Transcript The Value of ICF

Decision-Support in Post-Acute Care
Harry Feliciano, MD, MPH
Director, Part A Medical Affairs
Palmetto GBA © 2006
Presentation Overview
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Rationale for Going Beyond Diagnosis®
The Public Health Context
The Need for Decision-Support
Palmetto GBA’s Approach
ICF-enhanced Case Scenarios
Summary
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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
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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.
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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-forservice (FFS) payments
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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
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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
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Paid Claims Error Rate
• A paid claims error rate is also calculated
for each Medicare contractor
• Part of CMS’ evaluation of contractor
effectiveness
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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”.
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CERT Experience
• “Insufficient documentation” is a major
cause of errors identified within the CERT
review process
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Palmetto GBA’s Experience
• Many health care organizations are
struggling with the complex task of
collecting and organizing clinical
information addressing chronic, disabling
conditions.
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“I Hear the Train a Comin’… ”
• The Medicare population is growing
– 19.1 million in 1966
– 43.1 million in 2006
– 126% increase
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“…It’s Rolling Round the Bend”
65 yrs and over
75 yrs and over
85 yrs and over
100
Population in
millions
80
60
40
20
0
2025
2050
2075
Year
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2080
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:
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Coronary Heart Disease
Hypertension
Stroke
Congestive Heart Failure
Dementia
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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)
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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)?
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Diagnosis Alone is Insufficient
Potential confounding factors
ICD-9-CM
Outcomes
Health Status of Individual
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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 wellunderstood 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.
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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
Palmetto GBA © 2007
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
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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
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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 110
http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf
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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
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Case Scenarios
• What would you recommend?
– Inpatient Rehabilitation Hospital
– Skilled Nursing Facility
– Outpatient Hospital
– Home Health Services
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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
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Case Scenario #1
• Body Structures
– Structures related to movement
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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
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Case Scenario #1
• Activities and Participation
– Mobility
– Self-care
• Environmental Factors
– Products and technology
– Support and relationships
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Case Scenario #2
• Body Structures
– Structures related to movement
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Case Scenario #2
• Body Functions
– Sensory functions and pain
– Neuromusculoskeletal and movementrelated functions
Palmetto GBA © 2007
Case Scenario #2
• Activities and Participation
– Mobility
– Self-care
• Environmental Factors
– Products and technology
– Support and relationships
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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
Palmetto GBA © 2007
Contact Information
Harry Feliciano, MD, MPH
Director, Part A Medical Affairs
Palmetto GBA
Mail Code AG-300
Post Office Box 7004
Camden, South Carolina 29021-7004
E-mail: [email protected]
Tel: 803-763-5007
Palmetto GBA © 2007