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Senior and Post-Acute Healthcare News and Topics

Presentation Materials from LeadingAge New Orleans

For those of you that could not attend, I have attached the presentation and handouts/tools from our session on Care Coordination.  In addition to the Power Point (last attachment), there are a number of documents including (but not limited to), clinical pathways, careplans, patient education materials, etc.  Anyone with questions on any of these materials, please contact me at hislop3@msn.com or via comment to this post.

Week Care Coordination Rounds Weekly Progress Note

Weekly Cardiac Assessment (2)

Living with Chronic lung disease

Pulmonary pathway

Knee Arthroplasty pathway

Hip Arthroplasty pathway

Energy Conservation

Decision for Ortho Surgery

Care Coordination Journey

Clinical Pathyways

Cardiac pathway

Care Coordination Updated

 

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November 6, 2017 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , | Leave a comment

New Compliance/Survey Resource for SNFs

It is rare that I push or endorse any product on this site.  This is an exception worth making.

http://hcmarketplace.com/survey-success-for-long-term-care

The book is authored by my wife who also heads the Clinical Compliance practice within H2 Healthcare, LLC – the firm that I head.  She is our Senior Partner as well as the firm’s Chief Operating Officer.  Honestly, no one knows more about compliance from an operations perspective, in the post-acute industry, particularly SNFs, Hospice, Assisted Living, etc. than she does.

What makes this book a “must have” are the resources and tools contained, in one place.  She has shared a wealth of resources accumulated over her decades of practice, updated and put to use daily with clients, in her work.  For SNFs today, survey and compliance are linked and as so many of you have heard (or read) from me, the single most important aspect in obtaining quality-mix, keeping premium payments low on insurance packages, attaining favorable borrowing terms and eliminating unwarranted fines and forfeitures while having in-place, a de facto risk management and fraud prevention program is best-practice, clinical compliance.  This book will help a facility get there and stay survey ready; and clinically compliant.

This is a unique and worthy work as providers can gain first-hand insights on compliance and survey readiness from an expert who has led more deficiency free surveys, overturned more fines and forfeitures at the appeal and IDR level, and saved more clients and facilities untold millions of dollars in fines and forfeitures than perhaps, any other consultant and executive in the country.  I know, the word “biased” will come to mind but in this case, the work product will speak for itself.

September 22, 2017 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , | Leave a comment

Hospice, Hospital Readmissions and Penalty Implications

Late yesterday, a reader (who also happens to be a client from time to time), posed this question to me. “When hospitals discharge to hospice and if the hospice has to readmit to the hospital, the hospital doesn’t get penalized for the readmit?  Is this true?”  Since this question is not one that I have been asked, to my recollection, ever before my guess is that others may have a similar query or interest.  My answer to him/the question, follows.

The short answer is that the readmission penalty issue is not applicable for a hospice to acute hospital transfer/admission.  There is one single caveat that must be present, however: The patient in question must be on the Medicare Hospice benefit rather than traditional Part A and receiving services under some other Hospice offered program such as a Palliative Care program (a home health care style offering).  Below is the reason and regulatory/legal construct why the readmission penalty is not applicable.

  • When a patient elects and is qualified under the Medicare Hospice benefit, the patient opts (effectively) out of his/her traditional Medicare benefit structure – including the assumed coverage for inpatient hospital coverage offered under Medicare Part A.
  • The issue or applicability for readmission penalties for hospitals is only under traditional Medicare fee-for-service or qualified Medicare Advantage plans  It is also only applicable to certain originating DRGs (not all readmissions qualify for a penalty).
  • When a patient enrolls in the Medicare Hospice benefit, the assumptive relationship under Medicare with regard to the patient and his/her provider relationship changes.  The assumption becomes that the patient is effectively, now the “property” (bad word choice but illustrative nonetheless) of the Hospice.  This is so much so that no patient can receive the Hospice benefit under Medicare without becoming a patient of a qualified, certified Hospice provider. Unlike the relationship under traditional or managed Medicare, the patient care is thus the property and coordinated responsibility of the Hospice.  Prior to enrollment, the patient had no connective relationship to any provider – free (for the most part) to seek care from any qualified provider (Med Advantage networks notwithstanding).
  • By his/her enrollment in the Hospice benefit with a Hospice, the patient agrees to a set of covered benefits tied to his/her end-of-life care needs.  He/she also elects to have his/her care effectively provided by or through the Hospice exclusively.  In fact, the patient can’t really show-up at a hospital for an admission and expect to be admitted, without the approval of the Hospice.  The only option a patient has to receive care in this fashion is to “opt out” of the Hospice benefit.
  • Once a patient is enrolled in Hospice, there effectively is no “hospital” benefit left.  The use of a hospital by a Hospice patient is through the Hospice exclusively and any hospital or inpatient use is (only) technically via a GIP or other contracted event/need.  In fact, the hospital has no DRG or admission code nor records the GIP stay as a “hospital” admission.  It (the hospital) can’t create a bill to Medicare for this event and must seek all payment through the Hospice.  As no bill is generated to Medicare Part A with a corresponding DRG and billing code, no inpatient admission occurred and thus, no readmission occurs either applicable (or not) for a penalty.

