PASSPORT eCARE™ NEXT AND THE AFFORDABLE CARE ACT Maximizing Reimbursements

REVENUE CYCLE INSIGHTS
PATIENT ACCE S S
PASSPORT eCARE™ NEXT AND
THE AFFORDABLE CARE ACT
Maximizing Reimbursements
For Acute Care Hospitals
Executive Summary
The Affordable Care Act (ACA) authorizes several new Medicare reimbursement programs that start going
into affect in October 2012. Four programs directly affect acute care hospitals:
1.
Hospital Value-Based Purchasing (VBP) Program,
2. Hospital Readmission Reduction Program,
3. Bundled Payments for Care Improvement Initiative and
4. Medicare Shared Savings Program.
The Passport eCare™ NEXT suite of solutions helps hospitals maximize reimbursement under these new
programs in a variety of ways, as outlined in this white paper.
1
Hospital Value-Based Purchasing (VBP)
Program
Congress authorized the Hospital Inpatient
Value-Based Purchasing (VBP) program in
Section 3001(a) of the Affordable Care Act. The
program uses the hospital quality data reporting
infrastructure developed for the Hospital
Inpatient Quality Reporting (IQR) Program,
which was authorized by Section 501(b) of the
Medicare Prescription Drug, Improvement, and
Modernization Act of 2003.
The Hospital VBP program is part of the Centers
for Medicare & Medicaid Services’ (CMS’) longstanding effort to link Medicare’s payment system
to improve healthcare quality, including the quality
of care provided in the inpatient hospital setting.
Starting in October 2012, hospitals will
be paid for inpatient acute care services
based on the quality of care, not just
quantity of the services they provide.
Most acute care hospitals serving Medicare
patients are eligible to participate in Hospital
VBP. Participation is optional, but most will likely
participate to receive the payment.
The VBP payments are funded by reducing the
base operation Diagnosis-Related Group (DRG)
payments. The reductions will be 1.0% in FY 2013,
1.25% in FY 2014, 1.5% in FY2015, 1.75% in FY2016
and 2.0% in FY2017 and beyond. These payments
create a pool for funding performance-based
payments. These reductions apply to all eligible
hospitals, whether they participate or not.
The program doesn’t affect DSH adjustments,
IME adjustments or outlier adjustments. These
adjustments are included in the overall baseline
for determining the base DRG payment amount.
Hospitals that score well will receive back more
than the 1.0% they contribute to the payment pool.
For FY 2013, the total VBP payment pool for
the approximately 3,000 eligible acute care
hospitals was $917M. The actual 1% deductions
and matching payments will be implemented in
January 2013 to avoid end-of-year adjustments for
hospitals with fiscal year reporting.
Based on the recently published IPPS final rule
for FY2013, the proposed payment mechanism is
that the quality factor would be applied to each
diagnosis reimbursement automatically on a claim
by claim basis.
Hospital VBP score is based on data collected
through the Hospital Inpatient Quality Reporting
(IQR) Program. This program establishes clinical
quality outcomes, benchmarks and reporting
mechanisms. Prior to Hospital VBR, the program
was used by hospitals to avoid a 2.0% reduction
in their annual market basket update amount as
outlined in the MMS 2005 Act. CMS is adopting
12 of 45 quality measures of the Hospital IQR
Program for Hospital VBP. Measures were removed
primarily due to being “topped out”, meaning
there was not a sufficient spread between high
and low performers to differentiate quality. These
measures will continue to be reported through
the existing CMS’ funded QualityNet website.
These measures as a group constitute the Clinical
Process of Care portion of the score, which is 70%
of the total quality score.
The Hospital IQR measures today use a
combination of claims-based data and clinical
outcomes reporting. The claims-based measures
include Patient Safety Indicators, Inpatient
Quality Indicators, Hospital Acquired Conditions
Indicators, Mortality Measures and Readmission
Measures. The rest are based on hospital-reported
clinical outcomes reporting.
The remaining 30% of the overall quality score
is the Patient Experience of Care portion, which
is based on the existing Hospital Consumer
Assessment of Healthcare Providers and Systems
(HCAHPS) consumer survey. Providers can either
use their absolute score relative to the national
average or they can use their improvement over
the previous year. This represents 80% of the
Patient Experience score. Their improvement on
their lowest HCAHPS score is also factored into
the overall patient experience score, representing
the remaining 20% of the total.
