Transcript Slide 1

Critical Access Hospital
Program
Myron E Bloom MD MMM
Medical Director,
Rural Healthcare Quality Network
Critical Access Hospital Program
• Created by Congress in 1997 as part of
the Balanced Budget Act to support
“limited-service hospitals” located in rural
areas.
– Reimbursed on Medicare-allowable costs
or “cost-based reimbursement” for
inpatient and outpatient services
Critical Access Hospital Program
Enhancements made in the:
• Balanced Budget Refinement Act of 1999
• Medicare Medicaid and SCHIP Benefits
Improvement and Protection Act of 2000
• Medicare Prescription Drug, Improvement
and Modernization Act of 2003
Balanced Budget Act of 1997
(BBA)
• To qualify the CAH had to:
– Offer 24-hour emergency care services,
– Have a maximum 15 acute patients,
• Outpatient/Observation patients were not counted
– (counting only inpatients, not beds occupied)
• Facilities with Swing-beds were allowed to have up
to 25 acute or SNF-level beds, provided that no
more than 15 beds were used at any one time for
acute care patients.
– Keep each patient no more than 96 hours.
Balanced Budget Act of 1997
(BBA)
To qualify the CAH had to be a:
• Distance of 35 miles (or 15 in the case
of mountainous terrain or with only
secondary roads) from another hospital
or
• Necessary Provider of health care
services certified by the State.
– Certification will sunset January 1, 2006
The Balance Budget Refinement
Act of 1999
Changed length of stay to an annual
average of 96 hour patient stay,
and
Increased the opportunity for small
hospitals to join the CAH program.
The Medicare, Medicaid, and SCHIP
Benefits Improvement
and Protection Act of 2000 (BIPA)
• CAH Swing Beds became exempted
from PPS and paid on a cost basis,
• CAH provided ambulance services
would be paid on a reasonable cost
basis, if it is the only ambulance within
a 35 mile drive of the CAH.
The Medicare, Medicaid, and SCHIP
Benefits Improvement
and Protection Act of 2000 (BIPA)
• Emergency Room On-Call Physicians
payment were now considered an
allowable cost of outpatient CAH
services after October 1, 2001.
– So far just the cost of Doctors to be on call
Medicare Modernization Act of
2003 §405 (a)
After January 1, 2004 for Method I
• Reimbursement for services increased
to 80% of 101% of reasonable costs (up
from 100 %) or
• 101% less Part B deductible and
coinsurance amounts;
Medicare Modernization Act of
2003 §405 (d)
• Increased Flexibility in Method II with
– 115 % of the Fee Schedule Payment For
Professional Physician Services,
– 115 % of the 85 % of the Medicare
Physician Fee for non-physician
practitioner professional services.
• Each practitioner has the option to
participate in bundled Part B billing.
Medicare Modernization Act of
2003 §405 (b)
And after January 1, 2005,
• Cost-based reimbursement for other
on-call emergency room providers:
physician assistants,
nurse practitioners, and
certified nurse specialists.
• But on call practitioners can not be simultaneously on
call at any other facility.
Medicare Modernization Act of
2003 §405 (e)
And after January 1, 2004,
• A CAH could operate a maximum 25
beds for acute hospital level of care or
swing bed services,
– Notice “beds” not “patients”
• Previously a CAH could operate 15
acute inpatient beds and up to 10
swing beds.
Observation Patient Services
after MMA
• Any “beds” that are hospital-type beds
are counted in the maximum bed count,
– including those used by patients on
observation status.
• May NOT Co-mingle Inpatients and
Outpatients.
– Distinct Part Outpatient Areas and beds
not interchangeable with inpatient beds.
“Excluded from the Bed Count”
after MMA
• Stretchers and Examination tables in
Emergency Departments,
• Obstetric labor and delivery beds,
• postpartum and birthing room beds in which
the mother remains after giving birth are
counted!
• Newborn bassinets and isolettes,
• Operating and Procedure tables or
recovery beds (which must be used
exclusively for recovery).
Observation Patient Services
after MMA
• Observation services defined as “to evaluate
an outpatient’s condition to determine the
need for possible admission as an inpatient”.
– 48 hours maximum observation stay, after which
the patient should be admitted, discharged, or
transferred, and,
– Must always be medically necessary.
• Following an ER visit or outpatient medical procedures
• Chest pain workup, asthma, or congestive heart failure
treatments………………...InterQual criteria
Observation Patient Services
after MMA
• Observation falls under Part B and the
beneficiary may not understand the
complex fee structure,
– The CAH must give written notice of noncovered services prior to the stay.
• Observation days do not count in the
3 day qualification for transfer to ECF.
– Provider and patient/family consternation!