Like most things Medicare, you won’t find a succinct “memo” to this effect.  Instead, you have to know and go through the detail on the program benefit side and understand how billing, coding and benefit eligibility/program payments work for each provider segment.

 

April 20, 2017 Posted by | Hospice | , , , , , , , , | 2 Comments

Five-Star Quality Rating Guide

A new book was just released – The Five-Star Quality Rating System Technical Users’ Guide.  Readers may find this resource exceptionally valuable, particularly in-light of how important the Five Star system is today (Value Based Purchasing, Quality Reporting, Bundled Payments, Network participation/formation, etc.).  For disclosure purposes, I am co-author along with Maureen McCarthy, RN.  The link to purchase/learn more about the book is below.

http://hcmarketplace.com/five-star-quality-rating-system-tech-user-guide?code=EB333371&utm_source=mktg&utm_medium=eml&utm_content=FSQRSTUG&utm_campaign=eml_LTC_EB333371_022717&spMailingID=10503291&spUserID=MTY3ODg3NjkxMzk3S0&spJobID=1101986339&spReportId=MTEwMTk4NjMzOQS2

 

February 27, 2017 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , | Leave a comment

IMPACT Act, VBP, Care Coordination and the SNF Landscape

Now into February, its time to take stock of the Post-Acute/SNF landscape, particularly as the same pertains to the evolutionary policy initiatives in-play and moving forward.  To start, there is little evidence on the horizon of an all-out retreat on the policy changes begat by the ACA.  While some framework is building to “Repeal and Replace” the ACA/Obamacare, the same will leave fundamentally intact, the changes started and wrought by Bundled Payments, Value-Based Purchasing, and the IMPACT Act.  The Republican majority, a smattering of Democrats, and the incoming Secretary of HHS have signaled support for these initiatives.  Should a Repeal strategy move forward any time soon, these elements, skeletal perhaps or whole in-flesh, will likely remain.

Reviewing thematically, these policy initiatives are centered on an intentional focal shift from episodic, fee-for-service payments to payments based upon performance.  Performance in each element is tied to cost and quality.  The objective is to create better outcomes (quality) in a more efficient manner.  Because these things are government policy, they are clunky – less than simple.  In some cases such as with Value Based Purchasing and readmission measures, the methodology is so cumbersome and disjointed (some diagnoses are OK, some are not) that a layman, even one well-educated, could have a hard time qualifying and quantifying an appropriate readmission (by diagnoses, by risk, etc.).

Below is a quick review of the current policy initiatives and what they mean for 2017 for SNFs.

IMPACT Act: The purpose of the Act is to create standardized reporting of quality measures and cost measures across the post-acute domain (HHAs, SNFs, LTCaH, IRF).  The objectives are to reduce avoidable readmissions to acute care settings and to create standardized, comparable quality measures to identify federal policy improvements and payment consistencies.  CMS of course, uses more floral language regarding the objectives and intent.  Ultimately, the translation of the standardized data allows CMS to target regulatory changes and payment initiatives that reward provider performance and streamline (a bit oxymoronic for government) payment systems (rate equalization models).  Below are the pertinent domains under the IMPACT Act

Quality Measures

  • Skin integrity and changes in skin integrity
  • Functional status, cognitive function, and changes in function and cognitive function
  • Medication reconciliation
  • Incidence of major falls
  • Transfer of health information and care preferences when an individual transitions

Resource Use and Other Measures

  • Resource use measures, including total estimated Medicare spending per beneficiary
  • Discharge to community
  • All-condition risk-adjusted potentially preventable hospital readmissions rates

Assessments

  • Functional status
  • Cognitive function and mental status
  • Special services, treatments, and interventions
  • Medical conditions and co-morbidities
  • Impairments
  • Other categories required by the Secretary

