New CMS Care Transitions Program Q&As, Open Door Forum

The Centers for Medicare and Medicaid Services (CMS) have released a new round of Questions & Answers in regards to the Community-Based Care Transitions Program.

See the full list of these helpful Q&A’s here, and below are a couple of the newest posts that may be of interest to home health agencies. One in particular about whether some of the responsibilities of the lead applicant can be subcontracted to other entities.

There is also an “open door forum” scheduled for May 5 and the Home Care Alliance strongly encourages all interested agencies to register and participate.

Yes that is acceptable; however, the applicant would need to demonstrate that each proposed subcontractor possessed expertise in the delivery of care transition services.

Experience with chronic care management/disease management is not synonymous with care transitions experience. The per eligible discharge rate is meant to cover a relatively short term intense intervention around admission to and discharge from an acute care hospital. This rate would not support an ongoing chronic care management program which usually requires a per member per month payment for an indefinite period.

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Helpful Q&As Posted on Care Transitions Program

The Centers for Medicare and Medicaid Services (CMS) has recently posted new Question & Answers regarding the Community-Based Care Transitions Program.

One such question that has emerged from multiple home health agencies concerns what constitutes a “community-based organization” or CBO.  See below for a pair of Q&A’s offering guidance:

  • Q: Does a home health provider qualify as a Community-Based Organization (CBO)? 
  • A: A home health agency would only qualify as a CBO if it was based in the community it proposed to serve and had a governing body with broad community representation of multiple health care stakeholders, including consumers. To ensure broad stakeholder involvement, 50% of the board representation should come from outside the home health agency.  Please also see our response to FAQ# 10418 for guidance on consumer representation.
  • Q (#10418 from above): Does a coalition representing a collaboration of community healthcare providers (medical centers, Federal Qualified Health Centers (FQHCs), health plans, educational leaders and local government) qualify as a Community-Based Organization (CBO)?
  • A: If the coalition is (1) a legal entity, such as a 501(c) (3) organization or other organization that has a taxpayer identification number and can accept payment, (2) has a governing body that includes broad community representation of multiple health care stakeholders, including consumers and (3) is physically located in the community it proposes to serve, then it could qualify as a CBO.  In addition, there must be adequate consumer representation on the governing board with voting rights. The consumers may not be providers or immediate family members of providers to satisfy this requirement.

See the full list of Q&A’s relative to this program here.

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Care Transitions Program Part of Partnership for Patients

Centers for Medicare and Medicaid Services Administrator Dr. Don Berwick and US Health and Human Services Secretary Kathleen Sebelius announced a massive initiative and federal funding opportunity dubbed the “Partnership for Patients.”

This billion dollar commitment from the federal government will be split between two goals:

  • Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.
  • Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

Home health agencies will be most interested in the Community-Based Care Transitions Program, which will spread $500 million in funding to community-based organizations partnering with eligible hospitals for care transition services that include timely, culturally, and linguistically-competent post-discharge education, medication review and management, and patient-centered self-management support within 24 hours of discharge.

Recently, the solicitation and application have been released after months of waiting and the Home Care Alliance is continuing to encourage eligible agencies that qualify as Community-Based Organizations (CBO’s) to partner with hospitals, ASAP’s, and other providers to submit an application.

Here is the list of pertinent documents for this program:

Agencies that have any questions regarding this program can contact the Home Care Alliance.

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CMS Releases Proposed Rule on ACOs

A proposed rule has been released by the Centers for Medicare and Medicaid Services (CMS) for comment regarding the formation of Accountable Care Organizations or ACO’s, which create incentives for health care providers to work together to treat an individual patient across care settings.

Section 3022 of the Affordable Care Act created the Medicare Shared Savings Program that is intended to encourage providers of services and suppliers to create a new type of health care entity, which the statute calls an Accountable Care Organization. The proposed rule mentions home health, but it is important that comments on the rule are submitted to ensure that home health agencies are active participants in every ACO. Given the ACO initiative’s mission of caring for patients more efficiently and at a lower cost, this is an excellent opportunity for agencies to speak up.

The proposed rule was released on March 31 and comments will be accepted by CMS for 60 days.  You can comment:

  • 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-1345-P,
P.O. Box 8013,
Baltimore, MD 21244-8013.

Below is the full announcement from CMS on the Medicare Shared Savings Program that includes a summery of the Affordable Care Act provision on ACO’s and some information from the proposed rule.

SUMMARY OF PROPOSED RULE PROVISIONS FOR ACCOUNTABLE CARE ORGANIZATIONS UNDER THE MEDICARE SHARED SAVINGS PROGRAM

Overview

On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), proposed new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.  The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary.

