I also know that prior to those changes, there were many educational offerings to expose and redefine exactly how one should prove appropriateness for the rehabilitation admission. It was defined that if due-diligence in the pre-admission screen, detailing each of the required criteria were met and the physician concurred with the admission and saw the same needs within 24 hours after admission through the post admission evaluation, that THEN medical necessity is met and that a retrospective decision stating that they COULD have been treated at a SNF level of care would not be argued.

The defense provided in the pre-admission screen is clearly the largest evidence. It must define the exact purposes for treatment at an IRF/IRU level of care, even if that treatment mitigates potential risks that require greater surveillance than what is commonly available at a lesser level of care.

The discussion and audio transcript of that November 12th, 2009 call is at the CMS website.   Below, are very important paragraphs pulled from the discussions that took place that day.

1.)

2.) 

As Medical Necessity has been re-introduced into the RAC discussion for review, with at least two districts already reviewing REASONABLE and NECESSARY as the criteria for the admission decision, the items discussed above may HUGELY lead toward debate. Did you spend the time to justify the criteria required for admission? Does that documentation warrant a level of care that expects greater vigilance in medical and nursing management to maintain a safe effective intensive level of rehabilitation? Was the process a truly descriptive one and not just a page or two of check boxes, which CMS has stated will NOT meet the expectations for the pre-admission screen.

The first clarification document published by CMS states:

“Clarification regarding “check boxes” on the pre-admission screening form.
On the November 12 provider training conference call, CMS indicated that the pre-admission screening documentation must not be presented entirely in the form of “check boxes,” but instead must contain some narrative information. Thus, for example, the documentation cannot merely contain “yes/no” check boxes for whether the patient has a risk for clinical complications. It must describe in detail what conditions/comorbidities the patient has and why these indicate a specific risk for clinical complications that require physician monitoring in order for the patient to actively participate in an intensive rehabilitation therapy program. This detailed description, by the very nature of it, would need to be in narrative form. However, the rehabilitation physician is not required to write this narrative if the narrative is written by the licensed or certified clinician/clinicians conducting the preadmission screening.”

It takes time to complete a thorough pre-admission assessment, but an hour or two that can fully uphold reasonable and necessary loopholes gives some assurance that after you have expended your resources in full, that specific reimbursement will not be retracted.

Read another blog detailing medical necessity criteria

Health practitioners and technical occupations dropped by 18,800 in March to 578,100, resulting mostly from fewer advertisements in registered nursing, occupational therapy, speech pathology and physical therapy. However, jobs continue to outnumber practitioners looking for jobs, as the ratio of advertised vacancies to job seekers stands at 2.41 to 1.

The Bureau of Labor Statistics predicted last year that healthcare jobs will grow the fastest of all industries by 2020, with healthcare practitioners and technical occupations rising 25.9 percent between 2010 and 2020. Conference Board announcement and now there are signs the sector is moving the other way.

The behavior of heath care providers cutting back on job advertisements in wake of an increasing demand is a very curious observation. It may possibly be a symptom related to the market basket freeze referenced by my colleague, Darlene, in her recent blog. Is it possible healthcare is cutting back on the investment in practitioner resources as a going lean strategy? Salary and related employee costs known as the employee burden rate is the single largest component of a provider’s expense and historically was an easy target for cutting expenses. Nevertheless, when demand for what practitioners do is increasingly cutting back and freezing market basket values, it can only mean fewer people will receive the care they require; the social issue contributing to the recent change in CMS leadership.

Face it, business as usual is no longer affordable in healthcare. Moreover, it is up to each of us to be more innovative in figuring out where to reduce cost and improve quality of the service we provide; it does not appear to be happening with policy makers or those charged with our healthcare budget management.  Managing healthcare costs and value will require more of a team effort than currently applied and success will depend upon enterprise strategies rather than silo focused tactics.

This is good, right?

We must ask, “what has changed over the history of rehab outcomes reporting?” And while we take personal pride in looking back upon what we have learned, providers are hard-pressed to offer evidence to support the fact that quality or cost has been favorably influenced by these efforts. Many changes have occurred during the 25 years but most have been a result of payment or regulatory change. The pursuit of quality has never been a financial objective so there was no incentive to do anything different. If financial benefit (or consequences) did not result from better-worse-the same rankings, it seems these outcome reports may have less that meaningful use. Of greater concern is the question, “why are rehabilitation hospitals missing from the current incentive programs promising recognition and rewards for exceptions performance?” Could it be the rehab sector has been measuring and managing the wrong outcomes for the past 25 years?

