critical access hospital program myron e bloom md mmm medical director, rural healthcare quality...

Critical Access Hospital Program

Myron E Bloom MD MMMMedical Director,

Rural Healthcare Quality Network


• Created by Congress in 1997 as part of the Balanced Budget Act to support “limited-service hospitals” located in rural areas.

– Reimbursed on Medicare-allowable costs

or “cost-based reimbursement” for

inpatient and outpatient services


Enhancements made in the:

• Balanced Budget Refinement Act of 1999

• Medicare Medicaid and SCHIP Benefits

Improvement and Protection Act of 2000

• Medicare Prescription Drug, Improvement

and Modernization Act of 2003

Balanced Budget Act of 1997 (BBA)

• To qualify the CAH had to:– Offer 24-hour emergency care services,– Have a maximum 15 acute patients,

• Outpatient/Observation patients were not counted– (counting only inpatients, not beds occupied)

• Facilities with Swing-beds were allowed to have up to 25 acute or SNF-level beds, provided that no more than 15 beds were used at any one time for acute care patients.

– Keep each patient no more than 96 hours.

Balanced Budget Act of 1997 (BBA)

To qualify the CAH had to be a:

• Distance of 35 miles (or 15 in the case of mountainous terrain or with only secondary roads) from another hospital or

• Necessary Provider of health care services certified by the State.– Certification will sunset January 1, 2006

The Balance Budget Refinement Act of 1999

Changed length of stay to an annual average of 96 hour patient stay,

and

Increased the opportunity for small hospitals to join the CAH program.

The Medicare, Medicaid, and SCHIP Benefits Improvement

and Protection Act of 2000 (BIPA)

• CAH Swing Beds became exempted from PPS and paid on a cost basis,

• CAH provided ambulance services would be paid on a reasonable cost basis, if it is the only ambulance within a 35 mile drive of the CAH.

The Medicare, Medicaid, and SCHIP Benefits Improvement

and Protection Act of 2000 (BIPA)

• Emergency Room On-Call Physicians payment were now considered an allowable cost of outpatient CAH services after October 1, 2001.

– So far just the cost of Doctors to be on call

Medicare Modernization Act of 2003 §405 (a)

After January 1, 2004 for Method I

• Reimbursement for services increased to 80% of 101% of reasonable costs (up from 100 %) or

• 101% less Part B deductible and coinsurance amounts;

Medicare Modernization Act of 2003 §405 (d)

• Increased Flexibility in Method II with– 115 % of the Fee Schedule Payment For

Professional Physician Services, – 115 % of the 85 % of the Medicare

Physician Fee for non-physician practitioner professional services.

• Each practitioner has the option to participate in bundled Part B billing.

Medicare Modernization Act of 2003 §405 (b)

And after January 1, 2005,

• Cost-based reimbursement for other

on-call emergency room providers:physician assistants,

nurse practitioners, and certified nurse specialists.

• But on call practitioners can not be simultaneously on call at any other facility.

Medicare Modernization Act of 2003 §405 (e)

And after January 1, 2004,

• A CAH could operate a maximum 25 beds for acute hospital level of care or swing bed services,– Notice “beds” not “patients”

• Previously a CAH could operate 15 acute inpatient beds and up to 10 swing beds.

Observation Patient Servicesafter MMA

• Any “beds” that are hospital-type beds are counted in the maximum bed count, – including those used by patients on

observation status.

• May NOT Co-mingle Inpatients and Outpatients.– Distinct Part Outpatient Areas and beds

not interchangeable with inpatient beds.

“Excluded from the Bed Count” after MMA

• Stretchers and Examination tables in Emergency Departments,

• Obstetric labor and delivery beds,• postpartum and birthing room beds in which

the mother remains after giving birth are counted!

• Newborn bassinets and isolettes,• Operating and Procedure tables or

recovery beds (which must be used exclusively for recovery).


• Observation services defined as “to evaluate an outpatient’s condition to determine the need for possible admission as an inpatient”.– 48 hours maximum observation stay, after which

the patient should be admitted, discharged, or transferred, and,

– Must always be medically necessary.• Following an ER visit or outpatient medical procedures• Chest pain workup, asthma, or congestive heart failure

treatments………………...InterQual criteria


• Observation falls under Part B and the beneficiary may not understand the complex fee structure,– The CAH must give written notice of non-

covered services prior to the stay.

• Observation days do not count in the

3 day qualification for transfer to ECF.– Provider and patient/family consternation!

