Standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
June 24, 2009
Standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
Unlikely to Support Practices of Hospitals That Treat Post-Acute Providers as “Vendors”
Post-acute providers continue to be “plagued” by hospitals that claim that post-acute providers cannot enter hospitals and/or gain access to patients to coordinate post-acute services because they are “vendors.”
Some hospitals claim that access by “vendors” is prohibited by JCAHO standards. Other hospitals may permit access by post-acute providers only if they comply with complex, inapplicable restrictions that hospitals claim are based on JCAHO standards. Still other hospitals require post-acute providers to pay fees in order to gain access to patients for the purpose of coordinating post-acute services, which is likely to be an impermissible kickback or rebate in violation of the federal anti-kickback statute.
On the contrary, post-acute providers; such as home health agencies, home medical equipment (HME) companies, hospices, and private duty home care agencies; are not vendors and should not be treated like vendors. They are, instead, fellow providers. Vendors are manufacturers and distributors of supplies and equipment that are utilized by hospitals on their premises. Further, a review of JCAHO standards does not support claims by hospitals that their actions are appropriately based on these standards.
Element of Performance for EC.02.02.01, for example, says that hospitals are required to identify individuals entering its facilities. In an accompanying “Note,” however, JCAHO states that hospitals have the flexibility to determine which individuals entering its facilities require identification and how to do so. Consequently, this standard does not support the practices of hospitals identified above. In other words, contrary to the claims of hospitals, JCAHO standards do not require hospitals to treat post-acute providers as vendors or to limit or restrict their access as such.
JCAHO standards do, however, require hospitals to control access to and from areas it identifies as “security sensitive,” which may reasonably include patient care areas. Consequently, it may be appropriate to require post-acute providers to identify themselves to hospital staff upon their arrival at and departure from hospitals. No additional restrictions, however, should be placed on the activities or movements of post-acute providers who:
- have received referrals of patients; or
- cared for patients immediately prior to their admission to hospitals.
With regard to receipt of referrals, it is important to note that referrals for post-acute services do not have to come from physicians.
They may come from patients, their families, physicians, case managers/discharge planners, or other sources. Referrals may also be received by post-acute providers, either verbally or in writing. When post-acute providers are acting on verbal referrals, they should, however, document the name of the person who made the referral and the date and time when it was received.
Patients who received services from post-acute providers immediately prior to admission to an institutional setting may, of course, choose to receive services from different providers upon discharge. If patients do not choose different providers, care should be continued by the same providers with which the patient is likely to have a continuing provider-patient relationship.
Under both of the above circumstances, post acute providers should be permitted access to patients, their families, and information about them as part of the discharge planning process immediately upon admission, consistent with Conditions of Participation (COP’s) of the Medicare Program for hospitals that govern discharge planning. JCAHO standards do not appear to support practices of hospitals that treat post-acute providers as vendors. To the extent that such inappropriate practices interfere with the ability of post-acute providers to effectively coordinate services, post-acute providers should work with hospitals to change unnecessarily restrictive practices.
©Copyright, 2009. Elizabeth E. Hogue, Esq.
All rights reserved. No portion of this material may be used in any form without the advance written permission of the author.
President’s Plan for Health Care Reform
June 13, 2009
Paying for Health Care Reform
$313 Billion in Additional Savings to Create a Deficit Neutral Plan
We have the most expensive health care system in the world, but do not get the best results. The rising costs of health care are a burden on our families and a drain on our long-term economic growth. If we continue on the course we are on, health care expenditures will reach 20 percent of GDP within a decade. Rapidly rising health care costs are leading our nation down a fiscally unsustainable path.
For the health of the American people and the health of our economy, we must act now to bring down health care costs and reform the health care system. It is central to the long-term prosperity of the United States. That is why the President is committed to passing health care reform this year. Guided by the principle that we should fix what’s broken and build on what already works, the President wants to pass health care reform that allows one to keep their health insurance and choose their health care providers, expands coverage to the millions without, and brings down the cost of coverage.
The President is committed to undertaking reform that is completely paid for and deficit neutral over the next decade. That is why he put forward in his FY 2010 Budget an historic $635 billion down payment on reform. Roughly half of this amount comes from revenue proposals, including limiting the value of itemized deductions for families making over a quarter-million dollars a year to the rates they were during the Reagan years, and about half comes from savings from Medicare and Medicaid.
