CaringForward

Early Returns on the ACO Final Rule by CMS: Cautious Optimism

The CMS released the final rule on ACOs yesterday. So far the industry response has been largely positive, if a little guarded as people sort through the details. Most are giving CMS high marks for thoroughly considering the 1,300 or so comments submitted in response to the draft rule. Here's a breakdown of some of the coverage:

From post-acute and long-term care:

• McKnight's praises CMS for easing initial requirements and timelines for providers to participate, as well as for sweetening the incentives under the shared savings program.
• Long-Term Living Magazine also reports the news as positive, closing with this conditionally supportive statement from the AHCA: “We support the concepts of ACOs and their intended purpose, and certainly want to ensure skilled nursing and post-acute facilities are part of the cost-saving model. We’ll be examining the details in the coming days and weeks to ensure our sector can play an important role moving forward.”
• And Patrick Connole from Provider Magazine provides additional details, noting that the final rule reduces the number of quality measures from 65 to 33 and eliminates the electronic health records requirement. 

Other perspectives:

• Cheryl Clark from HealthLeaders Media posts an extensive summary and analysis, again with largely positive initial reactions from several sectors of healthcare. Clark does note one negative response from prominent provider alliance Premier Inc. related to beneficiaries being able to participate without sharing data. Even so, Premier's complete response to the final rule praises much more than it criticizes. 
• Healthcare IT News focuses its coverage on the lifting of the much-maligned EHR requirement, which in the draft rule called for “50 percent of primary care physicians [to] be defined as meaningful users by start of second performance year.” The final rule has makes it “no longer a condition of participation.” The article goes on to quotes that the final rule “retained EHR as a quality measure but weighted higher than any other measure for quality-scoring purposes.” Some had cited the initial requirement as being too nebulous and onerous to allow ACOs to get off the ground.

 See the complete, 696-page final rule here. 

Tuesday Links: AHCA sounds battle cry for SNFs that are "under attack," the power of social persuasion in marketing, and more

Here are some recent items of interest for skilled nursing facilities:

• It sounds as if the 62nd AHCA annual convention launched with a bang—the LTL blog says that both AHCA president Mark Parkinson and chairman Robert Van Dyk spoke directly about the challenges of Medicare cuts and ongoing healthcare reform in Washington. "We’re fighting for our very survival," according to Parkinson.
• The always excellent Tom Mann discusses the principle of social proof, and why you should care about and document the experiences of your residents to help market your facilities more successfully.
• Here's a passionate, personal account of a recent nursing home survey by eight surveyors, including two feds, as told by the surviving DON. An unsedated root canal sounds more pleasant.
• It turns out seniors don't understand Medicare or healthcare reform either. 
• Discouraging signs that legislators and the DEA still can't get it right when it comes to letting medical professionals compassionately treat pain for patients.

 

OIG Misleads Again About Improper Drug Prescriptions and Billing at SNFs

In January, the Office of Inspector General accused nursing homes of cheating Medicare on reimbursement classifications.

Then in March it published some downright scary findings about the number of convicted criminals employed by SNFs—92 percent employ a convict!

Most recently, this May OIG report says skilled nursing facilities are improperly prescribing and billing for psychotropic medications.

So, by OIG's version of reality, nursing homes are full of crooks, swindlers and negligent killers. We can only imagine how this fuels mistrust among wary individuals who typically know little else about skilled nursing care until they need to seek a facility for a loved one.

The most recent OIG report reflects the typical fearmongering and false or absent context.

The report finds that 14% of elderly nursing home patients made had Medicare claims for atypical antipsychotic medications. Scary? Well, the vast majority of 86% aren't on the meds. And without additional context, that number alone neither alarms nor comforts—who's to say if that's too many?

Aha! It's too many because 83% of those prescriptions were off-label (prescribed by a doctor for use other than the approved use). In this case, many prescriptions were for agitation in dementia patients, a difficult symptom to manage, and one that there is no specific drug approved to treat.

This is where OIG really wrenched up the panic.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” wrote Daniel R. Levinson, inspector general of the Department of Health and Human Services, in announcing the audit results. He further cited how more than half of these "potentially lethal" (aren't they all potentially?) antipsychotic drugs were not supposed to be covered under Medicare.

Dr. David Gifford, AHCA's senior vice president of quality and regulatory affairs, explains why off-label prescribing isn't such a bad thing. And in one of the best responses to this report, Dr. Daniel Carlat soberly and rationally defends the practice of prescribing antipsychotic medications to ease the suffering and improve the quality of life for elderly dementia patients. Does it create tough choices related to patient care and mortality? Of course. Have there been faulty practices in manipulating prescription patterns by pharmaceutical companies? Even Dr. Carlat concedes the point, but firmly stands up to Levinson on this OIG report:

"In this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular."

