1. Monopolies in nursing homes are limiting access to financially unaffiliated physicians:
-At least two nursing home chains in the country are now employing their own physician groups, under a separate LLC of course, and are referring all their nursing home admissions exclusively to their own employed physicians, excluding competing providers even when those providers have more training and experience in geriatrics than the employed physicians. Independent providers stand no chance competing in facilities with such monopolistic business practices were patients are not offered a choice. Genesis healthcare in the east coast has been at the forefront of this new model in their nursing homes.
Why should CMS be held accountable for this abuse?
CMS is failing to ensure patient choice of providers, as it does not mandate that facilities with conflict of interest have a process to offer choice, declare potential and actual conflicts of interests, and document that patients were indeed offered a choice. Allowing this exclusive referral practice to continue unabated violates CMS's rule that medicare and medicaid patients should be offered a choice when it comes to healthcare services.
2. Emerging Hospital/nursing home exclusive relationships:
-There is a trend in the nursing home industry where hospitals affiliate, one way or another, with nursing homes and rehab facilities, then patient referrals are preferentially steered, in both directions. In extreme cases, nursing homes or rehab facilities are actually owned by the hospital and are receiving referrals preferentially, and sometimes exclusively, impacting, and sometimes limiting, patients' choice to go to other facilities. There are many examples of this in Maine, and I dare assume that Maine is not alone.
Why should CMS be held accountable for this abuse?
. In this case CMS is failing to hold both the hospitals and nursing homes to existing CMS standards mandating that Medicare and medicaid patients should be given a choice of facility upon discharge from the hospital. CMS is willfully ignoring the lack of choice, and in doing so, is encouraging healthcare monopolies that eliminate competition and encourage the formation of competing monopolies in the same service areas, as the only way for competing healthcare businesses to survive the lack of free market competition.
Needless to say, such monopolies are a result of CMS's failure to enforce long standing rules regarding the protection of patient choice, focusing instead on clear cut black and white billing fraud cases that make headlines, but cost the system far less than the above mentioned systematic abuse practices.
3. Nursing homes referral as a form of kickback to consultants:
Nursing home facilities in some parts of the country are courting consultants (to get their patient referrals) by committing to making mass referrals to the consultants . For example, some facilities reward referrals from wound specialist by referring all patients with wounds to the wound consultant, even in cases where the attending physicians have expertise in the field or when wounds are minimal or healing. I actually have a case example where the referral was made to the wound specialist even though the wound was actually healed. That referral was made because the patient had wound listed on their admission diagnosis which triggered an automatic referral.
Ironically, such complete delegation of all wounds to outside consultants has not been proven to reduce wounds and does tend to diminish the nursing staff's knowledge of caring for such patients, which ultimately has the potential of patients receiving inferior wound care. Another way wound referrals are abused is when nursing homes are referring to a hospital owned wound cent in return for the hospital referring patients to the nursing home, this is often made practical by the hospital placing their own physicians as medical directors of the particular nursing home.
Another example of inappropriate referrals is when facilities institute policies to refer all patients on psychotropic medications to the psychiatry service, even if stable or the attending physician is comfortable managing their issues. Clinically, many of the dementia related psychiatry referrals are better managed by geriatric medicine, especially if the attending is trained in geriatric medicine.
Why should CMS be held accountable for this abuse?
. In this case CMS is failing to recognize and target wide spread referral abuse, where the only currency being exchanged is the patients themselves, in the form of referrals.
. CMS fails to develop and implement procedures and methods to identify referral abuse issues in which facilities, and not physicians, are driving referrals as a form of kickback for referrals backs to the facility, which can only be achieved through limiting patients' choice.
. The CMS survey process does not include training surveyors on potential referral abuse issues, and even if surveyors identify potential abuse they would not be able to include such findings in the survey report, as system abuse is not an elements of the CMS survey process. This should come as a shock to many concerned citizens.
