CMMI Demonstration to Reduce NH Hospitalizations Moves to Phase 2

Abstract

Many readers are familiar with the Center for Medicare & Medicaid Innovation and Medicare and Medicaid Coordination Office (CMMI-MMCO) ongoing project on reducing hospitalizations in nursing home residents. Now finishing its fourth year, recent data have shown all seven previously selected sites to have demonstrated variable but statistically significant reductions in total hospitalizations, avoidable hospitalizations, ED visits, and total costs. These seven sites, referred to as Enhanced Care and Coordination Providers (ECCP) have varied in their approaches, but all have used INTERACT tools and support staff of some sort. The two most successful projects have used advanced practice nurses (APRNs) and telemedicine to detect change in condition earlier and support ongoing treatment.One of the lingering questions from these studies is whether performance would have been even better if fiscal goals were aligned. The projects reduced hospitalizations, but the facilities engendered caring for a higher acuity of patients with no additional revenue, and they lost potential skilled nursing facility Medicare Part A revenue had the patients been hospitalized. The physicians lost revenue due to lower reimbursement from using nursing home codes instead of the more fiscally rewarding hospital codes. Additionally, the physicians often spent quite a bit of non-reimbursed time on care planning activities with family and staff.Building a Better MousetrapCMMI-MMCO understood this potential problem in optimal reduction of reducing hospitalizations and has developed a phase 2 project that will start in October 2016. This project has two interesting components to it. First, there is a mechanism whereby the facility and the physician will receive enhanced payments for caring for ill individuals meeting set criteria that would historically often be sent to the hospital for care. This approach should help determine if additional funding will allow more people to be adequately cared for without a hospitalization. The second component is designed to determine whether the original interventions, such as APRNs and telemedicine, plus the additional payments, prove to be superior to merely providing the additional payments. This aspect of the project will entail comparing the original facilities used to matched additional homes in the same general geographic area. These additional homes will have had no ECCP support or training.Research has shown that up to 80% of avoidable hospitalizations result from six common conditions, including pneumonia, urinary tract infections, cellulitis/skin ulcers, chronic obstructive pulmonary disease/asthma, dehydration, and congestive heart failure. This project will require meeting set criteria to establish the required diagnosis and receive the enhanced payment. For example, meeting the diagnosis of pneumonia will require chest x-ray confirmation of a new pulmonary infiltrate or two or more of the following:•%Fever >100°F (oral) or 2° above baseline•%Blood oxygen saturation level <92% on room air or on usual O2 settings in patients with chronic oxygen requirements•%Respiratory rate above 24 breaths/minute•%Evidence of focal pulmonary consolidation on exam, including rales, rhonchi, decreased breath sounds, or dullness to percussionPayment is limited to 7 days, but if the patient is still sick enough on day 8 to meet all the criteria for diagnosis, they can be treated for an additional period.How Will Physician Be Affected?The physician will be required to visit the patient by the end of the second day after notification by the facility of the acute change in condition. A physician or nurse practitioner must make the visit (or perform an appropriate telemedicine visit) within this interval both to receive their enhanced payment and to verify the diagnosis and ensure enhanced payment for the facility. A new CPT code will be billed that will average $70 more than previously allowable codes — basically the same reimbursement as a high-level hospital visit. Coding requirements are similar to other evaluation and management codes involving moderate to high complexity. This new code may only be used for the first visit involving the change in condition, and subsequent visits would be billable at current rates using existing codes. If the practitioner visits the patient because the facility suspects the beneficiary has one of the six targeted conditions, but upon examination it turns out they do not (e.g., bronchitis instead of pneumonia), the practitioner may still bill the new code for this service. Basically, the practitioner is being paid in good faith for a timely visit to address a serious threat of hospitalization.The practitioner is also eligible to use a new Care Coordination CPT code to receive payment for participation in nursing facility conferences and engaging in care coordination discussions with beneficiaries, their caregivers, and the long-term care facility interdisciplinary team. Issues that could be discussed include:•%Present illness and current health status, typical outcomes, scenarios, events, or prognosis•%Daily routine to help the facility deliver person-centered care•%Measurable goals agreed to jointly by the resident, representative(s), caregiver(s), and the interdisciplinary care team•%Necessary