Inpatient Facility Coding & Compliance Alert

Find your balance within CMS’s three pronged approach

Reducing hospital readmissions seems to be a high priority for CMS this year, with the agency seeming to try every possible strategy to curb the number of hospital admissions en bloc. Read on for a lowdown on how to reap benefits of your hard work, and avoid pitfalls.

Investing in Your SNF Care Can Mean a Fortune

CMS has agreed to give generous incentives to skilled nursing facilities (SNF) for better nursing care. Good care leads to better health outcomes that subsequently result in lesser number of patients needing to revisit the hospitals or get admitted again.

“With CMS paying close attention to this issue there will be some positive results, that is, fewer readmissions,” opines Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “For SNFs, if the care is properly provided, including appropriate physician participation, then avoidable hospitalization should be minimized. This is an area in which a broader view of both the delivery systems and payment systems need optimization. Such optimization would also increase the quality of care. More research and modeling needs to be accomplished in this area.”

Medicare research shows that if better interventions can be given, at least 45 percent of hospitalizations can be prevented. This equates to almost fifty percent of Medicare cost savings in the given scenario.

“Hospital admissions are expensive (relatively speaking) and if SNF services are appropriate, then the residents should not need hospitalizations until there is really something wrong,” admits Abbey.

Focus on Readmissions and Avoid HAC

Encouraging high quality of nursing care seems to be a welcome step, but you also need to brace for other not-so-pleasant provisions in the IPPS rule for FY 2017.

Get ready to face a reduction in your hospital’s base operating DRG payment if your hospital admission statistics demonstrate an excess readmission rate for conditions including pneumonia, heart failure (HF), total hip arthroplasty/total knee arthroplasty (THA/TKA), acute myocardial infarction (AMI), and chronic obstructive pulmonary disease (COPD). Beginning in 2017, coronary artery bypass graft (CABG) also will be included in the list.

With talks about the IPPS rule in the air, it’s natural to also mention the Hospital Acquired Conditions (HAC), where CMS proposes negative adjustment for the poorly performing hospitals. How should an average provider try to sync with this “carrot and stick” approach? On one hand, Medicare is bestowing incentives to SNF for better care resulting in lesser readmissions, and on the other hand, there adjustments for hospital providers for excess readmissions in certain conditions under the hospital IQR program, and also negative adjustments for excess admissions resulting due to HAC.

“Medicare is trying to do everything that they can in order to reduce hospital admissions from SNFs,” tells Abbey. “While these two issues are somewhat related, they are really separate. The reduction for hospitals is relative to HAC that is hospital acquired conditions. CMS is concerned about both readmissions (in general) and also admissions relative to HACs.”

Putting the pieces together: There will be more issues to watch for in the near future. “On the SNF side, one of the issues is obtaining physician services at the SNFs,” says Abbey. “There is this proposed legislation (CONNECT), that would greatly enhance telemedicine which in turn would affect physician monitoring of SNF patients. Thus, there any many aspects to this whole SNF situation. With the Baby Boom generation arriving at the point where more SNF services are needed, this whole situation will become more acute.” Keeping your long term targets in perspective, it’s time you draw out a strategy to brace the responsibilities that come your way.

Links: Access the full report on the 2014 results at https://innovation.cms.gov/Data-and-Reports/index.html.

Find more information about the new Medicare payment incentives for hospital readmissions reduction at: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-08-27.html.