Michael Nardone


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Michael Nardone

  1. 1. Pennsylvania’s Preventable Serious Adverse Events Initiative Michael Nardone, Deputy Secretary Office of Medical Assistance Programs Pennsylvania Department of Public Welfare National Association of State Medicaid Directors Annual Fall Conference November 11-14, 2008
  2. 2. <ul><li>Innovative state model to address Preventable Serious Adverse Events (PSAEs) </li></ul><ul><li>One component of Rx for PA/MA Program efforts to promote quality health care </li></ul><ul><li>Part of a broader national focus on preventing medical errors </li></ul>Medical Assistance Program Preventable Serious Adverse Events Initiative
  3. 3. <ul><li>Pay for Performance in Mandatory Managed Care (HealthChoices) and PCCM (ACCESS Plus) Program </li></ul><ul><li>Rx for PA principles integrated into existing MCO/PCCM contracts </li></ul><ul><li>Hospital Quality Incentives/Hospital Quality Grant Program </li></ul>MA Program Focused On Quality and Value Consistent with Rx for PA, OMAP has implemented a comprehensive set of initiatives designed to improve health outcomes for MA consumers
  4. 4. <ul><li>44,000 to 98,000 deaths each year </li></ul><ul><li>Total national costs of $17 billion to $29 billion </li></ul><ul><li>Increased hospital costs of about $2 billion nationally due to preventable adverse drug events </li></ul>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
  5. 5. 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
  6. 6. 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
  7. 7. Federal Programs Medicare Commercial Payers: Aetna, Blue Cross Blue Shield, Wellpoint Employers: Midwest Business Group on Health, Leapfrog Provider 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
  8. 8. <ul><li>Based on National Quality Forum standards and in collaboration with the Hospital & Healthsystem Association of PA (HAP) the Department : </li></ul><ul><ul><li>Developed new policy to help identify PSAEs </li></ul></ul><ul><ul><li>Used existing MA program regulations </li></ul></ul><ul><ul><li>Provided a starting point for health care organizations to establish measures and actions to actively improve patient care safety </li></ul></ul>Pennsylvania’s Preventable Serious Adverse Events Initiative
  9. 9. <ul><ul><li>The initiative represents a collaborative effort to reduce PSAEs and improve quality of care </li></ul></ul><ul><ul><li>Builds on current hospital policies and procedures </li></ul></ul><ul><ul><li>Pennsylvania’s model was the first of </li></ul></ul><ul><ul><li>its kind among state payers </li></ul></ul>DPW Hospitals <ul><ul><li>Other states are looking to Pennsylvania’s initiative to replicate in their own state </li></ul></ul>Pennsylvania Worked Closely With HAP To Develop The Initiative
  10. 10. <ul><li>Must be preventable </li></ul><ul><li>Must be within control of the hospital </li></ul><ul><li>Must occur during an inpatient hospital visit </li></ul><ul><li>Must result in significant harm </li></ul>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
  11. 11. <ul><li>Surgical Events </li></ul><ul><li>Product or Device Events </li></ul><ul><li>Patient Protection Events </li></ul><ul><li>Care Management Events </li></ul><ul><li>Environmental Events </li></ul><ul><li>Criminal Events </li></ul>NQF identifies 28 serious reportable events and classifies these events into one of six categories: The National Quality Forum
  12. 12. <ul><li>MA Program Payment Policy at Title 55 Pa.Code: </li></ul><ul><ul><li>1101.71 Utilization control – Establish procedure for reviewing utilization of and payment for MA services in accordance with the Social Security Act </li></ul></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>1163.71 through 1163.80 Utilization review – Hospital inpatient services are subject to utilization review procedures </li></ul></ul><ul><ul><li>1163.91 Provider misutilization – Providers subject to sanctions when services outside of the scope of customary standards of practice </li></ul></ul>Regulatory Framework For MA Preventable Serious Adverse Events Policy
  13. 13. <ul><li>Policy Applies To: </li></ul><ul><li>Acute care general hospitals </li></ul><ul><li>Fee-for-service delivery system </li></ul><ul><li>Policy Does Not Apply To: </li></ul><ul><li>Psychiatric hospitals </li></ul><ul><li>Psychiatric units of hospitals </li></ul><ul><li>Rehabilitation hospitals </li></ul><ul><li>Rehabilitation units of hospitals </li></ul><ul><li>(including drug and alcohol treatment hospitals/units) </li></ul>Policy Requirements MCOs under managed care delivery system will be required to implement policies to achieve the intent and purpose of the MA policy