As is common in current health policy, reimbursement policy and other policy interweaves with laws such as the IMPACT Act.  Value Based Purchasing and  Quality Reporting for SNFs, integrates quality measure reporting and results along with readmission performance with incentives or penalties imputed via Medicare reimbursement for 2018.  Beginning in October of 2016, SNFs began to submit QRP (Quality Reporting) data via the MDS.  The first data collection period concluded on 12/31/16.  The Quality Measures reported and applicable under the IMPACT Act (cross setting measures) are:

  • Part A stays with one or more falls with major injury (fracture, joint dislocation, concussion, etc.)
  • Percent of residents with new or worsened pressure injuries
  • Percent of Long-Term Care Hospital patients with an Admission and Discharge Functional Assessment and a Care Plan that addresses function

The Claims Measures are:

  • Discharge to community
  • Potential preventable, 30 day post SNF discharge, readmission to hospital events
  • SNF Medicare spending per beneficiary

The Quality Measures are the elements that impute, based on performance, a reimbursement penalty in 2018 up to 2% of Medicare payments via a reduction in the SNFs reimbursement (rate) update.

Value Based Purchasing (VBP): SNFs are a tad late to this party as other providers such as hospitals, physicians and home health agencies already have reporting and measurement elements impacting their reimbursement.  Hospitals for example, have DRG specific readmission penalties (penalties applicable to common admitting diagnoses).  For HHAs, a nine state demonstration project is under way linking a series of measures (process, outcomes, claims) from the OASIS with customer satisfaction from the HHCAHPS to reimbursement via an accumulation tied to a Total Performance Score.  The measurement years (data gathered) beget payment changes (plus or minus) in outlying years – 2016 data nets payment adjustments in 2018.  The payment graduation increases over time (2018 = 3%, 2022 = 8%).

For SNFs, the VBP measure is 30 day, all cause, unplanned readmissions to a hospital. The measurement reflects a 30 day window that begins at the point of SNF admission from a hospital.  The 30 day window of measurement spans place of care meaning that the patient need not reside in the SNF for this measurement to still have an impact.  For example, a patient admitted to an SNF, subsequently discharged after 14 days to a HHA and then  readmitted to the hospital on day 22 (post hospital discharge) is considered a “readmission” for SNF VBP purposes.  CMS has offered guidance here regarding diagnoses that are excluded from the readmission measure.  Readers that wish this additional information can contact me via my email (on the Author page of this site) or via a comment to this post.  In either case, please provide a valid email that I can use to forward the information.

To avoid getting too technical in this post, a quick summary of how VBP will work is below (readers with greater interest can contact me as provided above for a copy of a Client Alert our/my firm produced last fall on VBP).

  • A SNFs readmission rate is calculated in separate calendar year periods – 2015 and 2017.  The 30 day readmissions (rate) applicable to an SNF is subtracted from the number 1 to achieve the SNFRM (Skilled Nursing Facility Readmission Measure).
  • The 2015 rate is called the Improvement Score and the 2017 rate is called the Performance Score.  Both scores are compared against a benchmark for the period applicable.
  • The benchmark equals 100 points.  The difference between the two (Improvement and Achievement) correlate to points plotted on a range – the Achievement range and the Improvement range.  The higher of the two scores is used to calculate reimbursement incentives or withholds – performance score.
  • Performance scores in terms of points correlate to reimbursement incentives/ withhold.  The maximum reduction or withhold is 2%.  CMS has yet to identify the incentive amount but under law, the amount must be equal in total value to 50-70% of the total withheld.  In effect, we envision a system that imputes a floor of minus 2% with points up to the threshold limit equaling a net of zero (plus 2%) and then climbing above the threshold to the benchmark (national SNF best readmission (average) decile).  This maximum level (and above) is likely to equal 100% of the available incentive.

The 2015 data is already “baked” but 2017 is just beginning. SNFs need to be diligent on monitoring their readmissions as this window is the Improvement opportunity.  Reimbursement impact isn’t until 2019.

Care Coordination: This catch-all phrase is now in “vogue” thanks to the IMPACT Act and VBP, along with the recently released, new Conditions of Participation.  The implication or applicability for Care Coordination is found in the new COPs.  Care Coordination elements are located in 483.21 (a new section) titled Comprehensive Resident-Centered Care Plans.  Specifically, the references to  Discharge Planning (Care Coordination) in this section are implementation elements for the IMPACT Act requirements.  Below are the regulation elements for Care Coordination.

