Medicare IPPS FInal Rule and 2015 Rates by the Centers for Medicare & Medicaid Services on 08/22/2014

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2015 Rates; Quality Reporting Requirements for Specific Providers; Reasonable Compensation Equivalents for Physician Services in Excluded Hospitals and Certain Teaching Hospitals; Provider Administrative Appeals and Judicial Review; Enforcement Provisions for Organ Transplant Centers; and Electronic Health Record (EHR) Incentive Program

ACTION

Final Rule.

SUMMARY

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Protecting Access to Medicare Act of 2014, and other legislation. These changes are applicable to discharges occurring on or after October 1, 2014, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits are effective for cost reporting periods beginning on or after October 1, 2014.

We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014. In addition, we discuss our proposals on the interruption of stay policy for LTCHs and on retiring the “5 percent” payment adjustment for co-located LTCHs. While many of the statutory mandates of the Pathway for SGR Reform Act apply to discharges occurring on or after October 1, 2014, others will not begin to apply until 2016 and beyond.

In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or revising requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare.

We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers.

We are aligning the reporting and submission timelines for clinical quality measures for the Medicare EHR Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions.

In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.

https://www.federalregister.gov/articles/2014/08/22/2014-18545/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the

PCMH: Best Practices in Communication

Keeping patients healthy and out of the hospital requires team work. These two short simulations illustrate best practices in communication for medical practices and demonstrate the importance of proactive engagement.

Prescription Refills - Click the picture below to launch.
It is very dangerous for patients to skip medication. This 3 minute interaction illustrates how the front line staff can work with clinicians, patients, and caregivers to ensure timely medication refills.

Best Practices in Communication - Click the picture below to launch. 
This simulation illustrates how the front line staff can influence overall health outcomes.

Medicare Program; Evaluation Criteria and Standards for Quality Improvement Networks Quality Improvement Program Contracts

ACTION

Notice With Comment Period.

SUMMARY

This notice with comment period describes the general criteria we intend to use to evaluate the effectiveness and efficiency of the Quality Innovation Network (QIN) Quality Improvement Organizations (QIOs) that will enter into contracts with CMS under the Quality Innovation Network Quality Improvement Organizations (Solicitation Number: HHSM-500-2014-RFP-QIN-QIO) Statement of Work (SOW) on August 1, 2014. The evaluation of a QIN-QIO's performance related to their SOW will be based on evaluation criteria specified for the tasks and subtasks set forth inSections C.5, G.22 and G.29 of the QIN-QIO Base Contract and Attachment J-1(b) of the Base Contract; Attachment J-1 is QIN-QIO Task Order No. 001.

 

TABLE OF CONTENTSBack to Top

• DATES:
• ADDRESSES:
• FOR FURTHER INFORMATION CONTACT:
• SUPPLEMENTARY INFORMATION:
• I. Background
• II. Provisions of the Notice With Comment Period
• QIN-QIO Tasks
• Improving Cardiac Health and Reducing Cardiac Healthcare Disparities (See Section B.1 of Attachment J.1, QIN-QIO Task Order No. 001)
• Reducing Disparities in Diabetes Care: Everyone With Diabetes Counts (EDC) (See Section B.2 in Attachment J.1, QIN-QIO Task Order No. 001)
• Improving Prevention Coordination Through Meaningful Use of HIT and Collaborating With Regional Extension Centers (See Section B.4 in Attachment J.1, QIN-QIO Task Order No. 001)
• Reducing Healthcare-Associated Infections in Hospitals (See Section C.1 in Attachment J.1 of the QIN-QIO Task Order)
• Reducing Healthcare-Acquired Conditions in Nursing Homes (See Section C.2 in Attachment J.1, QIN-QIO Task Order No. 001)
• Coordination of Care (See Section C.3 in Attachment J.1,QIN-QIO Task Order No. 001)
• Quality Improvement Through Value-Based Payment, Quality Reporting, and the Physician Feedback Reporting Program (See Section D.1 in Attachment J.1, QIN-QIO Task Order No. 001)
• QIN-QIO-Proposed Projects That Advance Efforts for Better Care at Lower Cost (See Section D.2 in Attachment J.1, QIN-QIO Task Order No. 001)
• Quality Improvement Initiatives (See Section E.1 in Attachment J.1, QIN-QIO Task Order No. 001)
• III. Evaluation of the Tasks
• Annual and 54th Month Evaluation
• Overall Contract Evaluation
• Rounding Rules
• 1. Interim Calculations
• 2. Percentages/Proportions/Rates
• 3. Integers
• III. Collection of Information Requirements
• IV. Response to Comments
• VI. Regulatory Impact Statement

TABLESBack to Top

• Plan & Program Monitoring

DATES:Back to Top

Effective Date: August 1, 2014 to July 31, 2019 for the QIN-QIO contract.