Medicare Modernization Act of 2003 §405 (g)

And after October 1, 2004

• CAHs may establish distinct part (DP) Psychiatric and Rehabilitation units,

• Maximum of ten beds in each “DP” which will not count against the CAH inpatient bed limit.– Same Medicare payments as made to

general hospitals for these services.

Summary of MMA 2003

• Increased the beds that could be used for acute inpatient care from 15 to 25, – Any hospital-type bed located where the bed

could be used for acute inpatient care counts toward the 25 bed limit!

• Hospice beds count as part of the maximum bed count while not contributing to the 96 hour annual average length of stay.

• Distinct part Psychiatric and Rehabilitation units now allowed and do not count in either bed capacity or length of stay.

Proposed Rules for CoPFederal Register, March 25, 2005

H&P examination. expand permissible practitioners and the time frame for the H&P;

• Authentication of orders. allow orders to be authenticated by any practitioner responsible for the care of the patient for five year transition period;

• Post anesthesia evaluation. permit any individual qualified to administer anesthesia to do post anesthesia evaluation for inpatients.

• http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/pdf/05-5916.pdf

The PPS CoP catch up to CAH CoP

http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/pdf/05-5916.pdf

http://a257.g.akamaitech.net/7/257/2422/01jan20051800/edocket.access.gpo.gov/2005/pdf/05-5916.pdf

Conditions of ParticipationRev. 05-21-04

Critical Access Hospitals

Regulations and Interpretive Guidelines for Critical Access Hospitals (CAHs)

What is different for CAH’s?

• Network agreements for Credentialing Privileging, and Quality Assurance

• Required Emergency Services• Governing Body Responsibilities• Practitioner Responsibilities • Patient Care Policies• Quality Assurance Program• Periodic Evaluation

485.616(b) Agreements for Credentialing and Quality

Assurance

Each CAH shall have an agreement with respect to credentialing and quality assurance with:

(1) A hospital member of the network;

(2) QIO or equivalent entity; or

(3) Another appropriate qualified entity identified in the State rural health plan.

Condition of Participation §485.618

Emergency Services

• Emergency services 24-hours a day,

• Equipment, supplies, and medication used in treating emergency cases are readily available, and

• Blood and Blood Products on a 24-hours a day basis.

§485.618 Emergency Services

A doctor of medicine or osteopathy, a physician assistant, or a nurse practitioner on call and immediately available on site 24-hour a day within:

20 minutes for trauma30 minutes non-trauma

or 60 minutes if the CAH is a frontier area (less than 6 residents per square mile), the State has determined that longer than 30 minutes is the only feasible method of providing emergency care to residents, and maintains that 60 minutes is justified because other alternatives would increase the time needed to stabilize a patient in an emergency.

§485.627(a) Governing Body

• The governing body is responsible for the quality of care provided to patients.

• The governing body– must determine categories of practitioners

eligible for appointment / reappointment,– must approve the medical staff bylaws and ensure

that bylaws comply with State and Federal law, – must ensure that the medical staff is accountable

to the governing body for the quality of care provided to patients.

§485.631 Staff Responsibilities

All CAH patients

• Must be under the care of a MD/DO member of the medical staff

or

• Under the care of a practitioner who is under the supervision of a member of the medical staff.

§485.631(b) (i) Responsibilities of the Doctor of

Medicine or Osteopathy

• Provides medical direction for the CAH’S health care activities

and

• Consultation for, and medical supervision of, the health care staff.

§485.631(b)(1)(ii)Responsibilities of the Doctor of


– In conjunction with the physician assistant and/or nurse practitioner,

• Participates in developing, executing, and periodically reviewing the CAH’S written policies governing the services it furnishes.

§485.631(b)(1)(iii)Responsibilities of the Doctor of


– In conjunction with the physician assistant and/or nurse practitioner,

• Periodically reviews the CAH’S patient records, provides medical orders, and provides medical care services to the CAH patients.

– Periodically reviews and signs the records of patients cared for by nurse practitioners, clinical nurse specialists, or physician assistants,

• MD/DO must review and sign ALL medical records for patients cared for by mid-level practitioners at the CAH.

§485.631(b)(1)(iv)Responsibilities of the Doctor of


Survey Procedures §485.631(b)(1)(iv)

• Select a sample of inpatient and outpatient records, including both open and closed records, and verify that a MD/DO has reviewed and signed all records for patients cared for by mid-level practitioners.

