Download NHASA Presentation Kara Newbury 2.12.2014

National State of Affairs Update
Kara Marshall Newbury
Assistant Director, Health Policy
New Hampshire Ambulatory Surgery Association’s
Mid-Winter Updates
Concord, NH
February 12, 2014
ASCA Federal Legislative Agenda
Actively Lobbying:
• ASC Quality & Access Act
• Removing Barriers to Colorectal Cancer Screening
Act
• Electronic Health Records Improvement Act
Closely Monitoring:
• Site Neutrality (MedPAC proposal)
• Sustainable Growth Rate
ASC Quality & Access Act of 2013
(H.R. 2500/S. 1137)
• CPI-U to Hospital Market Basket
• Authorizes Value Based Purchasing for ASCs
• Transparency in Procedures List
• ASC Rep on Advisory Panel on Hospital Outpatient
Payment
• Introduced in May by Lead Sponsors:
• Senate: Ron Wyden (D-OR) and Mike Crapo (R-ID)
• House: Devin Nunes (R-CA-11) and John Larson (D-CT-1)
• Representative Ann Kuster (D-NH)
ACA Guidance: Colonoscopies
If a colonoscopy is scheduled and performed as a screening procedure pursuant to
the USPSTF recommendation, is it permissible for a plan or issuer to impose costsharing for the cost of a polyp removal during the colonoscopy?
• No. Based on clinical practice and comments received, polyp removal is an
integral part of a colonoscopy. Accordingly, the plan or issuer may not impose
cost-sharing with respect to a polyp removal during a colonoscopy performed as a
screening procedure.
• While a colonoscopy itself is preventive care, many insurance companies have
been asserting that if a polyp is removed during the procedure it can be
reclassified as "diagnostic," and the patient could be liable for part or all of the
cost.
• This change does not apply to Medicare patients.
H.R. 1070 – Removing Barriers to
Colorectal Cancer Screening Act
• Rep. Charlie Dent (R-PA)
• Medicare preventive screening colonoscopy
• Waives co-pays if polyps discovered during the
procedure
H.R. 1331 – Electronic Health Records
Improvement Act
• Rep. Diane Black (R-TN)
• ASCs: Physician “Meaningful Use” program
• 2015 – 50 percent threshold problematic; particularly
for ASC physician owners
• Legislation provides a three year exemption for
patient encounters in ASCs
Medicare Payment Advisory
Commission - MedPAC
• Recommends 0% increase for ASC payments in
2015
• Recommends 3.25% increase for HOPDs; 5.25% if
sequestration remains in effect
• CPI-U not an accurate update for ASCs
• Cost reporting for ASCs
MedPAC Site Neutrality Proposals
Addressing Medicare Payment Differences Across Settings:
Ambulatory Care Services
• Proposal: Equal Pay Rates Across Settings
• Frequently performed in physician offices (more
than 50%)
• Similar unit of payment
• Infrequently provided with an emergency
department (ED) visit
• Minimal difference in patient severity across
settings
MedPAC Site Neutrality Proposals
• MedPAC staff proposed 12 ambulatory
payment classification (APC) groups for which
payments could be equalized between HOPDs
and ASCs.
• Equalization would reduce Medicare spending
and cost sharing by $590 million a year, and
save beneficiaries $40–220 million, depending
on how HOPD copayments are determined.
Your Participation Critical
• National ASC Day: August 13, 2014
• Host a Facility Tour
• Fly-ins
– June 17-18
– September 9-10
Contact Blake McDonald at [email protected]
for more information.