. CMS has a policy of combating fraud and abuse, but it only deals with fraud, and is willfully neglecting abuse occurring in plain sight. There is no excuse for this indifference as CMS already has surveyors in every medical facility in the country at least once a year. Logic dictates that wide spread abuse costs the system much more than the sporadic fraud cases that occupy 100% of the fraud and abuse unit's attention. CMS's indifference towards abuse issues that don't rise to the level of outright fraud, is inexcusable.
Thursday, July 19, 2012
CMS is failing to protect nursing home patients from bad care caused by the DEA
DEA issues in nursing homes and role of CMS:
-CMS is mandated to protect nursing home residents from neglect and substandard care, and yet for the past two years regulations by another government agency, the DEA, have resulted in a built-in delay in carrying out doctor orders when it comes to orders for narcotics and other scheduled drugs, such as benzodiazepines used for seizure or panic attacks. This delay is directly impacting quality of care of nursing home residents, as doctors orders can not be carried out immediately by the licensed nursing staff.
-Current DEA rules, prohibit nurses from carrying out doctor orders for scheduled drugs, unless they are coupled with a hard prescription, forcing a delay until the doctor has provided a written script or until the pharmacist confirmed the orders with the prescribing provider (as if the patient was at home, and not in a nursing home). All this involves or is followed by a complex paperwork process. Moreover, the nursing home nurses are not allowed to use the emergency kit in the facility to treat emergencies such as seizures, panic attacks, or pain control in dying patients, despite having a valid verbal order from a dully licensed attending physician in an inpatient nursing home setting. All this is done in the name of protecting all of us from drug diversion by healthcare professionals, at the expense of nursing home patients' suffering for an added 30 minutes or so each time a stat order is given. In case of seizures it is well established that any delay in treatment is potentially life threatening, but try telling that to the DEA.
-It is noteworthy that if facilities happen to document the above mentioned delays in medication administration, CMS can and does in fact hold the nursing homes, not the DEA, accountable for negligence and substandard care. There is no mention of the DEA in the CMS deficiency tags handed to offending nursing homes.
Why is CMS responsible?
. CMS is failing to live up to their own self-declared goals and obligations when it comes to preventing substandard care, simply because this substandard care happens to be caused by a powerful federal agency, the DEA. Instead of addressing the route cause of this particular problem, CMS is robotically holding local facilities accountable for something they have no control over and is a direct consequence of federal (DEA) mandates.
-CMS is mandated to protect nursing home residents from neglect and substandard care, and yet for the past two years regulations by another government agency, the DEA, have resulted in a built-in delay in carrying out doctor orders when it comes to orders for narcotics and other scheduled drugs, such as benzodiazepines used for seizure or panic attacks. This delay is directly impacting quality of care of nursing home residents, as doctors orders can not be carried out immediately by the licensed nursing staff.
-Current DEA rules, prohibit nurses from carrying out doctor orders for scheduled drugs, unless they are coupled with a hard prescription, forcing a delay until the doctor has provided a written script or until the pharmacist confirmed the orders with the prescribing provider (as if the patient was at home, and not in a nursing home). All this involves or is followed by a complex paperwork process. Moreover, the nursing home nurses are not allowed to use the emergency kit in the facility to treat emergencies such as seizures, panic attacks, or pain control in dying patients, despite having a valid verbal order from a dully licensed attending physician in an inpatient nursing home setting. All this is done in the name of protecting all of us from drug diversion by healthcare professionals, at the expense of nursing home patients' suffering for an added 30 minutes or so each time a stat order is given. In case of seizures it is well established that any delay in treatment is potentially life threatening, but try telling that to the DEA.
-It is noteworthy that if facilities happen to document the above mentioned delays in medication administration, CMS can and does in fact hold the nursing homes, not the DEA, accountable for negligence and substandard care. There is no mention of the DEA in the CMS deficiency tags handed to offending nursing homes.
Why is CMS responsible?
