Transcript Slide 1

Texas Hospital Association
October 22, 2012
Rochelle Archuleta, AHA Policy
Aimee Hartlage, AHA Federal Relations
S. 1486
LTCH Improvement Act
Background &
Proposed Modifications
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LTCHs treat far greater proportion of patients
with Level 4 SOI (extreme severity)
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Goals for LTCH Criteria
• Demonstrate a unique and valuable role for LTCHs.
• Distinguish LTCHs from all other settings. (general acute
hospitals; other post-acute providers)
• Concentrate LTCHs on highest complexity, long-stay patients
• Proactively define LTCHs, rather than wait for CMS.
– Pending CMS proposal likely to be harsh on LTCHs.
• Achieve regulatory stability through meaningful
minimum standards.
• Provide bridge to the future delivery system reforms
and common patient assessment tool.
– Making a strong value case for LTCHs helps preserve future role for LTCHs
• Achieve support from AHA’s LTCH members.
• Generate savings for Congress.
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How do the criteria work?
• Implement new minimum standards for LTCH
patients and facilities.
• Provide policymakers with an insurance policy (ie,
the retrospective 70% Rule facility criterion) that
LTCHs are treating high acuity patients.
• Prohibit LTCHs from admitting patients suitable for
inpatient rehab and inpatient psych level care.
• Require all LTCHs to provide ventilator weaning
services. (19 LTCHs do not)
• Proposal does not alter the existing requirement
that LTCHs maintain an average length of stay
greater than 25 days.
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How were the criteria developed?
• Stage I. A consensus panel of experts developed
the criteria proposal in 2010.
– Panel: 14 hospital representatives, including 10 NFP reps
• Stage II. Following extensive advocacy of the
criteria, as introduced in S.1486, AHA convened a
smaller panel to refine the original proposal.
− Panel: 9 hospital representatives, including 6 NFP reps
• Data Analysis. Extensive data analysis by The
Moran Company from Summer 2010 through
present has validated the criteria framework.
– The analysis confirmed that the criteria proposal would
focus LTCHs on treating the highest overall acuity level
relative to all other health settings.
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For S1486 details, see At-A-Glance document.
www.aha.org/ltch
S.1486
Criteria Framework
Patient
Admission
Criteria
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Facility
Criteria
Retrospective
Facility
Criterion
(70% Rule)
Proposed Refinements to
Criteria Provisions in
S.1486
Criteria Modifications: Psych Patients
Revise Preadmission Criteria and Add New Patient Admissions
Criterion: LTCHs shall not admit patients who, at the time of
admission, have a primary medical need of inpatient psychiatric care.
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•
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S.1486: Prohibits IRF-like patients. Does not address psych patients.
Objective: Prohibit admission of rehab and psych patients to maximize
the LTCH distinction from IRF and IPF settings.
Prohibited psych patients are identified by their admitting diagnosis since
this admission criterion would be applied by the LTHC physician
conducting the patient admission evaluation.
Also a technical change to add the S.1486 prohibition on rehabilitation
patients to the preadmission screening criteria, in addition to the
admission criteria.
Admissions Criteria: Secondary Diagnoses
Criteria Refinement: Require a minimum of 5
secondary diagnoses for an LTCH admission.
• S.1486: At least 2 secondary diagnoses required
• Objective:
– Raise the standard.
– Set minimum standard to align with what knowledge is
available to the LTCH physician at the point of admission.
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Admissions Criteria: Continued Stays
Criteria Modification: Narrow the provision
S.1486: Continued stay assessments must occur at least weekly.
For cases that no longer need hospital-level care and lack a safe
discharge option, for the remaining days, pay LTCH PPS per
diem, up to the DRG.
– Must notify the bene of the continued stay assessment outcome.
– Must continue to actively seek a safe discharge option.
• Maintain S.1486’s requirement for weekly continued stay
assessments.
• Eliminate the payment component of this provision.
– Leave this to the Medicare manual provisions.
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Additional Facility Criterion: Vent Services
New Facility Criterion: LTCHs must have
the equipment and clinical personnel
needed to provide ventilator weaning
services.
S.1486: Does not require vent services.
Background:
– LTCHs are distinguished by the excellence of
their specialized ventilator-weaning programs.
– Policy analysis shows that LTCHs bring unique
value to the Medicare program for beneficiaries
receiving ventilator services.
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“70% Rule” 2.0
Streamline the 70% Rule version in S.1486:
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70% threshold
Cases with at least 3 CC/MCCs
Cases with a ventilator procedure code will count
Remove LOS criterion
Remove STACH Outlier criterion.