Since making this proposal, the Administration has worked with Congress on other ways to offset fully the cost of health care reform through additional savings and revenues. To that end, the Administration is detailing today savings proposals that will contribute another $313 billion over 10 years to paying for health care reform, bringing the total scoreable offsets put forward by the Administration to nearly $950 billion over 10 years. Together, this would extend the solvency of Medicare’s Hospital Insurance Trust Fund by seven years to about 2024, and reduce beneficiary premiums for physician and outpatient services by about $43 billion over the next 10 years. The Administration hopes these suggestions will help Congress as it continues to draft legislation, and remains open to any other proposals to pay for reform that Congress may put forward.
| Source |
Health Care Reserve Fund ($ in billions) |
|
|
10 years |
||
| FY 2010 Budget - Medicare and Medicaid Savings - Revenues |
$635 $309 $326 |
|
| Additional Medicare and Medicaid Savings - Incorporate productivity adjustments into Medicare payment - Pay better prices for Medicare Part D drugs - Other |
$313 $110
$22 |
|
| Total |
$948 |
|
Reforming the health care system does not end at expanding coverage and making sure that it is paid for; we also must address the underlying problems in our health care system that impede quality improvements and raise costs. The President therefore believes that in addition to scoreable offsets, we must take steps to transform the health care system, such as investing in health care information technology, patient-centered quality research, prevention and wellness, and in creating a system that pays providers for providing better care not just more care. Over time, these steps will help to produce a health care system that works better and costs less.
Paying for Health Care Reform: New Savings
As was emphasized when the President’s Budget was initially released, the reserve fund represents a substantial down payment but is not by itself sufficient to fully fund comprehensive reform. The President has insisted that reform must be deficit-neutral based on real savings and revenue estimates as determined by impartial scorers. Thus, in addition to the proposals included in the FY 2010 Budget, the Administration is putting forward policy options to further rein in federal health spending, make the system more efficient, and deliver better quality of care. When combined with the Budget proposals, these new options would extend the solvency of Medicare’s Hospital Insurance Trust Fund by seven years to about 2024. These new savings include:
- Incorporate productivity adjustments into Medicare payment updates. Productivity in the U.S. economy has been improving over time. However, most Medicare payments have not been systematically adjusted to reflect these system-wide improvements. We should permanently adjust most annual Medicare payment updates by half of the economy-wide productivity factor estimated by the Bureau of Labor Statistics. This adjustment will encourage greater efficiency in health care provision, while more accurately aligning Medicare payments with provider costs.
- Reduce subsidies to hospitals for treating the uninsured as coverage increases. Instead of paying hospitals to treat patients without health insurance, we should give people coverage so that they have insurance to begin with. As health reform phases in, the number of uninsured will go down, and we would be able to reduce payments to hospitals for treating those previously uncovered. This would be done by establishing a new mandatory mechanism to better target payments to hospitals for unreimbursed care remaining after coverage increases. Beginning in FY 2013, payments would be gradually phased down so that by 2019, funding would equal 25 percent of Medicare/Medicaid Disproportionate Share Hospitals (DSH) funding in 2013, and updated by inflation.
- Pay better prices for Medicare Part D drugs. In its meeting with the President and subsequent communication, the pharmaceutical industry has committed itself to helping to control the rate of growth in health care spending. There are a variety of ways to achieve this goal. For example, drug reimbursement could be reduced for beneficiaries dually eligible for Medicare and Medicaid. The Administration is working with the Congress to develop the most appropriate policy to achieve these savings.
Other Savings
- Adjust payment rates for physician imaging services to better reflect actual usage. To provide more accurate payment for physician imaging services, the Department of Health and Human Services would increase the equipment utilization factor for advanced imaging (such as magnetic resonance imaging (MRI) and computed tomography (CT) machines) from 50 percent to 95 percent. This proposal – which is closely aligned with a Medicare Payment Advisory Commission (MedPAC) recommendation – would better reflect how these technologies are actually used.
- Adopt MedPAC’s recommendations for 2010 payments to skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. To bring down costs and maintain quality, we shouldupdate payments based on MedPAC’s consideration of multiple variables, such as quality, access to care, and adequacy of payment. Doing so would implement MedPAC’s 2010 payment recommendations for skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals.