. CMS is failing to live up to their own self-declared goals and obligations when it comes to preventing substandard care, simply because this substandard care happens to be caused by a powerful federal agency, the DEA. Instead of addressing the route cause of this particular problem, CMS is robotically holding local facilities accountable for something they have no control over and is a direct consequence of federal (DEA) mandates.
Pay for performance, ACOs, a good idea with terrible consequences
The unintended consequences of the establishment of "Accountable care organizations" on geriatric care and independent providers:
- "Accountable care organizations" get incentive payments for following, CMS established, quality indicators. The rub is that the quality indicators used as a measure of good care are not always applicable to geriatric patients. For example, the standard of putting all stroke patients on a statin (i.e. Lipitor) doesn't necessarily apply to frail elderly over 80, 90, over even 100 years old, and yet in order to keep the quality indicators on target and get CMS bonus money, many hospitals who are part of ACOs are encouraging the application of these standards across the board, regardless of age or frailty. The hospital employed physicians are often given bonuses for meeting quality indicator targets, which adds another incentive to continue this robotic centralized decision making approach.
This point can be further illustrated by the fact that when the statins are stopped by geriatricians or PCPs post discharge from the hospital, the patients gets re-started on the statin upon their next hospital admission, as if nothing else matters except the hospital protocols to meet the quality indicator targets.
Other examples include diabetic patients goals; in geriatric cases the A1c goal is 8 for many nursing home patients, and hypoglycemia is considered a bigger threat to the elderly's well-being than uncontrolled diabetes. These emerging standards in geriatric care are not reflected in the quality indicators used in the general population, and geriatricians can be potentially penalized for doing the right thing while ACOs are financially rewarded for doing the wrong thing (one that happens to be good on paper and is based on CMS standards).
Why is CMS responsible for this?
. By incentivizing the establishment of Accountable Care Organizations, CMS is effectively pushing the health care industry to centralize care and decision making and eliminate the independent provider models as a choice of practice. It's is also promoting centralized rigid treatment protocols, that are based primarily on clinical goals linked to financial interests, and geared towards meeting targets that qualify corporate providers and institutions for bonus payments from CMS. These rigid quality indicator targets are based on information that is constantly evolving, making the system highly communistic in it's design.
. Pay for performance, based on rigid quality measures, is inherently problematic, as government standards are not likely to evolve with the evolution of science, and as ACOs take hold, employed providers would be unduly influenced to practice cookie-cutter centralized care, even when it eventually becomes outdated.
. As CMS pushes for establishment of ACO through financial incentives, it is actually undermining free market principles in healthcare and diminishes the role of physicians in developing a "patient centered" care plan. ACOs are also creating a conflict of interest for physicians as they practically now receive commission for following protocols at bedside.
An example of such care trends based on quality indicators is most obvious in palliative care or hospice patients. There are many hospice patients on comfort measures that leave the hospital on statins for having a history of hypercholestrolemia, or for their recent stroke or heart attack. In such cases the hospitalists are clearly documenting that prolonging life is no longer the goal, and yet they leave these patients on life prolonging medications, that if discontinued, would impact the quality indicators statistics for their institution, and in some cases impact the doctors' own bonuses.
And so we end up with a 90 year old patient on comfort measures being kept on Lipitor to make sure the ACOs stays on target in terms of quality indicators, and the doctors don't put up a fight because their bonuses depend on it.
- "Accountable care organizations" get incentive payments for following, CMS established, quality indicators. The rub is that the quality indicators used as a measure of good care are not always applicable to geriatric patients. For example, the standard of putting all stroke patients on a statin (i.e. Lipitor) doesn't necessarily apply to frail elderly over 80, 90, over even 100 years old, and yet in order to keep the quality indicators on target and get CMS bonus money, many hospitals who are part of ACOs are encouraging the application of these standards across the board, regardless of age or frailty. The hospital employed physicians are often given bonuses for meeting quality indicator targets, which adds another incentive to continue this robotic centralized decision making approach.
