Just the Facts
- January 1, 2016 is the start of Year 2…the end of the Observation Period. Year 2 includes a number of provisions that are important for health care providers. Applicable for DRGs 469 and 470.
a. Hospitals may discharge and SNFs may accept patients for inpatient Medicare coverage without a 3 day prior inpatient stay. The application however, is for discharges that are made to SNF providers with a Star rating at 3 Stars or above.
b. Hospitals become eligible for incentive payments or subject to, reduced payments/penalties in Year 2. The incentive applicable/penalty applicable is 5%.
c. Hospitals and post-acute providers can establish narrow networks or preferred provider agreements to share risk and incentives with immunity/safe-harbor from self-referral prohibitions (under certain conditions).
2. The application of quality measures and patient satisfaction apply for incentives and penalties, in addition to cost measurements.
a. Incentive eligibility is tied to average costs per episode and total costs per all episodes being below the established benchmark.
b. Incentive eligibility is tied to quality and satisfaction measures across the episode of care;
i. Hospital Level Risk-Standardized Complication Rate as applicable for TKA and THA
ii. HCAHPS – Consumer Assessment Survey measures
iii. Post-acute markers for avoidable readmissions
3. For incentive payments to occur, the costs incurred must be below the benchmark and the quality measures and satisfaction measures equal or greater than the expected/calculated regional averages/targets.
a. Only 5 Star, CMS rated SNF in every attainable category (overall, inspections, staffing and quality measures) in the region – year over year.
b. Year over year (multiple years) 5 star inspection ratings with no actual harm citations.
c. Highest quality measures in key categories including readmissions, wounds, skin, infections, etc.
d. Operational care protocols/pathways from inpatient to home health to outpatient for TKA and THA – physician reviewed and approved!
e. Operational comorbidity protocols/pathways for optimal patient care (e.g., cardiac, pneumonia, CHF, etc.)
f. Fully integrated continuum of locally owned and operated provider segments – SNF, Home Health, Outpatient. All Larksfield owned, all Larskfield staffed – no contractors!
g. Therapy staff trained, certified in wound, upper-extremity/hand, neuro, Parkinson’s, vital-stim. Same staff for inpatient, home health and outpatient. Better continuity, greater efficiency. Nationally recognized and awarded staff!
h. Documented and well-known reputation for care and satisfaction. Wichita based company with local management/leadership and local governance.
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