The answer could exist somewhere in the shifting expectations that providing care is no longer justified unless it is done with consideration of cost and effectiveness. Being a well respected provider is not a guarantee for success in the new world of healthcare payment. Demonstration of value will be required and its quantification will add new granularity and meaning to better-worse-equal to.

The Medicare Hospital Value-based Purchasing Program will feature:

Throughout history practitioners have performed and delivered care based upon what the payment system has paid for; there is no reason to expect this fact to change. Providers don’t create the economic reality they function within, they react and adapt to it. The economic incentives associated with the Value-based Purchasing Program will shift our focus from traditional outcomes to value metrics and we will succeed on new levels of performance.

We should anticipate a fundamental shift in the way we are reimbursed for the services we deliver and the amounts allocated for those services. Provider behavior will follow in the way the post-acute rehab provider treats and manages the highest-cost, chronically ill patients and where payers and patient seek treatment for those conditions. The use of advanced analytical and data tools to enhance efficiency and recommend the course of treatment with the highest likelihood of quality care and low cost will be the standard methodology to capture and report outcomes and value.

Social media and the Internet afford instantaneous communication across a broad constituency of interested parties for rapid reply to questions or concerns.  These same media afford the exposure of faults and shortcomings.  Questions asked target the state of a provider’s rehabilitation practices.  These media are the information super highways driven by novice and expert alike.

This is an incredible resource. In order to take full advantage of this intelligence, users need to learn how to ask better questions and resist the urge to find the quick solution to their need to know. Users will need to learn how to discriminate data quality. There must be a perception that the right elements are being measured in the right ways, and that apples and oranges are not being confused with each other. There needs to be trust in the quality of the information required.

The challenge of implementing clinical intelligence systems will be daunting and learning is required by the provider and the patient for effective use. Asking questions along the way will provide evidence that learning is occurring and the transformation is sustainable.

This long awaited update was mainly necessary because of the ”Quality Indicator” section changes.   Previously, we had respiratory status, pain, pressure ulcer and safety items that ranged from number 48 – 54. On the new PAI, pressure ulcers are covered in all questions 48 A-C, 49 A-C and 50 A-D.   Unfortunately, there have been a few items that have been changed that were not updated in this manual, so I suggest you write them in.

In Appendix H, page 1 there was an opportunity to correct the fact that there are no longer 100 CMGs.  Originally the payment model had 95 CMGs and 5 special CMGs. This number was reduced due to a RAND study in the 2006 rule for FY 2007 and now there are 87 CMGs and 5 special for a total of 353 CMG possible payments. Unfortunately, I often see and hear a misquoted total. On page H-1 write that on the side line.

Another opportunity missed in the new PAI manual was the discussion on what the weighted motor score means and how that correlates in the grouper software to assigning the correct CMG. The picture inserted below demonstrates the weighting values to more closely assign burden of care reimbursement. Although this is fairly transparent to persons that input whole numbers into the PAI, it is very significant in finding the correct Case Mix Index for payment within a RIC. Add this to Appendix H area as well.

Other items to note:

• Relative weights since they change annually are linked to the cms.gov website
• Appendix C – co-morbidities were linked to the cms.gov website
• Admission Class definitions under item 14 of the PAI still include ‘Evaluation’ which was the old description for a trial stay of less than 10 days.  After 2010, advise this is no longer acceptable.
• Payer classifications continue to use code 13 called CHAMPUS (The “Civilian Health and Medical Program of the Uniformed Services”); it is now known as TRICARE. Write that in so new staff know it’s the same code.
• They cautioned under the new Quality Indicator section II-29 that although it is not required, it will result in a 2 percent payment reduction in FY 2014 if not completed. They left off that the important time frame for submission is October 1, through Dec. 31, 2012.  Write that in.
• Although there is a great description of discharge location 13 – sub-acute setting, even defining that the settings are not the CMS recommended name used for billing purposes on the (UB-92) which is now called the (UB-04), it is more important that persons are familiar with using it to define a patient that is discharged to a setting that continues to provide a multidisciplinary approach to care – such as a rehab oriented skilled (SNF) nursing stay. It’s important that coders DO NOT use this discharge location information to code the UB.  The Office of Inspector General (OIG) has already targeted improper discharge setting on IRF bills and this helps complicate that matter.
• Appendix G is now a discussion on coding rather than the glossary
• Previously Appendix H was a very helpful question and answer section for each of the 18 areas of scoring.  This was removed and has realigned the new Appendix H to be Relative Weights or the old Appendix J.
• Old Appendix K is the new Appendix I – Privacy Rights
• There is no longer an Appendix J
• Scoring decision trees are the same although printing is much clearer. It is important that these remain the same so that longitudinal use of numbers are comparable.

