare resources, represent a significant challenge to individual providers, networks, and Medicare advantage plans. They tend to be on multiple medications and see a variety of specialist physicians as well as other skilled providers such as physical and occupational therapists, have frequent hospital admissions and readmissions, and often have no coordination of their care. The Better Care Program (BCP), as it’s called would be a capitated risk-adjusted network designed to promote quality care and cost containment.

According to Congress.gov, the bill “promotes accountability and better care management for chronically ill patient populations and coordinates items and services under Medicare parts A (Hospital Insurance), B (Supplementary Medical Insurance), and D (Voluntary Prescription Drug Benefit Program), while encouraging investment in infrastructure and redesigned care processes that result in high quality and efficient service delivery for the most vulnerable and costly populations. [It] requires the program to include specified elements and focus on long-term cost containment and better overall health of the Medicare population by implementing through qualified BCPs strategies that prevent, delay, or minimize the progression of illness or disability associated with chronic conditions.” The bill would fund “at least three Chronic Care Innovation Centers” and establish “new curricula requirements for direct and indirect graduate medical education payments that address the need for team-based care and chronic care management, including palliative medicine, chronic care management, leadership and team-based skills and planning, and leveraging technology as a care tool.

References
1. HR-1179: https://www.congress.gov/bill/113th-congress/house-bill/1179
2. HR-1250: https://www.congress.gov/bill/113th-congress/house-bill/1250
3. HR-3890: https://www.congress.gov/bill/113th-congress/house-bill/3890


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ACMA Urges CMS to Eliminate Home Health Face-to-Face Requirement


Posted on: 9/4/2014

On Tuesday, ACMA submitted a letter to CMS Administrator, Marilyn Tavenner, requesting that the agency eliminate the home health face-to-face encounter documentation requirement mandated by the Patient Protection and Affordable Care Act, and require only that a physician certify a visit took place and the patient needs home care with a date and a signature.

The letter came in response to the agency's request for comments in its proposed rule updating the Home Health Prospective Payment System (HH PPS) rates. The proposed rule includes measures to eliminate the home health face-to-face encounter documentation requirement.

The letter includes issues provided by ACMA's Public Policy Committee related to the requirement and its impact on both case management and patients.

In meetings with both CMS and Congress dating back to March of 2011, ACMA has called for changes to the home health face-to-face requirement. Following feedback and recommendations from ACMA and the Face-to-Face Coalition, CMS announced on December 8, 2011, that it would permit the use of Form 485 to meet the documentation requirement.

To view the letter, click here.

To learn more about the proposed rule, click here.

To read more about ACMA's efforts around this issue, click here.


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CMS Issues FY 2015 IPPS Final Rule


Posted on: 8/5/2014

The Centers for Medicare & Medicaid Services (CMS) late yesterday issued its hospital inpatient prospective payment system final rule for fiscal year 2015.

While CMS indicates it will continue to work with stakeholders to address an alternative payment methodology for short inpatient stays, the final rule does not repeal the two-midnight rule.

The final rule will be published in the August 22 Federal Register and most of its provisions will take effect October 1.

To view the final rule, click here.

To read more on AHANews.com, click here.


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Caring for an Aging Population: Future Challenges to Case Managers


Posted on: 7/22/2014

Based on the Administration on Aging, U.S. Department of Health and Human Services’ report, “A Profile of Older Americans,” (2010) in 2010 individuals aged 65 or older-numbered 40.4 million, which represents 13.1% of the population in the United States. It is estimated that by 2030, there will be almost twice the number of seniors than in 2008, about 72.1 million. This will account for approximately 19.3% of the population. Based on the Administration on Aging, Department of Health and Human Services report, the life expectancy has increased by 30 years for a child born in 2009 when compared to that of 1900. Much of this increase is related to a decrease in the death rate. The life expectancy is increasing as the standard of living has significantly improved over the past decades along with advances in health care. This trend will continue especially as it relates to advances in disease management and medical/surgical treatments along with increasing awareness surrounding health-conscious behaviors.

The anticipated rate of growth is projected to have significant implications to the care-giving system in the United States as well as significant economic and political implications for the nation and the world. Some of these include economic challenges and budget cuts to senior programs and the local communities subsequently impacting patients, families, communities and the healthcare system overall. Budget cuts to communities; particularly to the Area Agencies on aging directly impacts services that provide support to seniors within the community. These include things like Meals on Wheels and transportation services to assist senior that have no other means of support within the community. While the senior population is growing, the resources available to adequately care for them are decreasing.

Case managers rely heavily on these resources to safely transition patients out of the hospital and effectively set them up for success at home. This is not an easy task now for case management. Case managers spend many hours finding and coordinating scarce community resources to optimize a patient’s transition to home. The aging of the population and subsequent budget cuts to community services, especially those aimed specifically at senior programs will pose greater challenges to case managers in the future. These support services are essential when it comes to planning for safe transitions back into the community. A patient’s success depends on it and when failure occurs, not only is the patient and family harmed, it also drives a vicious cycle of additional financial burden to the healthcare system.