Comment Date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on September 10, 2014.

ADDRESSES:Back to Top

In commenting, refer to file code CMS-3300-NC. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (please choose only one of the ways listed):

1. Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the “Submit a comment” instructions.

2. By regular mail. You may mail written comments to the following address only:

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Attention: CMS-3300-NC,

P.O. Box 8010,

Baltimore, MD 21244-1850.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments to the following address only:

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Attention: CMS-3300-NC,

Mail Stop C4-26-05,

7500 Security Boulevard,

Baltimore, MD 21244-1850.

4. By hand or courier. Alternatively, you may deliver (by hand or courier) your written comments only to the following addresses:

a. For delivery in Washington, DC—

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

Room 445-G, Hubert H. Humphrey Building,

200 Independence Avenue SW.,

Washington, DC 20201

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.)

b. For delivery in Baltimore, MD—

Centers for Medicare & Medicaid Services,

Department of Health and Human Services,

7500 Security Boulevard,

Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, call telephone number (410) 786-9994 in advance to schedule your arrival with one of our staff members. Comments erroneously mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

FOR FURTHER INFORMATION CONTACT:Back to Top

Alfreda Staton, (410) 786-4194.

https://www.federalregister.gov/articles/2014/08/11/2014-18901/medicare-program-evaluation-criteria-and-standards-for-quality-improvement-networks-quality

Simulations are Powerful Training Tools for your Health Care Organization

Using Simulations for Training Front Line Staff

• Research shows that the level of interactivity within a learning environment is what drives learning.

• The more the learner interacts with the content, the more likely that learning will actually occur.

Engagement Matters

The imperative to create meaningful instruction is stronger than ever, and simulations can drive that engagement!

Each year, the Gallup organization conducts research to measure the level of engagement of employees within organizations.

They use the following terms to describe the state of the employees:

• Actively Disengaged;
• Not Engaged; and
• Engaged

According to a meta-analysis of data compiled by Gallup, the average company has as many as 18% of its employees actively disengaged and 49% of employees not engaged.

Lack of engagement can lead to less productivity, higher accident rates, lower rates of quality, and higher employee turnover.

Reasons to Implement Simulations

• Most effective as an application of learning, rather than as primary learning.

• Help learners bridge the learn-do gap, turning knowledge into action.

• Illustrate the links between individual behavior change and overall organizational success.

Best Practices in Communication

This simulation illustrates how the front line staff can influence overall health outcomes. 

One of the most important jobs in this office is answering the phone. 

The moment you connect with the patient on the other end the care process has begun. 

This course illustrates the power of frontline staff and how their choices affect health outcomes. 

Click on the Picture Above to Launch Simulation

Championing Patient-Centered Innovation

They say that necessity is the mother of invention. Identify a pain that people suffer from and invent the remedy. Simple enough, right?

Parents from all over have Marion Donovan to thank for coming up with a solutin to the daily pain of cleaning cloth diapers. Without her disposable diaper idea, Victor Mills may never have created Pampers. Salute Josephine Cochran for patenting the first home dishwasher and Whitcomb Judson for creating the first zipper for clothing.

But what about the real pains in life? What are the remedies for chronic knee pain, arthritis or hospital-acquired infections? Where will the solutions for these and hundreds of other ailments come from? The medical-device industry is a multibillion dollar industry with researchers and product developers searching for cures. But an often-overlooked source for great ideas are those who live or work on the front lines of health care with the necessary insight and expertise to add to the invention process.

Doctors as inventors.

By training, doctors are always looking for ways to cure patients and many successful medical inventions have resulted from a physician questioning why something is done the way a certain way. 

Pathologist Stephen C. Wardlaw and endocrinologist Robert A. Levine invented a simple device for performing complete blood counts, theQBC-STAR, which the U.S. military tapped during Operation Desert Storm. A seasoned urologist, Dr. Errol Singh came up with the DirectVision device, which improved upon the practice of catheterization for men.  

In an article for Health Affairs Alex Chatterji demonstrated that physicians account for almost 20 percent of about 26,000 medical-device patents filed in the United States from 1990 to 1996. Most physicians who file medical-device patents are not at academic institutions but in a group, two-physician practice or solo practice, Chatterji observed, suggesting that these individual inventors would apply for many more patents if they had fewer barriers to filing.

Nurses as innovators.