  • Requires documentation in the care plan of the resident’s goals for admission, assessment of discharge potential and discharge plan as applicable
  • Requires the resident’s discharge summary to include medication reconciliation of discharge meds to admission meds (including OTC)
  • Discharge plan must incorporate  a summary of arrangements for post-discharge care including medical and non-medical services plus place of residence
  • All policies pertaining to admission, transfer, discharge, etc. must be uniform, regardless of payer source
  • Requires the facility to provide to resident/resident’s representative, data from IMPACT Act quality measures to assist in decision-making regarding selection of post-acute providers

The above elements are in Phase 1 meaning providers should be in-compliance by now (regulation took effect 11/28/16).

February 15, 2017 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , , , , | 2 Comments

SNF M&A: The Provider Number Trap

Over my career, I have done a fair amount of M&A work….CCRCs, SNFs, HHAs, Physician practices, hospice, etc. While each “deal” has lots of nuances, issues, etc. none can be as confusing or as tricky to navigate as the federal payer issues; specifically, the provider number.  For SNFs, HHAs, and hospices, an acquisition not properly vetted and structured can bite extremely hard post-closing, if provider liabilities existed pre-close and were unknown and/or unknowable.  Even the best due diligence cannot ferret out certain provider number related liabilities.

The Medicare provider number is the unique reference number assigned to each participating provider.  When initially originating as a provider, the organization must apply for provider status, await some form of accreditation (for SNFs it is via a state survey and for HHAs and hospice, via private accreditation) and then ultimate approval by Medicare/DHHS.  As long as the provider that has obtained the number, remains in good standing with CMS (hasn’t had its provider status/agreement revoked), the provider may participate in and bill, Medicare and Medicaid (as applicable).

Provider numbers are assignable under change of control, providing the assuming party is eligible to participate in the Medicare program (not banned, etc.).  Change of control requires change of ownership or control at the PROVIDER level, not the facility or building level.  The building in the case of an SNF, is not the PROVIDER – the operator of the SNF is.  For example, if Acme SNF is owned and operated by Acme, Inc., then Acme, Inc. is the Provider so long as the SNF license in Acme’s state is to Acme, Inc.  Say Acme decides to sell the SNF property to Beta REIT and in turn, Beta leases the facility back to Acme.  Acme no longer owns the building but remains the Provider as it continues to hold the license, etc. consistent with the operations of the SNF.  Carrying this one step further.  Acme decides it no longer wants to run the SNF but wishes to keep the building.  It finds Zeta, LLC, an SNF management/operating company, to operate the SNF and leases the operations to Zeta.  Zeta receives a license from the state for the SNF and now Zeta is the PROVIDER, even though Acme, Inc. continues to own the building.

In the example above regarding Zeta, the typical process in such a change of control involving the operations of a SNF is for Zeta to assume the provider number of Acme.  The paperwork filed with CMS is minimal and occurs concurrent to the closing creating change of control (sale, lease, etc.).  What Zeta has done is avoid a lengthier, more arduous process of obtaining a new provider number, leaving Acme’s number with Acme and applying as a new provider at the Acme SNF location. While taking this route seems appealing and quick, doing so comes with potential peril and today, the peril is expansive and perhaps, business altering.

When a provider assumes the provider number of another entity at change of control, the new provider assumes all of the former provider’s related liabilities, etc. attached to the number.  CMS does not remove history or “cleanse” the former provider’s history. The etc. today is the most often overlooked;

  • Star ratings
  • Quality measures including readmission history
  • Claim error rate
  • MDS data (submitted)
  • Federal survey history
  • Open ADRs
  • Open or pending, probes and RAC audits

The above is in addition to, any payments owed to the Federal government and any fines, forfeitures, penalties, etc.  The largest liability is or relates to, the False Claims Act and/or allegations of fraud.  These events likely preceded the change of control by quite a distance and are either impossible to know at change of control or discoverable with only great, thorough due diligence.  The former in my experience such as whistleblower claims may not arise or be known until many months after the whistleblower’s allegation.  During the interim, silence is all that is heard.  Under Medicare and federal law, no statute of limitation exists for fraud or False Claims.  While it is possible via indemnification language in the deal, to arrest a False Claims Act charge and ultimately unravel the “tape” to source the locus of origin and control at the time of the provider number, the same is not quick and not without legal cost.  Assuming the former provider is even around or can be found (I have seen cases where no such trail exists), winning an argument with CMS that the new provider is blameless/not at fault is akin to winning the Battle of Gettysburg – the losses incalculable.  Remember, the entity that a provider is dealing with is the Federal government and as such, responsive and quick aren’t going to happen.  Check the current status of the administrative appeal backlog as a reference for responsive and quick.

