In May, the Home Healthcare Nurses Association (HHNA) and the National Association for Home Care (NAHC) met with the Center for Medicare and Medicaid Services (CMS) experts. The attendees were given updates, statistics, recommendations, as well as future plans of the CMS.
General Updates
Tom Hoyer, Director, Office of Chronic Care Policy Group, provided the following industry information:
1. The average number of home care visits per beneficiary has declined from 31.5 in 1998 to 21.5 to date.
2. The average Case Mix is 1.29 versus the 1.00 planned with the implementation of PPS. This will be monitored and adjustments will be made if there is the projected "Case mix creep" (a steady increase in the case mix).
3. Detailed quality data have not yet been analyzed but general data show there has been no reduction in the quality of care provided.
4. The statutory 15% cut planned for October 2002 would actually be approximately 5% and is currently in the President's budget. The CMS budget and plans will adjustment with or without this cut.
5. Regulatory reform is a key issue and is supported by both Tom Scully, CMS Director, and Health & Human Services Secretary Thompson.
6. OASIS recommendations should be seen in the Federal Register later this year.
7. "PPS has a strong start and the industry has behaved well."
8. There is an increased interest in palliative care and Hoyer sees hospice experts expanding their roles. Hospice should go outside their walls and educate hospitals, nursing homes, managed care companies, and others on the benefits and expertise of palliative care.
9. There is still a perception issue with electing Hospice benefits as some patients feel they are giving up "medical care" for "end care."
10. There may be new CPT and service codes as MDs or other clinicians assess and introduce Hospice Services in an institutional setting.
Medical Review Update
Beth Geiblehouse from the Quality Standards department of CMS provided updates on medical review:
1. The payment error rate has been reduced from 14% in 1996 to 6.3% in 2000. An error rate of <5% is the goal.
2. CMS is still doing progressive corrective actions with a key focus on education.
3. CMS is planning to double the education budget in the review departments next year. This will increase education from CMS to the Fiscal Intermediary (FI) as well as to providers.
4. The Fiscal Intermediary must now provide one-on-one educational training to providers upon request. Most of this education should be provided by a clinician.
5. CERT, The Contractor Rate Error Testing program is now beginning in home health. These independent contractors will evaluate claims processed by the FI to check the validity and accuracy of the provider payment.
6. Data Accuracy Verification Evaluation (DAVE) will begin soon. This program will validate the accuracy and completeness of OASIS.
7. There are plans to eliminate the 485 as a federal form. This is not mandated by regulation but currently requires annual OMB approval. Currently the plan is to allow agencies to continue to use it but it will no longer be considered a federal form.
8. Geiblehouse also noted that the Web site (http://www.cms.gov) has more information and is updated frequently with new questions and answers.
Update on Survey and Certification
Mavis Connolly, Technical Director, Continuing Care Services Branch, provided updates on survey issues:
1. The no. 1 rule is to "follow the regulations and give good patient care."
2. The OBQI training presented earlier this year is available to all agencies and is still accessible online. Additionally, there are three manuals that can be downloaded from the Web site.
3. Many agencies have not yet accessed their OBQI information (nationally, only 52% have accessed it). Although a date has not been established, this will soon be a requirement.
4. Starting in May each state will have an OBQI trainer. These trainers will provide 1-day training sessions and will be available to all providers.
5. State survey agencies do have access to the OBQI reports. Additionally, several rules were clarified:
a. The agency, not the State OASIS coordinator or the surveyors, decides which areas to target CQI activities.
b. Citations and deficiencies cannot be based on OBQI reports.
c. Citations cannot be given based on which area the agency chooses to target.
d. The final rule for the OBQI mandate has not yet been determined.
6. How will surveyors use the OBQI report?
a. Informational. It should be considered only a part of the bigger piece of activities and services provided by agencies. Surveyors are currently being educated on this.
b. It will assist the surveyor with presurvey preparation and could reduce actual time in the agency.
c. Surveyors may ask for specific records based on the OBQI report.
d. It will increase emphasis on patient outcomes.
e. There is no new survey tool.
7. There is also ongoing work to improve the survey process by increasing its effectiveness while improving consistency and objectivity.
8. Surveyors will assess how OASIS is collected, recorded, and transmitted.
9. The top 10 survey deficiencies were identified:
a. No MD review and signature on the Plan of Care (POC).
b. Incomplete POC.
c. Incomplete record.
d. Drugs and treatment not administered according to orders.
e. MD was not notified when there was a change in the patient's condition.
f. The detailed assessment did not include a drug review.
g. Lack of coordination of care.
h. Services were not coordinated after an issue/problem was identified.
i. Irregular evaluation of need for nursing services.
CMS has committed to improve education and services for the providers and patients it serves. In the future education and regulatory reform appear to be a top priority, but they continue to request our input.
You can help by:
1. Watching for key home care reports in the Federal Register. This can be accessed at http://www.access.gpo.gov/su_docs/aces/aces140.html. Comment periods are provided. Be sure to offer your comments and recommendations.
2. Checking the CMS Web site frequently at http://www.cms.gov. The site is now updated frequently to include questions and answers, updates, program memorandums, and actual manuals.
3. Staying connected with your professional home care organizations (NAHC, HHNA, VNAA) as they often seek information from their members to share directly with CMS.