This point can be further illustrated by the fact that when the statins are stopped by geriatricians or PCPs post discharge from the hospital, the patients gets re-started on the statin upon their next hospital admission, as if nothing else matters except the hospital protocols to meet the quality indicator targets.
Other examples include diabetic patients goals; in geriatric cases the A1c goal is 8 for many nursing home patients, and hypoglycemia is considered a bigger threat to the elderly's well-being than uncontrolled diabetes. These emerging standards in geriatric care are not reflected in the quality indicators used in the general population, and geriatricians can be potentially penalized for doing the right thing while ACOs are financially rewarded for doing the wrong thing (one that happens to be good on paper and is based on CMS standards).
Why is CMS responsible for this?
. By incentivizing the establishment of Accountable Care Organizations, CMS is effectively pushing the health care industry to centralize care and decision making and eliminate the independent provider models as a choice of practice. It's is also promoting centralized rigid treatment protocols, that are based primarily on clinical goals linked to financial interests, and geared towards meeting targets that qualify corporate providers and institutions for bonus payments from CMS. These rigid quality indicator targets are based on information that is constantly evolving, making the system highly communistic in it's design.
. Pay for performance, based on rigid quality measures, is inherently problematic, as government standards are not likely to evolve with the evolution of science, and as ACOs take hold, employed providers would be unduly influenced to practice cookie-cutter centralized care, even when it eventually becomes outdated.
. As CMS pushes for establishment of ACO through financial incentives, it is actually undermining free market principles in healthcare and diminishes the role of physicians in developing a "patient centered" care plan. ACOs are also creating a conflict of interest for physicians as they practically now receive commission for following protocols at bedside.
An example of such care trends based on quality indicators is most obvious in palliative care or hospice patients. There are many hospice patients on comfort measures that leave the hospital on statins for having a history of hypercholestrolemia, or for their recent stroke or heart attack. In such cases the hospitalists are clearly documenting that prolonging life is no longer the goal, and yet they leave these patients on life prolonging medications, that if discontinued, would impact the quality indicators statistics for their institution, and in some cases impact the doctors' own bonuses.
And so we end up with a 90 year old patient on comfort measures being kept on Lipitor to make sure the ACOs stays on target in terms of quality indicators, and the doctors don't put up a fight because their bonuses depend on it.
"Face to face rules", More paperwork to fill out just to cover system abusers in home health care
New home health agencies "face to face" paperwork requirement:
-Recently CMS, in an effort to combat home health abuses and fraud, has offered a change in regulation that requires additional documentation by "physicians". That includes documenting, on a separate form, patients' home bound status, the reasons for home based services, and documenting the date of last physician visit, which has to be within 30 days if recent discharge from rehab or hospital, and within 90 days if patient is already at home.
CMS "suggested" that physicians do the documentation, and so all national home health agencies have now created a new form for the physician to fill out and sign (NPs can't sign it because CMS rules don't mention Physician extenders). This is in addition to what physicians already document in their progress notes and the physician discharge orders, which are already mandated under other rules.
Please note that prior to this regulation, the home health agency had to establish "home bound status" themselves as they accepted a new referral, or on their first home visit. The providers (doctors and physician extenders) wrote orders in patient's charts for the services needed, and the other disciplines i.e. rehab, social services, and nursing did their own documentations of patient status and home needs post discharge from inpatient setting. The other disciplines input was taken into consideration by providers when ordering the post discharge home health services.
With the new regulation, there is a duplication of paperwork, but more importantly, there is a shift of responsibility from home health agencies to doctors in documenting home bound status, which then legitimizes future abuses by home health when they continue to provide services to patients who are no longer home bound, undermining the reason for which this whole new regulation was developed.
There are many patients who leave the rehab facilities "home bound" and cease to be "home bound" in the days and weeks post discharge. Having a signed document by doctors stating that these patients are home bound (until the end of times) absolves home health agencies from making any follow up evaluation of patients' home bound status and in turn absolves CMS from any monitoring of home health agencies on this issue, where prior abuses were considered an issue by CMS.
