Michael Nardone

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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

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Transcript of 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Promote Quality of Care

Ensure payment for medically necessary services

Identify potential PSAEs through claims review

Educate and support providers

Department’s Responsibility

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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

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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

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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

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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

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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

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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

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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

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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

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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

Website Library

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Michael Nardone, Deputy SecretaryOffice of Medical Assistance Programs

Pennsylvania Department of Public WelfareEmail: [email protected]

Questions?