Palmetto GBA © 2006 Decision-Support in Post-Acute Care Harry Feliciano, MD, MPH Director, Part A...
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Transcript of Palmetto GBA © 2006 Decision-Support in Post-Acute Care Harry Feliciano, MD, MPH Director, Part A...
Palmetto GBA © 2006
Decision-Support in Post-Acute Care
Harry Feliciano, MD, MPHDirector, Part A Medical Affairs
Palmetto GBA © 2007
Presentation Overview
• Rationale for Going Beyond Diagnosis®
• The Public Health Context
• The Need for Decision-Support
• Palmetto GBA’s Approach
• ICF-enhanced Case Scenarios
• Summary
Palmetto GBA © 2007
Palmetto GBA
• A Medicare contractor since 1966• ISO 9001:2000 registered quality management system• Serving more than 9.4 million beneficiaries
– Processed 119 million Medicare claims in 2006– Paid more than $28 billion in benefits in 2006
• Communicates Medicare coverage to health care providers from hospital to home health environments
• Led by innovative thinkers with a passion for continuous quality improvement
Palmetto GBA © 2007
The Centers for Medicare & Medicaid Services
(CMS)• CMS is a federal agency under the U.S.
Department of Health & Human Services• Responsibilities include administering the
Medicare program which provides health insurance for:– People age 65 or older– People under age 65 with certain disabilities, and– People of all ages with End-Stage Renal Disease.
Palmetto GBA © 2007
CMS Mission
• To ensure effective, up-to-date health care coverage and promote quality care for beneficiaries.
• Guiding principle: “The right care for every person, every time.”
• The Comprehensive Error Rate Testing (CERT) program supports this mission by continuously monitoring the accuracy of Medicare fee-for-service (FFS) payments
Palmetto GBA © 2007
Comprehensive Error Rate Testing (CERT)
• Nationally the CERT program measures the error rate for claims submitted to Medicare contractors – this is called the paid claims error rate.
• Records are reviewed by a third-party, independent contractor
Palmetto GBA © 2007
CERT Methodology
• The CERT Contractor:– Randomly selects a sample of approximately
120,000 submitted claims– Requests medical records from providers
who submitted the claims– Reviews the claims and medical records for
compliance with Medicare coverage, coding and billing rules
Palmetto GBA © 2007
Paid Claims Error Rate
• A paid claims error rate is also calculated for each Medicare contractor
• Part of CMS’ evaluation of contractor effectiveness
Palmetto GBA © 2007
Medicare Reimbursement Requirement
• Medicare statute requires that health care providers demonstrate that the items and services they provide are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”.
Palmetto GBA © 2007
CERT Experience
• “Insufficient documentation” is a major cause of errors identified within the CERT review process
Palmetto GBA © 2007
Palmetto GBA’s Experience
• Many health care organizations are struggling with the complex task of collecting and organizing clinical information addressing chronic, disabling conditions.
Palmetto GBA © 2007
“I Hear the Train a Comin’… ”
• The Medicare population is growing– 19.1 million in 1966– 43.1 million in 2006– 126% increase
Palmetto GBA © 2007
“…It’s Rolling Round the Bend”
0
20
40
60
80
100
Population in millions
2025 2050 2075 2080
Year
65 yrs and over75 yrs and over85 yrs and over
Palmetto GBA © 2007
Epidemiology of Chronic Disease
• Higher prevalence of chronic disease and associated disability in the segment of the population > 65 years of age when compared to younger Americans
• Examples include:– Coronary Heart Disease– Hypertension– Stroke– Congestive Heart Failure– Dementia
Palmetto GBA © 2007
Post-Acute Care
• Health care services following an acute inpatient hospital admission
• Providers include:– Inpatient Rehabilitation Facilities (IRFs)– Long-term Care Hospitals (LTCH)– Skilled Nursing Facilities (SNF)– Home Health Agencies (HHAs)
Palmetto GBA © 2007
Fundamental Question Facing Palmetto GBA & IRF Providers
• How do we identify those patients who are most appropriate for intensive medical rehabilitation resources provided in the IRF setting, rather than alternative care settings (e.g., acute hospital, skilled nursing facility, home health, or outpatient rehabilitation)?
