CMS Announces Next Generation ACO Model

The Centers for Medicare and Medicaid Services (CMS) recently announced a new Accountable Care Organization (ACO) model called the Next Generation ACO Model.  The Next Generation ACO Model differs from current Medicare ACO initiatives by offering financial arrangements with higher levels of risk and reward than are available under the current ACO programs.  In addition, the Model has alternative payment mechanisms to enable a transition from fee-for-service to capitation.  According to CMS, the goal of the Next Generation ACO Model is to test whether strong financial incentives for ACOs can improve outcomes and reduce the amount spent on health care for Medicare fee-for-service beneficiaries.

The Next Generation ACO Model has several unique tools to improve engagement with beneficiaries.  These tools include the following:

  1. Enhanced access to home visits, telehealth services, and skilled nursing facilities
  2. Ability to receive a reward payment for receiving care from the ACO
  3. A process allowing beneficiaries a decision in their alignment with ACOs and
  4. Collaboration between CMS and ACOs to inform beneficiaries about the characteristics and potential benefits of ACOs in relation to their care.

CMS expects that 15 to 20 ACOs will participate in the Next Generation ACO Model.  CMS has issued a request for applications outlining specific eligibility criteria.  There will be two rounds of applications in 2015 and 2016.  The deadline to submit a letter of intent in round one is May 1, 2015, with applications due on June 1, 2015.  The round two deadlines are one year later.

CMS Updates Nursing Home CPR Guidance

HC BLOG_CPROn January 23, 2015, the Centers for Medicare and Medicaid Services (CMS) revised surveyor guidance regarding Cardiopulmonary Resuscitation (CPR) in nursing homes.  The guidance clarifies a facility’s obligation to provide CPR.  CMS requires that nursing home staff maintain current CPR certification through a CPR provider whose training includes hands-on practice and in-person skills assessment.  Online-only certification is not sufficient.  However, the program may have an on-line knowledge component if it also requires an in-person demonstration or skills assessment to obtain certification or recertification.

The revised  surveyor guidance also incorporates CMS’ prohibition against a facility-wide “no CPR” policy because this may prevent implementation of a resident’s advance directives and does not meet the quality standards found in 42 C.F.R. § 483.20(k).  If a resident experiences a cardiac arrest and does not show obvious signs of clinical death, facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services in accordance with the resident’s advance directives or in the absence of any advance directives or a Do Not Resuscitate Order.   Finally, the guidance reiterates CMS’ requirement that CPR certified staff must be available at all times.

CMS Announces Changes to Nursing Home Five-Star Quality Rating System in 2015

On October 6, 2014, the Centers for Medicare and Medicaid Services (CMS) announced  that it will implement changes to the Nursing Home Five-Star Quality Rating System in 2015.  CMS launched the five-star system for nursing homes in December 2008.

The current five-star rating for each nursing home is based on the star ratings for three separate categories:  1) health inspections; 2) quality measures; and 3) staffing.  To determine a nursing home’s overall rating, CMS begins with the facility’s health inspection rating and then adds or subtracts “stars” depending on the facility’s staffing rating and its quality measures rating.

CMS will implement the following changes to the Five-Star Rating System in 2015.

Nationwide Focused Survey Inspections:  CMS and states will begin focused survey inspections nationwide in a sample of nursing homes to verify the staffing and quality measure information that is part of the Five-Star Quality Rating System.

Payroll-Based Staffing Reporting:  CMS will use a quarterly electronic reporting system to verify staffing information.  According to CMS, the system can be audited back to payroll to verify staffing information and thus increase the accuracy and timeliness of the data.

Additional Quality Measures:  CMS will increase the number and type of quality measures.  The first new quality measure—usage of antipsychotic medications—will be introduced in January 2015.

Timely and Complete Inspection Data:  CMS will work to ensure that states maintain timely and complete inspection data, including a user-friendly website.

Improved Scoring Methodology:  CMS plans to revise the scoring methodology used to calculate each facility’s quality measure rating, which is one of the three categories used to determine the overall star rating.

CMS’ Interpretive Guidance for Nursing Homes on Reprocessed Single-Use Devices and Egg Preparation

The Centers for Medicare and Medicaid Services (CMS) recently issued interpretive guidance in two areas of interest for nursing homes: use of reprocessed single-use devices and preparation of eggs in nursing homes.  Nursing homes should become familiar with these guidance documents to avoid survey deficiencies.

CMS revised its guidance regarding use of single-use devices: S&C Memorandum No. 14-25-NH, “Advance Copy — Single Use Device Reprocessing under Tag 441, Revisions to Interpretative Guidance in Appendix PP, State Operation Manual (SOM) on Infection Control,” issued May 9, 2014.  CMS made this revision to be consistent with current Food and Drug Administration (FDA) regulation that allows the reprocessing and marketing of single-use devices under specific conditions.  Nursing homes may purchase reprocessed single-use devices when these devices are reprocessed by an entity or a third-party reprocessor that is registered with the FDA.  CMS states that the nursing home must have documentation from the third-party reprocessor indicating that it has been cleared by the FDA to reprocess the specific device in question.

CMS also has revised its interpretative guidance and procedures relating to egg preparation in nursing homes: S&C Memorandum No. 14-34-NH, “Advance Copy of Revised F371; Interpretive Guidance and Procedures for Sanitary HC BLOG_eggsConditions, Preparation of Eggs in Nursing Homes,” issued May 20, 2014.  Nursing homes should use pasteurized shell eggs or liquid pasteurized eggs to eliminate the risk of residents contracting Salmonella Enteritidis.  Using pasteurized eggs allows nursing homes to meet resident preferences for soft-cooked, undercooked, or sunny-side up eggs.  CMS has stated that nursing homes should not prepare or serve soft-cooked, undercooked, or sunny-side up eggs from unpasteurized eggs.  Unpasteurized eggs must be cooked until the yolk and the white are completely firm.  For all other forms of egg preparation, including hot holding of eggs and eggs used as an ingredient before baking (such as in cakes or meat loaf), the nursing home must use pasteurized eggs or cook the food item to an internal temperature of 160 degrees.