ASCA Regulatory Agenda
• Payment Policy
• CPI-U vs. Hospital Market
Basket
• Procedure List
• Implant Reimbursement
• Quality Reporting
• ASC-9, ASC-10 & ASC-11
• ASC-8
• Office of the National
Coordinator (EHR)
• Survey & Certification
• Conditions for Coverage
– Radiologist on Staff
– Emergency
Preparedness
– Physician Discharge
• Interpretive Guidelines:
Recent Changes
– Emergency Equipment
– Temperature &
Humidity
– Patient Rights
Final Rule Recap
• 1.2% rate update for ASCs, 1.7% rate update for HOPDs
• Gap between ASC and HOPD payments widens, with
ASCs being paid 55% of what HOPDs receive for the
same procedures
• Significant expansion of bundled payments for HOPDs
and ASCs
• No change in problematic device reimbursement
policies
• Four additional procedures added
• Three of the four proposed quality measures finalized
Payment Methodology
• RVU x Conversion Factor = National Rate x wage index = Local Rate
• [Quality reporting adjustment begins in 2014]
RVU Annual Update: hospital cost reports, secondary rescaling
Conversion Factor Annual Update: inflation – productivity
adjustment
• *Special rules for device intensive and office based procedures
• ASCA’s Rate Calculator
Rate Change Inputs
 Change in the HOPD Relative Weights
 Secondary Rescaling
 Inflation minus  Productivity Adjustment
 Changes in Device Costs
? Physician Payment Changes
 or  Wage Index changes
Rate Change Process
--------------------------------------------------------------------------------------2013 Hospital RVUs
Updated based on hospital cost reporting
2014 Hospital RVUs
Secondary rescaling
2014 ASC RVUs
--------------------------------------------------------------------------------------2013 ASC conversion factor
Update based on CPI-U – productivity
2014 ASC conversion factor
--------------------------------------------------------------------------------------Wage index update
--------------------------------------------------------------------------------------Physician rate update and device cost update
--------------------------------------------------------------------------------------Quarterly ancillary update, mid-year surgical code additions
---------------------------------------------------------------------------------------
ASC Payable Procedures
• CMS pays for surgical procedures CPT 1,0006,999 (unless excluded)
• Ancillary Services
• List updated annually
• Mid-year coding changes
Reasons for Exclusions
 Pays for unless meets one or more of the following:
 ASC List Exclusion Criteria
 Is on the inpatient only list
 Poses a significant safety risk to the beneficiary
 Typically requires active medical monitoring and care past
midnight
 Directly involves major blood vessels
 Requires major or prolonged invasion of body cavities
 Generally results in extensive blood loss
 Is emergent in nature
 Is life-threatening in nature
 Commonly requires systemic thrombolytic therapy
 Can only be reported using an unlisted surgical procedure code
Annual Evaluation Process
• CMS evaluates the excluded procedures &
procedures newly removed from inpatient list
• Four codes were added in the final rule:
– 27415 (Osteochondral knee allograft)
– 27524 (Treat kneecap fracture)
– 60240 (Removal of thyroid)
– 60500 (Explore parathyroid glands)
• Significant number of newly packaged codes
Bundling Codes
• Expanded bundling of codes for outpatient
services payments
• Supporting items and services associated with a
procedure are bundled into a single payment
– Drugs, biologicals, and radiopharmaceuticals that
function as supplies when used in a diagnostic test or
procedure; drugs and biologicals that function as
supplies when used in a surgical procedure, including
skin substitutes; certain clinical diagnostic lab
services; certain procedures never done without a
primary procedure, and device removal procedures
Implant Reimbursement
• Currently: device must represent at least 50% of the
total cost in an HOPD to be considered “device
intensive” procedure eligible for reimbursement
• For all other ASC services involving device costs,
conversion factor is applied to the entire relative
weight for the service
– ASCA recommendation: CMS should not adjust device
portion of payment by the wage index
– ASCA recommendation: CMS should not apply ASC
conversion factor to the device-related portion of the
procedure for devices which CMS can determine a median
device cost
Quality Reporting Update
•
•
•
•
2% reduction begins in 2014
98% of ASCs reported successfully for 2012
8 previously announced measures
3 new measures with reporting slated to begin
in 2015 for data collected in 2014
• 50% claims threshold remains for ASC 1-ASC-5
• Low Medicare volume exemption (240 claims)
ASC-8
• Data collection will take place for the influenza season
between October 1, 2014, and March 31, 2015
• Other providers who currently report this information
must do so by May 15 every year. They anticipate the
initial reporting deadline for ASCs will be May 15, 2015;
however, that deadline will not be finalized until the
2015 ASC final payment rule.
• The data will be reported in 2015 through the CDC’s
National Healthcare Safety Network (NHSN).
• Operational Guidance Document for this measure
should be released this month.
