WASHINGTON — A proposal from the Centers for Medicare & Medicaid Services (CMS) requiring hospitals to inform a patient’s primary care physician when that patient is admitted to, transferred from, or discharged from the hospital has some provider organizations asking for changes.
The proposed rule would require the electronic notification of providers as a condition of hospitals’ participation in the Medicare program. The National Association of ACOs [accountable care organizations], or NAACOS, called the proposal “a step in the right direction” but also noted that “it contains several limitations, such as being limited to hospital admissions and forcing hospitals to determine with whom patients have established relationships.”
NAACOS members, which include more than 330 ACOs representing 5 million beneficiaries, would like more information than that, explained Clif Gaus, the organization’s president and CEO, during a phone call at which a public relations person was present. “Knowing when a patient is going to the hospital is important, but it’s not all-encompassing.”
“Back when the ACO program started, [I asked our members] what simple thing could improve their ability to better manage the care of beneficiary, both in terms of cost and quality,” he continued. “What they said was, ‘We don’t have access to when our beneficiary in an ACO is seeking services, either on an emergency basis or just outside our ACO network, and in may cases we could intervene with that — particularly with [emergency department] care — and have the call nurse contact the patients and ask about follow-ups; the same goes for admissions to skilled nursing facilities [or contracting for] home health services.’ There is still a big need for ACOs to have real time knowledge of when their beneficiaries are encountering care outside of the ACO network.”
The association says it knows of a great vehicle to use for getting that information: CMS’s HIPAA Eligibility Transaction System (HETS), which is used by all of those providers to check patients’ Medicare eligibility. “The HETS system was developed decades ago as the real-time electronic check on eligibility,” Gaus said. “The provider simply enters the beneficiary ID number and submits that in realtime to CMS computers,” which return information on whether the beneficiary is enrolled in Part A, Part B, or another Medicare program. The vast majority of providers use the system to check eligibility, he added.
Unlike Medicare Advantage, ACOs are not closed networks, and patients regularly seek care outside of them, said Gaus. “So we went on a search for what could be adapted [to meet this need] … and [HETS] popped up. They store [the information] for 24-48 hours — it seemed to us, in today’s electronic age, that a feed that went to the ACOs when an ACO beneficiary’s eligibility was being checked, that would be a real ‘canary in the coal mine’ for the ACO to contact the patient and provide the care they need.”
This information could be fed to the ACO by the information technology (IT) contractor who runs the HETS system for CMS, said Gaus. “They would cross-reference the beneficiary eligibility with the ACO to which they’re assigned, and then feed to that ACO those beneficiary names — or identification numbers — and where they were seeking care.” This wouldn’t have to be an instantaneous system, although that would be ideal; getting the information hourly or even every 8 hours would still be useful, he added.
Alternatively, this could be done through a system where the ACOs would query the HETS system to see whether any of their beneficiaries had accessed care outside the HMO, “but we’d prefer the ‘push’ system,” said Gaus.
NAACOS has tried reaching out to CMS to discuss the issue, but to no avail. “We’ve gone to CMS on this issue almost as long as NAACOS has been in existence, and have had a variety of non-responses or ‘We’ll look into it,'” said Gaus. CMS did not respond by presstime to an email regarding NAACOS’s suggestion, which the association also included in its comments on the proposed rule.
In general, the Medical Group Management Association (MGMA), which represents the interests of physician practices, likes the idea, said Rob Tennant, MA, the association’s director of health information technology policy, in a phone interview. “The more data the provider has … the better.” There is one possible concern, however: data overload, in which “you’re getting too much data and not enough of it is actionable,” and the data from the HETS system could overlap with the admissions/discharge/transfer (ADT) data the provider is also receiving, possibly causing confusion for the provider. “It’s a little like your own email box; if you get a thousand spam emails, you may miss the critical one from your boss,” he said.
Then there is the issue of getting data to the right physician office staff member. Ideally, “you want a direct email or an email with an attachment to go to the staff member in the practice who is responsible for care coordination,” said Tennant.
While NAACOS and MGMA generally like the idea of hospitals being required to provide more information to clinicians, the American Hospital Association (AHA) is objecting to the penalty for non-compliance. “To make the exchange of ADT information required as a CoP [condition of participation] — CMS also would put a hospital’s ability to participate in Medicare and Medicaid at risk,” wrote AHA executive vice president Tom Nickels in a letter to CMS administrator Seema Verma.
“This could cause hospital closures and create access problems for patients,” he said. “Moreover, the financial penalty is far stronger than other program penalties that are likely of greater importance to patients. Specifically, CMS’s proposed policies put hospitals at far greater risk for failure to share ADT information than for failure to protect a patient’s information, failure to publicly report on the quality it provides, and excessive mortality rates.”
Source: MedicalNewsToday.com