- Cut waste, fraud, and abuse. It is important that patients get the best care, not just more care. Unnecessary treatments are not only expensive, but also can harm the health of the patient. To discourage physicians from ordering unnecessary or excessive treatment, we should increase the scrutiny of physicians in high-risk areas or those that order a high volume of high-risk services (such as home health, durable medical equipment, and home infusion therapy) through additional pre-payment review.
Paying for Health Care Reform: 2010 Budget Proposals
The above savings would be in addition to the down payment for comprehensive health care reform of $635 billion over 10 years detailed in the FY 2010 Budget. The reserve fund is financed roughly half through proposals to generate more revenue, and half through efficiencies and savings from Medicare and Medicaid. Based on our projections, the Medicare proposals contained in the reserve fund would extend the solvency date of the Hospital Insurance (HI) Trust Fund by two years and reduce beneficiary premiums for physician and outpatient services by about $33 billion over the next 10 years. As a result of these proposals, Medicare beneficiaries will also see an improvement in the quality of their services. The reserve fund includes a broad array of savings proposals including:
- Reducing Medicare overpayments to private insurers. The establishment of a competitive system where payments are based upon an average of plans’ bids submitted to Medicare would save taxpayers close to $177 billion over 10 years, as well as reduce Part B premiums.
- Improving Medicare and Medicaid payment accuracy. By strengthening program integrity efforts, the Centers for Medicare and Medicaid Services (CMS) will address vulnerabilities that have led to billions of dollars in overpayments and fraud each year.
- Improving care after hospitalizations and reducing readmission rates. A combination of incentive payments and penalties should lead to better care and result in fewer readmissions – saving roughly $25 billion over 10 years.
- Expanding the Hospital Quality Improvement Program: By linking a portion of Medicare payments for acute in-patient hospital services to hospitals’ performance on specific quality measures, quality of care for beneficiaries will improve, and Medicare will save approximately $12 billion over 10 years.
Elizabeth Hogue on Kickbacks for Referrals
June 10, 2009
One of the health care industry’s finest attorneys when it comes to laws pertaining to Medicare Certified agencies has generously shared the following information with our readers. Questions about the content of the information should be directed to Elizabeth Hogue at her email below. Your comments below are always welcome.
Home Care Providers Indicted for Paying Kickbacks for Referrals
Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: ElizabethHogue@ElizabethHogue.net
On December 18, 2008 a federal grand jury indicted owners and employees of eight home health agencies in the Metro-Detroit area on charges that they took part in a plan to solicit and pay kickbacks in exchange for Medicare patient referrals. This plan was devised by Rebecca Sharp, president of Continuing Senior Care, Inc. in Ypsilanti, Michigan, who allegedly received over $1.1 million in kickbacks.
According to the indictment, Sharp obtained potential home health patients by directing her staff to randomly telephone senior citizens in order to offer them medical services and chore workers. If any senior citizen was curious as to how Continuing Senior Care received his or her contact information, employees were instructed to state that this information came from Medicare. When a senior citizen agreed to the offer, employees would acquire patients’ Medicare information. Patients would then be visited by a doctor, employed by Sharp, who measured vital signs and prescribed home health care to all patients, whether or not it was medically necessary.
Following this, Sharp referred the Medicare patients to home health care agencies. She allegedly offered to refer eighty patients and Medicare numbers each week in exchange for a $250 fee per patient. In addition, Sharp claimed that the doctors whom she employed would sign plans of care regardless of patients’ actual medical needs.
With regard to the ramifications of this case, U.S. Attorney Terrence Berg stated that “when Medicare is abused by unscrupulous persons to pay for unnecessary treatment and to garner kickbacks, that conduct harms both legitimate Medicare recipients as well as the program itself.”
There is a federal law that prohibits illegal remuneration. This law is often called the anti-kickback statute. It generally says that anyone who either offers to give or actually gives anything to anyone in order to induce referrals has engaged in illegal conduct. In this case, the payments allegedly made by home health agencies to Continuing Senior Care seem to have been made in exchange for referrals in direct violation of the anti-kickback statute.
In addition, it is important for providers to note that if the referrals were obtained illegally in violation of the anti-kickback statute and agencies submitted claims for services provided to patients referred by Continuing Senior Care, such claims may also violate the federal False Claims Act. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, has clearly stated that claims submitted for services provided to patients who were referred in violation of applicable prohibitions are “false claims.” Submission of false claims may also result in criminal prosecution and/or civil liability, amounting to many thousands of dollars and suspension or exclusion from participation in the Medicare and Medicaid Programs and other federal and state healthcare programs.
