michael nardone
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Pennsylvania’s Preventable Serious Adverse
Events Initiative
Michael Nardone, Deputy SecretaryOffice of Medical Assistance Programs
Pennsylvania Department of Public Welfare
National Association of State Medicaid Directors Annual Fall ConferenceNovember 11-14, 2008
Innovative state model to address Preventable Serious Adverse Events (PSAEs)
One component of Rx for PA/MA Program efforts to promote quality health care
Part of a broader national focus on preventing medical errors
Medical Assistance ProgramPreventable Serious Adverse Events Initiative
Pay for Performance in Mandatory Managed Care (HealthChoices) and PCCM (ACCESS Plus) Program
Rx for PA principles integrated into existing MCO/PCCM contracts
Hospital Quality Incentives/Hospital Quality Grant Program
Consistent with Rx for PA, OMAP has implemented a comprehensive set of initiatives designed to improve health outcomes for MA consumers
MA Program Focused On Quality and Value
Stakeholders are exploring new ways to hold providers accountable for and eliminate preventable medical errors that result in serious harm to the patient
The Institute of Medicine estimated that medical errors were responsible for:
Preventable Medical Errors Significantly Impact the Health Care Delivery System
44,000 to 98,000 deaths each year Total national costs of $17 billion to $29 billion Increased hospital costs of about $2 billion
nationally due to preventable adverse drug events
Public Reporting of Adverse Events
Hospitals Must Report Adverse Events, but Reports Are Not Public
Map created using Map-Maker Utility, Texas A&M University System.
Source: Navigant Consulting, Inc.
States Requiring Reporting Of Adverse Events
State Does Not Require Reporting of Adverse Events
State Non-Payment
Hospital Voluntary Non-Billing
Map created using Map-Maker Utility, Texas A&M University System.
Source: Navigant Consulting, Inc.
States With Non-Payment/Voluntary Non-Billing Policies For Adverse Events
Pennsylvania is the one of the first states to operationalize an initiative to link non-payment to PSAEs for its Medical Assistance program
No Non-Payment Policies for Adverse Events
Federal ProgramsMedicareCommercial Payers:Aetna, Blue Cross Blue Shield, WellpointEmployers:Midwest Business Group on Health, LeapfrogProvider Associations:Washington State Medical Association, Vermont Association of Hospitals and Health Systems, Minnesota and Massachusetts Hospital Associations
Other Leading Efforts To Address Preventable Serious Adverse Events
Based on National Quality Forum standards and in collaboration with the Hospital & Healthsystem Association of PA (HAP) the Department:
Developed new policy to help identify PSAEs
Used existing MA program regulations
Provided a starting point for health care organizations to establish measures and actions to actively improve patient care safety
Pennsylvania’s Preventable Serious Adverse Events Initiative
The initiative represents a collaborative effort to reduce PSAEs and improve quality of care
Builds on current hospital policies and procedures
Pennsylvania’s model was the first of its kind among state payers
DPW
Hospitals
Other states are looking to Pennsylvania’s initiative to replicate in their own state
Pennsylvania Worked Closely With HAP To Develop The Initiative
Pennsylvania’s MA program will adjust or recover payment for the care made necessary by the Preventable Serious Adverse Event
A Preventable Serious Adverse Event
Must be preventable
Must be within control of the hospital
Must occur during an inpatient hospital visit
Must result in significant harm
NQF identifies 28 serious reportable events and classifies these events into one of six categories:
The National Quality Forum
Surgical Events Product or
Device Events Patient
Protection Events
Care Management Events
Environmental Events
Criminal Events
MA Program Payment Policy at Title 55 Pa.Code:
1101.71 Utilization control – Establish procedure for reviewing utilization of and payment for MA services in accordance with the Social Security Act
1101.77 Enforcement actions – May terminate a provider’s agreement when services provided are determined to be harmful to the recipient, of inferior quality or medically unnecessary
1163.71 through 1163.80 Utilization review – Hospital inpatient services are subject to utilization review procedures
1163.91 Provider misutilization – Providers subject to sanctions when services outside of the scope of customary standards of practice
Regulatory Framework For MA Preventable Serious Adverse Events Policy
Policy Applies To: Acute care general hospitals Fee-for-service delivery system
