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Major Upgrade Needed: Care Coordination

I’ve been in and around healthcare for three plus decades and a concept that has always been front of mind for me is care coordination. This is something that is so important for a patient’s well-being in terms of improved outcomes and satisfaction. It is also a real opportunity for cost improvement. Unfortunately, I’ve seen this concept advanced via discussion but rarely via systemic adoption among providers. In fact, COVID set care coordination advances backward in many ways.

Care coordination is a patient focused process that seeks to single-point, map patient desired outcomes with patient needs. It seeks to connect providers to a common focus and to reduce steps, eliminate redundancy, and restrict unnecessary services or interventions. It in theory, reverses the driver’s seat role among the patient and providers, giving the patient voice the primary role as opposed to the provider (physician, etc.).

The challenge within the U.S. system is regulation and bureaucracy stifle care coordination. While we see regulations in the post-acute arenas prompting certain levels of care coordination, the regulations further segment rather than advance creativity. At the hospital/acute arena, the driver of care tends to be procedural and payment. There simply is little room for a holistic approach and/or a team approach. The driver of the admission is often, the need for an intervention. Multiple providers are involved (physicians) and the primary care provider of the patient by origin, is rarely if at all, involved. If the patient is elderly (the most common hospitalized patient), issues of multiple comorbidities and prior and current treatments confound the hospital stay. Tests are often repeated as no contemporaneous record follows the patient and history, may be sketchy at best. The ability to deliver effective care and coordinate the next step of the journey is bollixed by the need to complete the stay in the shortest time possible.

As more care and procedures for patients sub-65 with little prior comorbidity or controlled comorbidities are pushed outpatient, the inpatient hospital stays are dominated by elderly and/or complex care arising out of the need for major surgeries or trauma. For a senior patient, care coordination can be the difference between poorer outcomes, lengthier stays, and the need for additional inpatient stays, post-acute.

According to the Agency for Healthcare Research and Quality, care coordination is: “Care coordination in the primary care practice that involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. The main goal of care coordination is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient’s needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care”.

Broadly, care coordination involves a specific framework that emphasizes data sharing, teamwork, and patient-focused assessments clinical and psycho-social in nature.  The desired outcome is a shared plan of care that covers admission, in-stay communication and education, and transitions from acute to post-acute.  In some cases, the stay maybe an inpatient post-acute stay (e.g., SNF) with the same series of events (shared plan of care, communication and education, transition planning).

COVID in particular, illustrated how fractured the health care system in the U.S. remains.  Care denials and delays became the norm and patients lost connections with their physician, clinics, and other providers.  Access, already a problem, caved in many cases and for some, remains a continued problem as staffing shortages already at-risk, manifested.  A few weeks ago, I wrote a post about access problems for SNFs and Home Health resulting post COVID. The post is here: https://wp.me/ptUlY-vL

The U.S. healthcare system is notorious for its silos.  The silo issue is what care coordination attempts to ameliorate. For a senior adult patient, this issue of silos is incredibly perilous.  Without direct connection within the system, it is not uncommon for a senior to either avoid care due to the access complexity or receive care that is unnecessary or unwanted, driven entirely by systematized processes.  In other words, I have seen older adults all too often, become victims of polypharmacy for example, simply by seeing multiple physicians, all of which prescribe without going through medication reconciliation BEFORE writing the script.  I’ve seen repeat procedures within the same day – multiple tests that don’t get checked because the patient follows orders and doesn’t ask questions.  I’ve seen X-rays taken two days prior lead to an MRI, just to be cautious.

Objectively, and I have written this before, the system needs to be redesigned to advance the goals of patient care as primary, in fact, driven by a fundamentally simple concept known as primary care. The need for a different system and one that emphasizes care coordination, is succinctly stated by the Institute of Medicine.

  • Current health care systems are often disjointed, and processes vary among and between primary care sites and specialty sites.
  • Patients are often unclear about why they are being referred from primary care to a specialist, how to make appointments, and what to do after seeing a specialist.
  • Specialists do not consistently receive clear reasons for the referral or adequate information on tests that have already been done. Primary care physicians do not often receive information about what happened in a referral visit.
  • Referral staff deal with many different processes and lost information, which means that care is less efficient.