Palmetto GBA © 2007
Diagnosis Alone is Insufficient
Potential confounding factors
ICD-9-CM Outcomes
Health Status of Individual
Palmetto GBA © 2007
The Need for Decision-Support
• Types of decisions:– Structured decisions
• Repetitive, routine problems; clear procedures exist– Unstructured decisions
• Non-routine, require decision-maker to provide judgment, evaluation and insight in defining problem. No well-understood or agreed upon procedure exist
– Semi-structured decisions • Only part of the problem has a clear-cut answer provided by
an acceptable procedure
Source: Management Information Systems: Managing the Digital Firm. Kenneth C. Laudon, Jane Price Laudon, 9th edition. Prentice Hall, Inc 2006.
Palmetto GBA © 2007
Going Beyond Diagnosis®
• Systematic process for identifying and communicating the unique health care needs of Medicare beneficiaries
• Promotes the delivery of high quality health care services, efficiently
• Creates value for CMS, health care providers and beneficiaries
Palmetto GBA © 2007
Going Beyond Diagnosis® Web-based Training
• Palmetto GBA’s Going Beyond Diagnosis Series is available at the following URL:
• www.PalmettoGBA.com– Under Medicare Services – Providers, select
Regional Home Health & Hospice Intermediary (RHHI)
– Then select “Going Beyond Diagnosis” in the “Learning and Education” section, toward the bottom of the RHHI Home Page
Palmetto GBA © 2007
Palmetto GBA’s Approach
• Describing health status using the ICF:– Helps health care providers identify and
communicate the unique needs of individuals– Helps address the “insufficient documentation”
identified via the CERT process– Improves access to care by helping health care
providers identify and consider viable care pathways– Helps Palmetto GBA continuously improve its CERT
paid claims error rate
Palmetto GBA © 2007
Medicare IRF Requirements
1.The services must be reasonable and necessary (in terms of efficacy, duration, frequency, and amount) for the treatment of the patient’s condition; and
2. It must be reasonable and necessary to furnish the care on an inpatient hospital basis, rather than in a less intensive facility such as a SNF, or an outpatient basis.
Source: CMS Benefit Policy Manual (Publication 100-02), Chapter 1, Section 110http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf
Palmetto GBA © 2007
Inpatient Rehabilitation Hospital Screening Criteria
• CMS has established the following screening criteria to assist in the decision-making process:– Close medical supervision by a physician with specialized
training or experience in rehabilitation– Twenty-four hour rehabilitation nursing– Relatively intense level of rehabilitation services– Multi-disciplinary team approach & coordinated care– Significant practical improvement – Realistic goals– Length of rehabilitation program
Palmetto GBA © 2007
Case Scenarios
• What would you recommend?– Inpatient Rehabilitation Hospital– Skilled Nursing Facility– Outpatient Hospital– Home Health Services
Palmetto GBA © 2007
Description of Cases 1 & 2
• ICD-9-CM– 905.3 Late effect of fracture of neck of femur
• ICF– Body structure– Body functions– Activities– Participation– Environmental factors
Palmetto GBA © 2007
Case Scenario #1
• Body Structures– Structures related to movement
Palmetto GBA © 2007
Case Scenario #1
• Body Functions– Sensory functions and pain– Neuromusculoskeletal and movement-related
functions– Genitourinary and reproductive functions– Functions of the cardiovascular,…respiratory system– Functions of the digestive system– Mental function
Palmetto GBA © 2007
Case Scenario #1
• Activities and Participation– Mobility– Self-care
• Environmental Factors– Products and technology– Support and relationships
Palmetto GBA © 2007
Case Scenario #2
• Body Structures– Structures related to movement
Palmetto GBA © 2007
Case Scenario #2
• Body Functions– Sensory functions and pain– Neuromusculoskeletal and movement-
related functions
Palmetto GBA © 2007
Case Scenario #2
• Activities and Participation– Mobility– Self-care
• Environmental Factors– Products and technology– Support and relationships
Palmetto GBA © 2007
Summary
• Going Beyond Diagnosis®
– Promotes CMS’ vision of the “right care for every person, every time”
– Facilitates identification & communication of available post-acute care resources
– Promotes decision-support
Palmetto GBA © 2007
Contact Information
Harry Feliciano, MD, MPHDirector, Part A Medical AffairsPalmetto GBAMail Code AG-300Post Office Box 7004Camden, South Carolina 29021-7004E-mail: [email protected]: 803-763-5007