Policy Does Not Apply To: Psychiatric hospitals Psychiatric units of hospitals Rehabilitation hospitals Rehabilitation units of hospitals (including drug and alcohol treatment hospitals/units)
MCOs under managed care delivery system will be required to implement policies to achieve the intent and purpose of the MA policy
Policy Requirements
Promote Quality of Care
Ensure payment for medically necessary services
Identify potential PSAEs through claims review
Educate and support providers
Department’s Responsibility
Review existing hospital policies and procedures to ensure adherence to standards of care
Train staff on established hospital policy/procedures regarding PSAEs
Quality Management/Risk Management involvement
Identify applicable diagnoses that are POA: On claims During MA Program’s Automated Utilization
Review (AUR) process Submit medical records to MA Program within 30
days of request
Hospital’s Responsibilities
Preventable Serious Adverse EventsHow does it work- the process Systematic reviews of inpatient claims
Cases with a potential PSAE using identified codes
Claims identified with POA indicators Eliminate crossover claims
Claims can be identified through other routine reviews
Records requested from hospitals
Preventable Serious Adverse EventsHow does it work- the process (cont.) Department medical staff review records
Follow-up with hospitals with confirmed PSAE: Medical Director calls senior hospital staff Letter outlining PSAE sent to hospital
Corrective action plan (CAP) methodology under development
Preventable Serious Adverse Events PSAE Board Established
Chaired by FFS Medical Director
Currently meets monthly
Reviews process and findings
Makes decisions on how to improve and refine process and ensure quality issues are addressed
Preventable Serious Adverse EventsWhat We Have Learned/Next Steps Very early in process to reach any
conclusion
After record reviews completed by clinical staff, clearly documented PSAEs were falls and pressure ulcers
Additional education of quality and utilization needed
Need to develop stronger feedback loop
Description Pennsylvania CMS
Program Medical Assistance Medicare
Providers Targeted
General Acute Care Hospitals
General Acute Care Hospitals
Identifying Events
POA indicator associated with every diagnosis code
Roll-Out Dates Implemented January 14, 2008
October 1, 2007- required to submit POA indicator on primary/secondary diagnosis
April 1, 2008 - claims not properly reporting POA data returned by CMS
October 1, 2008 - hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission
Type of Events
More extensive list of preventable events
Narrower list of preventable events
Claim Determination
Retrospective – payment is adjusted or reclaimed
after review
Prospective- payments denied up front
Pennsylvania’s approach is consistent with, but not identical to, CMS’s approach
Comparison Of PA And CMS Adverse Events Initiatives
Hospitals, Nursing Homes and Ambulatory Surgical Centers are required to develop and implement an infection control plan
Plans must include MRSA testing and screening provisions for “high risk” patients and health care providers who may have had exposure to HAI
Hospitals are to begin implementation of electronic surveillance systems as part of the infection control and prevention plans
Act 52 of 2007 – Hospital Acquired Infections Control
Policy Part of Broader Effort To Eliminate Preventable Serious Adverse Events
Act 52 provides for quality incentive payments to facilities that show a reduction in HAI
Continue to work closely with the General Assembly to address PSAEs for all third party health care payers
Efforts to expand policy to other provider groups beyond acute care hospitals
Able to reach consensus with insurance industry and hospital and medical associations on legislative language
Bipartisan legislation reached second chamber before session ended
Policy Part Of Broader Effort To Eliminate Preventable Serious Adverse Events
The goal of the legislation is to use market forces to address the issue of Preventable Serious Adverse Events in the private health care industry
MA Bulletin 01-07-11: http://www.dpw.state.pa.us/ServicesPrograms/CashAsstEmployment/003673169.aspx?BulletinId=4300
RA Banner: http://www.dpw.state.pa.us/omap/provinf/RA010708.asp
UB-04 Desk Reference: http://www.dpw.state.pa.us/omap/provinf/promhb/PDF/promBGub04_hospdskref.pdf
Pennsylvania Health Care Cost Containment Council:www.Phc4.org
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Michael Nardone, Deputy SecretaryOffice of Medical Assistance Programs
Pennsylvania Department of Public WelfareEmail: [email protected]
Questions?