Assuming no payment irregularities occur, the list preceding is daunting enough for pause.  Assuming an existing provider number means assuming all that goes with it.  On the Federal side, that is a bunch.  The assuming party gets the compliance history of the former provider, including the Star rating (no, the rating is not on the SNF facility but on the provider operating the SNF).  As I have written before, Star ratings matter today.  Inheriting a two Star rating means inheriting a “dog that doesn’t hunt” in today’s competitive landscape.  It also means that any work that is planned to increase the Star rating will take time especially if the main “drag” is survey history.  The survey history comes with the provider number.  That history is where RAC auditors visit and surveyors start whenever complaints arise and/or annual certification surveys commence.

The Quality Measures of the former provider beget those of the assuming provider.  This starts the baseline for Value Based Purchasing.  It also sets the bar for readmission risk expectations, network negotiations and referral pattern preference under programs such as Bundled Payments.   Similarly, all of the previous MDS data submissions come with that same provider number, including those that impact case-mix rates under Medicaid (if applicable).  And, not exhaustively last but sufficient for now, all claims experience transfers.  This includes the precious error rate that if perilously close to the limit, can trip with one more error to a pre-payment probe owned, by the assuming provider.  Only extreme due diligence can discover the current error rate – perhaps.

Avoiding the peril of all of the above and rendering the pursuit or enforcement of indemnification (at the new provider’s expense) a moot issue is simple: Obtain a new provider number.  It is a bit time-consuming and does come with a modicum of “brain damage” (it is a government process) but in comparison to what can (and does) happen, a very, very fractional price to pay.  In every transaction I have been directly involved with, I have obtained a new provider number.  In more than one, it has saved a fair amount of go-forward headache and hassle, particularly on the compliance end.  Today, I’d shudder to proceed without a new provider number as the risks of doing so are enormous, particularly in light of the impact of Star ratings, quality measures and survey history.  Additionally, the government has never been more vigilant in scrutinizing claims and generating ADRs.  Inheriting someone else’s documentation and billing risks genuinely isn’t smart today.

While inappropriate for this post, I could list a plethora of examples and events where failure to obtain a new provider number and status has left the assuming provider with an absolute mess.  These stories are now, all too common.  Even the best due diligence (I know because my firm does it), cannot glean enough information to justify such a sweeping assumption of risk. Too much cannot be known and even that which can, should be rendered inconsequential by changing provider status.  Reliance on a definitive agreement and litigation to sort responsibilities and liabilities is not a prudent tactic. Time and resources are (always) better spent, applying for and receiving, a new provider number and provider status.

February 1, 2017 Posted by | Home Health, Hospice, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , | 3 Comments

Post Acute Resolutions for 2017

With a new year upon us and (perhaps) the most amount of free-flowing health policy changes happening or about to happen in decades, it seems appropriate to create some simple resolutions for the year ahead.  Similar to the personal resolutions most people make (get healthy, lose weight, clean closets, etc.), the following are about “improvements” in the business/operating environments.  They are not revolutionary; more evolutionary. Importantly, these are about doing things different as the environment we are in and moving toward is all about different.

First, a quick overview or framework for where health care is and where it is going.  A political shift in Washington from one party to another foretells of differences forthcoming.  It also tells us that much will not change and what will is likely less radical than most think.  Trump and the Republicans can’t create system upheaval as most of what the industry is facing is begat by policy and law well settled.  Similarly, no political operatus can change organically or structurally, the economic realities present – namely an aging society, a burgeoning public health care/entitlement bill, and a system today, built on a fee-for-service paradigm.  Movement toward a different direction, an insight of a paradigmatic shift, is barely visible and growing, while slow, more tangible.  In short: where we left 2016 begins the path through 2017 and beyond.

The road ahead has certain new “realities” and potholes abundant of former realities decaying.  The new realities are about quality, economic efficiency and patient satisfaction/patient focus.  The former realities are about fee-for-service, Medicare maximization, and more is better or warranted. The signs of peril and beware for the former is evident via today’s RAC activity and False Claim Act violations pursuit.  Ala Scrooge, this is the Ghost of Christmas Future – scary and a harbinger to change one’s behavior or face the certainty of the landscape portrayed by the Specter.

So, resolution time.  Time to think ahead, heed the warnings, realize the future portrayal and make plans for a different 2017.