In developing the proposed rule, CMS has worked closely with agencies across the Federal government to ensure a coordinated and aligned inter- and intra-agency effort to facilitate implementation of the Medicare Shared Savings Program (Shared Savings Program).

This fact sheet describes the proposals addressing the proposals for what ACOs are, how they can be created, and other general topics.  CMS has posted separate fact sheets on its web site to address in greater detail specific aspects of the proposed rule, such as the quality measures and performance scoring.

There will be a 60 day public comment period on this proposed rule. CMS encourages all interested members of the public, including providers, suppliers, and Medicare beneficiaries to submit comments so that CMS can consider them as it develops final regulations on the program.

Background:

Section 3022 of the Affordable Care Act, added a new section 1899 to the Social Security Act (the Act) that requires the Secretary to establish the Shared Savings Program by January 1, 2012.  This program is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to create a new type of health care entity, which the statute calls an “Accountable Care Organization (ACO)” that agrees to be held accountable for improving the health and experience of care for individuals and improving the health of populations while reducing the rate of growth in health care spending.  Studies have shown that better care often costs less, because coordinated care helps to ensure that the patient receives the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

ACOs and the Medicare Beneficiary:

An ACO provides an opportunity for Medicare beneficiaries to receive high quality evidence-based health care that eliminates waste and reduces excessive costs through improved care delivery.   However, there would be significant differences between ACOs, as described in the proposed rule and the private managed care plans offered under the Medicare Advantage program.  Beneficiaries would not enroll in a specific ACO.  Instead the proposed rule calls for Medicare to take a retrospective look at the beneficiary’s use of services to determine whether a particular ACO should be credited with improving care and reducing expenditures.  This means that an ACO would have an incentive to improve the quality of care for all patients seen by its member providers and suppliers.

The proposed rule would require providers participating in an ACO to notify the beneficiary that they are participating in an ACO, and that the provider will be eligible for additional Medicare payments for improving the quality of care the beneficiary receives while reducing overall costs or may be financially responsible to Medicare for failing to provide efficient, cost-effective care.  The beneficiary may then choose to receive services from the provider or seek care from another provider that is not part of the ACO.

The proposed rule would also require each provider in an ACO to notify the beneficiary that the beneficiary’s claims data may be shared with the ACO. This data sharing is intended to make it easier to coordinate the beneficiary’s care; however, the provider may not require a beneficiary to obtain services from another provider or supplier in the same ACO.  The provider must give the beneficiary the opportunity to opt-out of those data sharing arrangements.  For Medicare beneficiaries who choose not to opt-out of the data sharing arrangements, the proposed rule would limit data sharing to the purposes of the Shared Savings Program and would require compliance with applicable   privacy rules and regulations, including the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Proposed eligibility requirements for an ACO:

Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare fee-for-service beneficiaries they serve. The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries, instead of the fragmented care that has so often been part of fee-for-service health care.  The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

The Affordable Care Act specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

  • ACO professionals (i.e., physicians and hospitals meeting the statutory definition) in group practice arrangements,
  • Networks of individual practices of ACO professionals,
  • Partnerships or joint ventures arrangements between hospitals and ACO professionals, or
  • Hospitals employing ACO professionals.
  • Other Medicare providers and suppliers as determined by the Secretary

In the proposed rule, the Secretary has used her discretion to add certain critical access hospitals as eligible to participate in the Shared Savings Program.

The statute also requires each ACO to establish a governing body representing ACO providers of services and suppliers and Medicare beneficiaries. The proposed rule would make each ACO responsible for routine self-assessment, monitoring and reporting of the care it delivers.

To participate in the Shared Savings Program, the proposed rule would require an ACO to complete an application providing the information requested by CMS, including how the ACO plans to deliver high quality care at lower costs for the beneficiaries it serves.  As proposed, the ACO must agree to accept responsibility for at least 5,000 beneficiaries.  If the application is approved, the ACO must sign an agreement with CMS to participate in the Shared Savings Program for a period of three years.   An ACO will not be automatically accepted into the Shared Savings Program.

The proposed rule outlines a monitoring plan that includes analyzing claims and specific financial and quality data as well as the quarterly and annual aggregated reports, performing site visits, and performing beneficiary surveys.

Under the proposed rule, there are a number of circumstances under which CMS may terminate the agreement with an ACO, including avoidance of at risk beneficiaries and failure to meet the quality performance standards.

Tying payment to improved care at lower cost:

Under the proposed rule, Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems.  The proposed rule would require CMS to develop a benchmark for savings to be achieved by each ACO if the ACO is to receive shared savings, or be held liable for losses.  Additionally, an ACO would be accountable for meeting or exceeding the quality performance standards to be eligible to receive any shared savings.

