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  • 12-Month SGR Patch Approved in House While Congress Examines Permanent Repeal

    Recent advances made on a repeal of Medicare's flawed sustainable growth rate (SGR) and therapy cap may help chances of a permanent solution in 2015, but for this year at least, it appears Congress is opting for another temporary fix days before a March 31 deadline. The House bill that includes the 12 month patch also contains an unexpected provision—a delay on Medicare's implementation of the ICD-10 codes that had been set for an October 1 launch.

    With a looming March deadline that is set to trigger a 24% SGR cut, the House hurriedly voted on a bill that will replace the cut with a .5% provider payment update through the end of the year, and no update from January 1 to April 1 in 2015. The Senate is expected to vote on the patch by Monday, while the House passed the legislation on March 27 via an unusual voice vote that angered some Representatives on both sides of the aisle.

    In addition to the SGR fix, the legislation also continues extender provisions, including the therapy cap exceptions process and Geographic Pricing Cost Index (GPCI), until March 31, 2015.

    Somewhat surprisingly, the bill also contains a provision that delays the implementation of the International Classification of Diseases, 10th revision (ICD-10) for all HIPAA-covered entities. Prior to the action in Congress, the Centers for Medicare and Medicaid Services (CMS) made very public statements about its commitment to an October 1, 2014 rollout. Some observers speculate that the delay was included in the bill to make it more attractive to physician groups such as the American Medical Association (AMA), which opposed the fix in favor of hammering out a permanent repeal of SGR.

    Although members of both the House and Senate have recognized the need for permanent repeal and drafted bills to do just that, progress stalled when legislators were unable to agree on how the repeal would be paid for. House versions of the permanent repeal focused only on the SGR, while a Senate proposal would end both the SGR and the therapy cap. In press reports, both Speaker of the House John Boehner and Senate Majority Leader Harry Reid say they favor some form of permanent repeal, but that Congress once again ran out of time to work out the details.

    The approximate $20 billion cost of the temporary fix approved in the House will be paid for through a combination of cuts and programmatic changes that include reductions to clinical labs, radiology services, a delay on oral-only drugs for end-stage renal disease bundles, the establishment of a new value-based purchasing program for skilled nursing facilities based on performance around hospital readmissions, and a tightening up of code valuation under the fee schedule. Additional funds are identified through the use of SGR "transitional fund" money and an extension of Medicare sequester provisions.

    APTA continues to work with legislators toward a permanent end to the SGR and therapy cap, and will keep member advocates updated through PTeam alerts.

    Almost 60% of Patient Harm In SNFs Preventable, Says HHS IG Report

    A US Department of Health and Human Services (HHS) Inspector General's report says that nearly 60% of harm incidents experienced by patients in skilled nursing home facilities (SNF) are preventable, and that this gap in prevention resulted in hospitalizations that cost Medicare an estimated $2.8 billion in 2011. Among the preventable "adverse events" were falls, which the report related to both medication and resident care.

    The March 3 report (.pdf) from the HHS Office of the Inspector General (OIG) states that "Because many of the events that we identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events," and recommends that, among other things, the Centers for Medicare and Medicaid Services (CMS) direct its state facility surveyors "to review facility practices for identifying and reducing adverse events."

    The report focused on an analysis of 653 patients under Medicare who stayed in SNFs during the month of August, 2011, who began their SNF stay within 1 day after discharge, and whose stays in the SNF was 35 days or fewer. According to the report, 70% of the patients arrived at the SNF after hospitalization for nonsurgical treatment (most often septicemia or urinary tract infections), with the remaining 30% arriving after receiving surgery, usually hip or knee replacement.

    The study defined an adverse event as harm that resulted in "prolonged SNF stay or transfer to a hospital, permanent harm, life-sustaining intervention, or death." Events were classified by a panel of physicians after initial records screening by a panel of nurses led by a nurse practitioner. If evidence of an adverse event was identified by the nurse panel, the records were then reviewed by the physicians, who made a determination of whether the event was preventable. Researchers also analyzed "temporary harm events" that required medical intervention but did not cause lasting harm.

    According to the report, about 1 in 5 Medicare beneficiaries receiving post-acute care in SNF in August 2011 experienced an adverse event, and an additional 11% experienced a temporary harm event. Of those combined events, physician reviewers estimated that 59% were "clearly or likely preventable," and due to "substandard treatment, inadequate resident monitoring, and failure or delay of necessary care." The 59% preventable rate is an average of a 69% preventable rate for adverse events, and 46% preventable rate for temporary harm events.

    Among the IOG findings:

    • Of the preventable adverse events, 79% resulted in prolonged stay, transfer, or hospitalization; 14% required intervention to sustain life; and 6% resulted in or contributed to death
    • Harm related to medication was cited as a cause for 37% of the preventable events, with falls accounting for 4% of events in this category; harm related to resident care accounted for another 37% of preventable events, with falls making up 6% of that category; and 26% of preventable events were categorized as infection-related
    • Of the estimated $208 million spent by Medicare in August 2011 on all hospitalizations because of adverse events, $136 million was spent on hospitalizations associated with preventable events

    The report includes 2 major recommendations, both of which have been endorsed to greater and lesser degrees by CMS and the Agency on Healthcare Research and Quality (AHRQ). The bulk of the OIG recommendations focus on the development of lists of preventable events "to broaden and improve [SNF] staff understanding," the inclusion of preventable events in Quality Assurance and Program Improvement (QAPI) systems, and encouragement to SNFs to report adverse events to patient safety organizations (the only recommendation that received qualified agreement from CMS).

    The second major recommendation from the OIG was that CMS instruct state survey agencies "to include an assessment of adverse event identification and reduction in their evaluations of QAPI and [Quality Assessment and Assurance] compliance, and link related deficiencies specifically to resident safety practices." According to the report, CMS stated that activities under way to establish QAPI requirements for nursing homes "will include guidance for surveyors on how to evaluate nursing home efforts to identify and reduce adverse events."

    APTA provides physical therapists (PTs) and their patients and clients with education on exercise prescriptions for balance and falls prevention, a pocket guide on falls risk reduction (.pdf) and an online community where members can share information about falls prevention. In addition, APTA offers its members evidence-based resources on falls through PTNow as well as through PTNow ArticleSearch, its tool for access to current research works.The association's webpage on safe patient handling also includes information on how to patient and provider injury risk.