• “Prior to the May 21, 2004 revision, the interpretive guidelinescited a 25% review of outpatient records of by physicians. The current guidelines specify 100% because that is what the regulation states.”

• ‘CMS Central Office is now considering changing the regulation. In the near future Central Office Survey & Certification staff expect to send out a letter indicating that, until the regulation should be modified, a 25% sample for outpatient records will suffice IF the State law supports independent practice for the mid-level practitioner .” Alma Hardy, Medicare Provider Services Branch CMS - Region 10

§485.631(b)(2)Responsibilities of the Doctor of


• Is available through direct radio or telephone communication for consultation, assistance with medical emergencies, or patient referral.

• Is present for sufficient periods of time to provide the medical direction, medical care services, consultation, and supervision.

– Frontier facilities, at least once in every 2 week period, but a site visit is not required if no patients have been treated since the latest site visit.

.

485.631(c)(1) Physician Assistant, Nurse Practitioner,

and Clinical Nurse Specialist Responsibilities

• Participates in the development, execution and periodic review of the written policies governing the services the CAH furnishes,

• Participates with MD/DO in a periodic review of the patients' health records.



• performs the following functions to the extent they are not being performed by a doctor of medicine or osteopathy:

– Provides services in accordance with the CAH’S policies,

– Refers patients for needed services that cannot be furnished at the CAH, and assures that adequate records are maintained and transferred when patients are referred.



Whenever a patient is admitted by a nurse practitioner, physician assistant, or clinical nurse specialist,

an MD/DO on the staff of the CAH is notified of the admission.

The CAH regulations do permit mid-level practitioners to admit patients

as allowed by the State.

CMS regulations require that Medicare and Medicaid patients admitted by a mid-level practitioner be under the care of an MD/DO if any medical or psychiatric problem during hospitalization is outside the scope of practice of the admitting practitioner.

Interpretive Guidelines §485.631(c)(3)

• Evidence of “being under the care” of an MD/DO must be in the patient’s medical record,– As applicable, the patient’s medical record must

demonstrate MD/DO responsibility/care.

• Therefore If the CAH allows a mid-level practitioner to admit and care for patients, the governing body and medical staff must establish policies and bylaws to ensure patient safety.

Interpretive Guidelines §485.631(c)(3)

• Surveyors verify that:– Admitting is only done by practitioners currently

licensed and granted privileges as allowed by State law,

– An MD/DO is monitoring and is responsible for the care of each Medicare or Medicaid patient for all medical problems during the hospitalization outside the scope of practice of the admitting mid-level practitioners.

§485.635(a) Patient Care Policies

• The CAH services are furnished in accordance with appropriate written policies that are consistent with applicable State law.

• The policies are developed with the advice of a group of professional personnel – that includes doctors of medicine or osteopathy

and physician assistants, nurse practitioners, or clinical nurse specialists,

– AND at least one member who is NOT a member of the CAH staff.

§485.635(a) Patient Care Policies

• (i) A description of the services the CAH furnishes directly and those furnished through agreement or arrangement;

• (ii) Policies and procedures for emergency medical services;

• (iii) Guidelines for the medical management of health problems.

Interpretive Guidelines §485.635(a)(3)(iii)

• Policies should establish the agreement between the MD/DO providing the medical supervision and the mid-level practitioners for medical diagnosis and treatment.

• Policies should describe the scope of service performed by the mid-level practitioners.– They should cover most health problems;– They should describe the authorized treatments

and procedures available to the PA, NP and/or CNS.

Interpretive Guidelines §485.635(a)(3)(iii)

• Policies should describe the regimens to follow and also stipulate when consultation or referral is required.– They should describe the medical

conditions, signs, or developments that require consultation or referral.

Interpretive Guidelines §485.635(a)(4)

• To ensure policies are reviewed at least annually by the professional personnel. – “Review the meeting notes and policy and

procedure books to verify that the patient care policies are reviewed on an annual basis by the professional group,” which includes a member not on the CAH staff.

Administration of drugs and biologicals

485.635(d)(3)

• All orders must be legible and include date, time, name of the ordering practitioner and for verbal orders the signature of the accepting individual.