For me, this latest OIG report reinforces a frustrating pattern of accusation and confrontation that diminishes the agency's stated mission of "protect(ing) the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries." We've said it before here—it's a tough enough business running a nursing home as it is. Even in its role as the watchdog arm of HHS, we think the OIG could serve everyone, right down to the patients needing compassionate care, by reporting findings objectively, toning down the combative outrage, and working with the dedicated professionals in post-acute care to find solutions together.

 

PPS Presenting LTC Marketing and Census Strategies at MHCA Symposium June 7-9

We are pleased and honored that the folks from the Maine Health Care Assocition invited us to present a session at the MHCA Leadership Symposium in Northport, Maine, June 7-9, 2011.

Karen Michaud, MHCA's director of education, says the focus of this year's symposium is all about marketing, census building and embracing innovation: “The 2011 symposium focuses on helping providers recognize and develop new strategies for marketing their facilities.” 

Session topics concentrate on three key areas for skilled nursing and other long-term care providers:

• Cultivating a commitment to quality service and care
• Streamlining processes for admissions and referral management and utilizing technology to improve service, such as automated referral systems, electronic medical records and health information technology
• Developing a strong marketing plan, nurturing community relationships, increasing referrals, and improving relationships and responsiveness

 

Our session, scheduled for Wednesday June 8, should sound familiar for past visitors to CaringForward.com. “Coming To Your Census: 8 Steps to Excellence in LTC Census and Marketing Performance,” will present new rules and technology tools to help long-term care and post-acute care providers market more effectively, accelerate referral response times, strengthen referral relationships, and improve case mix and reimbursements. The session covers eight proven steps to excellence in marketing and admissions for long-term care, along with trends in new technologies that are helping top performers work faster and smarter. The session also discusses several real-world examples of providers that are applying these steps, along with automated Web-based marketing and referral management systems, with dramatic performance results.

Other sessions scheduled for the MHCA Leadership Symposium include:

 

• “Reaching Maximum Effectiveness with Functional Marketing Plans,” presented by Patty Cisco, founder of CISCO & CO.
• “Social Media in the Workplace: Developing a Social Media Policy for Your Employees” presented by Melissa O'Dea, attorney at O’Dea Woodman, P.C.
• “Defining the Business Case for Health Information Technology (HIT) in the Long Term Care Sector,” presented by Jim Leonard, director, Maine Office of the State Coordinator for Health Information Technology.

Thursday Roundup: ACOs and Long-Term Care, Movie Night for Nursing Homes, and the Tasty Sandwich Generation

Too long between blog posts, so here are some interesting things in the world of skilled nursing and long-term care worth sharing today:

• Mark Parkinson, CEO of AHCA, advises skilled nursing providers to start strengthening those hospital relationships in anticipation of accountable care organizations (ACOs). Even if ACOs never materialize. “Whether they are developed or not, I think there is a logic to episodic bundled payment.”
• More on ACOs and post-acute care: The Commonwealth Fund Commission publishes recommendation for encouraging the establishment of ACOs, and another group thinks ACOs would shortchange medically underserved communities.
• And in non-ACO news for nursing homes: Cook up that popcorn! Nursing homes can screen movies without paying MPLC license fees (and other LTC facilities get discounted rates). Nicely done by AHCA and LeadingAge to broker the deal.
• At first, I was excited to find out that I was part of the "sandwich generation," because it sounded delicious. Then I realized it's a bit more complicated. How people are coping to care for the generations before and after them.

Coverage Roundup of New ACO Rule: What Does it All Mean for SNFs and Long-Term Care?

As you probably know, CMS issued the initial rule for establishing accountable care organizations (ACOs), and it's a whopper at 429 pages. CMS issued the rule (“Medicare Shared Savings Program: Accountable Care Organizations”) on March 31, and opened a 60-day comment period. Here's a look at some of the subsequent analysis and commentary—and there's plenty of it:

• From The Health Care Blog, Vince Kuraitis shares eight first impressions about the ACO rule, notably that the requirements for hospitals to establish an ACO are serious: "The infrastructure, operational and reporting requirements for setting up an ACO have teeth." No dipping your toes in the water here.
• LeadingAge (formerly AAHSA) has published a whitepaper about how nursing homes, SNFs and other LTC and post-acute providers can participate in ACOs. It also has created a tool to assess providers' readiness to participate in an accountable care organization.
• HealthLeaders Media reports on mixed responses to the initial ACO rule. 
• AHCA weighs in with a pretty ho-hum statement about how ACOs can include nursing homes and other post-acute care providers.
• Again from HealthLeaders: Are the savings from participating in an ACO worth the costs? (Or as my boss is fond of asking, "Is the juice worth the squeeze?")
• We hope CMS will uphold this admirable promise to genuinely consider feedback during the 60-day comment period.
• Privacy, fraud and antitrust implications of the new ACO rule. More important things for SNFs, nursing homes and other post-acute and LTC providers to consider.

