DIVISION OF HEALTH CARE FINANCING & POLICY Patient Protection and Affordable Care Act Provider-Preventable Conditions

The Concept Public programs should not pay for treating a health problem arising out of a patient’s care at a facility if the secondary problem could reasonably have been avoided  Eliminating payment for poor quality care will improve patient safety  Cost savings is a secondary driver  If policies are expanded beyond serious adverse events, cost savings could be significant

The Components Conditions Setting Compliance – mandatory and optional

…new terms in the payment dictionary PPCs are based on Medicare nonpayment policies and include two distinct categories of conditions. OPPCs apply broadly to inpatient and outpatient settings and include three “never events.” States can identify other OPPCs for non-payment. HACs are identified from Medicare regulations and apply to all inpatient hospital settings Provider Preventable Conditions PPCsOPPCs 3 “Never Events” State Identified Medicare HCACs

Conditions – Never Events Surgical or other invasive procedure to treat a particular medical condition when the practitioner erroneously performs:  A different procedure altogether  The correct procedure but on the wrong body part  The correct procedure but on the wrong patient

Conditions – Health Care Acquired Conditions (HACs) Foreign object retained after surgery Air embolism Blood incompatibility Stage III and IV pressure ulcers Falls and trauma Manifestations of poor glycemic control Catheter-associated urinary tract infection Vascular catheter-associated infection Surgical site infection following identified procedures Deep vein thrombosis/pulmonary embolism

Setting PPCsOPPCs 3 “Never Events” State Identified Medicare HCACs In any inpatient hospital setting In any health care setting

Compliance PPCsOPPCs 3 “Never Events” State Identified Medicare HCACs Mandatory Optional – with CMS Approval

Putting it all together ConditionSettingCompliance HCACsInpatient HospitalMandatory Never EventsAny health care settingMandatory State-identified OPPCsAny health care setting (as defined by state and approved by CMS) Optional

Regulatory Requirements Identifying and reporting PPCs  Mandates provider self-reporting through the claims system regardless of the intention to bill  States may choose to verify through a “present on admission” (POA) indicator  MCOs will track and make PPC data available to the states upon request (sub-regulatory guidance to be issued)

Regulatory Requirements Non-payment and payment reduction for PPCs  No reduction when the condition defined as a PPC existed prior to initiation of treatment for the patient  “Reductions in provider payment may be limited to the extent that the identified PPC would otherwise result in an increase in payment; and that the State can reasonably isolate for nonpayment the portion of the payment directly related to treatment for, and related to, the PPC” CMS encourages states to develop appeals processes or to use existing appeals processes

Regulatory Requirements Effective date July 1, 2011 Compliance action delayed until July 1, 2012

DHCFP Proposed Plan Current Constraints  Cannot incorporate provider self-reporting into claims system with change of fiscal agents  Activation of POA indicator - TBD  No methodology for payment reduction on per-diem payment system

DHCFP Proposed Plan Address baseline compliance (no state-identified PPCs) Ensure compliance and policy consistency with MCOs Phase in 4 stages: 1. Prior Authorization 2. Retrospective Review 3. HP System Edits 4. Implementation of provider self-reporting with implementation of 5010 of X12 standards for HIPAA transactions

DHCFP Proposed Plan Prior Authorization (Stage 1)  HP manually screens PAs for PPCs  Approves (includes payments to secondary providers treating PPCs caused by primary providers)  Denies via new PPC denial code All cases are referred to SURS for further review

DHCFP Proposed Plan Prior Authorization (Stage 1)  HP manually screens PAs for PPCs  Approves -  Denies via new PPC denial code

DHCFP Proposed Plan Prior Authorization (Stage 1)  HP manually screens PAs for PPCs  Approves  Denies via new PPC denial code

DHCFP Proposed Plan  SURS retrospective review (Stage 2)  Using PA information  Using UNLV/CHIA data  Using “Never Event” report (SLA)

DHCFP Proposed Plan HP System Edits (Stage 3) proposed for 2012 POA indicator and Provider Self-Reporting at Claims Level (Stage 4) TBD

DHCFP Proposed Plan Payment Reduction Most per-diem states are using a case-by-case review and we can find no consistent methodology applied.  Case-by-case review could be accomplished via:  SURS staff  Recovery Audit Contractor  Fiscal Agent Medical Review

DHCFP Proposed Plan Discussion Identifying PPCs  DHCFP Plan  Input on other methodologies  OPPCs and provider types Payment Adjustments Costs which can be reasonably isolated as directly related to treatment for and related to the PPC  Per-diem denial  Methodology for reduction of a portion of costs