All Entries Tagged With: "healthcare reform"
New bundled payments initiative aims to lower costs, improve care coordination
Editor’s note: The following article is adapted from a blog Judith Kares, an instructor for HCPro’s Medicare Boot Camp® – Hospital Version, wrote for the Medicare Mentor website.
CMS recently announced a new initiative to lower costs and help physicians, hospitals, and other healthcare providers better coordinate care. The new Center for Medicare and Medicaid Innovation created by the Affordable Care Act launched the Bundled Payments for Care Improvement Initiative. The innovation center is tasked with finding new and better ways to provide and pay for healthcare to a growing population of Medicare and Medicaid beneficiaries.
The current Medicare system pays physicians, hospitals, and other providers that are part of the healthcare delivery team separately for services they provide, including services provided during an episode of care. For purposes of the new initiative, an episode of care might include a single hospital stay (e.g., for a heart bypass or hip replacement) and/or recovery from that stay. Under the bundled payments initiative, CMS will bundle payments for services delivered by healthcare team members during an episode of care rather than paying each provider separately.
CMS says bundling payments across providers for multiple services will give providers greater incentive to coordinate and ensure continuity of care across settings, resulting in better care for patients. Better coordinated care is likely to reduce unnecessary duplication of services and prevent medical errors, thereby improving the quality of care, while lowering costs.
The expected benefits of the bundled payments initiative are not based on supposition, but on the research and experience of leading healthcare institutions nationwide that participated in similar initiatives and demonstration projects. CMS cited one example in which a Medicare heart bypass surgery bundled payment demonstration saved $42.3 million, approximately 10% of expected costs, and saved patients $7.9 million in coinsurance while improving care and lowering hospital mortality.
In response to industry concerns, this new initiative emphasizes flexibility. In its request for applications, the innovation center described four broad approaches to bundled payments. This will give providers flexibility in determining which episodes of care and which services to bundle, facilitating participation by providers of varying size and readiness.
Organizations may apply to participate to the bundled payments initiative by submitting letters of intent no later than September 22 for Model 1 and November 4 for Models 2, 3, and 4.
Patient access is the key to VBP success
Medicare will begin paying hospitals for quality measures effective October 2012, CMS announced in a recent fact sheet. The new Hospital Value-Based Purchasing (VBP) program adopts performance measures in two areas:
- Clinical process, consisting of 12 measures
- Patient experience, consisting of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results
Hospitals preparing for VBP should realize that access to a strong network of post-acute providers is the secret to ensuring a positive patient experience, writes Jackie Birmingham, RN, MS in her Curaspan Connections column.
If hospitals don’t have access to a robust network of postacute providers, discharge planners have limited options to send patients for the next level of care. Patients may perceive that as a lack of quality, writes Birmingham, vice president of regulatory monitoring and clinical leadership at Curaspan Health Group in Newton, MA,. “Even if you provided the best care possible, it won’t matter. Perception is reality,” she says.
Birmingham says hospitals with strong postacute provider networks, and thus best positioned for success with VBP, typically include the following elements:
- Post acute provider performance data regarding turnaround times for referrals and readmissions. This information allows hospitals to get to the root cause of issues and address them. Improvements lead to better outcomes, including a better patient experience.
- Technology that connects acute and postacute providers so they can more quickly share information. Such software improves throughput, lowers LOS, and leads to increased patient satisfaction.
- Time dedicated to strengthening relationships with the patient. With technology removing many administrative burdens, clinicians are now able to spend more time with patients and their families to identify their needs.
Patients need more than information alone to continue to heal after leaving a hospital. They also need access to the appropriate providers who can continue their care, Birmingham writes. When your hospital begins to concentrate on VBP, ensure there’s a plan to address how patients transition to postacute care, she suggests.
Senators ask for a new ACO proposed rule
Seven U.S. senators believe the Accountable Care Organization (ACO) proposed rule will not only cost more than estimated but will not accomplish the program’s goals. They want CMS to try again.
CMS published the ACO proposed rule in the April 7 issue of the Federal Register. The ACO program allows groups of providers to work together to manage and coordinate care for Medicare beneficiaries through an ACO, according to CMS. An ACO may receive payments for shared savings if it meets certain quality performance standards.
Senators Tom Coburn (R-OK), Jon Kyl (R-AZ), Mike Crapo (R-ID), Mike Enzi (R-WY), John Cornyn (R-TX), Pat Roberts (R-KS), and Richard Burr (R-NC) wrote a letter to CMS asking the agency to scrap the current proposed rule and write a new one. The Senators say they have heard concerns from several leading healthcare institutions that believe the proposed rule will fail to accomplish the ACO program’s purpose. The senators also cite an American Hospital Association report which says implementing the ACO program will cost 10 times more than the proposed rule estimates.