  14. 14. <ul><li>Promote Quality of Care </li></ul><ul><li>Ensure payment for medically necessary services </li></ul><ul><li>Identify potential PSAEs through claims review </li></ul><ul><li>Educate and support providers </li></ul>Department’s Responsibility
  15. 15. <ul><li>Review existing hospital policies and procedures to ensure adherence to standards of care </li></ul><ul><li>Train staff on established hospital policy/procedures regarding PSAEs </li></ul><ul><li>Quality Management/Risk Management involvement </li></ul><ul><li>Identify applicable diagnoses that are POA: </li></ul><ul><ul><li>On claims </li></ul></ul><ul><ul><li>During MA Program’s Automated Utilization Review (AUR) process </li></ul></ul><ul><li>Submit medical records to MA Program within 30 days of request </li></ul>Hospital’s Responsibilities
  16. 16. Preventable Serious Adverse Events How does it work- the process <ul><li>Systematic reviews of inpatient claims </li></ul><ul><ul><li>Cases with a potential PSAE using identified codes </li></ul></ul><ul><ul><li>Claims identified with POA indicators </li></ul></ul><ul><ul><li>Eliminate crossover claims </li></ul></ul><ul><li>Claims can be identified through other routine reviews </li></ul><ul><li>Records requested from hospitals </li></ul>
  17. 17. Preventable Serious Adverse Events How does it work- the process (cont.) <ul><li>Department medical staff review records </li></ul><ul><li>Follow-up with hospitals with confirmed PSAE : </li></ul><ul><ul><li>Medical Director calls senior hospital staff </li></ul></ul><ul><ul><li>Letter outlining PSAE sent to hospital </li></ul></ul><ul><li>Corrective action plan (CAP) methodology under development </li></ul>
  18. 18. Preventable Serious Adverse Events PSAE Board Established <ul><li>Chaired by FFS Medical Director </li></ul><ul><li>Currently meets monthly </li></ul><ul><li>Reviews process and findings </li></ul><ul><li>Makes decisions on how to improve and refine process and ensure quality issues are addressed </li></ul>
  19. 19. Preventable Serious Adverse Events What We Have Learned/Next Steps <ul><li>Very early in process to reach any conclusion </li></ul><ul><li>After record reviews completed by clinical staff, clearly documented PSAEs were falls and pressure ulcers </li></ul><ul><li>Additional education of quality and utilization needed </li></ul><ul><li>Need to develop stronger feedback loop </li></ul>
  20. 20. Pennsylvania’s approach is consistent with, but not identical to, CMS’s approach Comparison Of PA And CMS Adverse Events Initiatives POA indicator associated with every diagnosis code Identifying Events Narrower list of preventable events More extensive list of preventable events Type of Events Medicare Medical Assistance Program Prospective- payments denied up front Retrospective – payment is adjusted or reclaimed after review Claim Determination 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 Implemented January 14, 2008 Roll-Out Dates General Acute Care Hospitals General Acute Care Hospitals Providers Targeted CMS Pennsylvania Description
  21. 21. <ul><ul><li>Hospitals, Nursing Homes and Ambulatory Surgical Centers are required to develop and implement an infection control plan </li></ul></ul><ul><ul><li>Plans must include MRSA testing and screening provisions for “high risk” patients and health care providers who may have had exposure to HAI </li></ul></ul><ul><ul><li>Hospitals are to begin implementation of electronic surveillance systems as part of the infection control and prevention plans </li></ul></ul>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
  22. 22. <ul><li>Continue to work closely with the General Assembly to address PSAEs for all third party health care payers </li></ul><ul><li>Efforts to expand policy to other provider groups beyond acute care hospitals </li></ul><ul><li>Able to reach consensus with insurance industry and hospital and medical associations on legislative language </li></ul><ul><li>Bipartisan legislation reached second chamber before session ended </li></ul>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
  23. 23. <ul><li>MA Bulletin 01-07-11: http://www.dpw.state.pa.us/ServicesPrograms/CashAsstEmployment/003673169.aspx?BulletinId=4300 </li></ul><ul><li>RA Banner: http://www.dpw.state.pa.us/omap/provinf/RA010708.asp </li></ul><ul><li>UB-04 Desk Reference: http://www.dpw.state.pa.us/omap/provinf/promhb/PDF/promBGub04_hospdskref.pdf </li></ul><ul><li>Pennsylvania Health Care Cost Containment Council: </li></ul><ul><li>www.Phc4.org </li></ul>Website Library
  24. 24. <ul><li>Michael Nardone, Deputy Secretary </li></ul><ul><li>Office of Medical Assistance Programs </li></ul><ul><li>Pennsylvania Department of Public Welfare </li></ul><ul><li>Email: [email_address] </li></ul>Questions?