interventions to address the underlying risk factors for hospitalization•%Clinically appropriate preventive services•%Development, updating, or confirmation of a person-centered care plan•%Resources needed ability to potentially be discharged to the community•%Establishment of a health care proxyIn order to bill for this care coordination service, the practitioner must conduct the discussion with the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary in a conference for a minimum of 25 minutes. At least one member of the LTC facility must be involved, and no examination of the beneficiary is required. The code can be billed only once per year in the absence of a significant change in condition. The code can also be billed within 14 days of a significant change in condition that increases the likelihood of a hospital admission and must be reflected in a comprehensive MDS assessment. Current payment is projected to be $78, or roughly equivalent to the advance care planning codes for the first half hour of conversation.What About the Facility?The facility caring for the patient with a qualifying diagnosis will also receive additional funds. These funds are to be used for the additional services, staff training and equipment needed to care for such patients. Examples of such activities could include:•%Implementation of quality improvement programs (e.g., INTERACT)•%Training to avoid acute changes in condition; purchasing of tools that aid in the early identification and treatment of changes in conditions (e.g., Society clinical practice guidelines, toolkits, and Know-It-All cards)•%Increased nursing presence and training in the facility•%Enhanced provision of respiratory, complex wound, and intravenous therapies•%New equipment to aid in assessments (e.g., bladder scanners, cardiac monitoring)•%Health information technologyThe Payment-Only group is only open to newly-recruited facilities. To participate in the Payment-Only Group, a facility must not be on the CMS list of Special Focus Facilities; must not have had any sanctions, indictments, probations, corrective action plans, or judgments imposed in the past 3 years relating to fraudulent or abusive billing practices; and be Medicare and Medicaid certified and not excluded from participation in the Medicare or Medicaid programs. The facility must have at least a Three-Star overall rating on Nursing Home Compare as of the date of the funding announcement (Aug. 27, 2015).The practitioner must verify the qualifying diagnosis in a timely fashion, or the facility will not receive payment. Currently the daily reimbursement to the facility is $218 per day, with a 7-day period per most episodes of illness. If the patient is hospitalized in the middle of the facility treatment, they will receive a prorated fee for the days they were treated in the facility.How Value-Based Medicine Fits InThe basic tenets of value-based medicine are well aligned with the goals of this project. The majority of ill long-term care patients have better outcomes if they can be treated there. Avoidance of delirium associated with transitions of care, timely administration of antibiotics, and the ability of the staff to know and more accurately describe subtle but significant changes are all examples of benefits to the resident treated in the facility. The cost savings can be substantial — the average pneumonia treated in the facility under this model would likely be less than $2,500, whereas the average cost in the hospital is about $15,000.Translating the success of this project into the real world of medical practice will take time. The form it takes will depend partly on the results of phase 2, but it’s likely that some sort of enhanced payment mechanism for the facility and treating practitioner will become a reality.Dr. Crecelius is a multifacility medical director for Delmar Gardens Nursing Homes and assistant clinical professor of Internal Medicine and Geriatrics at Washington University School of Medicine, both in St. Louis. He also is a past president of the Society and current chair of the Payment and Practice Management Public Policy Subcommittee. Many readers are familiar with the Center for Medicare & Medicaid Innovation and Medicare and Medicaid Coordination Office (CMMI-MMCO) ongoing project on reducing hospitalizations in nursing home residents. Now finishing its fourth year, recent data have shown all seven previously selected sites to have demonstrated variable but statistically significant reductions in total hospitalizations, avoidable hospitalizations, ED visits, and total costs. These seven sites, referred to as Enhanced Care and Coordination Providers (ECCP) have varied in their approaches, but all have used INTERACT tools and support staff of some sort. The two most successful projects have used advanced practice nurses (APRNs) and telemedicine to detect change in condition earlier and support ongoing treatment. One of the lingering questions from these studies is whether performance would have been even better if fiscal goals were aligned. The projects reduced hospitalizations, but the facilities engendered caring for a higher acuity of patients with no additional revenue, and they lost potential skilled nursing facility Medicare Part A revenue had the patients been hospitalized. The physicians lost revenue due to lower reimbursement from using