SNHP 342-Healthcare Finance Chapter 5 Case Study

Case 5: Adverse Events in Skilled Nursing Facilities
BACKGROUND
From 2008–2012, we conducted a series of studies about hospital adverse events, defined as harm resulting from medical care. This work included a congressionally mandated study to determine a national incidence rate for adverse events in hospitals. As part of this work, we developed methods to identify adverse events, determine the extent to which events are preventable, and measure the cost of events to the Medicare program. This study continues that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare. Although various healthcare stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs.
HOW WE DID THIS STUDY
This study estimates the national incidence rate, preventability, and cost of adverse events in SNFs by using a two-stage medical record review to identify events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care. Sample beneficiaries had SNF stays of 35 days or less.
WHAT WE FOUND
An estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.
Source: United States Department of Health and Human Services. (2013). Adverse events in skilled nursing facilities: National incidence among Medicare beneficiaries. Retrieved from http://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf
Question
1. Placing yourself in the position of the Nursing Home Administrator, what would you expect CMS to determine SNFs to do as a result of the findings?—
Case 6: Managed Care
BACKGROUND
Examining access to care takes on heightened importance as enrollment grows in Medicaid managed care programs. Under the Patient Protection and Affordable Care Act, states can opt to expand Medicaid eligibility, and even states that have not expanded eligibility have seen increases in enrollment. Most states provide some of their Medicaid services—if not all of them—through managed care. The Office of Inspector General received a congressional request to evaluate the adequacy of access to care for enrollees in managed care. This report determines the extent to which providers offer appointments to enrollees and the timeliness of these appointments. A companion report issued earlier this year, State Standards for Access To Care in Medicaid Managed Care, OEI-02-11-00320, found that state standards for access to care vary, and that they are often not specific to certain provider types or to areas of the state. Additionally, states have different strategies to assess compliance with access standards.
HOW WE DID THIS STUDY
We based this study on an assessment of availability of Medicaid managed care providers. The assessment included calls to a stratified random sample of 1,800 primary care providers and specialists to assess availability and timeliness of appointments for enrollees.
WHAT WE FOUND
We found that slightly more than half of providers could not offer appointments to enrollees. Notably, 35 percent could not be found at the location listed by the plan, and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was 2 weeks. However, over a quarter had wait times of more than 1 month, and 10 percent had wait times longer than 2 months. Finally, primary care providers were less likely to offer an appointment than specialists; however, specialists tended to have longer wait times.
Source: United States Department of Health and Human Services. (2014). Access to care: Provider availability in Medicaid managed care. Retrieved from http://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf
Question
1. As a healthcare administrator what recommendations would you implement from the findings in this plan with regards to access for the Medicaid managed care enrollee?
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