MedPAC Reviews Blending Medicare and Medicaid
In its June 2012 Report to the Congress, the Medicare Payment Advisory Commission (MedPAC) included an examination of current options and activity with respect to programs that integrate – or have the potential to integrate – Medicare and Medicaid services and financing for those individuals with coverage from both programs, often referred to as dual eligibles.[1] While the term "integration" does not have a single meaning in health policy discussions, in this context it generally refers to efforts to bring both Medicare and Medicaid dollars and Medicare and Medicaid services into a single system of care, so that the individuals using the services do not have to pay attention to whether they are from Medicare or Medicaid. It is believed that "integrating" the programs can both improve the quality of health care services people receive and lower the cost of providing that care.
Source: medicareadvocacy.org
Video: Medicaid, Nursing Homes and Asset Protection
How to Finance Nursing Home Care?
Medicare is one option in paying for nursing home care, but not the best alternative. It only pays for the full cost of the first 20 days of 4 per day. Medicare can pay for the next 80 days if the person has private Medicare supplement, but usually stops before the 100th day. When Medicare stops, the supplemental coverage also stops. An individual must stay for at least three days in a hospital or undergo skilled care. The transfer from hospital should happen at the same time period.
Source: medicaidbuyin.org
Accessing Medicare and Medicaid: Times Are Changing
Thank you for reading my blog so carefully. Currently, CMS (Medicare) monitors hospital readmission rates as a quality measure. Research by the Medicare Payment Advisory Commission (MedPAC) and others show that as many as 1 in 3 Medicare patients who leave the hospital will be readmitted within 30 days of discharge, and that a large portion of these readmissions can be avoided. Under the Affordable Care Act, CMS plans to implement a Hospital Readmissions Reduction Program that will reduce payments beginning in FY 2013 to certain hospitals that have excess readmissions for certain selected conditions. ALF’s are not relevant to this discussion since they are not certified Medicare providers and do not provide any Medicare covered service. The capacity of a skilled nursing facility to care for an admitted Medicare resident without discharging the resident back to the hospital within 30-days will become a critical to securing a reputation for quality with a SNFs most important referal source: hospital discharge planners. Interestingly, discharge rates to hospitals is not currently a quality measure matrix on the Medicare nursing home compare website (www.medicare.gov/nhcompare/), but that matrix is being redesigned and could be amended to include this data. I do not understand the connection private pay admissions and hospital readmission rates. Please elaborate and I hope you find this answer helpful.
Source: chicagonow.com
Program to Reduce Hospitalizations of Nursing Home Residents Receives NIH Grant
INTERACT is a quality improvement program designed to facilitate the early identification, assessment, documentation and communication about changes in the status of residents in SNFs, and provide the necessary tools to manage conditions before they become serious enough to necessitate a hospital transfer. The tools target three key strategies to reduce potentially avoidable hospitalizations: preventing conditions from becoming severe enough to require acute hospital care; managing selected acute conditions in the nursing home; and improving advance care planning for residents among whom a palliative or comfort care plan, rather than acute hospitalization, may be appropriate. The NIH funded project will involve an interdisciplinary team of experienced nursing home researchers conducting a randomized controlled trial to test the implementation of the INTERACT program.
Source: newswise.com
INTERACT : South Carolina Nursing Home Blog
"INTERACT is a quality improvement program designed to facilitate the early identification, assessment, documentation and communication about changes in the status of residents in SNFs, and provide the necessary tools to manage conditions before they become serious enough to necessitate a hospital transfer. The tools target three key strategies to reduce potentially avoidable hospitalizations: preventing conditions from becoming severe enough to require acute hospital care; managing selected acute conditions in the nursing home; and improving advance care planning for residents among whom a palliative or comfort care plan, rather than acute hospitalization, may be appropriate."
Source: scnursinghomelaw.com
Advocating for Your Loved One While in a Nursing Home
-Turn, Turn, Turn. Immobility is one of the most important factors in the development and progression of bedsores. One of the keys to preventing bedsore development is to utilize a two-hour turn schedule in a patient’s plan of care, so that pressure is not kept on one part of the body for too long. While the standard “two-hour” turn schedule is taught and re-taught to every Registered Nurse and Licensed Practical Nurse in their schooling and workplace orientation programs, it is rarely put into practice in the daily care routine. The reality of inadequate staffing in the nursing homes is that there is a lack of attention to each individual resident, whether it applies to turning in accordance with protocol, or toileting. These deviations from acceptable nursing practice result in a greater incidence of bed sore development, in addition to other preventable medical issues among the residents.
Source: amac.us
Medicare trying to curb overuse of antipsychotic drugs in nursing homes
“A CMS nursing home resident report found that almost 40 percent of nursing home patients with signs of dementia were receiving antipsychotic drugs at some point in 2010, even though there was no diagnosis of psychosis,” CMS Chief Medical Officer and Director of Clinical Standards and Quality Patrick Conway, M.D., said in a statement. “Managing dementia without relying on medication can help improve the quality of life for these residents. The Partnership to Improve Dementia Care will equip residents, caregivers, and providers with the best tools to make the right decision.”
Source: philly.com
Physicians can consider 2012 to be their final year to try reporting risk-free: a 1.5% noncompliance penalty won’t be assessed until 2015, but that payment adjustment will be based on whether physicians report quality measures in 2013. “While physicians may be aware of the 2015 PQRS deadline, many do not know that the penalty will be based on their performance in 2013,” said American Medical Association president Peter W. Carmel, MD. “CMS data show that many physicians are not yet participating in the PQRS program. A significant number of those who are trying have been unable to participate, showing that barriers to success still remain.”