For readers interest in care coordination and applications, tools, and additional reading, I’ve provided some resources below including a presentation I did with some colleagues at a LeadingAge national conference a few years back.

care-coordination-updated

https://www.qualityforum.org/ProjectDescription.aspx?projectID=73700

https://www.ahrq.gov/ncepcr/care/coordination.html

 

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May 8, 2023 Posted by | Health Policy and Economics, Policy and Politics - Federal | , , , , , , , , , | Leave a comment

PDPM: First Blush Analysis

One quarter (three months and change) down and PDPM appears to be mostly positive for SNFs.  CMS is reporting a higher average per diem payment level than under RUGs.  Despite some added coding complexity, paperwork burdens are down for providers (two MDS’ during most stays now vs. many under RUGs).  Anecdotally, the industry is seeing added access for certain patient types that previously, were difficult SNF placements.  The NTA category is the driver of this additional access as payments help offset, higher clinical costs associated with certain patient needs and comorbidities.  Approximately 2/3rds of facilities have experienced rate increases (67%); 23% experiencing decreases.  Where rate erosion has occurred is in facilities that were heavily skewed under RUGs to RU and RH level therapy payments – 75% or more utilization.  Conversely and logically, the winners have been facilities with a much more balanced book of business; a normative or typical RUG distribution (historically) and a patient/referral base that included more clinical complexity.  Studies that initially showed a 90% plus increase in Medicare per diem rates in October erroneously ignored the initial conversion bounce (NTA pick-up) that came into play for residents in a facility under RUGs on 9/30 that carried-over into PDPM on 10/1.  Suffice to say, the playing field has leveled.

Originally, CMS estimated that PDPM would be budget-neutral with a modest or slight bias toward rates being flat or down just a touch at the facility level.  The projection from CMS using 2017 data was for a 1.37% decrease.  November’s data/results ran 5.7% above the CMS projection.  While CMS has provided no immediate reaction to the “better than expected” trend for providers, the reality is that an adjustment of some form is likely.  MedPac has called for no rate increases for SNFs in FY21.  It is possible that a flat-rate scenario will emerge for at least a few years IF, rate pullbacks aren’t part of the immediate solution.

While fee-for-service rates under PDPM offer encouragement for providers, the overall occupancy trend and payer-mix is a sobering element.  Since 2010, overall fee-for-service utilization is down by 17.7%.  Length of stay for the same period also declined by 7.4% (covered days).

Three factors are heavily influencing the fee-for-service utilization and length of stay trends.  First, Medicare Advantage is a growing payer type (covered lives).  MA plans simply account for shorter stays at reduced rates where SNF care is required.  Second, home health agencies have filled the bill for certain care needs, circumventing altogether, an SNF stay.  It is not uncommon for a routine knee-replacement patient with stable comorbidities to transition home with a home health agency vs. to an SNF or IRF (inpatient rehab facility).   Pneumonias, infections, wounds, etc. can be managed at home; preferable for the patient and often, for the payer.  Third, ACOs and Bundled Payment programs (and MA plans too) work to steer patients to home or outpatient settings either avoiding the SNF entirely or shortening the inpatient stay by a day or series of days.

While the PDPM rate bump may seem good news, and it is, the euphoric feeling is temporary.  Increased revenue is a function of not just rate but utilization.  If utilization continues to remain on a downward path, the dip won’t be offset by rate.  Similarly, utilization patterns are shifting and as of today, I see no progression or shift toward increased SNF utilization.  Frankly, there remains in most markets, too many SNF beds for the functional demand (certainly, for the demand with a good payer source).  Assisted Living models, those adapted to a higher-level chronic care model, continue to erode long-term SNF census.  This erosion causes a two-part dilemma for SNFs. First, fewer patients/residents to occupy beds and second, the remaining patients tend to have Medicaid as a payer source.  For SNFs that can’t play and survive to a large extent in the post-acute realm, alternative options are scarce for long-term resident occupancy (I-SNPs perhaps?).

