So What Does All This Mean to Your Critical Access Hospital?

1. So What Does All This Mean to Your Critical Access Hospital? Michele Madison mmadison@mmmlaw.com 404-504-7621

2. Word World MBQIP – Medicare Beneficiary Quality Improvement Project CMI – Centers for Medicare/Medicaid Innovation VBP – Value Based Purchasing ACO – Accountable Care Organization EHR – Electronic Health Records HIPAA –Health Insurance Portability and Accountability Act

3. National Aims Better Care:improve the overall quality, by making healthcare more patient centered, reliable accessible and safe Healthy People/Healthy Communities: improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health in addition to delivering higher quality care Affordable Care: reduce the cost of quality health care for individuals, families, employers and government National Strategy for Quality Improvement in Healthcare March 2011

4. National Quality Priorities • Making care safer by reducing harm caused in the delivery of care • Ensuring that care engages each person and family as partners • Promoting effective communication/care coordination • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease National Strategy for Quality Improvement in Healthcare March 2011

5. National Quality Priorities • Working with communities to promote wide use of best practices to enable healthy living • Making quality care more affordable

7. MBQIP AIM: Making Care Safer Effective Prevention And Treatment Practices Purpose: • To involve more (all) CAHs to improve the quality of care which requires measuring to understand status quo and opportunities • To provide a rural-appropriate system of measurement and comparison • Identify best practices/successful QI interventions • To learn and share from each other on best practices and implement them to improve health care

8. Value Based Purchasing value-based incentive payments are made in a fiscal year to hospitals meeting performance standards established for a performance period for such fiscal year 17 Clinical Measures 1- HCAHPS-Patient Experience

9. VBP-Measures • Acute Myocardial Infarction (AMI); • Heart Failure (HF); • Pneumonia (PN); • Surgeries, as measured by the Surgical Care Improvement Project (SCIP); • Healthcare-Associated Infections (HAI); • Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).

10. VBP Dates • July 1, 2011 – March 31, 2012 • Compare July 1, 2009 –March 31, 2010 • Payments October 1, 2012

11. ACO

12. ACOs AIM: Engaging patient and families Clinical Care Coordination An organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it

13. ACO Organization 1) Physicians and other professionals in group practices 2) Physicians and other professionals in networks of practices 3) Partnerships or joint venture arrangements between hospitals and physicians/professionals 4) Hospitals employing physicians/professionals 5) Other forms that the Secretary of Health and Human Services may determine appropriate.

14. ACO Reporting An ACO must have defined processes to • promote evidenced-based medicine, • report the necessary data to evaluate quality and cost measures (this could incorporate requirements of other programs, such as the • Physician Quality Reporting Initiative (PQRI), • Electronic Prescribing (eRx), • Electronic Health Records (EHR), and • coordinate care

15. Patient Population • Minimum of 5000 Medicare Beneficiaries • Quality Measure Reporting • Clinical and Patient Experience Measures • Shared Savings • Patient Centered Medical Home

16. Legal Hurdles • Stark • Anti-kickback • Civil Monetary Penalty • Anti-trust Waiver??

17. CMI Centers for Medicare and Medicaid Innovation (CMI) The CMI will be the major focal point for the identification of problem areas in health care delivery and identification and testing of new models to improve program performance. To design, implement and evaluate Medicare and Medicaid demonstrations and pilot programs to test the feasibility, cost effectiveness and quality outcomes of new health care delivery models.

18. CMICont’d • To promote research and demonstration transparency by disseminating findings to inform law makers and interested parties about health care delivery issues, new innovative concepts, and demonstrations and pilot programs • Evaluative findings to develop new objectives for basic research and new research demonstrations • Has the authority to extend and expand the operation of successful models

19. DemonstrationProjects Establishes a Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. Establishes a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative beyond 2010

20. OtherModels • Independence at home demonstration program. • Hospital readmissions reduction program. • Community-Based Care Transitions Program. • Extension of gainsharing demonstration.

21. Medicaid Pediatric Accountable Care Organization Demonstration Project Demonstration project to evaluate integrated care around a hospitalization Global Payment System Demonstration Project Medicaid emergency psychiatric demonstration project

22. Meaningful Use Final Rule Published July 28, 2010

23. Ultimate Goal The ultimate goal of meaningful use of an Electronic Health Record is to enable significant and measurable improvements in population health through a transformed health care delivery system. The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.