The proposed rule would establish quality performance measures and a methodology for linking quality and financial performance that will set a high bar on delivering coordinated and patient-centered care by ACOs, and emphasize continuous improvement around the three-part aim of better care for individuals, better health for populations, and lower growth in expenditures.  The proposed rule would require the ACO to have in place procedures and processes to promote evidence-based medicine and beneficiary engagement in their care.  The proposed rule would require ACOs to report quality measures to CMS and give timely feedback to providers.  CMS expects that ACOs will invest continually in the workforce and in team-based care. To assure program transparency, the proposed rule would require ACOs to publicly report certain aspects of their performance and operations.

Under the proposed rule, an ACO that meets the program’s quality performance standards would be eligible to receive a share of the savings it generates below a specific expenditure benchmark that would be set by CMS for each ACO. The proposed rule would also hold ACOs accountable for downside risk by requiring ACOs to repay Medicare for a portion of losses (expenditures above its benchmark). To provide an entry point for organizations with varied levels of experience with and willingness to take on risk, the proposed rule would allow an ACO to choose one of two program tracks.  The first track would allow an ACO to operate on a shared savings only track for the first two years, but would then require the ACO to assume the risk for shared losses in the third year.  The second track would allow ACOs to share in savings and risk liability for losses beginning in their first performance year, in return for a higher share of any savings it generates.

The Shared Savings Program NPRM will appear in the April 7, 2011 issue of the Federal Register.  CMS will accept comments on the proposed rule until June 6, 2011, and will respond to them in a final rule to be issued later this year.  The Shared Savings Program will begin operating on January 1, 2012.

Please Note: Once the regulation is published on (April 7, 2011) the preceding link will be deactivated and the published version of the regulation will be available on the National Archives website at

http://www.archives.gov/federal-register/news.html.

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IMPROVING QUALITY OF CARE FOR MEDICARE PATIENTS: ACCOUNTABLE CARE ORGANIZATIONS

On March 31, 2011, the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), proposed new rules under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs).  ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.  The Medicare Shared Savings Program will reward ACOs that lower growth in health care costs while meeting performance standards on quality of care and putting patients first.  Patient and provider participation in an ACO is purely voluntary.

This fact sheet describes the proposals to ensure that ACOs provide high quality care, including proposed quality measures, and a proposed method for scoring the performance of the ACO for purposes of the Shared Savings Program. There will be a 60 day public comment period on this proposed rule. CMS encourages all interested members of the public, including providers, suppliers, and Medicare beneficiaries to submit comments so that CMS can consider them as it develops final regulations on the program.

Background:

The Medicare Shared Savings Program, which is to be implemented on January 1, 2012, is intended to encourage providers of services and suppliers (e.g., physicians, hospitals and others involved in patient care) to coordinate patient care and improve communications with each other to get each beneficiary the right care at the right time, and see that the care is provided right the first time.  To accomplish this, the Act allows providers to create ACOs that will be held accountable for improving the health and experience of care for individuals, improving the health  of populations, and reducing the rate of growth in health care spending.  Studies show that better care often costs less, because coordinated care helps avoid unnecessary duplication of services and preventing medical errors.

Proposals For Assessing Quality Included in the ACO Proposed Rule:

Proposed Quality Measures:  For 2012, CMS proposes to use a number of quality measures to establish the quality performance standard ACOs must meet in order to share in savings, provided they also meet the program’s cost savings requirement. These 65 measures span five quality domains: Patient Experience of Care, Care Coordination, Patient Safety, Preventive Health, and At-Risk Population/Frail Elderly Health.   The list of proposed measures is included in the appendix to this fact sheet.

CMS considered a broad array of process and outcome measures would help in assessing an ACO’s success in delivering high-quality health care at both the individual and population levels.  Several of the proposed quality measures align with those used in other CMS quality programs, such as the Physician Quality Reporting System, the Electronic Health Record (EHR) Incentive Program, and the Hospital Inpatient Quality Reporting Program. CMS also sought to align the proposed ACO quality measures with the National Quality Strategy and other Department of Health and Human Services priorities.  CMS proposes that the measures would be reported to CMS through a combination of claims submission, data collection using a tool designed for clinical quality measure reporting, and surveys.

CMS is proposing to define the first quality performance period as beginning January 1, 2012 and ending December 31, 2012.

Proposed Quality Performance Scoring:

As required by the Affordable Care Act, before an ACO can share in any savings created, it must demonstrate that it is delivering high quality care.  Thus, a calculation of the quality performance standard will indicate whether an ACO has met the quality performance goals that would allow it to be considered eligible for shared savings.  The proposed method for scoring the measures and determining the performance level that must be achieved to share in savings under the Shared Savings Program is described in the proposed rule.

