PACE and Telemedicine
All-Inclusive Care for the Elderly otherwise known as (PACE) is a benefit program provided by the Centers for Medicare and Medicaid Services (CMS) for patients that are 55 and older and can be nursing home certified. CMS works with state administering agencies to operate a PACE program in their respective state. PACE is only provided by states that choose to offer the program under Medicaid provisions. PACE is a benefit provided by Medicare and is optional with those having Medicaid. As one of the only programs that combine Medicare and Medicaid, the PACE objective is to keep the patient living in their communities and homes, instead of nursing homes. The program is a team health care approach with contracted providers and specialists in the patient’s community. Telemedicine is one type of patient care that offers the means of a patient-doctor relationship remotely. Telemedicine is “ the practice of medicine using electronic communication, information technology or other means between a physician in one location and a patient in another location with or without an intervening healthcare provider” (“Balancing access, safety”, 2011). The use of telemedicine is improving the patient’s access to care, improving their outcome, and reducing costs for both the patient and provider. CHIP and ACOs
Children’s Health Insurance Program (CHIP), provided by State and Federal governments and based on the Medicaid Assistance Program, provides health coverage for children whose families do not qualify for Medicaid, but can’t afford private insurance. States are responsible for setting up their own CHIP program through a set of mandatory federal guidelines. The Children’s Health Insurance Program Reauthorization Act (CHIPRA) recently extended eligibility standards through 2019 and extended federal funding through October 1,
2015 which allows for medical, dental, and mental health coverage for children and medical coverage for pregnant mothers and mothers up to 60 days postpartum (“Children’s health insurance,” 2013). With the passage of the Affordable Care Act (ACA), a program to create accountable care organizations (ACOs) was established. The federal ACO program only involves Medicare, but the states have the ability to merge the ACO management structure to state-funded programs like CHIP. “ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors” (“Accountable care organizations,” 2013). The ACO management structure allows states the ability to deliver a healthcare system that is more affordable and offers a coordinated effort to provide improved healthcare for low-income families. Medicare and ICD-10
Medicare is a social insurance program provided by our federal government. This coverage is for people over 65 years old and for permanently disabled people. Medicare was established in 1965. With almost half of all older Americans having no health insurance, Medicare was established to solve the problem. (“Medicare: a primer,”). Medicare accounts for almost one-fifth of our federal budget and has been growing year after year. With the continual growth in population reaching eligibility age, Medicare will run out of funds by 2026 (Kennedy, 2013). With the passage of the health care reform law, our federal government is implementing ways to control spending to ensure Medicare is available for generations to come. One of the cost saving measures is ICD-10 coding for medical diagnosis and inpatient procedures. The current ICD-9 coding system has long been viewed as outdated with
limited terms, medical
conditions, and current practices. The new ICD-10 coding system gives more specific choices for diagnostics and will ensure services are paid appropriately to reduce fraud and overpayments. The transition from ICD-9 to ICD-10 is required for everyone covered by the Health Insurance Portability Act on October 1, 2014. According to the Health and Hospital Systems Secretary, Kathleen Sebelius, “The new healthcare law is cutting red tape, making our health care system more efficient, and saving money”.
The standards set for the PACE program are very stringent. The certification process requires and application, on-site visits, and information provided by the state agency. The application process can take up to nine months and once accepted, the first three years are considered a trial period. Within the trial period, the PACE program is reviewed annually by the state administering agency to ensure compliance with the federal regulations and every two years after that. Compliance is vital to maintain participation in the PACE program. Any violation of the regulations will bring about suspension of enrollment of beneficiaries, penalties, and/or suspension of payments. The PACE program basic requirements state that it must be able to provide a complete healthcare service regardless of the amount of care needed or the time a service takes (PACE- fact sheet, ). Telemedicine offers a way to provide service and is growing in importance as part of the complete healthcare service for urban and rural patients. There is a steady increase of elderly patients with chronic ailments that are physically unable to leave their homes. Although the PACE model in centered on a day care center facility for patient medical services, waivers for reimbursement for telemedicine is providing a way to monitor and communicate with patients in their homes. To accommodate telemedicine, PACE allows services
that are authorized by the patient’s coordinated medical team whether or not those services are covered with Medicare or Medicaid (Report to the congress, 2012). With the passage of the Affordable Care Act of 2010 (ACA), the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) program standards and scope were broadened to allow states to enroll more patients. There are over 7 million people covered by the CHIP program (Children’s health insurance, ). When the majority of the health reform becomes effective on January 1, 2014 with the healthcare exchange, the ACA made sure to cover the CHIP programs eligibility and availability standards until October 1, 2019. Although establishing an ACO is voluntary, the federal government, through the ACA, has opened up a Pediatric ACO Demonstration Project under Title II, Subtitle I, §2706. This demonstration model began on January 1, 2012 and extends to December 31, 2016 (Accountable care organization, ). The ACO system will make the healthcare professionals that form ACOs to be certified and held accountable for quality, care, and cost of services. The federal government provides funding to help states push toward a coordinated system to encourage healthcare provider to simplify the process between Medicaid, CHIP, and the state. Through legislation, ACOs receive an incentive payment for participating and are eligible for share in savings by reducing Medicaid costs associated with increased, coordinated access to care.