nursing home codes instead of the more fiscally rewarding hospital codes. Additionally, the physicians often spent quite a bit of non-reimbursed time on care planning activities with family and staff. Building a Better MousetrapCMMI-MMCO understood this potential problem in optimal reduction of reducing hospitalizations and has developed a phase 2 project that will start in October 2016. This project has two interesting components to it. First, there is a mechanism whereby the facility and the physician will receive enhanced payments for caring for ill individuals meeting set criteria that would historically often be sent to the hospital for care. This approach should help determine if additional funding will allow more people to be adequately cared for without a hospitalization. The second component is designed to determine whether the original interventions, such as APRNs and telemedicine, plus the additional payments, prove to be superior to merely providing the additional payments. This aspect of the project will entail comparing the original facilities used to matched additional homes in the same general geographic area. These additional homes will have had no ECCP support or training.Research has shown that up to 80% of avoidable hospitalizations result from six common conditions, including pneumonia, urinary tract infections, cellulitis/skin ulcers, chronic obstructive pulmonary disease/asthma, dehydration, and congestive heart failure. This project will require meeting set criteria to establish the required diagnosis and receive the enhanced payment. For example, meeting the diagnosis of pneumonia will require chest x-ray confirmation of a new pulmonary infiltrate or two or more of the following:•%Fever >100°F (oral) or 2° above baseline•%Blood oxygen saturation level <92% on room air or on usual O2 settings in patients with chronic oxygen requirements•%Respiratory rate above 24 breaths/minute•%Evidence of focal pulmonary consolidation on exam, including rales, rhonchi, decreased breath sounds, or dullness to percussionPayment is limited to 7 days, but if the patient is still sick enough on day 8 to meet all the criteria for diagnosis, they can be treated for an additional period. CMMI-MMCO understood this potential problem in optimal reduction of reducing hospitalizations and has developed a phase 2 project that will start in October 2016. This project has two interesting components to it. First, there is a mechanism whereby the facility and the physician will receive enhanced payments for caring for ill individuals meeting set criteria that would historically often be sent to the hospital for care. This approach should help determine if additional funding will allow more people to be adequately cared for without a hospitalization. The second component is designed to determine whether the original interventions, such as APRNs and telemedicine, plus the additional payments, prove to be superior to merely providing the additional payments. This aspect of the project will entail comparing the original facilities used to matched additional homes in the same general geographic area. These additional homes will have had no ECCP support or training. Research has shown that up to 80% of avoidable hospitalizations result from six common conditions, including pneumonia, urinary tract infections, cellulitis/skin ulcers, chronic obstructive pulmonary disease/asthma, dehydration, and congestive heart failure. This project will require meeting set criteria to establish the required diagnosis and receive the enhanced payment. For example, meeting the diagnosis of pneumonia will require chest x-ray confirmation of a new pulmonary infiltrate or two or more of the following: •%Fever >100°F (oral) or 2° above baseline•%Blood oxygen saturation level <92% on room air or on usual O2 settings in patients with chronic oxygen requirements•%Respiratory rate above 24 breaths/minute•%Evidence of focal pulmonary consolidation on exam, including rales, rhonchi, decreased breath sounds, or dullness to percussion Payment is limited to 7 days, but if the patient is still sick enough on day 8 to meet all the criteria for diagnosis, they can be treated for an additional period. How Will Physician Be Affected?The physician will be required to visit the patient by the end of the second day after notification by the facility of the acute change in condition. A physician or nurse practitioner must make the visit (or perform an appropriate telemedicine visit) within this interval both to receive their enhanced payment and to verify the diagnosis and ensure enhanced payment for the facility. A new CPT code will be billed that will average $70 more than previously allowable codes — basically the same reimbursement as a high-level hospital visit. Coding requirements are similar to other evaluation and management codes involving moderate to high complexity. This new code may only be used for the first visit involving the change in condition, and subsequent visits would be billable at current rates using existing codes. If the practitioner visits the patient because the facility suspects the beneficiary has one of the six targeted conditions, but upon examination it turns out they do not (e.g., bronchitis instead of pneumonia), the practitioner may still bill the new code for this service. Basically, the practitioner is being paid