Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents Payment Model

1. Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility ResidentsPayment Model

2. Payment Model OPTIMISTIC is a project by Indiana University • Funded by Centers for Medicare & Medicaid Services (CMS) to test a new payment model for long-term care facilities and practitioners to: • improve quality of care by reducing avoidable hospitalizations • lower combined Medicare and Medicaid spending.

3. Contents • Payment Model Overview • ECCP Eligibility • Facility Payment for Six Qualifying Conditions • Practitioner Payment #1 – for Six Qualifying Conditions • Practitioner Payment #2 – For Care Coordination

4. Payment Model Overview • ECCP Eligibility • Facility Payment for Six Qualifying Conditions • Practitioner Payment #1 – for Six Qualifying Conditions • Practitioner Payment #2 – For Care Coordination

5. Funded programs • Alabama Quality Assurance Foundation - Alabama • HealthInsight of Nevada - Nevada and Colorado • Indiana University - Indiana • The Curators of the University of Missouri - Missouri • The Greater New York Hospital Foundation, Inc. - New York • University of Pittsburgh Medical Center (UPMC) Community Provider Services - Pennsylvania

6. Why Implement Payment Model? The initial four years of the demonstration project (2012-2016) addressed preventing avoidable hospitalizations through various clinical quality models.

7. Why Implement Payment Model? HOWEVER…. the initial demonstration did NOT address the existing payment policies that may be leading to avoidable hospitalizations.

8. Why Implement Payment Model? BECAUSE… • MedPAC has reported it is financially advantageous for LTC facilities to transfer residents to a hospital* • In decisions regarding provision of care, the focus should always be on providing the best setting for the resident/patient *Medicare Payment Advisory Commission (MedPAC) June 2010 Report to Congress

9. Payment Model Existing 2012-2020 New 2016-2020 new payment mechanism only clinical quality model+new payment mechanism Continuing LTC OPTIMISTIC Facilities = 19 New LTC OPTIMISTIC Facilities = 25

10. Payment Reforms

11. Principal Payment Reform Goal: Six Conditions 10.3% 6.5% 4.9% 32.8% 14.2% 11.6%

12. Payment Model Overview • ECCP Eligibility • Facility Payment for Six Qualifying Conditions • Practitioner Payment #1 – for Six Qualifying Conditions • Practitioner Payment #2 – For Care Coordination

13. OPTIMISTIC Eligible Residents Inclusion criteria: • Reside in the LTC facility for ≥101 cumulative days from the resident’s admission date • Enrolled in Medicare (Part A and Part B FFS) and Medicaid, or Medicare (Part A and Part B FFS) only • Reside in Medicare or Medicaid certified LTC bed

14. OPTIMISTIC Eligible Residents (cont’d) Exclusion criteria: • Enrolled in a Medicare Advantage plan • Receiving Medicare through the Railroad Retirement Board • Elected Medicare hospice benefit • Medicaid only • Opted-out of participating in the Initiative Resident’s eligibility must be renewed if discharged to the community for more than 60 days.

15. Payment Model Overview • ECCP Eligibility • Facility Payment for Six Qualifying Conditions • Practitioner Payment #1 – for Six Qualifying Conditions • Practitioner Payment #2 – For Care Coordination

16. Facility Payment for Six Qualifying Conditions

17. Facility Payment for Six Qualifying Conditions (cont’d) New code added for the participating nursing facilities

18. Facility Payment for Six Qualifying Conditions (cont’d) Resident appropriately managed in facility per CMS guidelines Resident is on covered Part A SNF stay No billing new code Resident provided with in-person evaluation* by MD, NP or PA Resident experiences qualifying condition Resident is NOT on a Medicare Part A SNF stay OK to bill * Or qualifying telemedicine assessment

19. Facility Payment for Six Qualifying Conditions (cont’d) Nursing Facility Detectionof acute change of condition • Documented in the medical record by a physician or a nurse at the LPN level or higher • STOP AND WATCH tool, SBAR, free text note, structured clinical documentation are acceptable formats as long as they are part of the medical records

20. Facility Payment for Six Qualifying Conditions (cont’d) Practitioner Confirmation • MD, NP or PA must confirm qualifying diagnosis by in-person evaluation or qualifying telemedicine assessment • ANY attending practitioner can provide confirming diagnosis for the purposes of facility payment • Once qualifying diagnosis confirmed, facility may bill for acute care services, regardless of whether the practitioner also bills Medicare.

21. Facility Payment for Six Qualifying Conditions (cont’d) Practitioner Confirmation • Evaluation or assessment must occur by the end of the 2nd day after change in condition • Evaluation must be documented in resident’s medical record • If there is more than one qualifying diagnosis, both should be reported even though facility may only bill one code once per day

22. Facility Payment for Six Qualifying Conditions (cont’d) Enhanced Services at Nursing Facility • Facility may not bill unless diagnosis has been confirmedby the provider. • If treatment begins before official confirmation, facility may bill retroactive to the start of treatment IF confirmation occurs no more than two days afterward.

23. Facility Payment for Six Qualifying Conditions (cont’d) Enhanced Services at Nursing Facility cont. • Facility must be able to provide the appropriate care for the patient • Services must be provided in-house by facility staff or contracted service providers • Duration of benefit is specific to each of the six conditions.