2
Medicare patients can access both the clinical
quality outcomes and the patient satisfaction
outcomes through the HHS website.
The 12 Clinical Quality Measures
The table below outlines the 12 quality
achievement thresholds and benchmarks for the
FY 2013 Hospital VBP Measures.
NQI Measure
Identifier
Measure Title
Brief Explanation
AMI-7a
Percent of Heart Attack Patients
Given Fibrinolytic Medication
Within 30 Minutes Of Arrival
Blood clots can cause heart attacks. Doctors may
give this medicine, or perform a procedure to open
the blockage, and in some cases, may do both.
AMI-8a
Percent of Heart Attack Patients
Given PCI Within 90 Minutes Of
Arrival
The procedures called Percutaneous Coronary
Interventions (PCI) are among those that are the
most effective for opening blocked blood vessels
that cause heart attacks. Doctors may perform PCI,
or give medicine to open the blockage, and in some
cases, may do both.
HF-1
Percent of Heart Failure Patients
Given Discharge Instructions
The staff at the hospital should provide you with
information to help you manage your heart failure
symptoms when you are discharged.
PN-3b
Percent of Pneumonia Patients
Whose Initial Emergency Room
Blood Culture Was Performed
Prior To The Administration
Of The First Hospital Dose Of
Antibiotics
A blood culture tells what kind of medicine will
work best to treat your pneumonia.
PN-6
Initial Antibiotic Selection for CAP Antibiotics are medicines that treat infection, and
in Immunocompetent Patient
each one is different. Hospitals should choose the
antibiotics that best treat the infection type for
each pneumonia patient.
SCIP-Inf-1
Prophylactic Antibiotic Received
Within One Hour Prior to Surgical
Incision
Getting an antibiotic within one hour before surgery
reduces the risk of wound infections. This measure
shows how often hospital staff make sure surgery
patients get antibiotics at the right time.
3
NQI Measure
Identifier
Measure Title
Brief Explanation
SCIP-Inf-2
Prophylactic Antibiotic Selection
for Surgical Patients
Some antibiotics work better than others to prevent
wound infections for certain types of surgery. This
measure shows how often hospital staff make sure
patients get the right kind of preventive antibiotic
medication for their surgery.
SCIP-Inf-3
Prophylactic Antibiotics
Discontinued Within 24 Hours
After Surgery End Time
Taking preventive antibiotics for more than 24 hours
after routine surgery is usually not necessary. This
measure shows how often hospitals stopped giving
antibiotics to surgery patients when they were no
longer needed to prevent surgical infection.
SCIP-Inf-4
Cardiac Surgery Patients with
Controlled 6AM Postoperative
Serum Glucose
All heart surgery patients get their blood sugar
checked after surgery. Any patient who has high
blood sugar after heart surgery has a greater
chance of getting an infection. This measure tells
how often the blood sugar of heart surgery patients
was kept under good control in the days right after
their surgery.
SCIP-Card-2
Surgery Patients on a Beta
Blocker Prior to Arrival That
Received a Beta Blocker During
the Perioperative Period
Many people who have heart problems or are
at risk for heart problems take drugs called beta
blockers to reduce the risk of future heart problems.
This measure shows whether surgery patients who
were already taking beta blockers before coming
to the hospital were given beta blockers during the
time period just before and after their surgery.
SCIP-VTE-1
Surgery Patients with
Recommended Venous
Thromboembolism Prophylaxis
Ordered
Certain types of surgery can increase patients’ risk
of having blood clots after surgery. For these types
of surgery, this measure tells how often treatment
to help prevent blood clots was ordered by the
doctor.
SCIP-VTE-2
Surgery Patients Who
Received Appropriate Venous
Thromboembolism Prophylaxis
Within 24 Hours Prior to Surgery
to 24 Hours After Surgery
This measure tells how often patients having certain
types of surgery received treatment to prevent
blood clots in the period from 24 hours before
surgery to 24 hours after surgery.
