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


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

• 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


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.


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


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


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


Paid Claims Error Rate

• A paid claims error rate is also calculated for each Medicare contractor

• Part of CMS’ evaluation of contractor effectiveness


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”.


CERT Experience

• “Insufficient documentation” is a major cause of errors identified within the CERT review process


Palmetto GBA’s Experience

• Many health care organizations are struggling with the complex task of collecting and organizing clinical information addressing chronic, disabling conditions.


“I Hear the Train a Comin’… ”

• The Medicare population is growing– 19.1 million in 1966– 43.1 million in 2006– 126% increase


“…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


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


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)


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)?


Diagnosis Alone is Insufficient

Potential confounding factors

ICD-9-CM Outcomes

Health Status of Individual


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.


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


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’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


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


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


Case Scenarios

• What would you recommend?– Inpatient Rehabilitation Hospital– Skilled Nursing Facility– Outpatient Hospital– Home Health Services


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


Case Scenario #1

• Body Structures– Structures related to movement


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


Case Scenario #1

• Activities and Participation– Mobility– Self-care

• Environmental Factors– Products and technology– Support and relationships


Case Scenario #2

• Body Structures– Structures related to movement


Case Scenario #2

• Body Functions– Sensory functions and pain– Neuromusculoskeletal and movement-

related functions


Case Scenario #2

• Activities and Participation– Mobility– Self-care

• Environmental Factors– Products and technology– Support and relationships


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


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

Palmetto GBA © 2006 Decision-Support in Post-Acute Care Harry Feliciano, MD, MPH Director, Part A...

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