Nurses have also been prolific innovators in heath care. Because nurses work so closely with patients, they often improvise ways to increase patient comfort, enhance treatment and facilitate care by developing workarounds: Myriad inventions have made their way from nurses' imagination into clinical practice.

For example, in the 1950s Bessie Blout developed a feeding-tube apparatus for amputees.

Emergency department nurse, Anita Dorr, developed the Crash Cart in 1968.

The I.V. House, an intravenous therapy product line, is the 1990 invention of mother-daughter duo Betty M. Rozier, an entrepreneur, and Lisa M. Vallino, a pediatric emergency nurse.

ColorSafe IV lines were developed by two registered nurses, Terri Barton-Salinas and Gail Barton-Hay in 2003.

Oncology and intensive care nurse, Terri Street came up with T-Tag, a tamper-proof, color-coded tag that attaches easily to intravenous, enteral and oxygen tubing. The color-coding (such as sea-green on Saturday), alerts nurses of day the tubing was put into use. 

Armed with medical knowledge and the compassion to provide care for those in need, doctors and nurses are in a perfect position to solve the problems facing health care. Involving these individuals in the dialogue about how improve patient care is critical for ensuring that the solutions developed have the biggest and most meaningful impact possible 

Collaborating to create new products. 

Numerous paths can bring a health-care invention idea to life, but in all cases, collaboration and the right connections are required. True innovation can occur when the brilliant ideas of physicians, nurses, other caregivers and patients are connected to the stakeholders and organizations capable of helping to bring those ideas to life. In an industry that is ripe for disruption, patient-centric innovation will lead to the discovery and deployment of products and processes that improve quality of care and positively affect patient outcome.

A new division of my company, Edison Nation Medical, provides a valuable resource in serving as a trusted partner to evaluate an idea, determine the efficacy and then develop the product to the point where it is ready to be licensed to a medical-products manufacturer. For example, operating room nurse Ginny Porowski developed a simple yet novel way for more safely disposing of surgical gowns after observing colleagues removing them and seeking a way to reduce the spread of hospital-acquired infections. Porowski partnered with Edison Nation Medical and today the GoGown is licensed to Medline Industries, a multibillion dollar distributor of medical products.

With similar inventiveness, Dr. William Nordt, an orthopedic surgeon, realized the lack of a simple, cost-effective remedy for those experiencing overuse injuries and created an elastomeric knee brace. He licensed the innovation to Donjoy Global in 2009 and today the Reaction Knee Brace is a widely used treatment option for chronic knee pain. Dr. Nordt developed and licensed his product with the help of my company, Eventys, which serves as the product development and engineering arm of Edison Nation.

Read More from http://www.entrepreneur.com/

HHS Report Finds Medicare Advantage Plans Exaggerate Members’ Diseases To Make More Money

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TOPICS: MEDICARE, DELIVERY OF CARE, HEALTH COSTS

By Fred Schulte, The Center For Public Integrity

AUG 07, 2014

This copyrighted story comes from . All rights reserved.

Many Medicare Advantage health plans routinely over bill the government for treating elderly patients — and have done it for years, a federal study shows.

Department of Health and Human Services researchers found that many plans exaggerate how sick their patients are and how much they cost to treat. Medicare expects to pay the privately run plans — an alternative to traditional Medicare —$160 billion this year.

The HHS study does not accuse any specific insurers of wrongdoing or name  the plans that were scrutinized. But the researchers offer the most comprehensive evidence to date that suspect billing practices have been common across much of the Medicare Advantage industry and are likely to get worse unless officials crack down.

“Further policy changes will likely be necessary,” the study concludes.

Congress created Medicare Advantage in 2003 to encourage private insurance companies to venture into the senior care market. The plans now insure 16 million elderly and disabled people, nearly a third of those eligible for Medicare. They are popular with seniors because they often provide extra benefits, such as eyeglasses and dental care, and can cost less out-of-pocket than standard Medicare.

Medicare pays the Advantage health plans higher rates for sicker patients and less for healthy people using a complex formula called a “risk score.” But the HHS study spells out several ways health plans have inflated those scores, from reporting surprisingly high levels of medical conditions such as alcohol or drug dependence to billing for an inordinately high number of patients with complications of diabetes.

Despite its broad implications for Medicare spending, the study by HHS researchers Richard Kronick and W. Pete Welch has attracted scant notice in Washington. It was quietly posted late last month on an online research site run by the Centers for Medicare & Medicaid Services, part of HHS.