CMS proposes that the performance on each measure will be scored on a linear points scale and roll up into 5 scores for each of the 5 domains. The percentage of points earned for each domain will be aggregated using an equal weighting method to arrive at a single percentage that will be applied to the maximum sharing rate for which the ACO is eligible.
For the first year of the Shared Savings Program, CMS proposes to set the quality performance standard at the reporting level. This means that during the first performance period, ACOs will be required to report the quality measures completely and accurately in order to share in savings. However, CMS proposes to still score quality in the first year for informational purposes and to help define the benchmarks for future program years. CMS proposes to set the quality performance standard at a higher level in subsequent years.

Proposed Incorporation of the Physician Quality Reporting System into the Shared Savings Program:

The Affordable Care Act allows CMS to incorporate the Physician Quality Reporting System reporting requirements and incentive payments into the Shared Savings Program. ACO participant providers/suppliers who are also Physician Quality Reporting System eligible professionals may earn the Physician Quality Reporting System incentive as a group practice under the Shared Savings Program, by meeting its quality performance standard

The Shared Savings Program NPRM will appear in the April 7, 2011 issue of the Federal Register.  CMS will accept comments on the proposed rule until June 6, 2011 and will respond to them in a final rule to be issued later this year.  The Shared Savings Program will begin operating on January 1, 2012.

Return to www.thinkhomecare.org.

Regulatory Review

Expedited Review Process:

Masspro completed a series of workshops to discuss the “expedited review process,” used by home health agencies to notify Medicare beneficiaries that their Medicare services are ending. There are two separate forms and slightly different rules depending on Medicare “fee-for-service” (Notice of Medicare provider Non-Coverage) or Medicare Advantage (Notice of Medicare non-Coverage).  These forms are to be used when all Medicare services are ending for medical reasons.  If care is ending for a technical reason such as homebound, then the beneficiary is given a HHABN.  This is a recent clarification from Quest to Masspro our local QIO.

Quest is the part of the Quality Net system that QIO’s use to communicate with CMS.  QIO’s can ask Quest questions that require clarification by CMS and then publish the answers.

Is it appropriate for the HHA to issue a Notice of Medicare Provider Non-Coverage in these types of cases, and for the QIO to review?

Answer:

It is not appropriate for HHAs to issue Notices of non-coverage for home-bound status; only when it is believed that the beneficiary no longer requires a skilled level of care

Face-to-Face:

CMS put out a transmittal a few weeks ago to define several dates that relate to the Face-to-face Requirement.

The effective date is January 1, 2011

The implementation date that CMS contractors must have their systems ready is March 10, 2011

The enforcement date is April 1, 2011. After this date, agencies will not be reimbursed if the F2F documentation is not present in the medical record.

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More Face To Face Clarifications Issued

The following was issued by NAHC Regulatory Affairs

CMS issued an update to the Medicare Benefit Policy Manual, Pub 100-02 Chapter 7 via a Transmittal issued this afternoon at: http://www.cms.gov/transmittals/downloads/R139BP.pdf. Summarized below are new pieces of information (including exception in case of death of patient) and clarifications found in the Transmittal.

General Issues

  • The certifying physician must document that he or she or an allowed non-physician practitioner (NPP) had a face-to-face encounter with the patient.
  • Certain NPPs may perform the face-to-face encounter and inform the certifying physician regarding the clinical findings exhibited by the patient during the encounter. However, the certifying physician must document the encounter and sign the certification.
  • The documentation must include the date when the physician or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient’s clinical condition as seen during that encounter supports the patient’s homebound status and need for skilled services on the certification or an addendum to the certification.
  • It is acceptable for the certifying physician to dictate the documentation content to one of the physician’s support personnel to type.
  • It is also acceptable for the documentation to be generated from a physician’s electronic health record.
  • It is unacceptable for the physician to verbally communicate the encounter to the HHA, where the HHA would then document the encounter as part of the certification for the physician to sign.

Exceptional Circumstances in Case of Death:

  • · When a home health patient dies shortly after admission, before the face-to-face encounter occurs, if the contractor determines a good faith effort existed on the part of the HHA to facilitate/coordinate the encounter and if all other certification requirements are met, the certification is deemed to be complete.

Hospitalist Role

  • A physician who attended to the patient in an acute or post-acute setting, but does not follow the patient in the community (such as a hospitalist) may certify the need for home health care based on his/her contact with the patient, and establish and sign the plan of care. The acute/post-acute physician would then transfer/hand off the patient’s care to a designated community-based physician who assumes care for the patient.
  • Or, A physician who attended to the patient in an acute or post-acute setting may certify the need for home health care based on his/her contact with the patient, initiate the orders for home health services, and transfer the patient to a designated community-based physician to review and sign off on the plan of care.

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