Nursing homes should also take note of guidance issued to surveyors relating to egg preparation.  Signed health release agreements between the resident (or the resident’s representative) and the facility acknowledging that the resident has accepted the risk of eating undercooked unpasteurized eggs are not permitted.  Thus, if the nursing home prepares or serves unpasteurized or undercooked eggs — eggs that do not have a completely firm yolk and white — CMS has instructed surveyors to consider citing deficiencies at F371.

Image courtesy of Flickr by Brenda Gottsabend

Growth in Independent Freestanding Emergency Rooms Leads to Concerns

Colorado and the rest of the country have seen a growing number of freestanding emergency rooms. Freestanding emergency rooms are standalone facilities physically separate from a hospital that provide emergency services. Some freestanding emergency rooms are part of a hospital system — an offsite location of a hospital. Independent freestanding emergency rooms are not affiliated with a hospital; they are independent facilities that provide emergency services. It is the independent freestanding emergency rooms that have been the target of much of the recent concerns and criticisms.

HC BLOG_EROne important distinction between independent freestanding emergency rooms and freestanding emergency rooms affiliated with a hospital system involves Medicare reimbursement and regulatory compliance issues. Medicare does not certify freestanding emergency rooms or recognize them as departments. Therefore, independent freestanding emergency rooms cannot receive the Medicare facility fee. However, emergency departments that are affiliated with a hospital can operate as a provider-based hospital department and receive Medicare reimbursement. 42 C.F.R. §§ 482.1 through 482.57. Finally, the Emergency Medical Treatment and Labor Act (EMTALA) — setting out requirements regarding the treatment and transfer of emergency patients — only applies to hospitals participating in federal health care programs. 42 C.F.R. § 489.24.

In 2008, the Centers for Medicare and Medicaid Services (CMS) recognized the emerging trend of freestanding emergency departments and issued a memorandum on this issue to state survey agency directors. CMS Directive S&C-08-08, “Requirements for Provider-Based Off-Campus Emergency Departments and Hospitals That Specialize in the Provision of Emergency Services,” Jan. 11, 2008. CMS noted that it had occasionally encountered interest from providers that want to participate in Medicare as a hospital that specializes in emergency services (distinct from a dedicated emergency department that might be located off the main hospital campus as described at 42 C.F.R. § 489.24(b)).

The CMS memorandum indicated that an emergency services hospital must demonstrate that it satisfies the statutory definition of a hospital found in section 1861(e) of the Social Security Act, including the requirement that the provider is primarily engaged in the provision of services to inpatients. If an applicant specializes in emergency services, CMS stated that it would pay particular attention to the size of the applicant’s emergency department compared to its inpatient capacity. CMS interpreted the statutory requirement that a hospital be primarily engaged in the provision of inpatient services to mean that the provider devotes 51 percent or more of its beds to inpatient care. CMS stated that it would examine other factors in addition to the bed ratio, but the burden is on the applicant to show that inpatient care is the primary health care service. Based on this memorandum, it is unlikely that an independent freestanding emergency room will succeed in being recognized under Medicare as a hospital that specializes in emergency services.

While the number of hospital emergency rooms has declined, emergency room visits have increased. According to a study in the Journal of the American Medical Association, the total number of hospital-based emergency rooms declined 3.3 percent from 1998 to 2008, while emergency department visits increased by 30 percent. Emergency department visits by publicly insured and uninsured patients increased at an even faster pace. The study identified several risk factors for emergency department closure, including safety-net status. This finding is concerning, the study points out, as the number of individuals covered by Medicaid and other forms of public insurance is likely to increase with health care reform. Therefore, the closure of safety net emergency rooms is of grave concern. As a Kaiser Health News article explains, these emergency rooms are not being replaced. The independent freestanding emergency rooms that have recently opened tend to be located in suburban areas, often near high-end shopping centers, and target patients with private insurance.

A Denver Post article describes how freestanding emergency rooms are drawing legislation and critics. A bill proposing new licensing standards for emergency rooms that are not affiliated with a hospital was introduced in the Colorado Senate in 2014.  The original bill would have required an independent freestanding emergency room to be located more than 25 miles from a hospital or, if less than 25 miles from a hospital, the bill would have required the independent freestanding emergency room to become affiliated with a hospital within two years of the bill’s effective date. Although the legislation was amended to allow independent freestanding emergency rooms, but included requirements such as serving all patients regardless of ability to pay, the bill did not pass.

The Colorado legislation appears rooted in ongoing criticism of independent freestanding emergency rooms. Much of the concern has centered on cost-related issues. Potential patients often choose to visit a freestanding emergency room with its longer hours and shorter waiting times, even though their problems are non-urgent or semi-urgent, because they cannot get an appointment with their primary care doctor or a nearby urgent care center is closed. Thus, insurers must pay higher fees for services that could have been treated more cost-effectively. While patients have a higher co-payment for emergency services, it is likely that it is not significantly higher to offset the convenience of a freestanding emergency center.

As health care reform evolves, it is likely that independent freestanding emergency rooms will be the target of regulators in Colorado and elsewhere.

Image courtesy of Flickr by Eric Heath