24. Health Outcome Policy Priorities Improve Quality, Safety, Efficiencies and Reduce Health Disparities Engage Patients and Families Improve Care Coordination Improve Population and Public Health Ensure Adequate Privacy and Security Protections for Personal Health Information

25. Final Rule • Stage 1: • Electronically capturing health information in a coded format • Track key clinical conditions and communicating that information for Care Coordination Purposes • Implement Clinical Decision Support tools to facilitate disease and medication management; reporting clinical quality measures; and public health information

26. Stages 2013--2015 • Stage 2 Encourage the use of Health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible, such as the electronic transmission of orders entered using CPOE and the electronic transmission of diagnostic test results. • Stage 3 Focus on promoting improvements in quality, safety and efficiency, focusing on decision support for national high priority conditions, patient access to comprehensive patient data and improving population health

27. MU Elements • Eligible Professionals have 15 Core Elements • Hospitals have 14 Core Elements • Menu Sets offer flexibility, but at least one Menu set must address a public objective • 5 objectives out of 10 from the Menu Set • 6 Total Clinical Quality measures • If an element is not applicable and the provider does not have any eligible patients then the measure may be excluded

28. Demonstration of Meaningful Use During the First Year Eligible Professionals and Hospitals shall file an attestation statement that they are in compliance with the meaningful use measures. Reporting Period is 90 days During the Second Year, Eligible Professionals and Hospitals shall electronically report the information. Reporting Period is Full Year

29. Hospital Payments Hospital Specific Calculation: [$2Million + (0 x (1149-1 discharges) +(200 x (23,000-1150 discharges) + [Medicare Share] x [Transition Factor]. If the adoption is after 2013 the payment will reduce based upon modified Transition Factor Critical Access Hospital: (Reasonable costs incurred for the purchase of certified EHR technology) times (Medicare share percentage).   The Medicare share percentage equals the lesser of (1) 100 percent; or (2) the sum of the Medicare share fraction for the CAH and 20 percentage points. Paid through prompt interim payment– cost reporting period No payment after 2015 and no payments for more than 4 consecutive years

30. Medicaid Hospital Calculation (Overall EHR Amount) * (Medicaid Share) or Overall EHR Amount Equals {Sum over 4 year of [ (Base Amount Plus Discharge Related Amount Applicable for Each Year) * Transition Factor Applicable for Each Year]} * Medicaid Share Equals {(Medicaid inpatient-bed-days + Medicaid managed care inpatient-bed-days) divided by [(total inpatient-bed days) times (estimated total charges minus charity care charges) divided by (estimated total charges)]}

31. Key Dates for Hospitals • October 1, 2010 – Reporting year begins for eligible hospitals and CAHs. • January 3, 2011 – Registration for the Medicare EHR Incentive Program begins. • January 3, 2011 – For Medicaid providers, states may launch their programs if they so choose. • April 2011 – Attestation for the Medicare EHR Incentive Program begins. • May 2011 – EHR Incentive Payments expected to begin. • July 3, 2011 – Last day for eligible hospitals to begin their 90-day reporting period to demonstrate meaningful use for the Medicare EHR Incentive Program. • September 30, 2011 – Last day of the federal fiscal year. Reporting year ends for eligible hospitals and CAHs. • November 30, 2011 – Last day for eligible hospitals and critical access hospitals to register and attest to receive an Incentive Payment for Federal fiscal year (FY) 2011

32. HIPAA 5010 • Less ambiguity in the implementation guides • Enhanced usability and usefulness of certain transactions such as referrals and authorizations (X12 and NCPDP) • Improved utility of the NCPDP standards, compliance with Part D requirements • Supports standardization of companion guides across the industry • Supports increased use of EDI between covered entities • Supports e-health initiatives now and in the future • Provides infrastructure on ICD-10 and Present on Admission Indicator

33. ICD-10 • Measuring the quality, safety and efficacy of care • Designing payment systems and processing claims for reimbursement • Conducting research, epidemiological studies, and clinical trials • Setting health policy • Operational and strategic planning and designing healthcare delivery systems • Monitoring resource utilization • Improving clinical, financial, and administrative performance • Preventing and detecting healthcare fraud and abuse • Tracking public concerns and assessing risks of adverse public health events

34. Dates of Importance • HIPAA 5010 Level 1 Compliance • January 1, 2011 • HIPAA 5010 Implementation • January 1, 2012 • ICD-10 • October 1, 2013

35. PAYMENT MODELS • Linking Payment to Quality • Enhanced Quality Reporting for Physicians and Hospitals • Be ready for HIPAA 5010 and ICD-10

36. Thank you Michele Madison Partner, Healthcare mmadison@mmmlaw.com 404-504-7621 This presentation is provided as a general informational service to clients and friends of Morris, Manning & Martin LLP. It should not be construed as, and does not constitute, legal advice on any specific matter, nor does this message create an attorney-client relationship. These materials may be considered Attorney Advertising in some states. Please note, prior results discussed in the material do not guarantee similar outcomes.