ASC Medicare Quality Reporting Program
MEASURES
ClaimsBased
Measures
Web-Based
Measures
DATA
COLLECTION
REPORTING
PERIOD
HOW
PAYMENT
REPORTED
YEAR
October 1,
(1) Burns (2) Falls (3) Wrong site,
2012 –
Medicare
side, etc. (4) Hospital transfer (5)
CY 2012
claims data
December 31,
• $917
Prophylactic IV antibiotic
timing billion in savings - $350 from
2012
defense
• Debt ceiling increase $900 billion January 1,
(6) Safe surgical checklist$400
use (7) immediate July 1, 2013
Self
2012 –
Vote
30 to15,Dec.reported
31st
ASC facility volume• data
on on BBA – Sept.
– August
December 31,
selected ASC surgical•procedures
2013
QualityNet
Joint Select2012
Committee
on Deficit
Reduction
(8) Influenza vaccination
coverage among healthcare
personnel
October 1,
Self
2013 – March Not specified reported
31, 2014
CDC NHSN
CY 2014
CY 2015
CY 2016
New Measures Finalized
• Cataracts: Improvement in Patient’s Visual
Function within 90 Days Following Cataract
Surgery (NQF #1536)
• Endoscopy/Poly Surveillance: Appropriate followup interval for normal colonoscopy in average risk
patients (NQF #0658)
• Endoscopy/Poly Surveillance: Colonoscopy
Interval for Patients with a History of
Adenomatous Polys – Avoidance of Inappropriate
Use (NQF #0659)
Quality Measure Summary
Measure
1. Patient Burn
2. Patient Fall
3.Wrong Site, Side, Patient, Procedure, Implant
4.Hospital Admission/Transfer
5. Prophylactic IV Antibiotic Timing
6. Safe Surgery Check List Use
7. Volume of Certain Procedures
8.Influenza Vaccination Coverage Among Health Care Workers
9. Endoscopy/Polyp Surveillance: Appropriate follow-up interval
for normal colonoscopy in average risk patients
10. Endoscopy/Poly Surveillance: Colonoscopy Interval for
Patients with a History of Adenomatous Polyps – Avoidance of
Inappropriate Use
11. Cataracts: Improvement in Patient’s Visual Function within
90 Days Following Cataract Surgery
Payments
Affected
Beginning
2014
2014
2014
2014
2014
2015
2015
2016
2016
2016
2016
HITECH
The Health Information Technology for Economic
and Clinical Health (HITECH) Act, passed as part of
the American Recovery and Reinvestment Act of
2009 (PL 211-5), authorized incentive payments to
eligible professionals (EPs) and eligible hospitals to
promote the “adoption and meaningful use of
certified electronic health record technology
(CEHRT).”
Main Components of Meaningful Use
HITECH specifies the following three components:
1. Use of certified EHR in a meaningful manner (e.g.,
e-prescribing)
2. Use of certified EHR technology for electronic
exchange of health information to improve quality
of health care; and
3. Use of certified EHR technology to submit clinical
quality measures (CQM) and other such measures
selected by the Secretary
Requirements of Stage 1 Meaningful
Use
• 90-day reporting period the first year; annually
thereafter;
• Reporting through attestation;
• Objectives and Clinical Quality Measures;
• Reporting may be yes/no or
numerator/denominator attestation;
• To meet certain objectives/measures, 80% of
patients must have records in CEHRT
Requirements of Stage 1
Meaningful Use
• Stage 1 Objective and Measures Reporting
• Eligible Professionals (EP) Must Complete:
– 15 core objectives
– 5 objectives out of 10 from menu set
– 6 total clinical quality measures (3 core or alternate
core and 3 of 38 from additional set)
• Hospitals Must Complete:
– 14 core objectives
– 5 objectives out of 10 from menu set
– 15 clinical quality measures
Applicability of MU Objectives and
Measures
• Some MU objectives are not applicable to
every practice. Exclusions do not count against
the 5 deferred measures, and EP is excluded
from having to meet that measures
• Examples would be: dentists who do not
perform immunizations; chiropractors do not
e-prescribe
Payment Adjustments and Exceptions
• Statutory Requirement to Take Effect in 2015
• Must demonstrate meaningful use at least
three months prior to the end of the calendar
year (EPs) or fiscal year (hospitals) and meet
registration and attestation requirement by
July 1, 2014 (hospitals) or October 1, 2014
(EPs)
Four Categories of Exceptions
• Lack of availability of internet access or barriers to
obtaining IT infrastructure;
• Time-limited exception for newly practicing EPs or new
hospitals who will not otherwise be able to avoid
penalties;
• Unforeseen circumstances such as natural disasters
(handled on case-by-case basis);
• (EP only) exceptions dues to a combination of clinical
features limiting a provider’s interaction with patients,