The Senators acknowledge that the ACO concept is a worthwhile goal, stating “An ACO model that can increase provider coordination and patient accountability would be a step in the right direction.” However, they believe “this proposed rule misses the target.”
Face-to-face requirement
Please take a moment to let us know how the face-to-face encounter requirement has affected your organization. Please feel free to elaborate on any challenges you have encountered in the comments section below.
Improve relationships with postacute facilities
The creation of accountable care organizations (ACO) and global payment pilot projects are among the more often discussed initiative in the Patient Protection and Affordable Care Act.
Hospitals can begin laying the groundwork for ACOs by developing relationships with postacute facilities in their communities. They should discuss quality initiatives and improving transfers now before ACOs and global payments take effect in 2013.
Because case managers, social workers, and discharge planners are typically those who communicate with postacute providers, they are the ideal candidates for fostering relationships. Unfortunately, many case managers already have much on their plate and cannot devote much time to meeting with postacute representatives to establish strategic initiatives. This is why Baystate Health (BH) in Springfield, MA, created a role in 2006 devoted exclusively to postacute relations.
Meet Susana Hall, RN, BSN, MBA, director of postacute care (PAC) relationships at BH. Hall essentially is the operations part of a PAC team, developing the health system’s relationships with postacute care providers in western Massachusetts. She does that in two ways—ensuring that postacute facilities share and participate in BH’s vision of quality and negotiating with facilities regarding acceptance of difficult and hard-to-place patients.
Hall meets with representatives from the region’s postacute facilities in strategic planning sessions. During those sessions, they talk about improving transitions and discuss any quality lapses. Hall also negotiates with postacute providers that may be reluctant to accept difficult patients. For example, she says it is sometimes difficult to place Alzheimer’s patients because they tend to “act out” when arriving at a new facility.
“I can call and say, ‘We need your help. I need to ask if you will work with us on a challenging case. What can we do together to make this happen?’ ” Hall says. “We have strong clinical teams in our regional SNFs, and when we approach a challenging case as a team and focus on what is in the best interest of the patient, we have great outcomes. We all work for the same person—the patient.”
In some cases, Hall has negotiated to have BH support the cost of one-on-one services for Alzheimer’s patients until they settle into the new location. Because she is a director, Hall works predominately with administrators, so she often negotiates with chief operating officers and CEO.
CMS issues proposed rule on value-based incentive payments to acute care hospitals under the IPPS
Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., wrote the following post for the Medicare Mentor blog.
As part of its continuing efforts to forge a closer link between Medicare’s payment systems and improvement in healthcare quality, CMS recently published a proposed rule to provide value-based incentive payments to those acute care hospitals that meet relevant requirements. These incentive payments are to be incorporated into the IPPS (which is the principal acute care hospital payment methodology) effective for discharges on and after the beginning of FY 2013 (10/1/12).
As stated in a related fact sheet issued at the same time, “The transition of these [quality] initiatives to value-based purchasing is intended to transform Medicare from a passive payer of claims based on volume of care to an active purchaser of care based on the quality of services its beneficiaries receive.” The proposed hospital value-based purchasing program (the “Hospital VBP”) would provide value-based incentive payments to hospitals based on their achievement, or improvement, on a set of specific quality measures. These measures are designed to foster improved clinical outcomes, as well as to improve the overall quality of the inpatient experience from the patient’s perspective.
Under the hospital VBP, CMS would evaluate a hospital’s performance during an identified performance period based on achievement or improvement relative to performance standards established for that period. Those hospitals that met the standards established for that period would receive incentive payments going forward. These incentive payments would be funded through a reduction in base operating DRG payments for all hospital discharges, beginning with a 1% reduction to base operating DRG payments in FY 2013 and rising to a 2% reduction by FY 2017.
Proposed Quality Measures for FYs 2013 and 2014
For FY 2013, which would be the first year for implementation of the hospital VBP, CMS proposes to use 17 clinical process of care measures as well as 8 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that documents patients’ experience of care. These specific quality measures are set out in Appendix A of the related fact sheet.
For FY 2014, in addition to those measures identified for FY 2013, CMS proposes to adopt three mortality outcome measures, eight hospital-acquired condition (HAC) measures, and nine Agency for Healthcare Research and Quality (AHRQ) measures. These additional quality measures are also set out in Appendix A of the related fact sheet.