CC/MCCs
• CMS: The MS-DRG CC/MCCs target sicker patients;
• CC/MCCs are correlated with the APR-DRG SOI; and
• CC/MCC data are administratively feasible to CMS.
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Other S.1486 Changes
• Add 2-year moratorium on LTCH hospitals,
satellites and beds
– 2-year extension is seamless with MMSEA’s 5-year
moratorium.
– Eliminate the MMSEA moratorium exceptions
• 2-year freeze of 25% Rule (at 50%/75% levels)
– Instead of 25% Rule elimination under S.1486
– Extend CMS’s 25% Rule relief through discharges on and
before Sept 30, 2014.
• Removed provision seeking to eliminate the 1time budget neutrality adjustment
• Removed provision seeking to eliminate the
very short stay outlier policy
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Achieving Compliance
Transition assistance for LTCHs that are noncompliant with the “70% Rule”
• Multi-Year Phase-in
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6-month cure period for LTCHs that fail 70% Rule
test.
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2-year phase-in for not-for-profit and for-profit LTCHs
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Year 1: 60%; Year 2: 70%
3-year phase in for the govt-owned LTCHS
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Year 1: 60%; Year 2: 65%; Year 3: 70%
Modeled after existing cure period for LTCH 25-day
ALOS requirement.
Timing
Seamless extension of MMSEA moratorium
and CMS’s new 25% Rule relief.
Start Date
Criteria
OPTIONS:
Ongoing
-- 6 months after enactment
-- October 1, 2012
-- Other?
Moratorium Dec 29, 2012
(Seamless with end of
MMSEA moratorium)
25% Rule Relief Discharges beginning
October 1, 2012
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End Date
Dec 28, 2014
Discharges
through
Sept 30, 2014
Facility Compliance
NFP v FP Facility Compliance Levels:
When you combine the compliant and near-compliant (within 10%) LTCHs, facility
compliance levels are very close for NFP and FP LTCHs.
70% Rule Compliance
Overall Case Compliance
Overall Facility Compliance
FP Facility Compliance
NFP Facility Compliance
Govt-Owned Fac. Compliance
Compliant + Near Compliant Facilities
For-Profit Compliant + Near Compliant
Not-For-Profit Compliant + Near Compliant
AHA Analysis
80%
82%
86%
79%
33%
91%
94%
91%
"Near compliers" are within 10% of compliance with the 70% Rule.
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Criteria Encourage High Acuity
The criteria proposal favors every LTCH that treats a high
acuity patient mix.
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100% of LTCHs will have to modify their admissions standards to reflect
these more stringent standards;
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This proposal is about the type of patients of treated in LTCHs; not about the
ownership status of LTCHs;
The proposal intentionally raises the bar for LTCH admissions to build
credibility with Congress and other policymakers; and demonstrate LTCH
value by ensuring a level of service that is unmatched by any other setting.
A very high rate of NFP LTCHs (79%) comply with the proposal, including
very highly regarded NFP LTCHs (e.g., Partners; CHRISTUS; RML; Barlow).
When compliant and near-compliant (within 10%) LTCHs are combined, FP
(94%) and NFP (91%) compliance levels are very similar.
Examining Compliers vs. Non-compliers
Percent of Cases in Excluded Categories as a Percent of All Cases
Within Compliant, Non-Compliant and All LTCHs
3.5%
3.0%
Percentage of Total Cases
3.0%
2.5%
2.2%
2.0%
1.5%
1.0%
Compliant
LTCHs
(N=357)
1.3%
1.2%
1.0%
0.8%
0.7%
Non-Compliant
LTCHs (N=77)
0.7%
0.4%
0.5%
0.0%
Psych Cases
Source: 2011 MedPAR Data, POS Data, and LTCH Impact File
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All LTCHs
(N=434)
Rehab Cases
Cases with < 5 SDX
Examining Compliers vs. Non-compliers
Average Number of CC/MCCs
6.0
5.2
5.3
Average # of CC/MCCs
5.0
4.0
3.0
2.7
2.0
1.0
0.0
All LTCHs (N=434)
Compliant + Near-Compliant Non-Compliant LTCHs Excl.
LTCHs (N=397)
Near-Compliant (N=37)
Analysis of the 2011 Medicare Provider Analysis and Review (MedPAR) dataset (March 2012 update).
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LTCH Payments by Category
Category
Total Medicare
Payment
(2011 MEDPAR)
($ in Millions)
< 5 SDX
Rehab
Psych
Non-compliant cases
Compliant cases
All Cases
All Cases minus
Exclusions
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$24
$25
$27
$691
$4,678
$5,445
$5,369
Rochelle Archuleta
AHA Policy
[email protected]
Aimee Hartlage
AHA Federal Relations
[email protected]
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