Under this latter scenario taxes go up and spending is restrained compared to the other one. Some of the assumptions involved — like we allow Medicare payments to doctors to fall sharply or all the Bush tax cuts do in fact permanently expire next January — are unrealistic. More likely, were we to follow the broad outlines of this path, we’d have higher budget deficits for a few more years as the economy recovers. But if we then make the necessary tax and spending changes, we could then rejoin the virtuous path.
“Either the law’s upheld, in which case we need to have a repeal and replace strategy come November. We’ve got to win November,” he told Newsmax. “Number two, it could just strike individual mandate in which case if President Obama’s re-elected, he could keep the rest of the law in place which, frankly, would implode the private insurance market forcing us to a single payer. We need to respond for that. Lastly, the Supreme Court could strike the whole law. If it strikes the whole law, that creates opportunity to come back with a patient-centered health care plan as opposed to a bureaucratic, top-heavy, Washington plan that Obamacare is.” Newsmax
Second, make a note of the rules the plan specifies such as the time when you can join or opt out of the plan, the rights you have under the plan and the services covered by the plan. Pay special attention to the conditions regarding visiting a specialist doctor and receiving authorization for particular procedures or you may find out too late that you have to bear these expenses on your own.
If providers do want to participate in the esMD program, they must first find out if their review contractor accepst esMD transactions. Additionally, providers will have to obtain access to an esMD gateway. To obtain access to a gateway, providers can either build their own or hire a Health Information Handler (HIH) to construct the gateway system. To find out which HIHs offer esMD gateway services to providers, click here. To learn more about requirements for participating in the esMD program, click here.
HIPAA 5010 Deadline is June 30 Medicare Fee-For-Service Will Reject 4010 Transactions After June 29th After June 29, any Medicare Fee-for-service claims submitted in version 4010 format will be rejected back to the submitter with the following message: “MSG-117 ON JUL 1, 2012, C LMS MUST BE ASC X12 V5010″. All claims received after normal close of business cutoff times on June 29, 2012 must be sent as ASC X12 ver. 5010 or NCPDP D.0. Providers that are still conducting one or more of the Version 4010 transactions electronically, such as submitting a claim or checking claim status, or rely on a software vendor, billing service or clearinghouse to do this on their behalf, are affected. In addition, beginning July 1, 2012, the Coordination of Benefits (outbound ASC X12 837) and Health Care Claim Status Response (ASC X12 277) transactions will be sent in version 5010 only. Medicare FFS will be allowing an additional 30 days to complete the transition to the ASC X12 Health Care Claim Payment/Advice (835), also called the Remittance Advice. Therefore, as of August 1, 2012, Medicare FFS will be generating only the 5010 version of the 835 Remittance Advice for all trading partners. For more help with Version 5010 upgrades and Medicare claims, contact your MAC (Medicare Administrative Contractor). If you have difficulty reaching a MAC, send an email describing your issue, with “5010 Extension” in the subject line, to ProviderFeedback@cms.hhs.gov. Medicare E-Prescribing Deadline June 30 Medicare providers must file at least 10 electronic prescriptions by June 30 to avoid penalties under Medicare’s e-prescribing program. The Medicare e-Rx Incentive Program requires filing at least 10 G-8553 codes by June 30th in order to avoid a 1.5% Medicare deduction in 2013. Note: if you were not a successful e-prescriber in 2011 you must file via claims. From calendar year (CY) 2012 through 2014, a payment adjustment that increases each calendar year will be applied to an eligible professional’s Medicare Part B Physician Fee Schedule (PFS) covered professional services for not becoming a successful electronic prescriber. The payment adjustment of 1.0% in 2012, 1.5% in 2013, and 2.0% in 2014 will result in an eligible professional or group practice participating in the eRx Group Practice Reporting Option (eRx GPRO) receiving 99.0%, 98.5%, and 98.0% respectively of their Medicare Part B PFS amount for covered professional services. The penalty is a 1.5 percent payment reduction for all Medicare claims filed in 2013. Physicians can apply for a hardship exemption but it must be done before June 30 deadline. You can file for a hardship exemption through the Quality Reporting Communication Support Pageor by submitting one claim with the ‘G’ hardship codes by June 30, 2012. For more details you can review this MLN Matters. CMS Accepting Applications for Next Round of Advanced Payment ACOs Notices of intent to apply to the Medicare Shared Savings Program are due June 29. Applications to Advance Payment Model are due Sept. 19. As of Aug. 1, the CMS will begin accepting applications for a new round of Advance Payment ACOs, which offers upfront and monthly payments to health care providers who have come together to share responsibility and provide coordinated high quality care to their Medicare patients. Under the Medicare Shared Savings program the selected participants can use the payments to make important investments in their care coordination infrastructure. The program is designed to help smaller ACOs, with less capital, participate in the Shared Savings Program. Additional information can be found in a CMS fact sheet. 
The article says that 90% of Medicare beneficiaries have “Medigap and other supplemental insurance policies”. This is incorrect because 25% of Medicare beneficiaries are enrolled in Medicare Advantage which are “Medicare replacement plans” and not supplements. Medicare Advantage plans would seem to be the future of Medicare because every plan includes co-pays for each service received. These co-pays certainly make people think twice about expensive tests or things like physical therapy. Advantage plans are required by Medicare to set a cap on out-of-pocket expenses. These caps currently range from $2,000 to $6,700 per year. The only problem I see with Medicare Advantage is that these are “for profit” businesses run by insurance companies. Profits (and administrative costs like marketing) add up to billions of dollars each year – and this is money that should be staying in the Medicare coffers.
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