The duplicative paperwork by the physicians is only serving the purpose of protecting home health agencies from future scrutiny by CMS and does nothing to limit abuse by home health agencies. So why would CMS offer new rules that protects recent system abusers from future CMS citations and add to the physicians' paperwork in the process.
Why is CMS responsible is dead wrong on this issue?
. In this case, CMS maybe violating the 1980s "paperwork reduction act" outright.
Aside from that, CMS is shielding home health agencies from future fraud and abuse claims by allowing them to no longer be accountable for establishing patients' home bound status on their own. It would not be a stretch to assume that CMS based these new home health friendly rules on the advise of home health agencies themselves without any independent scrutiny.
.CMS is also covering its own failure for not monitoring home health agencies adequately in the past, by erroneously concluding that all that was needed is one more piece of paper signed by doctors to make this particular abuse issue disappear.
.CMS does not attach any reimbursement to this added paperwork provision.
.CMS has created a situation where NPs or PAs can order the home health services, but only physicians can sign the associated forms, because in the regulation, the word "physician" was used instead of "provider".
Why are we helpless to fix this CMS error?
CMS is huge, inflexible, and no longer accessible to the average advocate or physician. It's own commissioners quit citing inability to affect change.
Solution, more Transparency, less corporate say at the decision making level at CMS, more independent voices at CMS to see through the boast advise given by corporate healthcare.
Where is the AMA and other professional organizations when all this is going on?
Good question!
-Recently CMS, in an effort to combat home health abuses and fraud, has offered a change in regulation that requires additional documentation by "physicians". That includes documenting, on a separate form, patients' home bound status, the reasons for home based services, and documenting the date of last physician visit, which has to be within 30 days if recent discharge from rehab or hospital, and within 90 days if patient is already at home.
CMS "suggested" that physicians do the documentation, and so all national home health agencies have now created a new form for the physician to fill out and sign (NPs can't sign it because CMS rules don't mention Physician extenders). This is in addition to what physicians already document in their progress notes and the physician discharge orders, which are already mandated under other rules.
Please note that prior to this regulation, the home health agency had to establish "home bound status" themselves as they accepted a new referral, or on their first home visit. The providers (doctors and physician extenders) wrote orders in patient's charts for the services needed, and the other disciplines i.e. rehab, social services, and nursing did their own documentations of patient status and home needs post discharge from inpatient setting. The other disciplines input was taken into consideration by providers when ordering the post discharge home health services.
With the new regulation, there is a duplication of paperwork, but more importantly, there is a shift of responsibility from home health agencies to doctors in documenting home bound status, which then legitimizes future abuses by home health when they continue to provide services to patients who are no longer home bound, undermining the reason for which this whole new regulation was developed.
There are many patients who leave the rehab facilities "home bound" and cease to be "home bound" in the days and weeks post discharge. Having a signed document by doctors stating that these patients are home bound (until the end of times) absolves home health agencies from making any follow up evaluation of patients' home bound status and in turn absolves CMS from any monitoring of home health agencies on this issue, where prior abuses were considered an issue by CMS.
The duplicative paperwork by the physicians is only serving the purpose of protecting home health agencies from future scrutiny by CMS and does nothing to limit abuse by home health agencies. So why would CMS offer new rules that protects recent system abusers from future CMS citations and add to the physicians' paperwork in the process.
Why is CMS responsible is dead wrong on this issue?
. In this case, CMS maybe violating the 1980s "paperwork reduction act" outright.
Aside from that, CMS is shielding home health agencies from future fraud and abuse claims by allowing them to no longer be accountable for establishing patients' home bound status on their own. It would not be a stretch to assume that CMS based these new home health friendly rules on the advise of home health agencies themselves without any independent scrutiny.
.CMS is also covering its own failure for not monitoring home health agencies adequately in the past, by erroneously concluding that all that was needed is one more piece of paper signed by doctors to make this particular abuse issue disappear.