Legend: AMI = Acute Myocardial Infarction, HF = Heart Failure, PN = Pneumonia, SCIP = Surgical Care Improvement
Project, Inf = Healthcare-associated infections, Card = Cardiology, VTE = Venous Thromboembolism Prophylaxis
4
The 8 Patient Satisfaction Measures
References
The table below outlines the Patient Experience
of Care dimensions of the HCAHPS scores that are
used for FY 2013 Hospital VBP measures.
CMS website on Hospital VBP
http://www.cms.gov/Hospital-Value-BasedPurchasing/
Measure Description
CMS Hospital VBP FAQ (outlines the 13 Hospital
IQR rules and formula on page 17 and the HCAHPS
questions and formula on page 22)
http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/
hospital-value-based-purchasing/Downloads/FY2013-Program-Frequently-Asked-Questions-aboutHospital-VBP-3-9-12.pdf
1.
Communication with Nurses
2. Communication with Doctors
3. Responsiveness of Hospital Staff
4. Pain Management
5. Communication About Medicines
6. Cleanliness and Quietness of Hospital
Environment
7.
The IPPS Rule that outlines Hospital VBP formula
and pool collection mechanisms (page 791)
http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/FY-2013-IPPSProposed-Rule-Home-Page.html
Discharge Information
8. Overall Rating of Hospital
QualityNet website (includes overview of the
claims-based and self-reported quality measures)
www.qualitynet.org
Passport eCare NEXT™ Suite and Hospital VBP
Program
HCAHPS Site (includes approved survey vendors)
http://www.hcahpsonline.org/home.aspx
PatientRisk™ is able to identify patients that are
admitting for AMI, Heart Failure, Pneumonia
and Inpatient Surgery and flag them at time of
registration. This is the quality alert in PatientRisk.
Since it's a first-class alert in Passport eCare NEXT,
it can be used to group accounts into a work queue,
prioritize cases in a work queue and be measured
for closure.
HCAHPS Quality Rule
http://www.hcahpsonline.org/qaguidelines.aspx
Public Quality Data Access
http://www.hospitalcompare.hhs.gov
This alert allows for the creation of work queues
specific to Case Management. Unlike today, when
case management is primarily reacting post-service,
with PatientRisk quality alert case managers can
engage early in the care cycle and intervene if
quality protocols are violated.
PatientDischarge™ communicates discharge
instructions in Passport eCare NEXT, PatientKiosk™
and PatientSimple™. Having discharge instructions
communicated at admission as well as available
post-service through the patient portal should
increase hospital scores on the discharge
Information question of the patient satisfaction
survey.
5
Hospital Readmission Reduction
Program
Section 3025 of the 2010 Affordable Care Act
establishes a Hospital Readmissions Reduction
Program where hospital Medicare Inpatient
Prospective Payment System (IPPS) payments
would be reduced for excess readmissions beginning
on or after October 2012.
The program defines readmissions based on the
National Quality Forum (NQF)-endorsed 30-day
Risk-Standardized Readmission measures for acute
myocardial infarction (AMI), heart failure, and
pneumonia.
The payments are adjusted based on the difference
between the hospital's readmission performance and
the national averages for the same procedures. The
hospitals performance is adjusted for factors that
are clinically relevant including patient demographic
characteristics, co-morbidities and patient frailty.
The performance is based on discharge data for the
previous three years and a minimum of 25 cases.
For FY2013, the 3 year period is from July 1, 2008 to
June 30, 2011.
For FY2013, Readmissions adjustments are capped
at a 1% reduction. The reduction is based on the
sum of the total DRG payments by service category
multiplied by the excess readmission ratio for that
category.
In FY2013, 307 hospitals will be receiving the full 1%
penalty and 2,214 hospitals will receive some level of
penalty.
weighted and then combined into an overall score.
The characteristics and weights are the same
measures that CMS uses to assess population risk in
determining a facility’s target readmission rate.
This alert allows for the creation of work queues
specific to Case Management. Unlike today, when
case management is primarily reacting post-service,
with PatientRisk Quality alert case managers can
engage early in the care cycle and intervene if
quality protocols are violated.