Kronick directs the HHS Agency for Healthcare Research and Quality, whose mission is to improve health care delivery. Welch works for the HHS Office of the Assistant Secretary for Planning and Evaluation. The authors note that the study does not necessarily reflect HHS views, but both offices are influential in advising the government on policy matters.

CMS officials declined comment.  

“This is clearly impacting what taxpayers are paying for Medicare Advantage, I think, not in a good way,” said Dr. David Wennberg, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice who has studied Medicare billing trends.

Health care fraud expert Malcolm Sparrow, a professor at Harvard’s Kennedy School of Government, said the problems with billings based on risk scores reveal how “financial incentives” can improperly influence how medicine is practiced.

“The problem seems significant,” he said.

The new study amplifies the findings of a Center for Public Integrity investigation published in June. The investigation found that Medicare made nearly $70 billion in “improper” payments — mostly overcharges from inflated risk scores — to Medicare Advantage plans from 2008 through 2013. The center’s investigation also found that risk scores rose much faster in some health plans than others and that federal officials repeatedly yielded to industry pressure to minimize efforts to recoup overpayments.

Medicare Advantage plans are paid a set monthly fee for each patient based on the risk scores, and the government largely trusts the health plans to report the health status of people they enroll. About 70 medical conditions can boost payment rates.

Clare Krusing, a spokeswoman for America’s Health Insurance Plans, the industry’s trade group, said the higher billing resulted from health plans working with patients “to understand their specific health conditions, and consequently make sure they get the care they need.”

“What was not highlighted (in the study) is the fact that these programs have demonstrated improved quality in patients’ health,” she wrote in an email.

However, the study concludes that people who join Medicare Advantage plans are healthier than those who remain on standard Medicare, which pays doctors and hospitals for each service they provide. The study also says it’s “unlikely” the higher payments health plans derive from diagnosing more medical conditions “are related to substantial health benefits.”

In short, the numbers of patients diagnosed with diseases which result in higher payments increased far faster at many Medicare Advantage health plans than among people on standard Medicare. Exaggerating the severity of a medical condition to raise fees is known in medical circles as “upcoding.”

For instance, “drug and alcohol dependence” is as much as eight times more common in the highest coding Medicare Advantage plans than among patients in standard Medicare.

Even more striking, according to the study, is how much higher reported diabetes rates have been in certain health plans than others. The study tracked rapid rises in many medical conditions from 2004, when risk scoring began, through last year, and made them public for the first time.

Overall, diabetes with serious complications, which pays higher rates, was reported up to five times more often among enrollees in some Medicare Advantage plans than among people on standard Medicare. Conditions such as major depression also were far more common in some plans than others.

Holly J. Cassano, a medical coding consultant in Florida, said the government’s decision to make the billing data public was “an enormous leap … in the right direction for continued transparency in all areas of health care.”

 “The main issue, now that it has been revealed, is ‘upcoding’, which no one likes to discuss, but the data is in black and white and speaks volumes,” Cassano, CEO of Accucode Consulting, wrote in an email.

Medicare Advantage enjoys solid political backing on Capitol Hill and has successfully fought back efforts by the Obama administration to make substantial cuts to its payment rates. Lobbying by the insurance industry and the fear of angering seniors also has largely quieted concerns in Congress that Medicare Advantage plans can be a poor value for taxpayers.

Congress recognized problems with Medicare Advantage coding as far back as 2005, when lawmakers directed CMS to find ways to cut back on rising, and presumably unjustified, risk scores. But CMS didn’t act until 2010, when it adjusted risk scores downward. The Affordable Care Act theoretically requires further reductions, but the political storm over the planned cuts has made their fate uncertain.  

CMS has cut back payment levels for several diseases that appear to have prompted upcoding by Medicare Advantage plans. But the study’s authors noted that health plans are likely to find new conditions to replace lost revenue.

Even though the study does not name plans, it says all those examined had at least 10,000 members and that one plan among the highest billers had more than 200,000 members. The study indicates that the longer patients stay in Medicare Advantage, the more their risk scores rose, suggesting that government’s failure to reel in coding has been costly.

The Center for Public Integrity has sought similar billing data from CMS for the past year as well as the names of Medicare Advantage plans that have been suspected of overbilling the government — and by how much. In late May, the Center sued the Department of Health and Human Services to make its Medicare Advantage audits and other related records public. The lawsuit is pending.

Last month, CMS published a draft regulation that would allow for “a formal process to recoup overpayments” made to the health plans. A final decision on the proposal is due by Nov. 1.

http://www.kaiserhealthnews.org/Stories/2014/August/07/Medicare-advantage-plans-exaggerate-diseases-to-make-money-says-study.aspx