Medicare Modernization Act
of 2003 §405 (g)
And after October 1, 2004
• CAHs may establish distinct part (DP)
Psychiatric and Rehabilitation units,
• Maximum of ten beds in each “DP”
which will not count against the CAH
inpatient bed limit.
– Same Medicare payments as made to
general hospitals for these services.
Summary of MMA 2003
• Increased the beds that could be used for
acute inpatient care from 15 to 25,
– Any hospital-type bed located where the bed
could be used for acute inpatient care counts
toward the 25 bed limit!
• Hospice beds count as part of the maximum
bed count while not contributing to the 96 hour
annual average length of stay.
• Distinct part Psychiatric and Rehabilitation
units now allowed and do not count in either
bed capacity or length of stay.
Proposed Rules for CoP
Federal Register, March 25, 2005
 H&P examination. expand permissible
practitioners and the time frame for the H&P;
• Authentication of orders. allow orders to be
authenticated by any practitioner responsible for
the care of the patient for five year transition
period;
• Post anesthesia evaluation. permit any
individual qualified to administer anesthesia to
do post anesthesia evaluation for inpatients.
• http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.ac
cess.gpo.gov/2005/pdf/05-5916.pdf
The PPS CoP catch up to CAH CoP
Conditions of Participation
Rev. 05-21-04
Critical Access Hospitals
Regulations and Interpretive Guidelines for
Critical Access Hospitals (CAHs)
What is different for CAH’s?
• Network agreements for Credentialing
Privileging, and Quality Assurance
• Required Emergency Services
• Governing Body Responsibilities
• Practitioner Responsibilities
• Patient Care Policies
• Quality Assurance Program
• Periodic Evaluation
485.616(b) Agreements for
Credentialing and Quality
Assurance
Each CAH shall have an agreement with
respect to credentialing and quality
assurance with:
(1) A hospital member of the network;
(2) QIO or equivalent entity; or
(3) Another appropriate qualified entity
identified in the State rural health plan.
Condition of Participation
§485.618
Emergency Services
• Emergency services 24-hours a day,
• Equipment, supplies, and medication
used in treating emergency cases are
readily available, and
• Blood and Blood Products on a 24hours a day basis.
§485.618
Emergency Services
A doctor of medicine or osteopathy, a
physician assistant, or a nurse practitioner
on call and immediately available on site 24hour a day within:
20 minutes for trauma
30 minutes non-trauma
or 60 minutes if the CAH is a frontier area (less than 6 residents
per square mile), the State has determined that longer than 30
minutes is the only feasible method of providing emergency
care to residents, and maintains that 60 minutes is justified
because other alternatives would increase the time needed to
stabilize a patient in an emergency.
§485.627(a)
Governing Body
• The governing body is responsible for the
quality of care provided to patients.
• The governing body
– must determine categories of practitioners
eligible for appointment / reappointment,
– must approve the medical staff bylaws and ensure
that bylaws comply with State and Federal law,
– must ensure that the medical staff is accountable
to the governing body for the quality of care
provided to patients.
§485.631
Staff Responsibilities
All CAH patients
• Must be under the care of a MD/DO
member of the medical staff
or
• Under the care of a practitioner who is
under the supervision of a member of
the medical staff.
§485.631(b) (i)
Responsibilities of the Doctor of
Medicine or Osteopathy
• Provides medical direction for the
CAH’S health care activities
and
• Consultation for, and medical
supervision of, the health care staff.
§485.631(b)(1)(ii)
Responsibilities of the Doctor of
Medicine or Osteopathy
– In conjunction with the physician assistant
and/or nurse practitioner,
• Participates in developing, executing,
and periodically reviewing the CAH’S
written policies governing the services
it furnishes.
§485.631(b)(1)(iii)
Responsibilities of the Doctor of
Medicine or Osteopathy
– In conjunction with the physician assistant
and/or nurse practitioner,
• Periodically reviews the CAH’S patient
records, provides medical orders, and
provides medical care services to the
CAH patients.
§485.631(b)(1)(iv)
Responsibilities of the Doctor of
Medicine or Osteopathy
– Periodically reviews and signs the records of
patients cared for by nurse practitioners, clinical
nurse specialists, or physician assistants,
• MD/DO must review and sign ALL
medical records for patients cared for
by mid-level practitioners at the CAH.
Survey Procedures
§485.631(b)(1)(iv)
• Select a sample of inpatient and outpatient records,
including both open and closed records, and verify that a
MD/DO has reviewed and signed all records for
patients cared for by mid-level practitioners.
• “Prior to the May 21, 2004 revision, the interpretive guidelines
cited a 25% review of outpatient records of by physicians. The
current guidelines specify 100% because that is what the
regulation states.”