References
Fiscal Year 2013 IPPS Final Rule
http://cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/FY-2013-IPPS-FinalRule-Home-Page.html
QualityNet overview of the Hospital Readmissions
Reduction Program
http://www.qualitynet.org/dcs/ContentServer?c=Pa
ge&pagename=QnetPublic%2FPage%2FQnetTier2&c
id=1228772412458
CMS Overview of the Hospital Readmission
Reduction Program
http://cms.gov/Medicare/Medicare-Fee-for-ServicePayment/AcuteInpatientPPS/ReadmissionsReduction-Program.html/
Affected Hospital Stats
http://www.npr.org/blogs/
health/2012/10/03/162220243/admit-it-medicareerrs-in-crackdown-on-hospital-quality
PatientRisk™ and Hospital Readmission
Reduction Program
PatientRisk is able to identify patients that are
admitting for AMI, Heart Failure, Pneumonia and flag
them at time of registration. This is the quality alert
in PatientRisk. Since it's a first-class alert in Passport
eCare NEXT, it can be used to group accounts into a
work queue, prioritize cases in a work queue and be
measured for closure.
In addition, PatientRisk is also able to identify
patients with a higher likelihood of readmission,
based on demographic characteristics and other
clinically relevant factors. These elements are
6
Bundled Payments for Care
Improvement Initiative
Centers for Medicare and Medicaid Services (CMS)
is working in partnership with providers to develop
four different models for bundling payments through
the Bundled Payments for Care Improvement
Initiative.
The Bundled Payments for Care
Improvement initiative is not the National
Pilot Program on Payment Bundling but
will likely inform how CMS implements
the this program in early 2013.
The Acute Care Episode (ACE) demonstration is
another initiative that’s very similar to the model
4 of the Bundled Payments initiative and will also
likely influence CMS’s National Pilot Program
implementation. The differences in the programs are
outlined in the Bundled Payments FAQ.
price will be a 2% to 3% discount from an amount
based on the historical fee-for-service payments for
the episode.
In Model 4, CMS makes a prospectively determined
bundled payment to the hospital that would
encompass all services furnished during the
inpatient stay by the hospital, physicians and other
practitioners. Physicians and other practitioners
would submit “no pay” claims to Medicare and
would be paid out of the bundled payment.
CMS invited providers to participate in the program
on August 23, 2011. Completed applications for
Model 1 were due on October 21, 2011. Model 2-4
Letters of Intent (LOI) were due on November 4,
2011. Completed applications for Models 2-4 were
due by June 28, 2012.
Three of the models involve a retrospective bundled
payment arrangement, with a target payment
amount for a defined episode of care. In these
models, CMS and providers set a target payment for
a defined episode of care. Providers would propose
the target price which would be set by applying a
discount to total costs for a similar episode of care
as determined by historical data. Payment would be
made under the original fee-for-service (FFS) system,
at a negotiated discount in the 2%-3% range. At the
end of the episode, total payments are compared to
the target price. Providers will share in the savings.
Model 1, episode of care is the inpatient stay in
the acute care hospital. Payments are discounts of
established Inpatient Prospective Payment System
(IPPS). Physicians are paid separately under the
Medicare Physician Fee Schedule.
Model 2, episode of care is the inpatient stay and
post-acute care and it ends 30 or 90 days after
discharge. Model 3 is just the post acute care and
ends at least 30 days after discharge. The bundle
for both models includes physician services, postacute care provider, related readmissions, clinical
laboratory services, durable equipment, prosthetics,
orthotics and supplies, and Part B drugs. Target
7
MODEL
Feature
MODEL 1
MODEL 2
Inpatient Stay Only Inpatient Stay plus
Post-discharge
Services
Eligible Awardees • Physician group
practices
• Acute care
hospitals paid
under the IPPS
• Health systems
• Physician-hospital
organizations
• Conveners of
participating
health care
providers
• Physician group
practices
• Acute care
hospitals paid
under the IPPS
• Health systems
• Physician-hospital
organizations
• Post-acute
providers
• Conveners of
participating
health care
providers
MODEL 3
Post-discharge
Services Only
• Physician group
practices
• Acute care
hospitals paid
under the IPPS
• Health systems
• Long-term care
hospitals
• Inpatient
rehabilitation
facilities
• Skilled nursing