The Affordable Care Act (ACA) has enacted the transition from ICD-9 to ICD-10 for all patients covered by the Health Insurance Portability and Accountability Act (HIPAA). The new code set will change how a patient’s healthcare providers submit and receive payments for services. The Department of Health and Human Services, Centers for Medicare and Medicaid announced its final ruling in regard to healthcare professionals that provide Medicare fee-forservice (FFS) care on August 24, 2012 stating that ICD-10 will be implemented by October 1,
2014 for all patients covered by HIPAA. Each medical provider will be given a Health Plan Identifier (HPID) to submit claims to Medicare (MLN matters, ). With the use of the Electronic Data Exchange (EDI), healthcare providers will be able to communicate with Medicare and vice versa for faster service, payment transactions, and reduce costs (Electronic billing, ). For the healthcare providers that don’t comply with the new system, they are subject to fines, penalties, and claims being returned and not paid by Medicare.
Telemedicine will greatly increase the type and amount of care that PACE recipients receive. PACE is required to provide all services that are offered by both Medicare and Medicaid to patients living in both urban and rural areas. While that is easier to accomplish with patients living in urban areas, working with those living further away from a PACE center poses a potential problem with providing delivery of healthcare service. With telemedicine, providers can access and monitor vitals, provide health education, and reduces patients traveling long distances for care. Telemedicine and continuing technological innovations will improve the quality of care, patient outcomes, and greater satisfaction with the care and treatment they receive.
The Center for Medicare and Medicaid has been working closely with states, federal agencies, organizations, and leaders to enroll children who are eligible for the CHIP program and were not signed up. States are adopting the ACO structure for CHIP programs on a voluntary basis to connect with a unified system that will simplify the system when the health exchange is implemented on January 1, 2014. By providing coordinated care, the ACO providers work together to improve a patient’s health and the care they receive. The ACOs are responsible for
working together to provide the correct care at the right time. The ACO
structure is a huge benefit for those who are covered with the CHIP program. The focus is taken off of the amount of patients seen for fee-for-service payments and focuses on the patient’s wellbeing, personalized care, and preventative measures to keep them healthy.
ICD-10 coding is meant to upgrade the current coding system by including more diagnostic codes, a higher quality drug data, safety and quality indicators, and reducing payment errors. The transition will help Medicare patients to receive better care with more accurate patient charting and information that will be able to be shared with other plans, providers, and companies. With a consistent and accurate way to diagnose, providers will be able to spend more time treating patients and less time filling out forms. According to Kathleen Sebelius of the HHS, the passage of the Affordable Care Act reduced hospital admissions, fraud and payment changes and improved Medicare’s outlook without cutting benefits (Trustees:Medicare on sounder,).
Financing and reimbursement for the PACE program is based on dual eligibility with Medicare and Medicaid. The PACE provider receives capitation payments from Medicare and Medicaid to cover all of the medical treatment necessary to treat the patient covered under PACE. A capitation is a payment based on a patient’s risk-adjusted benchmark. This benchmark is achieved by using a base payment rate and multiplying that number by a risk score that is determined by data that are collected when the patient enrolls in the PACE program. The PACE provider then receives a full payment based on the risk-adjusted benchmark as their payment from Medicare. This payment is used to cover any services that are approved by the patient’s
team of providers or IDT whether the service is a covered benefit under Medicare or Medicaid or not. Telemedicine is covered under this payment structure and allows alternatives to treatments that would otherwise not be covered under other programs (Report to congress, ). The payment model for
PACE will ensure that patients receive the care they need where they need it. The ACO structure changes the way patient treatments are reimbursed. ACOs that provide care for the CHIP program is required to meet quality and performance measures to receive “enhanced” payments for services that are performed and to share in the profits from reducing healthcare spending through performance and efficiency (The impact of healthcare reform,). This payment structure makes the ACOs accountable for coordinating care and improving overall health, not reducing care to reduce costs. When reimbursement is directly tied to quality and performance of care, the ACOs will be inclined to provide the best to every patient they care for regardless of their personal circumstances.
To receive reimbursement through Medicare, ICD-10 coding is mandatory as of October 1, 2014. For any doctor, provider, supplier, or entity that submits a claim to Medicare requires claims to be sent electronically as a condition of payment (Electronic billing, ). The ICD-10 coding system is a more defined set of diagnostic codes that will assist in the proper payment of services provided and reduce fraud and excessive spending that currently exists with ICD-9. According to the Department of Health and Human Services, “The proposed changes would save healthcare providers and health plans up to $4.6 billion over the next 10 years”. The ICD-10 reimbursement system for Medicare will transform and update the current system and ensure the life of Medicare is extended by the reduction of spending.