• The ordering practitioner must sign, date, and time a verbal order as soon as possible consistent with Federal & State law and CAH policy.– “The next time the prescribing practitioner provides

care to the patient, assesses the patient, or documents in the patient’s medical record”

Interpretive Guidelines §485.635(d)(3)

• “We recognize that in some instances…the ordering practitioner…is “off duty” for…a…period of time. In such cases, it is acceptable for a covering practitioner to co-sign the verbal order of the ordering practitioner. The signature indicates that the covering practitioner assumes responsibility for his/her colleague’s order as being complete, accurate and final. This practice must be addressed in the CAH’S policy.

• However, a qualified practitioner such as a physician assistant or nurse practitioner may not “co-sign” a MD/DO’s verbal order or otherwise authenticate a medical record entry for the MD/DO who gave the verbal order.”

Interpretive Guidelines §485.638(a)(4)(ii)

• All or part of the history and physical exam may be delegated to other practitioners in accordance with State law and CAH policy, but the MD/DO must sign and assume full responsibility for the H & P. – This means that a nurse practitioner or a physician

assistant may perform the H & P.– All entries must be timed, dated, and authenticated

and may be made only by individuals as specified in CAH and medical staff policies.

§485.639(c)(2)

CRNA anesthetist must be under the supervision of the operating practitioner unless the Governor in the State in which the CAH is located requests exemption by submitting a letter to CMS. – Washington CRNAs have been exempted.

§485.641(a) Periodic Evaluation

• The CAH carries out or arranges for a periodic evaluation of its total program to be performed at least once a year.– The utilization of CAH services, including number

of patients served and the volume of services;– The purpose of the evaluation is to determine

whether the utilization of services was appropriate, the established policies were followed, and if any changes are needed.

Interpretive Guidelines §485.641(a)

• “A representative sample means not less than 10 percent of both active and closed patient records.”– Who is responsible for the review of both active and

closed clinical records? – How are records selected and reviewed?– How does the process ensure that the sample of

records is representative of services furnished? – What criteria are utilized in the review of both active

and closed records?

§485.641(b) Quality Assurance

• The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment and the outcomes. – All services affecting patient health and safety;– Nosocomial infections and medication therapy;– Diagnosis and treatment by the mid-level

practitioners is evaluated by a MD/DO on the CAH staff or by another doctor under contract with the CAH.


• The quality and appropriateness of the diagnosis and treatment furnished by MD/DOs are evaluated by--

• (i) hospital that is a member of the network;

• (ii) QIO or equivalent entity; or• (iii) Other appropriate and qualified

entity identified in the State rural health care plan; and


• The CAH staff considers the findings of the evaluations and takes corrective action if necessary.

• The CAH also takes appropriate remedial action to address deficiencies found through the quality assurance program.

• The CAH documents the outcome of all remedial action.

CAH General Hospital

Quality Assurance / Quality Improvement

Required oversight of Credentialing &

QA, PR, PI

Oversight not required

Emergency Services 24/7 with physician, PA or ARNP

available within 30 minutes and must participate in the Washington State

Designated Trauma System.

Emergency services not required

Bed size Maximum 25 acute care or Swing beds.

May have 10 bed Psychiatric and

Rehabilitation units.

No limitation on census; Swing and ECF beds optional

Length of Stay average of 96 hr in acute care

No limitation

Washington State’s 37 CAH• Pomeroy August 1999 • Dayton January 2000• South Bend April 2000• McCleary July 2000• Davenport August 2000• Deer Park November 2000• Grand Coulee January 2001 • Odessa January 2001 • Chewelah August 2001 • Newport October 2001 • Ritzville January 2002• Prosser January 2002• Leavenworth January 2002• Ilwaco February 2002• White Salmon March 2002• Goldendale April 2002• Ephrata April 2002• Othello July 2002• Morton July 2002• Quincy October 2002• Tonasket November 2002

• Brewster December 2002 • Port Townsend January 2003 • Forks January 2003 • Republic January 2003 • Colville June 2003 • Colfax August 2003 • Omak October 2003• Sedro-Wolley January 2004 • Sunnyside January 2004• Pullman June 2004• Clarkston August 2004• Ellensburg October 2004• Chelan October 2004 • Enumclaw November 2004• Shelton January 2005• Pasco February 2005

• Considering Conversion to CAH– Snoqualmie Valley– Wenatchee Valley Medical Center– Walla Walla General

CAH Program in Washington State

• The Critical Access Hospital program In Washington State is administered by the Department of Health through the Office of Community and Rural Health (OCRH) and the Office of Facility and Services Licensing (FSL) Office of Survey, in close collaboration with the Washington State Hospital Association.

critical access hospital program myron e bloom md mmm medical director, rural healthcare quality...

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