or if EP practices at multiple locations, lack of control
over availability of CHERT
EP Exception
• EPs whose primary specialty is listed in PECOS
as anesthesiology, radiology or pathology 6
months prior to the first day of the year which
penalties would be imposed
• Five year limit applies to all exceptions
• EP must have lack of control over availability
of CEHRT at practice locations
Office of the National Coordinator for
Health Information Technology (ONC)
Electronic Health Records in the ASC setting
• Advancing Interoperability and Health
Information Exchange: sought comments on how
to expand beyond what is currently being done
through ONC programs and the EHR incentive
program
• ASCA met with ONC and ASC submitted
comments in response to public request
• EHR stakeholder group
Conditions for Coverage
• Radiologist on Staff (Proposed)
• Emergency Preparedness (Proposed; in
comment period)
• Physician Discharge (ASCA Workgroup)
§416.49 (b) Radiologic Services
ASCA Comment Letter
• Option A: 416.49(b)(2) The ASC’s governing body
must oversee the provision of radiologic services
in keeping with state law and in accordance with
approved policies and procedures of the ASC.
• Option B: Supervision of the provision of
radiologic services shall be performed by a
physician or other credentialed practitioner, in
accordance with State law and the individual
ASC’s radiology policies.
Emergency Preparedness
§ 416.41(c), adopted in November 2008, currently
requires ASCs to have a disaster preparedness plan.
ASCs must:
(1) have a written disaster plan that provides for the
emergency care of its patients, staff and others in
the facility;
(2) coordinate the plan with state and local
authorities; and
(3) conduct drills, annually and complete a written
evaluation of each drill, promptly implementing any
correction to the plan.
Emergency Plan
Proposed Rule
• §416.54 (a) – (d)
• Must include a facility-based and community-based risk
assessment, utilizing an all-hazards approach;
• Strategies for addressing emergency events identified by the risk
assessment;
• Address patient population, including, but not limited to the type
of services the ASC has the ability to provide in an emergency; and
continuity of operations, including delegations of authority and
succession plans;
• Include a process for ensuring cooperation and collaboration with
local, tribal, regional, State, and Federal emergency preparedness
officials’ efforts to ensure an integrated response during a disaster
or emergency situation, including documentation of the ASC’s
efforts to contact such officials, and when applicable, of its
participation in collaborative and cooperative planning efforts.
Policies and Procedures
Proposed Rule
(b) Based on the emergency plan, risk assessment and communications
plan; updated at least annually.
• System to track location of staff and patients in the ASC’s care both during and
after the emergency;
• Safe evacuation from the ASC;
• Means to shelter in place: patients, staff, and volunteers who remain in ASC;
• System to preserve patient information, protect confidentiality of patient
information and ensure records are secure and readily available;
• Use of volunteers and other staffing strategies, including the process and role
for integration of State and Federally designed health care professionals to
address surgery needs during an emergency;
• Arrangements with providers to receive patients in the event of limitations or
cessation of operations to ensure the continuity of services to patients;
• The role of the ASC in the provision of care and treatment by an alternate care
site identified by emergency management officials
Communication Plan Proposed Rule
• Names and contact information for staff, entities providing
services under arrangement, patients’ physicians, other ASCs,
volunteers;
• Contact information for Federal, State, tribal, regional, and local
emergency preparedness staff and other sources of assistance;
• Primary and alternate means for communicating with staff,
government agencies;
• Method for sharing information and medical documentation for
patients under the ASC’s care, as necessary, with other health care
providers to ensure continuity of care;
• A means, in the event of evacuation, to release patient
information;
• Means of providing information about the general condition and
location of patients under the facility’s care;
• Means of providing information about the ASC’s needs and the
ability to provide assistance to the authority having jurisdiction.