A significant emphasis in the healthcare arena now is the focus on safe transitions and keeping patients well-managed in the community and within primary care. Without the availability of adequate community resources, it will be impossible to achieve these goals. Case managers are already challenged to find scarce resources at discharge to safely coordinate the discharge plans for patients. These include the lack of available caregivers, both formal and informal, challenges with family care giver time away from work, need for help with meals , transportation to and from doctors’ appointments or simple errands to the pharmacy, medication assistance to afford their necessary medicines, etc. The lack of these resources leads to unsafe transitions, which consequently lead to poor patient outcomes and readmission. Poor patient outcomes and readmission drive the viscous cycle of increase in the per member spend and the overall healthcare cost.

As a profession, case management needs to understand the changing population demographics on the horizon and the challenges that coincide with the aging population. We need to become strong advocates for adequate and continued funding to support senior programs in our communities.

To read more in an article from the Fisher Center for Alzheimer’s Research Foundation, click here.

References
A Profile of Older American (2010). The Administration on Aging (AoA), U.S. Department of Health and Human Services. The annual Profile of Older Americans was originally developed and researched by Donald G. Fowles, AoA. Saadia Greenberg, AoA, developed the 2010 edition. Retrieved from http://www.aoa.gov/aoaroot/aging_statistics/profile/2010/docs/2010profile.pdf

Maturing of America: Communities moving forward for an aging population. Retrieved from http://www.n4a.org/files/MOA_FINAL_Rpt.pdf


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CMS Proposed Rule Would Eliminate Home Health Face-to-Face Requirement


Posted on: 7/1/2014

Today, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule would updating the Home Health Prospective Payment System (HH PPS) rates. The proposed rule includes measures to eliminate the home health face-to-face encounter documentation requirement mandated by the Patient Protection and Affordable Care Act, and require only that a physician certify a visit took place and the patient needs home care with a date and a signature.

In meetings with both CMS and Congress dating back to March of 2011, ACMA has called for changes to the home health face-to-face requirement. Following feedback and recommendations from ACMA and the Face-to-Face Coalition, CMS announced on December 8, 2011, that it would permit the use of Form 485 to meet the documentation requirement.

To access the proposed rule, click here. The proposed changes to the face-to-face encounter requirement begin on page 34.

To read more about ACMA's efforts around this issue, click here.


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Senate Appropriations Subcommittee approves HHS spending bill


Posted on: 6/18/2014

On June 10, a Senate Appropriations Subcommittee approved the FY 2015 Labor-HHS-Education appropriations bill. The spending bill provides $156.77 billion in discretionary funding, the same amount as the FY 2014 level. Included in this bill is $265 million for Children's Hospitals Graduate Medical Education, the same as was budgeted in FY 2014. President Obama has proposed cuts to Children's Hospitals GME, rural health programs and the Agency for Healthcare Research and Quality, but the American Hospital Association (AHA) has urged the Senate to reject these cuts and to increase funding for several quality care initiatives.

For more information, click here.

To read the bill, click here.

To read AHA's letter to the subcommittee, click here.


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ACMA Shares Observation Concerns and Recommendations with House Ways and Means Health Subcommittee


Posted on: 6/10/2014

On Tuesday, June 3rd, ACMA submitted a letter to the House Ways and Means Health Subcommittee outlining concerns and recommendations related to observation services for consideration by the Committee and for inclusion in the printed record of its May 20, 2014, hearing.

The letter contains feedback and recommendations provided by ACMA's Public Policy Committee and comes in response to the House Ways and Means Health Subcommittee's request for observation status stories and concerns.

On Tuesday, May 20, 2014, the House Ways and Means Health Subcommittee heard testimony from witnesses regarding current hospital issues in the Medicare program, specifically the ongoing problem of observation status. The Congressional hearing is the first to consider hospital observation status.

To view ACMA's letter to the Committee, click here.

Further information on submissions is available at http://waysandmeans.house.gov/committeesubmissions.


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Study reports adding socioeconomic data to standardized measures has big effect on calculated readmission rates


Posted on: 6/3/2014

A recent study published by Health Affairs found that more meaningful comparisons can be made when socioeconomic data is added to standardized readmission measures. The researchers compared 30-day readmissions rates from hospitals that used one of two models. The first model was the current model used by the Centers for Medicare and Medicaid Services (CMS) for public reporting of condition-specific hospital readmission rates of Medicare patients. The second model involved census tract-level socioeconomic data, such as poverty rate, education level and housing vacancy rate.

The results saw a noticeable effect on the calculated hospital readmission rates for several types of patients. The narrowed range of observed variation in readmission rates attributed to the inclusion of socioeconomic data includes:

  • Decrease for patients admitted for acute myocardial infarction from 6.5% to 1.8%
  • Decrease for patients admitted for heart failure from 14% to 7.4%
  • Decrease for patients admitted for pneumonia from 7.4% to 3.7%

Although the socioeconomic data narrowed the range of observed variation in calculated readmission rates, there was not a significant difference between the two models in the average readmission rates for these three conditions.

To read the abstract in Health Affairs, click here.


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Report shows hospitals are improving care faster than other settings


Posted on: 5/27/2014

The 2013 National Healthcare Quality Report released by the Agency for Healthcare Research and Quality (AHRQ) shows that hospital quality improvements are surpassing those of home health, nursing home care and ambulatory settings. The study found that every measure publicly reported on the Hospital Compare website showed improvement over time, and 75% of hospital quality measures showed significant improvement.

For more information, click here.

To read the report, click here.


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