Proposed Performance Scoring
The proposed performance period would generally be a year, with some exceptions, including a nine-month performance period (July 1, 2011 through March 31, 2012) for incentive payments to be paid during FY 2013.
The scoring process appears to be the most complex aspect of the hospital VBP. CMS proposes to score each hospital’s performance on each quality measure, which would be evaluated based on the higher of its achievement score in the performance period or its improvement score. The latter would be determined by comparing the hospital’s score in the performance period with its score during a baseline period of performance.
For each of the proposed clinical process and patient experience of care measures that apply to a hospital for FY 2013, CMS proposes that a hospital would earn 0-10 points for achievement, based on where its performance for the measure fell within an achievement range (which is a scale between an achievement threshold and a benchmark). With regard to the improvement score, CMS proposes that a hospital would earn 0-9 points for improvement, based on how much its performance on the measure during the performance period improved from its performance on the measure during the baseline period. Finally, CMS would calculate a Total Performance Score (TPS) for each hospital, which would involve combining and weighting relevant factors.
Proposed Incentive Payments
After calculating each hospital’s TPS, CMS would translate that TPS into a value-based incentive payment using a linear exchange function. For FY 2013, CMS proposes to notify each hospital of the
- Estimated amount of its value-based incentive payment through its QualityNet account at least 60 days prior to Oct. 1, 2012; and
- Exact amount of its value-based incentive payment on or about Nov. 1, 2012.
Because of the complexity of the proposed rules and the significant potential impact on inpatient reimbursement, hospitals are strongly encouraged to review these rules in considerable detail and to provide all relevant comments, together with supporting data, to CMS within the comment period.
Meet face-to-face requirement for home healthcare services
The new year is upon us and with it comes a new requirement for Medicare patients who require home healthcare services.
A provision of the Affordable Care Act mandates that certifying physicians document that they or an allowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient before certifying eligibility for the home health benefit. This encounter must occur within 90 days before the start of care or 30 days afterward.
The goal of the new rule is increasing physician involvement in patient care, according to Jackie Birmingham, RN, MS, is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group. Birmingham wrote about the new requirement in the current issue of Curaspan Connections.
Birmingham writes:
I’m old enough to remember house calls, and while I know they won’t return, I still believe physician involvement—contact with patients—should be at the very foundation of health-care delivery. Apparently lawmakers, looking for (more) ways to cut costs and increase accountability, agree but found that’s not always the case. So, we now have this new regulation that micro-manages providers.
Hospital case managers can meet this requirement in the following ways:
- Determine who will perform the face-to-face encounter as part of the discharge process
- Develop a policy for documenting encounters and transmission of documentation to home-health agencies.
Remember that without certification, there’s no reimbursement. Home healthcare agencies will be looking for documentation; otherwise, they may not accept patients Birmingham writes. This can cause throughput problems as patients linger in hospitals, or patients may be sent home without services, only to be readmitted.
Offer physicians insight not just ‘education’
Editor’s Note: The following blog post originally appeared on the Association of Clinical Documentation Improvement Specialists (ACDIS) blog site.
I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to clinical documentation improvement (CDI) efforts toward affecting overall change in patterns of physician documentation. It read:
“Anyone can memorize things, but the important thing is to understand it.”
Most people remember reading college textbooks, listening to professorial lectures, taking notes, and regurgitating the information we supposedly “learned” on tests and final exams, as part of our endeavors of higher learning. We always seemed to ask ourselves why we were “learning” the majority of that rote information anyway. It was difficult to appreciate and understand its practicality and usefulness.
Now, let’s look at CDI training and education. The majority of training, education, and execution of CDI programs center around:
- understanding the MS-DRG system
- learning what a MCC/CC is
- gaining a practical sense and understanding of coding rules and policies governing principal and secondary condition selection/assignment
- learning how to review the record
- learning how to identify opportunities to improve clinical documentation and financial reimbursement
Finally we learn how to enter the data into the tracking software for reporting purposes. If we’re lucky we learn to track
- how many queries were left
- how many were responded to
- how many contained a positive response
- how often records were reviewed
- how much of a financial impact CDI has on hospital’s bottom line
The entire process is similar to the college experience in the sense we “memorize” the steps of CDI, apply its principles consistently, and ensure we review the standard number of records each day in the name of that learning. While I am not fundamentally against established “quotas” for record review, I do advocate for quality of chart reviews which work in tandem with CDI efforts to educate of physicians, particularly to the extent that we are not repeatedly leaving the same queries day in and day out for the likes of acute blood loss anemia or the type of congestive heart failure. [more]
Improve communication between physicians and case managers to prepare for reform
No one is really sure what is going to happen with healthcare reform, but we can be pretty sure today’s reimbursement model and treatment plans will be different tomorrow.