•
‘CMS Central Office is now considering changing the regulation. In the near future Central Office
Survey & Certification staff expect to send out a letter indicating that, until the regulation should be
modified, a 25% sample for outpatient records will suffice IF the State law supports independent
practice for the mid-level practitioner .” Alma Hardy, Medicare Provider Services Branch CMS Region 10
§485.631(b)(2)
Responsibilities
of the Doctor of
.
Medicine or Osteopathy
• Is available through direct radio or telephone
communication for consultation, assistance with
medical emergencies, or patient referral.
• Is present for sufficient periods of time to provide
the medical direction, medical care services,
consultation, and supervision.
– Frontier facilities, at least once in every 2 week period,
but a site visit is not required if no patients have been
treated since the latest site visit.
485.631(c)(1)
Physician Assistant, Nurse Practitioner,
and Clinical Nurse Specialist
Responsibilities
• Participates in the development,
execution and periodic review of the
written policies governing the services
the CAH furnishes,
• Participates with MD/DO in a periodic
review of the patients' health records.
485.631(c)(2)
Physician Assistant, Nurse Practitioner,
and Clinical Nurse Specialist
Responsibilities
•
performs the following functions to the
extent they are not being performed by a
doctor of medicine or osteopathy:
–
–
Provides services in accordance with the CAH’S
policies,
Refers patients for needed services that cannot
be furnished at the CAH, and assures that
adequate records are maintained and
transferred when patients are referred.
485.631(c)(3)
Physician Assistant, Nurse Practitioner,
and Clinical Nurse Specialist
Responsibilities
Whenever a patient is admitted by a
nurse practitioner, physician assistant,
or clinical nurse specialist,
an MD/DO on the staff of the CAH is
notified of the admission.
The CAH regulations do permit
mid-level practitioners to admit patients
as allowed by the State.
CMS regulations require that Medicare
and Medicaid patients admitted by a midlevel practitioner be under the care of an
MD/DO if any medical or psychiatric
problem during hospitalization is outside
the scope of practice of the admitting
practitioner.
Interpretive Guidelines
§485.631(c)(3)
• Evidence of “being under the care” of an
MD/DO must be in the patient’s medical
record,
– As applicable, the patient’s medical record must
demonstrate MD/DO responsibility/care.
• Therefore If the CAH allows a mid-level
practitioner to admit and care for patients,
the governing body and medical staff must
establish policies and bylaws to ensure
patient safety.
Interpretive Guidelines
§485.631(c)(3)
• Surveyors verify that:
– Admitting is only done by practitioners currently
licensed and granted privileges as allowed by
State law,
– An MD/DO is monitoring and is responsible for
the care of each Medicare or Medicaid patient for
all medical problems during the hospitalization
outside the scope of practice of the admitting
mid-level practitioners.
§485.635(a)
Patient Care Policies
• The CAH services are furnished in
accordance with appropriate written policies
that are consistent with applicable State law.
• The policies are developed with the advice of
a group of professional personnel
– that includes doctors of medicine or osteopathy
and physician assistants, nurse practitioners, or
clinical nurse specialists,
– AND at least one member who is NOT a member
of the CAH staff.
§485.635(a)
Patient Care Policies
• (i) A description of the services the
CAH furnishes directly and those
furnished through agreement or
arrangement;
• (ii) Policies and procedures for
emergency medical services;
• (iii) Guidelines for the medical
management of health problems.
Interpretive Guidelines
§485.635(a)(3)(iii)
• Policies should establish the agreement
between the MD/DO providing the medical
supervision and the mid-level practitioners
for medical diagnosis and treatment.
• Policies should describe the scope of service
performed by the mid-level practitioners.
– They should cover most health problems;
– They should describe the authorized treatments
and procedures available to the PA, NP and/or
CNS.
Interpretive Guidelines
§485.635(a)(3)(iii)
• Policies should describe the regimens
to follow and also stipulate when
consultation or referral is required.
– They should describe the medical
conditions, signs, or developments that
require consultation or referral.
Interpretive Guidelines
§485.635(a)(4)
• To ensure policies are reviewed at least
annually by the professional personnel.
– “Review the meeting notes and policy and
procedure books to verify that the patient
care policies are reviewed on an annual
basis by the professional group,” which
includes a member not on the CAH staff.
Administration of drugs and
biologicals
485.635(d)(3)
• All orders must be legible and include date, time,
name of the ordering practitioner and for verbal
orders the signature of the accepting individual.
• The ordering practitioner must sign, date, and
time a verbal order as soon as possible
consistent with Federal & State law and CAH
policy.