in good faith for a timely visit to address a serious threat of hospitalization.The practitioner is also eligible to use a new Care Coordination CPT code to receive payment for participation in nursing facility conferences and engaging in care coordination discussions with beneficiaries, their caregivers, and the long-term care facility interdisciplinary team. Issues that could be discussed include:•%Present illness and current health status, typical outcomes, scenarios, events, or prognosis•%Daily routine to help the facility deliver person-centered care•%Measurable goals agreed to jointly by the resident, representative(s), caregiver(s), and the interdisciplinary care team•%Necessary interventions to address the underlying risk factors for hospitalization•%Clinically appropriate preventive services•%Development, updating, or confirmation of a person-centered care plan•%Resources needed ability to potentially be discharged to the community•%Establishment of a health care proxyIn order to bill for this care coordination service, the practitioner must conduct the discussion with the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary in a conference for a minimum of 25 minutes. At least one member of the LTC facility must be involved, and no examination of the beneficiary is required. The code can be billed only once per year in the absence of a significant change in condition. The code can also be billed within 14 days of a significant change in condition that increases the likelihood of a hospital admission and must be reflected in a comprehensive MDS assessment. Current payment is projected to be $78, or roughly equivalent to the advance care planning codes for the first half hour of conversation. The physician will be required to visit the patient by the end of the second day after notification by the facility of the acute change in condition. A physician or nurse practitioner must make the visit (or perform an appropriate telemedicine visit) within this interval both to receive their enhanced payment and to verify the diagnosis and ensure enhanced payment for the facility. A new CPT code will be billed that will average $70 more than previously allowable codes — basically the same reimbursement as a high-level hospital visit. Coding requirements are similar to other evaluation and management codes involving moderate to high complexity. This new code may only be used for the first visit involving the change in condition, and subsequent visits would be billable at current rates using existing codes. If the practitioner visits the patient because the facility suspects the beneficiary has one of the six targeted conditions, but upon examination it turns out they do not (e.g., bronchitis instead of pneumonia), the practitioner may still bill the new code for this service. Basically, the practitioner is being paid in good faith for a timely visit to address a serious threat of hospitalization. The practitioner is also eligible to use a new Care Coordination CPT code to receive payment for participation in nursing facility conferences and engaging in care coordination discussions with beneficiaries, their caregivers, and the long-term care facility interdisciplinary team. Issues that could be discussed include: •%Present illness and current health status, typical outcomes, scenarios, events, or prognosis•%Daily routine to help the facility deliver person-centered care•%Measurable goals agreed to jointly by the resident, representative(s), caregiver(s), and the interdisciplinary care team•%Necessary interventions to address the underlying risk factors for hospitalization•%Clinically appropriate preventive services•%Development, updating, or confirmation of a person-centered care plan•%Resources needed ability to potentially be discharged to the community•%Establishment of a health care proxy In order to bill for this care coordination service, the practitioner must conduct the discussion with the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary in a conference for a minimum of 25 minutes. At least one member of the LTC facility must be involved, and no examination of the beneficiary is required. The code can be billed only once per year in the absence of a significant change in condition. The code can also be billed within 14 days of a significant change in condition that increases the likelihood of a hospital admission and must be reflected in a comprehensive MDS assessment. Current payment is projected to be $78, or roughly equivalent to the advance care planning codes for the first half hour of conversation. What About the Facility?The facility caring for the patient with a qualifying diagnosis will also receive additional funds. These funds are to be used for the additional services, staff training and equipment needed to care for such patients. Examples of such activities could include:•%Implementation of quality improvement programs (e.g., INTERACT)•%Training to avoid acute changes in condition; purchasing of tools that aid in the early identification and treatment of changes in conditions (e.g., Society clinical practice guidelines, toolkits, and Know-It-All cards)•%Increased nursing presence and training in the facility•%Enhanced provision of respiratory, complex wound, and intravenous therapies•%New equipment to aid in assessments (e.g., bladder scanners, cardiac monitoring)•%Health