24. Facility Payment for Six Qualifying Conditions (cont’d) Extension of Enhanced Services • If condition is not resolved, the complete process may be retriggered • A new in-person practitioner assessment is required to confirm qualifying condition • No “gap” or delay is required • All documentation in medical record is required for reactivation: Detection, practitioner confirmation, and treatment

25. Facility Payment for Six Qualifying Conditions: Pneumonia

26. Facility Payment for Six Qualifying Conditions: Pneumonia

27. Facility Payment for Six Qualifying Conditions: Congestive Heart Failure

28. Facility Payment for Six Qualifying Conditions: Congestive Heart Failure

29. Facility Payment for Six Qualifying Conditions: COPD/Asthma

30. Facility Payment for Six Qualifying Conditions: COPD/Asthma

31. Facility Payment for Six Qualifying Conditions: Skin Infection

32. Facility Payment for Six Qualifying Conditions: Skin Infection

33. Facility Payment for Six Qualifying Conditions: Fluid or Electrolyte Disorder, or Dehydration

34. Facility Payment for Six Qualifying Conditions: Fluid or Electrolyte Disorder, or Dehydration

35. Facility Payment for Six Qualifying Conditions: UTI

36. Facility Payment for Six Qualifying Conditions: UTI

37. Facility Payment for Six Qualifying Conditions (cont’d) Submitting for payment • Facility’s responsibility to trigger payment code for six qualifying conditions. • Submit as Medicare Part B claim. • Only one code may be billed per day for a single beneficiary, even if that beneficiary has more than one of the six conditions being treated in the facility.

38. Facility Payment for Six Qualifying Conditions (cont’d) Submitting for payment cont. • Facility may not bill on the calendar day which a resident is discharged, regardless of the time of discharge. Separately, CMS will be collecting data on each use of the new billing code as well as other information to monitor the Initiative.

39. Facility Payment for Six Qualifying Conditions (cont’d) Submitting for Payment cont. IF a resident is receiving enhanced services for a qualifying condition, AND is transferred to the hospital for 2-3 days for an UNRELATED issue • The benefit period continues from the original assessment and facility may continue billing upon their return if the qualifying condition is present • A re-evaluation is not required upon resident’s return.

40. Facility Payment for Six Qualifying Conditions (cont’d) Example 1: Hospitalization during benefit period Consider a resident treated by a facility for Days 1-3, then transferred to the hospital for two days (Days 4-5), returning on Day 6. The facility may bill for Day 6 and Day 7 without a re-evaluation as long as the condition has not yet been resolved.

41. Facility Payment for Six Qualifying Conditions (cont’d) Submitting for Payment cont. • Day 1 – the day change in condition is identified AND practitioner confirms diagnosis by the end of the second day • OR, if the practitioner evaluation occurs after the second day, then the day of evaluation is Day 1.

42. Facility Payment for Six Qualifying Conditions (cont’d) Example2: Determining Day 1 for billing If a resident experienced an acute change in condition on June 1, the evaluation must occur no later than 11:59 pm on June 3 to satisfy Initiative requirements. In that case, facilities may bill the new codes for June 1-3 as appropriate. If the evaluation does not occur until June 4, then the facility would be eligible for payments beginning on that day.

43. Facility Payment for Six Qualifying Conditions (cont’d) Submitting for Payment cont. • If the billing period begins based on one qualifying diagnosis (or set of qualifying diagnoses), and a follow-up practitioner assessment leads to a different qualifying diagnosis (or set of diagnoses), that assessment would trigger a new seven-day* billing period and should be reported as a completely separate acute change in condition. • *(Or five days in the case of dehydration only)

44. Facility Payment for Six Qualifying Conditions (cont’d) Example 3: Billing periods if change qualifying diagnosis If a resident is diagnosed with both COPD and Cellulitis on Day 1, then on Day 4 an assessment indicates that cellulitis has resolved but COPD hasn’t, then a new seven-day period would begin for the COPD-only diagnosis on Day 4.  Days 1-3 could be billed under either the Cellulitis or COPD code, but Day 4 and beyond must be billed under the COPD code.  The facility could then bill through Day 10, if appropriate, without an additional follow-up assessment.

45. Facility Payment for Six Qualifying Conditions (cont’d) Submitting for Payment cont. • Separately-billable services under Medicare can still be billed during a benefit period. This applies to any Medicare services that can currently be billed above and beyond a Part A per diem or when a resident’s stay is not covered under Part A.

46. Example of Facility Payment

47. Payment Model Overview • ECCP Eligibility • Facility Payment for Six Qualifying Conditions • Practitioner Payment #1 – for Six Qualifying Conditions • Practitioner Payment #2 – For Care Coordination

48. Practitioner Payment #1 for Six Qualifying Conditions

49. Practitioner Payment #1 for Six Qualifying Conditions (cont’d) Acute Nursing Facility Care Code G9685 Current LTC Facility Visit CPT Code 93310 Equivalent Hospital Visit CPT Code 99223 New code added for the participating practitioners

50. Practitioner Payment #1 for Six Qualifying Conditions (cont’d) • Resident appropriately managed in facility per CMS guidelines • Resident is on a covered Medicare • Part A SNF stay • Resident provided with in-person evaluation* by CMS-approved practitioner by the end of the second day after the change in condition • Practitioner can bill new code • Resident provided with in-person evaluation* by UNAPPROVED practitioner at any time • Resident experiences suspected qualifying acute change of condition • Resident is not on a covered Medicare Part A SNF stay • Practitioner • cannot bill new code * Or qualifying telemedicine assessment