Resolution 1: The future is about measurable, discernible quality.  No post-acute provider, home health or SNF, can survive (much) longer without having 4 or higher Star ratings and a full-blown, operational focus on continuous quality improvement.  The deliverable must be open, clear and transparent, visible in quality measures and compliance history.  FOCUS ON QUALITY AND IN SPECIFICS INCLUDING HAVING A FULL-BLOWN, FULLY INTEGRATED QAPI PROGRAM.

Resolution 2: The future is about patient preference and satisfaction.  For too many decades, patients have gotten farther detached from what health care providers did and how they (providers) did it.  No longer.  Compliance and new Conditions of Participation will require providers to stop paying lip-service to patient centered-care and start now, to deliver it.  The new environment is no longer just what the provider thinks the patient wants or should have but WHAT the patient thinks he/she wants and should have.  TIP: Brush-up on the Informed Consent protocols! FOCUS ON PATIENT PREFERENCES IN HOW CARE IS DELIVERED, WHAT PATIENT GOALS ARE, AND THEIR FEEDBACK/SATISFACTION WITH SERVICE. 

Resolution 3: Efficiency matters going forward.  This isn’t about cost.  It is about tying quality to cost and to a better outcome that is more economically efficient.  The measurement here is multi-faceted.  The first facet is utilization oriented meaning length-of-stay matters.  The quicker providers can efficiently, effectively and safely move patients from higher cost settings to lower costs settings, is the new yardstick.  The second facet is reductions in non-necessary or avoidable expenditures such as via Emergency Room transfers and hospitalizations/rehospitalizations.  NOTE: This ties back to the first resolution about quality. MANAGE EACH ENCOUNTER TO MAKE CERTAIN THAT EACH OF LENGTH OF STAY IS OPTIMAL, AT EACH LEVEL, FOR THE NEEDS OF THE PATIENT AND THAT ANY COMPLICATIONS AND AVOIDABLE ISSUES (FALLS, INFECTIONS, CARE TRANSITIONS) IS MINIMIZED.

Resolution 4: The new world going forward demands that we begin to transition from a fee-for-service mindset to a global payment reality.  This transition period will represent some heretical demands. While fee-for-service dies slowly as we know it, its death will include interstitial periods of pay-for-performance aka Value-Based Purchasing.  Similarly and simultaneously, new models such as bundled payments will enter the landscape.  Our revenue reality is moving and thus, a whole new set of skills and ideas about revenue capture and management must evolve. RESOLVE TO STOP LOOKING AT HOW TO EXPAND AND MAXIMIZE EACH MEDICARE ENCOUNTER.  THE NEW REALITY IS TO LOOK AT EACH PATIENT ENCOUNTER IN TERMS OF QUALITY AND EFFICIENCY FIRST, THEN TIE THE SAME BACK TO THE PAYMENT SYSTEM.  REVENUE TODAY WILL FOLLOW AND BE TIED TO PATIENT OUTCOMES, ETC.

Resolution 5: To effectuate any kind of permanent change, new competencies need development.  Simultaneous, old habits non-effective or harmful, need abandoning.  The new competencies required are care management, care coordination, disease management, and advanced care planning.  Reward going forward will require providers to be good at each of these.  Each ties to risk management, outcome/quality production, and transition efficiency.  Remember, our rewards in the future are tied to efficiency and quality outcomes.  Advanced Care Planning for example, covers both.  Done well, it minimizes hospitalizations while focusing on moving patients through and across higher cost settings to lower cost settings. THIS IS THE YEAR OF BUILDING.  RESOLVE TO CREATE CORE COMPETENCIES IN ADVANCE CARE PLANNING, CARE COORDINATION AND THE DEVELOPMENT AND IMPLEMENTATION OF BEST-PRACTICE, DISEASE MANAGEMENT ALGORITHMS AND CARE ALGORITHMS IN AND ACROSS COMMON DIAGNOSES AND RISK AREAS (e.g., falls, skin/wound, heart failure, pneumonia, infections, etc.).

Resolutions 6: The world of post-acute is changing.  To change or adapt with it requires first and foremost, knowledge.  Too many providers and often, leadership within don’t understand the dynamics of the environment and what is shifting, how and when.  Denial cannot be operative and as Pasteur was famed to say, “chance favors the prepared mind”.  Opportunity is abundant for those providers and organizations that are up-to-speed, forward thinking and understand how to use the information available to them.  RESOLVE TO EDUCATE YOURSELF AND THE ORGANIZATION.  KNOW HOW THE 5-STAR SYSTEM WORKS.  KNOW WHAT VALUE-BASED PURCHASING IS ALL ABOUT.  KNOW THE MARKET AREA YOUR ORGANIZATION IS IN AND HOW YOUR ORGANIZATION COMPARES FROM A QUALITY PERSPECTIVE (MEASURED) TO OTHERS.  KNOW THE HOSPITAL PLAYERS AND THE NETWORKS.  KNOW YOUR ORGANIZATION’S STRENGTHS AND WHAT IMPROVEMENTS NEED TO BE MADE.