Training & Testing
Proposed Rule
Training:
• initial training for all staff, individuals providing on-site services under
arrangement, and volunteers;
• emergency preparedness training at least annually,
• document training,
• ensure staff can demonstrate knowledge of procedures.
Testing:
• Conduct exercises to test the emergency plan, including:
– Participation in community mock disaster drill annually. If one is not available,
conduct an individual facility-based mock disaster drill at least annually;
– If actual disaster, one year exemption from drill;
– Paper-based, tabletop exercise: group discussion led by a facilitator, using a
narrated, clinically-relevant emergency scenario, and a set of problem
statements, directed messages, or prepared questions designed to challenge
an emergency plan;
– Analyse ASC’s response to and maintain documentation of drills, exercises and
emergency events and revise the ASC’s emergency plan, as needed.
§416.52 Physician Discharge
• Discharge order, signed by the operating physician
• Expected Duration of Services: ASCs may not provide services that,
under ordinary circumstances, would be expected to exceed 24
hours following an admission. Patients admitted to an ASC will be
permitted to stay 23 hours and 59 minutes, starting from the time
of admission. (See 73 FR at 68714 (November 18, 2008)).
• The time calculation begins with the admission and ends with the
discharge of the patient from the ASC after the surgical procedure.
The discharge occurs when the physician has signed the discharge
order and the patient has left the recovery room. Other starting or
end points, e.g. time of administration of anesthesia, or time the
patient leaves the OR, may not be used to calculate compliance
with the 24-hour requirement.
Interpretive Guidelines Recent
Changes
• §416.44 (c) Emergency Equipment
• §416.44 (a) Physical Environment
(Temperature and Humidity)
• §416.50 Patient Rights
– Patient Notification Requirements
– (c) Advance Directives
§416.44 (c) Emergency Equipment
ASC medical staff and governing body of the ASC
coordinates, develops and revises ASC policies and
procedures to specify the types of emergency
equipment required for use in the ASC’s operating
room. The equipment must meet the following
requirements:
(1) Be immediately available for use during emergency
situations.
(2) Be appropriate for the facility’s patient population.
(3) Be maintained by appropriate personnel.
§416.44 (a) Physical Environment:
Temperature and Humidity
Temperature, humidity and airflow in ORs must
be maintained within acceptable standards to
inhibit microbial growth, reduce risk of infection,
control odor, and promote patient comfort. ASCs
must maintain records that demonstrate they
have maintained acceptable standards.
§416.44 (a) Physical Environment:
Temperature & Humidity
• Acceptable standards for OR temperature, such as
those recommended by the Association of Operating
Room Nurses (AORN) or the Facility Guidelines Institute
(FGI), should be incorporated into the ASC’s policy.
• RH in ORs to be maintained between 20 - 60 percent.
American Society for Heating, Refrigerating, and Air
Conditioning Engineers (ASHRAE), which was also
incorporated into FGI 2010 Guidelines and approved by
American Society for Healthcare Engineering of the
American Hospital Association and the American
National Standards Institute.
§416.50 Patient Rights
• The ASC must inform the patient or the patient’s
representative or surrogate of the patient’s
rights, and must protect and promote the
exercise of these rights, as set forth in this
section.
• The ASC must also post the written notice of
patient rights in a place or places within the ASC
likely to be noticed by patients waiting for
treatment or by the patient’s representative or
surrogate, if applicable.
§416.50 (a) Notice of Rights:
Same-Day Notification
• An ASC must, prior to the start of the surgical
procedure, provide the patient, or the patient’s
representative, or the patient’s surrogate with
verbal and written notice of the patient’s rights in
a language and manner that ensures the patient,
the representative, or the surrogate understand
all of the patient’s rights as set forth in this
section. The ASC’s notice of rights must include
the address and telephone number of the State
agency to which patients may report complaints,
as well as the Web site for the Office of the
Medicare Beneficiary Ombudsman.
Interpretive Guidelines:
Information on Advance Directives
An advance directive is a written instruction,
such as a living will or durable power of attorney
for healthcare, recognized under State law
(whether statutory or as recognized by the
courts of the State), relating to the provision of
healthcare when the individual who has issued
the directive is incapacitated.
(See 42 CFR 489.100.)