I believe what we need now is a very active FAQ and ANSWER internet board through the help desk.  If we can take questions for clarifications on scoring to the help desk that allows subject matter expert debate and resolution with the final say published back to the FAQ so that everyone applies scoring consistently, I believe we could all rest a little more easily.

Although scoring should remain at a fairly basic and uncomplicated level, clinicians will often attempt to define their own ruler and application of scores. Follow the decision trees, they are extremely helpful. There is one more thing that did not change between publications, “Do not modify the FIM UDSMR^TM  instrument itself”  page III-2.

Check out MediServe’s software solution to help ensure accurate IRFPAI scores.

I am wondering how these practices will play out in the future of accountable care. Transparency of cost information is a significant driver in the effort to lower care costs and improve efficiencies of care delivery. Understanding the relationships between cost and payment would seem to be a rationale step to making better decisions about effectiveness and efficiency for everyone involved in the process.

Electronic clinical records and data systems are providing sources of information about the care delivery process previously unavailable.  There is a growing awareness that access to provider information may actually increase the knowledge base to all, including patients.

In a recent study appearing in the Annals of Internal Medicine, Patient Interest in Sharing Personal Health Record Information, the practice of holding clinical notes beyond patient access was challenged and offered a conclusion that “existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their healthcare.”

“Patients want to look into their doctor’s black box, and many doctors are a bit nervous about what they’ll find,” said one of the researchers from Beth Israel Deaconess said in a news release. The researcher continued, “but I expect that over time everyone will benefit enormously from such transparency.”

As the electronic record of patient care releases more insight into the cost and effectiveness of the care delivery process, all involved will need to adjust their historical perspectives of who should see what; the new accountability will demand it.

Take the staff awareness survey at MediServe.com.

Five years ago Sister Mary Jean Ryan, CEO of SSM Healthcare, set the standard for healthcare organization quality and was recognized by having been awarded the Malcolm Baldridge National Quality Award for performance excellence in health care.  Since then healthcare leaders have looked to the Baldridge process as a means to increase organizational effectiveness rather than organization recognition.  These best practices underscore the four key areas that organizations focus upon to manage their business and achieve organizational goals returning high value for all stakeholders. They are leadership, people, measurement and processes.  Organizations facing the challenge of improving the effectiveness and efficiency of patient care service delivery can look to the winners of the Baldridge competition for comparison to organizations known to be the best.

Value in patient care has come to represent the idea and activities associated with getting the best care at the best price. The evolving healthcare economy and Accountable Care initiatives impose greater demands upon delivery organizations to demonstrate the value of services provided.  To do so providers must assess their effectiveness in the key areas, use the essential best practices and plan to significantly improve results. Taken in context and applied to healthcare, optimizing value translates to improving performance in patient care delivery.

Performance improvement in healthcare is a disruptive technology and faces resistive inertia of the institutional status quo and human behaviors.  Traditional approaches of listening to the “voice of the customer” and providing them what they want will only partially fill the paradigm for the transformational change to value-based care delivery. Performance improvement, innovation and leadership will be accelerated by the evidence provided by the success of others when advancing disruptive technologies to optimize value of patient care.

The disruptive technology comes in the form of evidence-based management which relies upon monitoring and measuring key areas of systems and clinical process to provide insight to variance from the expected. The cultural impact of metric driven management affects organizations at all levels.  Five years of Baldridge winners have been analyzed to identify what distinguished them from others, common to this elite group has been:

- an “organizational” approach to excellence and not focusing on a narrow aspects of the business;

- the ability and discipline to identify and apply the “best practices” that other organizations have used successfully in their path to organizational excellence;

- a system wide implementation of best practices to optimize the results that support excellence;

- and the continuous management and focus upon the key areas as most significant for achieving the type of results that support the transition from good to great.