Happy 2017!  The beauty of a New Year is that somehow, we get a re-start; a chance to do and be different than what we were in the prior year.  For me, I like the CQI approach best which is more about constant evolution than a wholesale, got to change now, approach.  Success is about doing things different as realities and paradigms shift.  We are certainly, from a health care and post-acute industry perspective, in a paradigm shift.  Take 2017 and brand it as the Year to Become Different!  The Year of Metamorphosis!

January 4, 2017 Posted by | Home Health, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , | Leave a comment

Presentation Available: New Conditions of Participation for SNFs – Phase 1 Implementation

On the Reports and Other Documents page ( http://wp.me/PtUlY-4g ), I have uploaded a Power Point presentation my firm has made available to clients covering the new Federal Conditions of Participation for SNFs and the implementation elements that are part of Phase 1 (titled “New COPS for SNFs Phase 1”).  The presentation covers what is happening in terms of the new regulations arising out of the law, focused on Phase 1 requirements which began November 28.  The presentation will also alert providers, etc. to Phase 2 issues as applicable.

Additional background information on the Phases and the Rule can be found on this site at these post references: http://wp.me/ptUlY-kU

http://wp.me/ptUlY-kL

As always, questions, etc. can be forwarded to me via a comment accompanying this post or via e-mail (contact information on the Author page).  Remember, if you wish a reply/response, please include a valid e-mail address/contact with your post or question.

Happy Holidays!

 

December 19, 2016 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , | 2 Comments

The Election is Over….Now What?

We knew that sooner or later, the first Tuesday in November would arrive and with that, a new President and changes (many or few) to Congress. The outcome certain, we move to uncertainty again concerning “what next”?…or as applicable here, what next from a health policy perspective.

With Donald Trump the incoming President-Elect, only so much from a policy perspective is known.  Hillary Clinton’s path was easier to divine from a “what next” perspective as fundamentally, status quo was the overall direction. Trump’s likely direction and thus, changes to current policy, etc. are hazy at best.  Thematically, there are points offered throughout the campaign that give some guidance.  Unfortunately, much that drives current reality for providers is more regulatory begat by legislative policy than policy de novo.

Without divining too much from rhetoric, here’s what I think, from a health policy perspective, is what to expect from a Trump Administration.