OIG Misses Mark with Claim that SNFs are Cheating on Medicare Billing

So, CMS makes the Medicare reimbursement rules. SNFs follow the rules. Health and Human Services publishes a special thank you: "SNFs, you're cheating."

It's tough business running a SNF. Medicaid underpays. (Really, really underpays—by $5.6 billion in 2010.) CMS establishes dizzyingly complex clinical assessments and categories for Medicare reimbursement (66 utilization groups in RUG-IV), and changes them periodically just to keep nursing homes on their toes.

Skilled nursing facility operators scramble, and rescramble, to keep up, and to apply and manage clinical and reimbursement programs to appropriately bill for reimbursements. They continuously invest in resources to provide services that meet the increasingly complex clinical needs of post-acute patients. They work diligently make their communities, hospital case managers and referring physicians aware of these entened services, from rehab/therapy to vent beds to dementia care and more.

So the HHS Office of Inspector General publishes a 37-page research report claiming SNFs are cheating on Medicare billing.

OK, it doesn't use the word "cheating," but the title "Questionable Billing By Skilled Nursing Facilities" doesn't leave much room for interpretation.

Before analyzing the results, let me say that OIG delivered a comprehensive, well-designed research report. The methodology and analysis are meticulous and exhaustive—with data from more than 12,000 skilled nursing facilities, controls for patient age and diagnosis, clinical breakdowns based on therapy levels and activities of daily living (ADL), and perspectives based on facility ownership (chain or independent).

But the quality methodology produces some spurious conclusions. There's a lot of detail and data, so I'll summarize: Between 2006 and 2008, nursing homes increased Medicare billings for ultra high therapy and high ADL requirements. SNF chains and for-profits billed at even higher levels in those categories. Therefore, OIG concludes that SNFs are possibly (probably?) "gaming" the system by performing or billing for unnecessary clinical/therapy services for patients.

That conclusion ignores many factors. Post-acute care has and continues to become more medically complex. Facilities work hard to add therapy, clinical and care services that patients need and hospitals request, at no small expense. It follows that billings and reimbursements in those categories would increase.

And citing increases in specialized care and high-reimbursement billings from SNF chains and for-profits paints an incomplete picture. Perhaps those larger chains have been able to invest more in providing extended therapy and care services. Maybe they have been more aggressive in pursuing billings in reimbursement groups that pay higher rates. Or perhaps not, but the study unfairly excludes these possibilities from its analysis.

It just seems frustrating for HHS/OIG to take such an accusatory tone in the report—especially given that the research methodology and data are so good. This would have been a great opportunity to share the data with the skilled nursing community for collaborative analysis and discussion about trends in care and reimbursement. Instead, it's yet another example of regulators acting with good intentions, but needlessly punishing SNFs instead of working with them on the common goal of quality care.

$103 per Patient Day Lost to SNF Final Rule and Health Care Reform?

AHCA has posted a thorough, state-by-state breakdown of looming Medicare cuts for skilled nursing facilities based on the final PPS SNF rule and recently enacted health care reform legislation. (It's actually been up for more than a month, but I just discovered it.)

Now, $103 is an extreme, the projected cut in Medicare reimbursement per patient day in California by 2019. But even the immediate cuts are significant for all states, generally running between $12-$20 per patient day in 2010 and 2011 just based on changes in RUGs IV and other PPS adjustments.

  
 

AHCA Brings National Nursing Home Week 2010 to Facebook, Twitter

Yesterday kicked off AHCA's annual National Nursing Home Week, and they're spreading the word social media style. The NNHW Facebook page has 1,128 fans as of this posting, and active updates and sharing of ideas among the page's followers. And NNHW has a Twitter feed here, which is how I came across the Facebook page.

Some National Nursing Home Week Trivia from AHCA:

In what year was National Nursing Home Week founded? 
Answer: 1967 

What is the total number of nursing facility employees in the U.S.? 
Answer: Approximately 1.7 million 

What organization is the official partner of NNHW this year? 
Answer: The National Association of Activity Professionals (NAAP) 

What is the NNHW theme this year? 
Answer: Enriching Every Day 

What are the “Five Steps to Positive PR”? 
Answer: (1) Know Your Contacts; (2) Make It Personal; (3) All Hands on Deck; (4) One Reminder is Not Enough; (5) The Power of Follow-up.