In addition to the necessity to avoid payment of kickbacks, therefore, providers must be scrupulous about avoiding all illegal strategies for obtaining referrals. When referrals are obtained by any unlawful means, the consequences can be extremely significant for providers.
Consequently, as part of the development of new marketing strategies, management must always explore the legal boundaries of proposed methods of marketing prior to implementation. In order to do so, marketing staff cannot be allowed to implement new marketing programs without review and approval by management. Review must include a thorough examination of whether the marketing program, as proposed, violates applicable prohibitions and, if so, whether it can be changed so that it passes muster.
(To learn more about the above issues from a book titled Preventing Fraud and Abuse, send a check for $30.00 that includes shipping and handling made out to Elizabeth E. Hogue, Esq. to Fulfillment, 107 Guilford, Summerville, SC 29483. To obtain an 80-minute DVD that educates marketing staff and others about fraud and abuse compliance, send a check for $105.00 that includes shipping and handling to the above address.)
Front Loading Visits
June 4, 2009
Everyone seems to be familiar with the concept of front loading visits and yet, during clinical record reviews at a variety of clients’ offices, I do not see it being used routinely. Too often, the same old tired weekly frequencies are ordered. And yet, we know that most hospitalizations occur within the first weeks of home health care. Patients coming out of the hospital are at higher risk for re-hospitalization during the first month post hospitalization.
Financial considerations may be seen as a barrier to some agencies and yet, when done with care consideration, it does not necessarily add to the overall episode costs. In fact, overall episode costs may be lowered while improving outcomes. Consider the following patient post hospitalization for congestive heart failure. A ‘generous’ schedule might be 18 visits which would be translated into 2W9.
What if we took those 18 visits and divided them as follows:
3W1 with two additional phone calls to verify weight and medication compliance
2W1 with three additional phone calls to verify weight and medication compliance
1W7 with 2 PRN visits for weight gain greater than three pounds AND twice weekly phone calls to monitor weight and medication compliance.
This comes to only 14 visits if the PRN visits are both used. Now, if the patient puts on five pounds and orders are obtained to increase diuretics, additional visits can be ordered in the interim to monitory symptoms.
And, if the patient does well, the agency saves the cost of 4 visits – roughly $400.00 – while at the same time delivering care of a higher quality to the patient.
That sounds like a plan to me.
I Love My Job
June 2, 2009
I love my job. By nature I am curious. Opening a clinical record and reading about the history of patient and the interactions between patient and nurse satisfies my urge to be nosey.
Sometimes, however, I feel as though I am being punished. Impeccable charting directly from a teaching manual can bore a person to tears. Consider the following two examples of charting about an elderly gentleman with lung cancer, completely in denial and usually intoxicated.
- Patient remains non-compliant with medication routine exhibiting drug seeking behavior. Notified MD. No new orders.
- PRN visit for complaints of anorexia. Patient states to nurse, “I called you because I can’t eat. Now you are asking me why I can’t eat. Y’all are F***ing crazy! Tell that doctor I ain’t going back until I get my pills.”
While the first note is completely accurate it really doesn’t paint a picture of the patient.
The second example tells me a whole lot more. The patient uses colorful language to be sure. The one quote tells me that he may be extremely difficult to teach. I know that it will be challenging to get this patient to buy into compliance. In other words, ‘I get the picture’. And that picture comes more accurately from the patient’s own words than anything a nurse will ever learn out of a book.
In another agency, I was reading the visit note from a nurse had gone to visit a patient in an assisted living community. The opening sentence in the note explained that the patient was complaining because the green beans at lunch were not cooked the way she preferred.
Consider how much information is in that one sentence. The patient is complaining about vegetables. Patients who are in serious pain or have no appetite due to illness usually don’t care about green beans. And this patient is not apathetic, a common symptom of depression. She really did care about her green beans. And it is apparent that this patient remembered what she ate and how it was prepared so short term memory is intact. Again, the nurse has painted a picture I can see and understand.
Compare that to, “Patient denies pain or discomfort. Reports lunch was eaten prior to nurse arrival.”
In our efforts to be professional, concise and ‘appropriate’, we often forget the real purpose of clinical documentation. Effective communication between care providers enhances the quality of care given to patients. When reading the examples above, I know I am better able to pick up care following the more colorful examples than the ones that read like a nursing text book.
