Long-Term and Post-Acute Care Providers Engaged in Health Information Exchange: Final Report. Barriers

10/29/2013

  • Barriers to Expansion of Telehealth. The use of telehealth has shown promise for improving patient care management, outcomes and cost, but EMHC identified challenges with the reimbursement structure coupled with high cost of the equipment create challenges for expanding the technologies use across a broader population with a large, rural geographic area.

  • Policy Barriers in New Delivery Models Related to LTPAC. Staff at EMHC identified three policies that have limited their ability to implement innovative service delivery under their Pioneer ACO model. The policies are based on long-standing Medicare FFS coverage rules. These rules and their implications for service delivery and cost savings are described below:

    • One of the FFS rules requires that home health recipients be "homebound" in order to qualify for Medicare coverage of home health services. EMHC indicates that this rule will continue to be applied even when, beginning in 2014, the EMHS ACO will enter its third year as an Pioneer ACO program and e-paid: (i) for Medicare Part A covered services using a payment method that shares savings with Medicare for cost of Part A covered services; and (ii) a per member/per month capitated payment rate for Part B covered services.15

    • As previously described in this report, EMHC determined that delivery of telehealth health services to target population patients who are not homebound (e.g., CHF telehealth program) would reduce costs by reducing avoidable hospitalizations and ED visits. EMHC staff identified the continued application of the requirement that patients must be homebound to qualify for home health services even when services are delivered under its ACO program will limit their ability to deliver cost-effective, high-quality care.

    • The second Medicare FFS coverage rule stems from the Medicare Part A program Medicare coverage for SNF beneficiaries. They must have had a qualifying three day prior hospital stay to qualify for Medicare Part A coverage. EMHC staff indicated that CMS has determined that beginning in 2014 it will waive the three-day prior hospitalization requirement for the Pioneer ACO attributed patients. EMHC reports that once this waiver goes into effect it anticipates that the EMHS ACO will increase its ability to deliver cost-effective quality care by eliminating unnecessary prior hospital stays or reducing the number days an individual stays in a hospital prior to SNF admission. EMHS is working with nursing homes in the Bangor region to prepare for direct admissions to SNF from the EMMC ED. The three-day stay barrier, will be removed when, as described above, the EMHS ACO enters its third year as an Pioneer ACO program and will be paid: (i) for Medicare Part A covered services using a payment method that shares savings with Medicare, and (ii) a capitated rate for Part B covered services.

    • The Bangor Beacon geriatric tele-psychiatry project for nursing facilities also identified CMS regulatory barriers to providing services to nursing facilities in Penobscot County. CMS prohibits reimbursement for telemedicine services for patients residing in a MSA designated location. While the Beacon tele-psychiatry project successfully expanded access to geriatric psychiatry, the program was discontinued due to CMS payment prohibition. Nursing facility patients needing geriatric psychiatry consultation are now transported via ambulance to Acadia Hospital the EMHS affiliated psychiatry hospital.


15. For eligible beneficiaries who are enrolled in Part A and Part B, Part A finances post-institutional home health services furnished during a home health spell of illness for up to 100 visits during a spell of illness. Part A finances up to 100 visits furnished during a home health spell of illness if the following criteria are met: Beneficiaries are enrolled in Part A and Part B and qualify to receive the Medicare home health benefit; Beneficiaries must have at least a three consecutive day stay in a hospital or rural primary care hospital; and home health services must be initiated and the first covered home health visit must be rendered within 14 days of discharge from a three consecutive day stay in a hospital or rural primary care hospital or within 14 days of discharge from a SNF in which the individual was provided post-hospital extended care services. If the first home health visit is not initiated within 14 days of discharge, then home health services are financed under Part B. After an individual exhausts 100 visits of Part A post-institutional home health services, Part B finances the balance of the home health spell of illness. Basically, if an eligible beneficiary has Part A and Part B, Part B will cover and finance home health if the above criteria isnot met. If an eligible beneficiary has Part A only -- all home health is covered and paid for under Part A. If an eligible beneficiary has Part B only -- all home health is covered and paid for under Part B. The requirements that beneficiaries need skilled services and be homebound applies to all eligible beneficiaries regardless of whether it is paid for under Part A or B.

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