One last caveat for providers at this juncture, is worth noting.  PDPM rates are up and CMS has yet to begin audits.  I suspect facilities will see some “shock and awe” once these audits begin.  Remember, audits are done by intermediaries and contractors – not by CMS directly.  I have seen some claim funk as facilities have strutted their way to some higher payments by additional speech utilization – utilization that wasn’t there under RUGs.  I’m watching facilities aggressively pursue cognition via Speech Therapy engagement; seeking to score residents at certain times of the day where cognition may be lower (later day, after a nap, etc.).  A note of warning here is warranted.  Coding opportunities are available under PDPM and IF, such an opportunity correlates to a higher payment, that’s great PROVIDED that, the care delivered and documented, supports the coding.  I am already seeing residents coded at one level of cognition, Speech being used for “cognitive training” and nursing documentation stating that the resident is, “alert and oriented x 3”.  Which is it as it can’t be both?  The proper approach is to evaluate the overall needs of the resident and develop a careplan with the whole team that reflects this holistic assessment.  The key then going forward, is for all disciplines to appropriately document the care provided, consistent with the careplan.

 

 

 

 

 

February 10, 2020 Posted by | Skilled Nursing | , , , , , , , , , , , | Comments Off on PDPM: First Blush Analysis

SNFs, Therapy Contracts and Fraud: Another Warning and Example

I know I sound redundant but clearly, the message is still not permeating through the industry (except for readers here). The Department of Justice and the OIG for the Department of Health are scrutinizing SNFs, their therapy billings, and the use of therapy contractors.  Why?  It is all due to a known and now routinely validated, prevalence of over-billing and thus fraud and/or violations (same thing really) of the False Claims Act.  I have written on this subject on this site multiple times before and those that have heard me speak at various industry events, received the same message. Bottom-line: If you are an SNF and you use a contract therapy company to provide your therapy services, you must monitor the performance of your therapy contractor and assure that all Medicare billing and Condition of Participation requirements are being met.  The acts of the therapy contractor (over-billing, miscoding, improper care, etc.) are the “ACTS” of the SNF as far as the Federal government is concerned.  The SNF is responsible for ALL elements of care provided and the accuracy and compliance elements of any and all claims submitted to Medicare.https://rhislop3.wordpress.com/wp-admin/post.php?post=1138&action=edit#

In another case, recently disclosed, a group of three SNFs in New York (Arch Care) operated by Catholic Health Care System settled improper (false) claim allegations with the Department of Justice for $3.5 million.  The settlement is based on improper and inflated claims submitted to Medicare for unnecessary, erroneous and improper therapy care provided by RehabCare (a division thereof in this case).  The cause of the settlement or the crux of the issue related to the SNFs failure to monitor the therapy provider and to assure that the erroneous/illegitimate claims were not submitted to Medicare.  The result of the claims submission is overpayment and thus, the recovery and settlement.  Noticeably absent is any action taken against the therapy company by the Department as none such can be taken – the therapy contractor did not bill Medicare – the SNF did!

SNFs need to pay attention to these cases – more are assuredly forthcoming.  There are simple remedies to avoid these problems on the part of any SNF or group of SNFs.  Below is just a small sample.  For additional resources, attend the upcoming HcPro webinar that I  am conducting next week (posted on this site) or contact me directly.

  • Implement a triple-check system immediately.
  • If an SNF hasn’t audited its Medicare billings lately via an outside contractor, do so immediately especially if the SNF uses a therapy contractor.  Be prepared if irregularities are found to self-disclose.  Self-disclosure is required and it is the only way to potentially avoid treble damages, criminal liability, etc.
  • Retain an outside auditor and develop a routine audit system. I have checklists which can be used to guide in this process plus sources for auditors.
  • Educate your MDS and billing staff immediately on red-flag issues when it comes to your Medicare billings.
  • Integrate certain outcome and patient/resident/family feedback elements into your QA process.  Seek direct feedback monitor care outcomes and risk areas.

March 5, 2015 Posted by | Skilled Nursing | , , , , , , , , , , | Comments Off on SNFs, Therapy Contracts and Fraud: Another Warning and Example