– “The next time the prescribing practitioner provides
care to the patient, assesses the patient, or
documents in the patient’s medical record”
Interpretive Guidelines
§485.635(d)(3)
• “We recognize that in some instances…the ordering
practitioner…is “off duty” for…a…period of time. In such
cases, it is acceptable for a covering practitioner to cosign the verbal order of the ordering practitioner. The
signature indicates that the covering practitioner
assumes responsibility for his/her colleague’s order as
being complete, accurate and final. This practice must
be addressed in the CAH’S policy.
• However, a qualified practitioner such as a physician
assistant or nurse practitioner may not “co-sign” a
MD/DO’s verbal order or otherwise authenticate a
medical record entry for the MD/DO who gave the verbal
order.”
Interpretive Guidelines
§485.638(a)(4)(ii)
• All or part of the history and physical exam
may be delegated to other practitioners in
accordance with State law and CAH policy,
but the MD/DO must sign and assume full
responsibility for the H & P.
– This means that a nurse practitioner or a physician
assistant may perform the H & P.
– All entries must be timed, dated, and authenticated
and may be made only by individuals as specified in
CAH and medical staff policies.
§485.639(c)(2)
CRNA anesthetist must be under the
supervision of the operating
practitioner unless the Governor in the
State in which the CAH is located
requests exemption by submitting a
letter to CMS.
– Washington CRNAs have been exempted.
§485.641(a)
Periodic Evaluation
• The CAH carries out or arranges for a
periodic evaluation of its total program to be
performed at least once a year.
– The utilization of CAH services, including number
of patients served and the volume of services;
– The purpose of the evaluation is to determine
whether the utilization of services was
appropriate, the established policies were
followed, and if any changes are needed.
Interpretive Guidelines
§485.641(a)
• “A representative sample means not less
than 10 percent of both active and closed
patient records.”
– Who is responsible for the review of both active and
closed clinical records?
– How are records selected and reviewed?
– How does the process ensure that the sample of
records is representative of services furnished?
– What criteria are utilized in the review of both active
and closed records?
§485.641(b)
Quality Assurance
• The CAH has an effective quality assurance
program to evaluate the quality and
appropriateness of the diagnosis and
treatment and the outcomes.
– All services affecting patient health and safety;
– Nosocomial infections and medication therapy;
– Diagnosis and treatment by the mid-level
practitioners is evaluated by a MD/DO on the CAH
staff or by another doctor under contract with the
CAH.
§485.641(b)
Quality Assurance
• The quality and appropriateness of the
diagnosis and treatment furnished by
MD/DOs are evaluated by-• (i) hospital that is a member of the
network;
• (ii) QIO or equivalent entity; or
• (iii) Other appropriate and qualified
entity identified in the State rural health
care plan; and
§485.641(b)
Quality Assurance
• The CAH staff considers the findings of
the evaluations and takes corrective
action if necessary.
• The CAH also takes appropriate
remedial action to address deficiencies
found through the quality assurance
program.
• The CAH documents the outcome of all
remedial action.
CAH
General Hospital
Quality Assurance /
Quality Improvement
Required oversight
of Credentialing &
QA, PR, PI
Oversight not
required
Emergency Services
24/7 with physician,
PA or ARNP
available within 30
minutes and must
participate in the
Washington State
Designated Trauma
System.
Emergency services
not required
Bed size
Maximum 25 acute
care or Swing beds.
May have 10 bed
Psychiatric and
Rehabilitation units.
No limitation on
census; Swing and
ECF beds optional
average of 96 hr in
acute care
No limitation
Length of Stay
Washington State’s 37 CAH
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Pomeroy
Dayton
South Bend
McCleary
Davenport
Deer Park
Grand Coulee
Odessa
Chewelah
Newport
Ritzville
Prosser
Leavenworth
Ilwaco
White Salmon
Goldendale
Ephrata
Othello
Morton
Quincy
Tonasket
August 1999
January 2000
April 2000
July 2000
August 2000
November 2000
January 2001
January 2001
August 2001
October 2001
January 2002
January 2002
January 2002
February 2002
March 2002
April 2002
April 2002
July 2002
July 2002
October 2002
November 2002
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Brewster
December 2002
Port Townsend January 2003
Forks
January 2003
Republic
January 2003
Colville
June 2003
Colfax
August 2003
Omak
October 2003
Sedro-Wolley
January 2004
Sunnyside
January 2004
Pullman
June 2004
Clarkston
August 2004
Ellensburg
October 2004
Chelan
October 2004
Enumclaw
November 2004
Shelton
January 2005
Pasco
February 2005
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Considering Conversion to CAH
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Snoqualmie Valley
Wenatchee Valley Medical Center
Walla Walla General
CAH Program in Washington State
• The Critical Access Hospital program In
Washington State is administered by the
Department of Health through the Office of
Community and Rural Health (OCRH) and
the Office of Facility and Services
Licensing (FSL) Office of Survey, in close
collaboration with the Washington State
Hospital Association.