§416.50 (c) Standard:
Advance Directives, Q-0224
The ASC must comply with the following requirements:
• (1) Provide the patient or, as appropriate, the patient's
representative with written information concerning its
policies on advance directives, including a description
of applicable State health and safety laws and, if
requested, official State advance directive forms.
• (2) Inform the patient or, as appropriate, the patient's
representative of the patient's right to make informed
decisions regarding the patient's care.
• (3) Document in a prominent part of the patient's
current medical record, whether or not the individual
has executed an advance directive.
§416.50 (c)Advance Directives
Statement of Limitations - ASCs
• A statement of limitation must:
– Clarify any differences between ASC-wide conscience
objections and those that may be raised by individual
ASC staff;
– Identify the state legal authority permitting such
objection; and
– Describe the range of medical conditions and
procedures affected by the objection
§416.50 (c) Standard:
Advance Directives, Q-0224
The ASC must comply with the following requirements:
• (1) Provide the patient or, as appropriate, the patient's
representative with written information concerning its
policies on advance directives, including a description
of applicable State health and safety laws and, if
requested, official State advance directive forms.
• (2) Inform the patient or, as appropriate, the patient's
representative of the patient's right to make informed
decisions regarding the patient's care.
• (3) Document in a prominent part of the patient's
current medical record, whether or not the individual
has executed an advance directive.
Interpretive Guidelines:
Information on Advance Directives
Each ASC patient has the right to formulate an
advance directive consistent with applicable State
law and to have ASC staff implement and comply
with the advance directive, subject to the ASC’s
limitations on the basis of conscience.
To the degree permitted by State law, and to the
maximum extent practicable, the ASC must respect
the patient’s wishes and follow that process.
Interpretive Guidelines:
Information on Advance Directives
• The facility must provide the patient or the patient’s
representative, as appropriate, the following
information in writing, prior to the start of the surgical
procedure:
– Information on the ASC’s policies on advance directives;
– A description of the applicable State health and safety
laws. (Note that CMS does not determine whether this
description is accurate. State Survey Agencies are
responsible for making this accuracy determination.); and
– If requested, official State advance directive forms, if such
exist.
• Blanket Refusal vs. Statement of Limitation
§416.50 (c)Advance Directives
Blanket Statement of Refusal
• A blanket statement of refusal by the ASC to
comply with any patient advance directives is
not permissible.
• However, if and to the extent permitted under
State law, the ASC may decline to implement
elements of an advance directive on the basis of
conscience or any other reason permitted under
State law if it includes in the information
concerning its advance directive policies a clear
and precise statement of limitation.
§416.50 (c)Advance Directives
Statement of Limitations - ASCs
• A statement of limitation must:
– Clarify any differences between ASC-wide conscience
objections and those that may be raised by individual
ASC staff;
– Identify the state legal authority permitting such
objection; and
– Describe the range of medical conditions and
procedures affected by the objection
Advance Directives
Pre-Admission Recommendations
• Ask the patient if they have an advance
directive and document this in medical record.
• If yes, then ask patient to bring it with them
the day of surgery.
• If no, ask patient if they would like more
information.
Advance Directives
Day of Procedure Recommendations
• If patient brings advance directive to the center, a
copy should be made and placed in the ASC’s
medical record.
• If they “forget” to bring it, then document this in
the patient’s medical record.
• If the patient has to be transferred to the hospital,
a copy of the advance directive needs to be sent
to the hospital with the patient.
Advance Directive Policy
Recommendations
• Delete blanket statement refusing to honor.
• Statement of Limitation
– Include language stating your center will: always
attempt to resuscitate a patient and transfer that
patient to a hospital in the event of deterioration.
– Have governing board approve new statement of
limitations, if allowed by state.
– Document the new policy in meeting minutes.
– Change center policies after governing board
approval, and education employees on changes.
Government Affairs Department
Contact Information
Steve Miller
Director of Government &
Public Affairs
[email protected]
Kristin Murphy
Asst Director, Government Affairs for
Legislative Affairs
[email protected]
Heather Falen Ashby
Asst Director, Government Affairs for
Political Affairs
[email protected]
Kara Marshall Newbury
Asst Director, Government Affairs for
Health Policy
[email protected]
Blake McDonald
Asst Director, Government Affairs for
Outreach
[email protected]
Jack Coleman
Grassroots Manager
[email protected]