facilities
• Home health
agency
• Physician-hospital
organizations
• Conveners of
participating
health care
providers
MODEL 4
Inpatient Stay Only
• Physician group
practices
• Acute care
hospitals paid
under the IPPS
• Health systems
• Physician-hospital
organizations
• Conveners of
participating
health care
providers
Payment of Bundle Discounted IPPS
and Target Price
payment; no
separate target
price
Retrospective
comparison
of target price
and actual FFS
payments
Retrospective
comparison
of target price
and actual FFS
payments
Prospectively set
payment
Clinical Conditions All MS-DRGs
Targeted
Applicants to
propose based
on MS-DRG for
inpatient hospital
stay
Applicants to
propose based
on MS-DRG for
inpatient hospital
stay
Applicants to
propose based
on MS-DRG for
inpatient hospital
stay
Types of Services
Included in Bundle
Inpatient hospital
services
• Inpatient hospital • Post-acute care
and physician
services
services
• Related
readmissions
• Related post• Other services
acute care
defined in the
services
bundle
• Related
readmissions
• Other services
defined in the
bundle
• Inpatient hospital
and physician
services
• Related
readmissions
8
MODEL
Feature
MODEL 1
MODEL 2
Inpatient Stay Only Inpatient Stay plus
Post-discharge
Services
Expected Discount To be proposed
Provided to
by applicant;
Medicare
CMS requires
minimum discounts
increasing from 0%
in first 6 mos. to 2%
in Year 3
Payment from
CMS to Providers
• Acute care
hospital: IPPS
payment less
pre-determined
discount
• Physician:
Traditional
fee schedule
payment (not
included in
episode)
MODEL 3
Post-discharge
Services Only
MODEL 4
Inpatient Stay Only
To be proposed
by applicant; CMS
requires minimum
discount of 3% for
30-89 days postdischarge episode;
2% for 90 days or
longer episode
To be proposed by
applicant
To be proposed by
applicant; subject
to minimum
discount of 3%;
larger discount for
MS-DRGs in ACE
Demonstration
Traditional fee-forservice payment to
all providers and
suppliers, subject
to reconciliation
with predetermined
target price
Traditional fee-forservice payment to
all providers and
suppliers, subject
to reconciliation
with predetermined
target price
Prospectively
established
bundled payment
to admitting
hospital; hospitals
distribute payments
from bundled
payment
PatientDischarge™ and Bundled Payments for
Care Initiative
PatientDischarge allows patients to select and
schedule follow-up visits with qualified post acute
care providers, based on previous patient feedback.
The list of providers can be dynamically determined
based on the patient demographics, insurance
information and order data. Hospitals can then focus
customers to post-acute care providers where the
bundled payment percentages have already been
negotiated and common payment mechanisms
established.
By pulling post-acute care scheduling into the
registration workflow, providers ensure that the
patient course of care will reconcile with the
established bundled payment arrangements with
chosen post-acute care providers.
References
CMS website on Bundled Payments for Care
Improvement
http://innovations.cms.gov/initiatives/bundledpayments/index.html
CMS Bundled Payments for Care Improvement Fact
Sheet
http://innovations.cms.gov/Files/fact-sheet/
Bundled-Payment-Fact-Sheet.pdf
CMS Bundled Payments FAQ
http://innovations.cms.gov/Files/x/
BundledPaymentsFAQ.pdf
CMS Bundled Payments Application Guidance
http://innovations.cms.gov/Files/x/
BundledPaymentsAppGuidance.pdf
9
Passport eCare™ NEXT and the Medicare
Shared Savings Program
Under the Patient Protection and Affordable Care
Act (ACA), Centers for Medicare and Medicaid
Services (CMS) created the Medicare Shared
Saving Program to incent care providers to better
coordinate care for Medicare patients through
Accountable Care Organizations (ACOs). The
Shared Savings Program rewards ACOs that lower
their growth in health care costs while meeting
performance standards on quality of care.
Participation in the program is voluntary. To
participate, ACOs must make a three-year
commitment, have at least 5,000 Medicare Fee for
Service patients and not be participating in other
shared savings programs. Participating ACOs will
continue to be paid under the Medicare Fee for
Service rules.
However, CMS will also develop a
benchmark for each ACO against which
performance is measured to determine
shared savings or losses. The benchmark
is an estimate of what the total Medicare
Fee for Service Parts A and B would have
been in the absence of the ACO, even if
all those services were not provided by
providers in the ACO.