  1. ObamaCare: Trump ran on a theme of “repeal and replace” ObamaCare aka the Affordable Care Act. This concept however, needs trimming.  Repealing in total, existing federal law the magnitude of the ACA is difficult if not nearly impossible, especially since implementation of various provisions is well down the road.  The ACA and its step-child regulations are tens of thousands of pages.  Additionally, even with a Republican White House and Republican-majority Congress, the Congressional numbers (seats held) are not enough to avoid Democratic Senate maneuvers including filibuster(s). This means that the real targets for “repeal and replace” are the insurance aspects namely the individual mandate, Medicaid expansion, certain insurance mandates, the insurance exchanges, a likely the current subsidy structure(s).  The other elements in the law, found in Title III – Improving the Quality and Efficiency of Health Care, will remain (my prediction) – too difficult to unwind and not really germane to the “campaign” promise.  This Section (though not exclusively) contains a slew of provisions to “modernize” Medicare (e.g., value-based purchasing, physician quality reporting, hospice, rehab hospital and LTACH quality reporting, various payment adjustments, etc.).  Similarly, I see little change made, if any to, large sections of Title II involving Medicaid and Title IV involving Chronic Disease.  Bottom line: The ACA is enormous today, nearly fully intertwined in the U.S. health care landscape and as such, too complex to “wholesale” eliminate and replace. For readers interested in exploring these sections (and others) of the ACA, a link to the ObamaCare website is here http://obamacarefacts.com/summary-of-provisions-patient-protection-and-affordable-care-act/
  2. Medicaid: The implications for Medicaid are a bit fuzzier as Trump’s goals or pledges span two distinct elements of the program.  First, Trump’s plan to re-shape ObamaCare (repeal, etc.) would eliminate Medicaid expansion.  As mentioned in number 1 prior, this is a small part of the ACA but a lipid test for Republican governors, especially in states that did not embrace expansion (e.g, Wisconsin, Kansas, etc.).  Second, Trump has said that he embraces Medicaid block-grant funding and greater state autonomy for Medicaid programmatic changes (less reliance on the need for states to gain waivers for coverage design, program expansion, etc.).  It is this element that is vague.  A series of questions arise pertaining to “policy” at the federal level versus funding as block grants are the latter.  The dominant concern is that in all scenarios, the amount of money “granted” to the states will be less than current allocations and won’t come with any matching incentives.  With elimination of the expansion elements, how a transition plan of coverage and care will occur is a mystery – federal assistance? state funding mostly?  What I do predict is that Medicaid will only suffer the setback of a restructure and replacement of the Medicaid expansion elements under the ACA.  I don’t see block grants happening any time soon as even Republican governors are opposed without a plan for wholesale Medicaid programmatic reform.  Regardless of the approach, some initial Medicaid changes are in the offing, separate from the Block Grant issue.  The Medicaid Expansion issue is no doubt, a target in the “repeal and replace Obama Care”.  The trick however is to account for the large number of individuals that gained coverage via expansion (via eligibility increases due to increased poverty limits) – approximately 8 million impacted.  This is less about “repeal” and more about “replace” to offset coverage lapse(s) for this group.
  3. Related Health Policy/ACA Issues: As I mentioned earlier, the ACA/ObamaCare is an enormous law with tentacles now woven throughout the health care industry.  The Repeal and Replace issues aren’t as “clean” as one would think.  The focus is the insurance mandate, the subsidies, the mandated coverage issues and to a lesser extent, Medicaid.  That leaves fully 80% of the ACA intact including a series of policy changes and initiatives that providers wrestle with daily. These issues are unlikely to change in any substantive form.  Republicans support alternative delivery projects, value based purchasing, etc. as much if not more than Democrats.  Additionally, to repeal is to open a Pandora’s Box of agency regulations that tie to reimbursement, tie to other regulations, etc.  For SNFs alone, there exists all sorts of overlap between Value Based Purchasing, Bundled Payments, new Quality Measures and quality reporting (see my post/presentation on this site regarding Post-Acute Regulatory Changes).  The list below is not exhaustive but representative.
    • Value Based Purchasing
    • CMS Center for Innovation/Alternative Delivery Models/Bundled Payments
    • Additional Quality Measures and Quality Reporting
    • Inter-Program and Payment Reform – Rate Equalization for Post-Acute Providers
    • IMPACT Act
    • ACO Expansion

As providers watch the inauguration approach and a new Congress settle in, the wonder is around change. Specifically, what will change.  My answer – bet on nothing substantive in the short-run.  While Mr. Trump ran partially on a platform that included regulatory reduction/simplification, the lack of overall specifics regarding “which or what” regulations on the health care front are targets leaves us guessing.  My guess is none, anytime soon.

The Trump focus will be on campaign specific agenda first: ObamaCare, Immigration, Taxation, Foreign Trade, Energy, etc. – not health policy per se.  There is some flow-through gains providers can anticipate down-the-road that can be gleaned from the Trump campaign but these are a year or more off.  If Trump does deal with some simplification on drug and research regulation (faster, cheaper, quicker approvals), funding for disease management and tele-medicine and a fast-track of some Republican policy “likes” such as Medicare simplification, Medicaid reform at the program level, and corporate tax reduction (will help for-profit providers), then gains will occur or opportunities for gains will occur.

From a strategic and preparatory perspective, stay the course.  Providers should be working on improved quality outcomes, reducing avoidable care transitions/readmissions, looking at narrow networks and network contracting/development opportunities and finding ways to reduce cost and improve care outcomes.  Regardless of what a Trump Administration does first, the aforementioned work is necessary as payment for value, bundles/episodes of care, and focus on quality measures and outcomes is here to stay and to stay for the foreseeable future.

November 18, 2016 Posted by | Home Health, Hospice, Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , , | Leave a comment

Conference Presentation

In September, I spoke at the Kairos Health conference in Pennsylvania on request/behalf of HCPro.  The topic was on upcoming/current regulatory and compliance issues in Post-Acute Care.  By request, I am providing the presentation on this site.  Readers can find it on the Reports and Other Documents Page.  The title is “Upcoming Post-Acute Regulatory Issues”.  It is free for viewing or download.  As always, questions, comments, etc. feel free to comment to this post or drop me a note at the email address provided on the Author page of this site.

October 13, 2016 Posted by | Policy and Politics - Federal, Skilled Nursing | , , , , , , , , , , , | 1 Comment