Brian Ellsworth, Senior Associate Director Policy Development Group Medicare Patient Assessment System Project: Meeting with ASPE & HCFA, March 30, 2001 Brian Ellsworth, Senior Associate Director Policy Development Group

Three key questions posed by HHS What patient assessment information does a Medicare provider routinely collect during a Medicare-covered episode of care? What patient assessment information does the government need to collect in a centralized database? How can the government’s data collection process be the most efficient and accurate?

AHA key concerns about patient assessment forms Nursing shortage: excessive paperwork is driving already scarce nurses out of the field Cost pressure: elements of mandated patient assessment forms are often duplicative or irrelevant, and imposed within constrained prospective payment systems (PPS) Compliance risk: inherent unreliability of some elements of assessment forms can lead to error

AHA key concerns…continued Scope of information required to be stored in centralized databases can raise privacy concerns Lack of standardization inhibits ability to cross-train assessors and develop coherent information systems to manage and utilize patient data

Massive data gathering became an end unto itself How did we get here? Initial concept was to standardize the process of assessment and care planning in nursing homes Need for case mix information for prospective payment systems lead to tendency to add on to forms originally designed for other purposes Massive data gathering became an end unto itself

Hospitals – patient assessment data Patient demographic information History and physical Clinically-relevant information entered into the medical record – diagnostic tests, etc. Medical record goes to coders which translate diagnosis, comorbidities and procedures into ICD-9 and billing codes…which are entered onto the claim form

Hospital Data Flow } Payment to provider History and Physical Demographic Data Pertinent Clinical Information Medical Record Abstract by codersal Diagnosis codes Procedure codes } Subject to code set standardization under HIPAA Claims form submitted to FI DRG Grouper Payment to provider

Skilled Nursing Facilities – patient assessment data Minimum Data Set (MDS) required as a Condition of Participation for Medicare and Medicaid Extra MDS assessments required for Medicare Part A SNF PPS – completed at various intervals during Medicare Part A covered stay and upon significant changes in resident condition

Home Health Agencies – patient assessment forms Outcome Assessment and Information Set (OASIS): 82 questions completed at admission, every sixty days, discharge and upon any significant change Approximately 22 questions used for case mix classification under Medicare home health PPS

ICD-9 coding on form not consistent with coding guidelines Case study: OASIS ICD-9 coding on form not consistent with coding guidelines Not coded to highest level of specificity v-codes can not be entered in ICD-9 lines Variances with established coding rules (e.g., don’t code CVA late effects, ICD-9 438) ADL measures based on “ability” instead of performance GAO January, 2001 report identifies significant additional costs of OASIS implementation

OASIS case study…continued HCFA wants to extend OASIS submission to non-Medicare/Medicaid patients Adverse event reports (13 domains) Not risk adjusted Immediately sent to surveyors without phase-in to check data integrity Patient-specific information on facility reports

SNF and Home Health Patient Assessment Data Flow History and Physical Demographic Data Pertinent Clinical Information Medical Record MDS or OASIS Assessment Abstract by codersl Diagnosis codes Procedure codes RUG/HHRG Grouper at provider HIPPS Code Claims form submitted to FI Payment to provider

Inpatient Rehabilitation Facilities Functional Independence Measure (FIM) is used voluntarily by 60 to 70 percent of the field FIM used for outcomes analysis for over ten years Hospitals strongly prefer the FIM over the untested MDS-PAC

Suggestions for HHS & HCFA about implementation of Section 545 of BIPA First, do no further harm… Implement FIM instead of MDS-PAC for inpatient rehab PPS Allow swing beds the option to not complete the MDS as their payment is transitioned to a SNF PPS-type system Make optional the current HCFA requirements on home health agencies to assess non-Medicare/Medicaid patients with OASIS

Do no further harm…continued Instruct researchers on future PPS development to explicitly consider data burden in system design & refinement LTC hospitals and Psych PPS SNF and HHA PPS refinements Seriously reconsider any near term plans on the MDS-PAC and Uniform Needs Assessment Instrument (UNAI)

Second, develop concrete action plan Winnow down Medicare-required elements of existing forms to payment-related items (all other items optional) Conduct research on generic forms of risk adjustment across settings Begin to standardize similar elements across existing patient classification systems

Action plan continued… Construct evolutionary process to grow the common core over time Conduct R&D for quality and payment systems only on a “representative sample” of providers and beneficiaries (using expanded data) Only expand beyond payment-related items where there is established reliability, consensus about relevance and ability to standardize (either directly comparable or able to crosswalk)

Additional suggestions Examine HIPAA standards for financial and administrative transactions Template for the process of standardization of complex health care processes & data Baseline for standardization of diagnostic and procedure data standardized code sets under HIPAA transaction final rule offer the potential to minimize redundancy of information required under patient assessment forms

Functional and cognitive impairment issues Compare and contrast ADL Sum from RUGs, Functional Independence Measure (FIM),and ability-based ADLs from OASIS Examine recent discussions at NCVHS about generic measures of functional impairment and examine literature on psychometric issues with ADL measurement Cognitive impairment measurement issues and data burden are significant

Summary of key points Elevate streamlining of existing patient assessment instruments as an immediate priority Drive standardization through the base of data needed for accurate claims payment and risk adjustment of outcomes data

Example of Generic Post-acute and Chronic Care Patient Classification System