The benchmark is updated every year. CMS is
implementing a one-sided model (shared savings)
and a two-sided model (shared savings and losses).
Sharing percentage is greater in the two-sided
model (60% vs 50%).
If an ACO meets quality standards and achieves
savings that meets or exceed a Minimum Savings
Rate (MSR), the ACO will share in savings based on
the quality score of the ACO. And, conversely, if an
ACO falls below the Minimum Loss Rate (MLR), the
ACO will share in losses in the two-sided model.
Shared Savings Program is one of three Medicare
ACO programs, also including Advanced Payment
Initiative and the Pioneer ACO Model. All three
models use the same quality performance
assessment, quality measures, modes of data
collection and timing of data submission and
reporting. This model is derived by the Physician
Quality Reporting System (PQRS). For participants
who quality for PQRS reporting incentives, they will
be able to submit one set of reports through the
ACO Group Practice Reporting Option (GPRO) web
interfaces, available for download at QualityNet
website.
For the quality performance standards, ACOs are
measured against 33 existing nationally recognized
quality measures. These quality measures are the
same as those used by other CMS quality programs
such as the Physician Quality Reporting System
(PQRS) and the Electronic Health Record (EHR)
Incentive Programs. The 33 measures are reported
through a combination of claims data (4 measures)
administrative data, ACO GPRO Web Interface
(22 measures) and patient experience surveys
(7 measures). The claims based measures are all
calculated using professional (Medicare Part B)
claims.
For the patient experience care measures, CMS will
administer and pay for the Consumer Assessment
of Healthcare Providers and Systems (CAHPS)
survey for the first two years of the Shared Savings
Program (2012 and 2013) and the first year of the
Pioneer ACO initiative (2012). After that, the ACOs
will select and pay for a CMS-certified vendor to
administer the patient survey.
In the first year, payments will be based on savings
and submitting quality data. After the first year,
ACOs will report and also perform on selected
quality measures. CMS will publish national
benchmarks for ACO quality measures after the first
year. Minimum attainment level will be set at the
30th percentile, maxing out at the 90th percentile.
PatientRisk™ Identifies ACO Members
PatientRisk includes an ACO flag, which identifies
patients who are enrolled in an ACO plan. For the
Medicare ACO programs, CMS simply sends a
spreadsheet of patients originally enrolled, and
then patients who have opted out of the program.
Passport is able to store this member data in a
database and then flag the registration when the
10
patient present for services. This flag enables unique
downstream workflows, including a special ACO
discharge work flow in Passport’s PatientDischarge
solution.
PatientRisk also flags patients who will affect the
quality measures used in the ACO reimbursement
calculation. Both of these flags are first-class alerts
in Passport eCare NEXT and can be used to group
accounts into a work queue, prioritize cases and be
measured for closure in a quality scorecard.
PatientDischarge™ and Medicare Shared Savings
Program
Patient Discharge allows patients to select and
schedule follow-up visits with qualified post acute
care providers, based on previous patient feedback.
The list of providers can be dynamically determined
based on the patient demographics, insurance
information and order data. Hospitals can then
focus customers to post-acute care providers where
revenue sharing arrangements have already been
negotiated and common payment mechanisms
established.
http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/sharedsavingsprogram/
Downloads/MSSP-ACOs-List.pdf
QualityNet Site (Under Physican Offices)
www.qualitynet.org
CAHPS Website
http://www.cahps.ahrq.gov/
Press Ganey CGCAHPS Page
http://www.pressganey.com/ourSolutions/
medicalPracticeSolutions/satisfactionSuite/
cgcahpsInsights.aspx
Physician Comparison Website
http://www.medicare.gov/find-a-doctor/providersearch.aspx?AspxAutoDetectCookieSupport=1
By pulling post-acute care scheduling into the
registration workflow, providers ensure that the
patient course of care will reconcile with the
established bundled payment arrangements with
chosen post-acute care providers.
