Reprinted from The HCCA-AIS MEDICAID COMPLIANCE NEWS, monthly news and valuable how-to strategies for identifying and reducing today’s top Medicaid compliance risks.
By Eve Collins, Editor
October 2011 Volume 5 Issue 10
Two related CMS initiatives are designed to help reduce incidents of harm to patients from conditions acquired in health care settings or during transitions between settings, areas that could adversely affect payments to Medicaid providers in the near future.
The health reform law mandated that CMS implement Medicaid payment adjustments for “health care-acquired conditions” (HCACs). In the final rule released on June 1, CMS said that states should adopt Medicare’s hospital-acquired conditions as “the floor,” but it gave states the flexibility to go beyond those conditions if they see the need (MCN 6/11, p. 5).
In a Sept. 14 “open door forum” for providers, clinicians and patient advocates, CMS officials described current initiatives to improve access to health care for low-income beneficiaries, including those with Medicaid and dual eligibles.
“Everyone knows someone who has been affected by harm, whether it’s in the hospital or across settings of care as people are going from hospital to home or nursing setting,” said a representative of the CMS Innovation Center, which runs the Partnership for Patients Initiative. HHS launched the three-year initiative in April to “tackle all forms of harm to patients” that result in injury or further illness while they are in a provider’s care, she said.
The goals of the program are to decrease hospital-acquired conditions by 40% and reduce hospital readmissions by 20% by the end of 2013.
“Achieving these goals will not only save lives and greatly reduce injuries to millions of Americans, it will also result in savings of millions of dollars….Over the next 10 years, it could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings,” she said.
Reducing hospital readmissions is largely related to care transitions as a patient is moved from one care setting to another such as from a hospital to a nursing facility, according to HHS. The health reform law created the community-based care transition program (CCTP) “to test models for improving care transitions,” she said. The initial focus is on Medicare fee-for-service beneficiaries, but that includes dual eligibles, and CMS wants to reach other populations, she explained.
Patients Are Frail
The CCTP is designed to improve quality of care, reduce readmission rates and achieve measurable savings for “high-risk beneficiaries,” including those with chronic conditions, organ system failure, frailty and other conditions that could make transitioning the patients very difficult.
“Strong evidence shows that we can significantly reduce hospital readmissions caused by these flawed care transitions, and there are a lot of communities that have been very innovative, so we want to learn from them and spread that knowledge as fast as we can to deliver that care to other patients,” the CMS Innovation Center official said.
One out of every 20 patients in U.S. hospitals is affected by a hospital-acquired condition, and one in five Medicare beneficiaries is readmitted within 30 days of discharge from a hospital. “There are similar readmission rates for Medicaid and other payers,” the official added.
The CCTP is open to the majority of hospitals (excluding critical access hospitals and specialty facilities) with high readmission rates. The facilities must partner with a community-based organization, which is a group with “a multi-stakeholder governing body that includes consumers, [is] providing care transition services across the continuum of care, and [is] partnering with one or more hospitals that meet the eligibility criteria,” the CMS official explained.
The applicants must address how they plan to align the CCTP with transition initiatives for patients with Medicaid, Medicaid managed care programs and private insurance. “What we really want to see in the applications is the community has gotten together [and] they’ve really looked at their community that they want to serve. They have to tell us who that target population is in terms of the high risk,” she said.
The CCTP is not a grant program. CMS will enter into two-year provider agreements with the participants, with the option for a third year based on their success in measures such as lower costs, improved health and improved care.
A good source for assistance with the initiative is the Medicare quality improvement organizations, which “can help you think through how [to] tie this Medicare piece into all the other payers,” the CMS Innovation Center official said.
“Those two key aims — the 40% reduction in harm and the 20% reduction in readmissions — that’s for all patients and all payers. We really want this to spread as widely as we can. Even though there’s a focus from the payment side in this program on Medicare fee-for-service, we do have partners that span the public and private sectors, all programs, and we want them all to be working very closely together,” she said.
Visit http://innovations.cms.gov and www.cms.gov/opendoorforums and click on “Low-Income Health Access Open Door Forum.”
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