information technologyThe Payment-Only group is only open to newly-recruited facilities. To participate in the Payment-Only Group, a facility must not be on the CMS list of Special Focus Facilities; must not have had any sanctions, indictments, probations, corrective action plans, or judgments imposed in the past 3 years relating to fraudulent or abusive billing practices; and be Medicare and Medicaid certified and not excluded from participation in the Medicare or Medicaid programs. The facility must have at least a Three-Star overall rating on Nursing Home Compare as of the date of the funding announcement (Aug. 27, 2015).The practitioner must verify the qualifying diagnosis in a timely fashion, or the facility will not receive payment. Currently the daily reimbursement to the facility is $218 per day, with a 7-day period per most episodes of illness. If the patient is hospitalized in the middle of the facility treatment, they will receive a prorated fee for the days they were treated in the facility. The facility caring for the patient with a qualifying diagnosis will also receive additional funds. These funds are to be used for the additional services, staff training and equipment needed to care for such patients. Examples of such activities could include: •%Implementation of quality improvement programs (e.g., INTERACT)•%Training to avoid acute changes in condition; purchasing of tools that aid in the early identification and treatment of changes in conditions (e.g., Society clinical practice guidelines, toolkits, and Know-It-All cards)•%Increased nursing presence and training in the facility•%Enhanced provision of respiratory, complex wound, and intravenous therapies•%New equipment to aid in assessments (e.g., bladder scanners, cardiac monitoring)•%Health information technology The Payment-Only group is only open to newly-recruited facilities. To participate in the Payment-Only Group, a facility must not be on the CMS list of Special Focus Facilities; must not have had any sanctions, indictments, probations, corrective action plans, or judgments imposed in the past 3 years relating to fraudulent or abusive billing practices; and be Medicare and Medicaid certified and not excluded from participation in the Medicare or Medicaid programs. The facility must have at least a Three-Star overall rating on Nursing Home Compare as of the date of the funding announcement (Aug. 27, 2015). The practitioner must verify the qualifying diagnosis in a timely fashion, or the facility will not receive payment. Currently the daily reimbursement to the facility is $218 per day, with a 7-day period per most episodes of illness. If the patient is hospitalized in the middle of the facility treatment, they will receive a prorated fee for the days they were treated in the facility. How Value-Based Medicine Fits InThe basic tenets of value-based medicine are well aligned with the goals of this project. The majority of ill long-term care patients have better outcomes if they can be treated there. Avoidance of delirium associated with transitions of care, timely administration of antibiotics, and the ability of the staff to know and more accurately describe subtle but significant changes are all examples of benefits to the resident treated in the facility. The cost savings can be substantial — the average pneumonia treated in the facility under this model would likely be less than $2,500, whereas the average cost in the hospital is about $15,000.Translating the success of this project into the real world of medical practice will take time. The form it takes will depend partly on the results of phase 2, but it’s likely that some sort of enhanced payment mechanism for the facility and treating practitioner will become a reality.Dr. Crecelius is a multifacility medical director for Delmar Gardens Nursing Homes and assistant clinical professor of Internal Medicine and Geriatrics at Washington University School of Medicine, both in St. Louis. He also is a past president of the Society and current chair of the Payment and Practice Management Public Policy Subcommittee. The basic tenets of value-based medicine are well aligned with the goals of this project. The majority of ill long-term care patients have better outcomes if they can be treated there. Avoidance of delirium associated with transitions of care, timely administration of antibiotics, and the ability of the staff to know and more accurately describe subtle but significant changes are all examples of benefits to the resident treated in the facility. The cost savings can be substantial — the average pneumonia treated in the facility under this model would likely be less than $2,500, whereas the average cost in the hospital is about $15,000. Translating the success of this project into the real world of medical practice will take time. The form it takes will depend partly on the results of phase 2, but it’s likely that some sort of enhanced payment mechanism for the facility and treating practitioner will become a reality. Dr. Crecelius is a multifacility medical director for Delmar Gardens Nursing Homes and assistant clinical professor of Internal Medicine and Geriatrics at Washington University School of Medicine, both in St. Louis. He also is a past president of the Society and current chair of the Payment and Practice Management Public Policy Subcommittee.