On Tuesday, March 3 there was a joint hearing of the Assembly and Senate Health Committee on the subject "Do Medi-Cal Rates Ensure Access to Care." It was preceded by a Capitol press conference on new legislation that would repeal the 10% provider rate reductions and eliminate the claw back of the 10% to June 2011. SB 243 by Senator Hernandez, chair of the Senate Health Committee, and AB 366 by Assemblyman Bonta, chair of the Assembly Health Committee, have companion bills that would eliminate the cuts and increase some rates for outpatient health care providers to Medicare levels.

DME and medical supply providers are among a small group of other providers who are still subject to the clawback of the 10% overpayment from either Oct. 2013 or Feb 2014 to June 2011. CAMPS remains in contact with DHCS on any plans to implement the claw back and there is no date for implementation. We are lobbying the Legislature to eliminate the claw back and will continue to do so as the budget discussions continue. As was the case last year these individual bills serve as a focal point for the discussion, but the issue will be resolved during the 2015-16 budget deliberations. The Governor continues to resist calls for Medi-Cal rate increases and DHCS will only do so when an access issue is clearly demonstrated.

Taking Responsibility for Reductions in Hospital Readmissions: Be Careful!

by Elizabeth E. Hogue, Esq.

Hospital administrators are increasingly focused on decreasing readmission as they continue to receive penalties in the form of reductions in reimbursement from the Medicare Program. Hospital staff appropriately seek assistance from post-acute providers in order to achieve reductions. There is no doubt that Medicare-certified home health agencies, HME suppliers, private duty home care agencies, hospices, skilled nursing facilities (SNFs), assisted living facilities (ALFs), outpatient therapists, etc. can assist hospitals to reduce readmissions. The post-acute industry generally welcomes the recognition that it has a crucial role to play in this regard.

BUT, BE CAREFUL! It appears that staff at some hospitals have only a superficial understanding of how reductions can be achieved. This is true, in part, because there is a general lack of evidence and data to show what activities contribute to reductions in readmissions. It remains unclear whether hospital discharge planning activities, for example, can have a substantial impact on reductions in readmissions.

There is a tendency on the part of hospitals, however, to put the entire responsibility for reductions on the shoulders of post-acute providers. This point of view may lead to some potentially harmful results, including failure to reduce readmissions. It may also support the argument that hospitals should be able to choose post-acute providers for patients since they suffer the financial consequences when patients are readmitted.

On the contrary, it seems likely that reductions in readmissions will be achieved only through partnerships between hospitals and post-acute providers of all kinds. The operative word is clearly "partnership." This point of view is supported by Conditions of Participation (CoPs) of the Medicare Program for hospitals that govern discharge planning. Specifically, discharge planners/case managers at hospitals are required to:

• Screen all inpatients soon after admission to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning. Screening must include consideration of the following factors:
  • Patients' functional status and cognitive ability
  • Type(s) of post-hospital care that patients require, such as:
    • Home Health, attendant care, and other community-based services
    • Hospice or palliative care
    • Respiratory therapy
    • Rehabilitation services (PT, OT, Speech, etc.)
    • End Stage Renal Dialysis services
    • Pharmaceuticals and related supplies
    • Nutritional consultation/supplemental diets
    • SNFs
    • ALFs
    • Medical equipment and related supplies
    • Home and physical environment modifications
    • Transportation services
    • Meal services
    • Household services, such as housekeeping, shopping, etc.
  • Whether the type(s) of post-hospital care require(s) the services of health care professionals or facilities
  • Availability of required post-hospital health care services to patients
  • Availability and capability of family and/or friends to provide follow-up care in the home
• Evaluate post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one. Evaluations must include the ability of patients to self-care post-discharge. An evaluation of the ability to self-care requires hospitals to actively solicit information regarding this issue not only from patients or their representatives, but also from family, friends, and support persons.
• Develop a discharge plan, if indicated by the evaluation or at the request of the patient's physician
• Initiate implementation of the discharge plan prior to the discharge of inpatients. This requirement includes provision of inpatient education/training to patients for self-care, or to patients' families or other support persons who will provide care in patients' homes. It includes arrangements for: 
  • Transfer to rehabilitation hospitals, long term care hospitals, or long term care facilities 
  • Referrals to home health agencies or hospices
  • Referrals for follow-up with physicians and therapists
  • Referrals to pertinent community resources that may assist with financial, transportation, meal preparation or other post-discharge needs

Anecdotally, it appears that hospital discharge planners/case managers are not consistently engaging in these activities and others required by the CoPs. Compliance with the CoPs for discharge planning may have a significant impact on reductions in readmissions in partnership with post-acute providers of all types.

©2015 Elizabeth E. Hogue, Esq.  All rights reserved.