References
CMS website on Medicare Shared Savings Program
http://www.cms.gov/Hospital-Value-BasedPurchasing/
ACO Quality Measures Overview (p4 table of the 33
measures and data submission method)
https://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/sharedsavingsprogram/
Downloads/ACO_QualityMeasures.pdf
ACO Payment Methodology
http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/sharedsavingsprogram/
Downloads/ACO_Methodology_Factsheet_
ICN907405.pdf
ACO Shared Savings Program Pilots
11
Patient Access Changes Due to ACA
The ACA represents a major change in Medicare
reimbursement methodologies. In the same way the
high deductible plans and health savings accounts
required patient access to create estimates, triage for
charity and collect patient-owed portions up-front,
ACA will affect similar changes in order to optimize
quality scores and readmission rates.
Specifically, two changes are pretty
obvious: discharge planning will start at
registration and case management will
likely engage much earlier in the revenue
cycle.
We'll go into the mechanics of these two changes in
some detail.
Discharge Planning Starts at Registration
Communication of discharge instructions, selection
of post-acute care provider and scheduling of postacute care follow-up are all likely to be tacked on
to the existing registration process. The rational is
that registration is more systematic, measured and
actively managed than discharge. And, patients are
already receiving other key pieces of information
at registration, including consent forms, estimates,
receipts and medical necessity notices. Patients
are also able to make these decisions more easily
before service, before they go through the emotional
distress of a major medical event and are under pain
medication. Lastly, registration has all the key pieces
of information to do the discharge planning step, the
order, the coverage and the patient demographics.
So, folding discharge planning into the registration
workflow and systematically measuring it like other
registration activities makes good sense for those
hospitals who are now managing post-acute care.
managers can ensure that protocols are followed
and properly documented and that patients are
discharged to best practices, protecting a hospital
from having a readmission count against their rate.
So, in the same way that patient access systems can
identify patients with coverage issues and assess
the likelihood for charity enrollment, they will now
be identifying clinically risky patients and routing
them to case management for proactive supervision
through the care cycle.
This benefit of involving case management is even
more apparent for facilities that have implemented
pre-service clearance. In these facilities, case
management can engage at the time of scheduling
or soon thereafter, ensuring that the patient is
receiving the right course of care at the right
service location within the health system and that
pre-service communication is clear and concise.
By adding the pre-service care piece to the postacute care communication and referral, the entire
course of care can be carefully managed for those
patient encounters driving the quality scores and
readmission rates.
In both of these workflow changes, the key
admissions initially will be those in ANI, heart attack,
pneumonia, inpatient surgeries and those patients
enrolled in ACOs. By having two workflows in
place, hospitals can focus the process change on
the specific patient population that requires the
additional steps in discharge planning and case
management, ensuring the change is minimized and
focused on the high-leverage encounters.
Case Management is Engaging Earlier in the
Revenue Cycle
Case management is the obvious group to manage
and document the high-risk admissions that are now
driving a hospital's quality score and readmission
rate. But, to do so, case management will need to
engage early in the care cycle, as the patient is being
scheduled and registered. By engaging earlier, case
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Conclusion
Medicare reimbursement change is here, starting with the Value-based Purchasing Program and
Readmission Risk program in October 2012 and expanding soon to the Bundled Payments for
Improvement of Care and Medicare Shared Savings programs.
The Passport eCare NEXT suite of products expand Passport’s best-of-breed patient access suite to
address these changes. PatientRisk allows clinically risky patient encounters to be identified early in
the revenue cycle, enabling case managers to engage early in the care cycle ensuring compliance and
optimal flow through the system. PatientDischarge communicates discharge instructions and schedules
post-acute care follow-up for patients, helping to reduce readmission rates while coordinating care with
post-acute providers in a shared payment model.
Combined, these products allow discharge planning to start at registration and allow case managers
to engage earlier in the revenue cycle, the two key process changes needed to maximize Medicare
reimbursement in the post-ACA environment.
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ABOUT PASSPORT HEALTH COMMUNICATIONS INC.
Passport Health Communications Inc. creates software and solutions to enable hospitals and health care
providers to improve business operations and secure payment for their services. Founded in 1996 and
headquartered in Franklin, Tenn., the organization is among the nation’s fastest-growing Software-as-aService companies. Passport’s eCare® brand of revenue cycle management solutions are available across
multiple platforms and are delivered to one in three U.S. hospitals and more than 8,600 other health care
facilities in all 50 states.
720 Cool Springs Blvd., Suite 200, Franklin, TN 37067 | 888-661-5657 | www.passporthealth.com