Currently, payers use a fee-for-service model. In the Medicare population, providers receive payment for inpatient stays according to a DRG. Commercial payers pay hospitals based on either a DRG system or a percentage of billed charges.
Healthcare reform will eliminate the fee-for-service model and create a world where payers bundle hospital and physician payments. That payment model will then evolve into an “episodic” payment plan where facilities and providers are paid one fee for a episode of care provided within a 60-90 day window. There is a fixed dollar amount for that episode, no matter what treatment is provided or whether the patient is readmitted during that time frame. From there, payment will move to a capitated model where providers received a flat fee for each patient, with percentage increases for top quality scores and other metrics. While all these changes are going on, accountable care organizations (ACO) will be forming.
An ACO is composed of one or more hospitals and physician groups that work together using evidence-based care to improve the quality of care, while controlling costs. The Medicare Payment Advisory Commission (MedPAC) an entity that reports to Congress, is continually researching and monitoring the ACO concept.
Case management’s role
Over the years, communication between physicians and nurses has greatly improved. For example, the physician used to simply tell the case manager and/or social worker to set up a SNF placement. Now, the case manager or social worker creates a discharge plan upon admission and discusses the appropriateness of the plan with the physician.
However, there is still room for improvement. Physicians and nursing staff have communicated at each other, but not necessarily with each other in determining the plan of care. One example of the opportunity for improved communication is when a physician writes an order for a test. It is essential for case managers to discuss with physicians whether it is necessary to keep the patient in the hospital for the test or whether the test can be completed as an outpatient.
Under healthcare reform, the communication and relationships between physicians and nurses will need to be integrated. It will be imperative for case managers and physicians to work as a team to maintain collaboration and quality care of the patients. They will need to work together to provide proactive discharge planning and patient education. They will need to team up to provide necessary tests and treatments, while making sure they use resources appropriately.
The healthcare organization I work for is very proactive in its healthcare reform planning. The organization provides education to physicians and involves them in the planning process for the future of healthcare. Our senior case management team is already creating processes and education that will provide opportunities to begin physician and case management integration, starting with our ED physicians. The minute the patient enters our healthcare organization, case managers and physicians begin to collaborate.
What is your organization doing to prepare for healthcare reform? If you do not know, find out. Now is the time to get involved in preparing your organization and healthcare team for what is ahead.
Case management involvement in implementing healthcare reform
Where healthcare reform is going, is anyone’s guess at this time.
Contact your legislators and be heard!
The government powers have voted the Patient Protection and Affordable Care Act into law, but the appropriate implementation is lacking. This creates a situation where the nursing profession, especially case management, should make its voice is heard.
I know you are thinking, “right, like anyone on Capital Hill is going to listen or care what I have to say”. That is where you are wrong.
A few weeks ago, I was privileged to be a part of the American Case Management Association’s (ACMA) Advocacy on Capital Hill event. I joined other ACMA representatives in Washington DC to visit my state’s legislators, as well as other officials. It was a great experience, and we were able to voice our concerns as a powerful, organized association.
Our goal was to focus on specific areas of healthcare reform that case management can positively affect. Case managers are skilled, clinical experts in the areas of transitional care and the admit per case management protocol. Many credible healthcare organizations are developing great processes for measuring transition of care outcomes. The healthcare reform law is huge, so we focused on the areas we can speak to with expertise and authority. Nurses can greatly impact healthcare reform, as we are advocates for the patients and our healthcare organizations.
I was impressed and amazed at the differences in knowledge there was on Capital Hill regarding case management and its importance. We visited some offices where the lawmakers had little knowledge, if any, about case management, while others were well-versed in the impact of case management.
My visit to Senator Charles Grassley’s (R-IA) office is one that sticks out in my mind. I was very impressed with his knowledge of case management. He sees the importance in having case management involved in healthcare reform and the Accountable Care Organizations (ACO). I have e-mailed Senator Grassley’s office a couple of times since my trip and his staff quickly replies to my questions and concerns.
I encourage nurses and case managers to get to know their senators and representatives. Become knowledgeable of what their views are on nursing involvement in healthcare reform Contact them, and advocate for nursing participation in healthcare reform.
My experience on Capital Hill was awesome, and I learned so much. It is great to discuss these important matters and develop relationships with my senators and representatives. Don’t be afraid to be heard!