The transformation of healthcare will not occur without pain and risks along the way. Leaders need be prepared with new tools and intelligence to manage these transitions. Performance management and best practices are evolving based upon measurement and data providing evidence to support operational decisions.  Now more than ever, optimizing value requires greater insight and intelligence capabilities even if you choose not to race.

See MediServe’s tools to help optimize the value of patient care

…The purpose of the interdisciplinary team is to foster frequent, structured, and documented communication among disciplines to establish, prioritize and achieve treatment goals.

Team conferences must be held once a week; seven consecutive calendar days that begin the day of admission.

Document participation by professionals from each of the following disciplines (each of whom must have current knowledge of the patient as documented in the IRF medical record):
A rehabilitation physician with specialized training and experience in rehabilitation services;
A registered nurse with specialized training or experience in rehabilitation;
A social worker or a case manager (or both); and
A licensed or certified therapist from each discipline involved in treating the patient.

The weekly interdisciplinary team meeting must be led by a rehabilitation physician who is responsible for making the final decisions regarding the patient’s treatment in the IRF. The physician must document concurrence with all decisions made by the interdisciplinary team. Documentation must include the name and professional designation of each interdisciplinary team member in attendance.

The periodic interdisciplinary team conferences must focus on:
Assessing the patient’s progress toward rehabilitation goals;
Considering possible resolutions to any problems that could impede the patient’s progress toward the goals;
Reassessing the validity of the rehabilitation goals previously established; and
Monitoring and revising the treatment plan, as needed.

With these expectations in mind, how does anyone answer the question, “how effective is the team?” Passing an audit or survey review for evidence of team management is not much more than providing documentation that the team meeting happened and signatory attestation is in evidence.  But was the team meeting effective?  What value did it provide and at what cost?  Every manager and clinician asks these question but few have quantified answers.  In the current environment of driving cost and waste out of the delivery system the weekly meeting must be challenged for its value in doing more than documenting occurrence.

Assessment of effectiveness should start with clarifying and defining expectations.

A quick response to the following checklist may provide some insights to the organization’s clinical and operational culture:

What the team and team conference is supposed to do is probably best answered by asking the team itself.  Their responses will provide evidence for planning the next step. Opinions and the checklist are not a substitute for a formal team performance assessment but will give indication if expectations of team performance are common to all and can uncover areas of improvement that will help you become a better team member and team builder.

Speaking at the HIMSS conference in Las Vegas, Aetna CEO, President and Chairman Mark Bertolini announced the end of insurance companies and pointed to a transformation in the way they run their business (http://www.healthdatamanagement.com/news/HIMSS12-Aetna-CEO-insurers-face-extinction-44041-1.html).  The unique combination of factors and circumstances create an inflection point in the business of insuring people against health risks.  The traditional business model of underwriting medical risk is unsustainable over the long haul and has forced insurance companies to look to alternative business models.

Mr. Bertolini suggested that model is managing populations through a different relationship with providers, physicians and the hospitals with whom they do business and requiring a dependence upon current and accurate information about the effectiveness of patient care delivery.  By giving away the tools to make information sharing possible, Aetna hopes to partner with providers to make it easier for everyone to be better informed about the effectiveness and efficiency of caring for patients.

Provider transformation was also in evidence as traditional service delivery through nursing homes is being shifted to home care management.  Joseph Berger’s article in The New York Times (http://www.nytimes.com/2012/02/24/nyregion/managed-care-keeps-the-frail-out-of-nursing-homes.html) details the change in care delivery models that move services and patients out of nursing homes and into their communities as a way to combat the rising costs and decreasing payment for institutional care.

Time will demonstrate the effectiveness of transforming services and delivery of care to alternative less costly sites; but these early attempts and initial successes are prompting others to ask why not “us” in seeking alternatives.  For inpatient rehabilitation facilities the question will be: which of our patients could be managed in a SNF if we provided the rehab personnel and resources to deliver the intensity of care required?  If that is sounding like bundling perhaps we better reconsider our positions.

See why MediServe has been a valuable IRF software solution for some of the largest rehab healthcare providers.