Telemedicine provided by PACE increases patients access to the care they need. By using telemedicine, services to those who are home bound are greatly improved. Monitoring patients remotely by way of digital technology, providers are able to collect data and determine a treatment plan based on the information they receive. By using telemedicine patients have shown to have less hospital stays, reduced length of stays and improved quality of life. Current Medicaid programs make it difficult for patients to get the
care they need when they need it. There are limits to services, high co-pays, and a low number of providers who are willing to see Medicaid patients due to low reimbursement rates. With the implementation of the ACO structure, payment is based on quality and delivery of care. The ACO model will level the field of healthcare by providing the best service to all patients regardless of their financial circumstance.
The ICD-10 coding change does not directly affect a patient’s access to Medicare services. ICD-10 will affect the kind of treatment that patients receive. More specific ICD-10 codes will increase the understanding of the patient’s course of treatment and the treatment that is provided. ICD-10 guidelines can affect the patient populations included or excluded from a measure which my change the type of care associated with the measure being evaluated. Although ICD-10 doesn’t change the access to care, it creates a substantial benefit by way of information and data evaluation that will improve the type and quality of care they receive.
The Nationwide Health Information Network, referred to as the eHealth Exchange, is a program that was established in 2004 to improve quality and efficiency of healthcare through a nationwide health information exchange. This program was developed under the Office of the National Coordinator for Health Information Technology (ONC) to provide a web-based service of specifications to securely exchange healthcare data. The eHealth Exchange will tie health information, pharmacies, government, providers, networks, and payors into one large integrated network.
In September 2011, the Center for Medicare and Medicaid Services began a pilot project called the Electronic Submission of Medical Documentation (esMD). This program will allow providers to correspond requests for medical documentation through secure, electronic responses using the NHIN standards (“What is the”, ). CMS has adopted NHIN Exchange and an open source of
connectivity. The esMD pilot gives healthcare providers an additional option for responding to requests for documentation and reduces the time it takes to process requests. Called the Direct Project, it is like secure email or instant messaging system, where two entities that already share a relationship with each other can use technical means to electronically exchange health information (“Nationwide health information,” 2012). ACO regulations set by the ACA require the use of a health information exchange in order to be an approved provider. The standards set mandate that providers associated with an ACO are able to exchange health information to coordinate care, provide alerts, and recognize
and close gaps in care for patients. The ACO model hinges on the use of NHIN and is the basis for communication throughout the system.
With the esMD requirements used by the CMS, ICD-10 is a necessary improvement to ensure improved quality of the data that are exchanged through the NHIN. ICD-10 modernizes and creates interoperability with the electronic records transmitted throughout the NHIN. ICD-10 creates a common language for diagnosis and delivers a live exchange of up to date patient information. ICD-10 supports claims data that are submitted to CMS that is uses for payment, helps create payment policies,, program Integrity, clinical and research projects, and provides analysis for reimbursement (“The centers for,”).
Health Informatics Workforce
PACE and telemedicine are both programs that need a significant amount of I.T.staff to maintain its data. The technical data collected through telemedicine and PACE are required to measure performance and treatment of patients. A dedicated .I.T. staff is necessary to implement and maintenance health information technology and telehealth systems. According to recent reports, 79% of information technology organizations are hiring in response as the federal mandates on health information technology are being
implemented (“79 percent of,”). As health information technology expands and continuously changes in the coming years, the health information workforce will be the backbone of the success of the electronic technology system. The need for a strong health informatics workforce in the ACO model is a necessity. The basis of the model is the ability to coordinate care for patients and exchange that information with the CMS, including CHIP. As a requirement to provide services for CMS patients, ACOs
must have their healthcare providers using certified electronic health records (EHR) to receive payments through the Medicare and Medicaid EHR Incentives. With this requirement, an I.T. staff is critical to maintain this process. As the ACO model is adopted by more healthcare providers along with the implementation of the health exchange in 2014, the demand for health informatics professionals will increase.
The U.S. Department of Health And Human Services, including Medicare, requires that the use of ICD-10 by October 1, 2014. The transition from the current system requires a lot of preparation. A large amount of I.T. professionals are currently working with vendors, healthcare providers, and billing services to implement the new system by the due date. According to recent studies, “Only 9.8% of 1820 primary-care and specialty doctors said they had electronic systems that met U.S. rules for “meaningful use”, “.(Nussbaum, 2013) It seems there will be a last minute push by healthcare providers to comply with the system, requiring a large amount of I.T. professionals to complete the work.
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