.CMS does not attach any reimbursement to this added paperwork provision.
.CMS has created a situation where NPs or PAs can order the home health services, but only physicians can sign the associated forms, because in the regulation, the word "physician" was used instead of "provider".
Why are we helpless to fix this CMS error?
CMS is huge, inflexible, and no longer accessible to the average advocate or physician. It's own commissioners quit citing inability to affect change.
Solution, more Transparency, less corporate say at the decision making level at CMS, more independent voices at CMS to see through the boast advise given by corporate healthcare.
Where is the AMA and other professional organizations when all this is going on?
Good question!
The problem with CMS regulation on hospice in nursing homes
CMS Hospice related rules and documentation requirements in nursing homes:
Hospice rules currently require that re-certification for hospice services be done ONLY by "hospice employed" providers, excluding the primary physicians from the decision making process. The same rules also stipulate that primary physicians can not discontinue hospice if they feel that it is no longer indicated. Both provisions are shocking but true.
To illustrate what this means in practice, we can look at a case example of Hospice referral in a nursing home below:
. I write a physician order to refer a patient to hospice (as the primary provider), based on a qualifying diagnosis and an estimated life expectancy of less than 6 months.
. The Hospice team would then come in to the nursing home and evaluate the case to determine if it meets criteria for hospice.
. Once qualified, the patient is certified as hospice appropriate, and hospice service is initiated, this is called "initial certification". Medicare part-A is then billed for the service based on a daily rate for 180 days until the next certification time.
. The hospice team is required to re-establish qualification for hospice after 180 days and then every 60 days, by having their own hospice employed physician or NP (physician extender) re-certify patients as hospice appropriate. This step was supposedly designed to limit hospice fraud and abuse; I'm not sure how!
The other twist here is that the primary physicians, who are also required by CMS to do regular visits on regular intervals on all nursing home patients (hospice or not), are now being bypassed, as they now have no say in this hospice re-certification process of their own patients. The primary attendings are also not allowed to discontinue hospice, even if their patients stabilize and no longer qualify for hospice; that privilege is reserved exclusively for, presumably unbiased, "hospice employed" physicians and NPs, unless the patients themselves decline the hospice benefit.
In cases were patients no longer meet criteria for hospice, Hospices often keep patients on the service until the next due date for re-certification, adding weeks and months of unnecessary hospice billing to medicare part-A, even if in the interim, the primary attending physician is documenting that the patient is no longer meeting hospice criteria; Astonishingly, they are not breaking any rules when they do do.
Suggestion to CMS on hospice rules:
-Remove the paperwork burden of additional hospice certifications by using the already mandated visits by patient's own providers for recertification of hospice in nursing homes and ask that the patients own providers document the continued need for hospice, or lack thereof. The hospice team could then match the doctors recommendations to existing hospice criteria to confirm continued eligibility.
This would decrease fraud and abuse by empowering the, more independent providers, to make the call on hospice, and reaffirms the role of primary attending in medical decision making.
Additional related suggestions to CMS related to better cost savings on hospice:
If CMS is interested in limiting cost related to hospice care they should consider the following (in addition to above):
- stop the direct referral by facilities to hospice without first consulting with providers. In this case providers rubber stamp the referrals after the fact. This is especially problematic when it comes to nursing home chains who also owns their own hospice service.
- stop the unnecessary transfers of hospice patients from skilled or NF to acute hospices, as hospice is supposed to be provided regardless of where the patient resides, and such transfers are often removing patients away from a stable environment that they call home, with significant added cost to the system. This is an emerging trend where hospitals, acute hospices, and nursing homes affiliate, directly or indirectly, and share medical directors that sign of on such transfers of patients to the higher cost entity.
- Improve patient choice of hospices in facilities where there is a financial disincentive, through co-ownership, to refer to their main competing hospices (currently the token choice provided often doesn't include the major competitors).
Subscribe to:
Posts (Atom)