The federal government is pressuring the medical community to reduce patient care costs while improving the quality of patient care to all patients, including Medicare beneficiaries. Congress, recognizing that hospital readmissions are too common and are costly and often avoidable, passed the Hospital Readmission Reduction Program (HRRP), which ties-in readmission metrics to monetary penalties to encourage hospitals to reduce readmission rates. Federal lawmakers also passed the Health Information Technology for Economic and Clinical Health Act (HITECH), which is intended to stimulate the rapid evolution and adoption of information technology in the healthcare industry, promote the development and use of clinical decision support (CDS) treatment algorithms, encourage active provider participation in discharge planning and care to decrease recidivism, and enhance care coordination through provider-patient communication.

Consistent with these legislative strategies, the Center for Medicare and Medicaid Services (CMS) appears to be encouraging contracted quality improvement organizations (QIOs) to adopt quality care principles (meaningful use criteria), created pursuant to HITECH, as additional criteria to be applied in the evaluation of the adequacy of care provided to Medicare beneficiaries under their jurisdiction.

In 1982, Congress established utilization and quality control peer review organizations (PROs) (now known as QIOs) to perform two broad functions: (1) promote quality health care services for Medicare beneficiaries; and (2) determine whether services rendered are medically necessary, appropriate and meet professionally recognized standards of care. The goal of the QIO program is to improve medical outcomes for Medicaid beneficiaries.

QIOs have recently targeted psychiatrists as well as safety-net hospitals, along with other covered institutions providing inpatient psychiatric care; reviewing both the adequacy of the care provided as well as the appropriateness of the discharge planning pursuant to Section 1156 of the Social Security Act. QIOs are applying “meaningful use” criteria adopted pursuant to HITECH to assess whether the physicians and institutions being reviewed are acting in accord with professionally recognized standards of care. QIOs such as Telligen, LLC (formerly IFMC Illinois) have issued sanction notices suggesting substantial violations of Section 1156 for a providers’ failure to meet “meaningful use” criteria. QIOs appear to be applying a higher level of scrutiny to cases where patients are readmitted to the same or another institution within 30 days.

QIOs such as Telligen have essentially associated the principle of “professionally recognized standards of care” under Section 1156 with “meaningful use criteria” enunciated under HITECH along with other historically applied principles of care. The term “professionally recognized standard of care” is not specifically defined by regulators (the Quality Improvement Organization Manual suggests that the term may be equated to evidence-based practices and/or documented consensus statements, best practices and/or identified norms).
The failure of a physician, hospital or other covered institution to implement acceptable corrective action plans can lead to financial penalties or exclusion from reimbursement for services rendered to Medicare patients. This remedy goes beyond HITECH provisions, which simply provide that institutions not presently in compliance are not entitled to incentive payments.

Recent actions by QIOs like Telligen, requiring covered facilities — including safety-net institutions — to meet “meaningful use” criteria under HITECH creates significant concerns. While the intent of HITECH is to promote implementation of electronic record systems and the adoption of clinical decision support (CDS) algorithms and enhanced care coordination through provider communication, implementation of HITECH “meaningful use” criteria is to be staged through 2016. Regulators have recognized that physicians and other covered providers need time to implement electronic record systems and required protocols.

Major medical associations such as the American Medical Association (AMA), American Academy of Family Physicians (AAFP), College of Healthcare Information Management Executives (CHIME), and the HIMSS Electronic Health Record Association (EHRA), have all expressed concern about the implementation of Stage III meaningful use criteria by 2016. They cite ongoing problems in implementing EHR systems and in integrating the use of these systems throughout various healthcare networks and suggest that CMS has failed to adequately assess the impact of Stage I meaningful use criteria on hospital operations. The associations also note that there has been no evaluation of Stage II meaningful use criteria, in that these criteria have not yet been implemented. It is these criteria that impose patient stewardship responsibilities and require extensive discharge planning and follow-up. The associations suggest postponing implementation of Stage II and Stage III meaningful use criteria.

Contractors have recently devoted substantial attention to psychiatric admissions to safety-net hospitals. During the review process, Telligen alleged concerns ranging from the failure to: (a) stabilize patients prior to discharge/transfer; (b) arrange for adequate follow-up care; (c) address issues of readmission and recidivism; (d) the taking of appropriate legal action to compel administration of psychotropic drugs or involuntary admission. Each of the alleged concerns/violations were based in part on HITECH “meaningful use” criteria relating to EHR systems, clinical decision support (CDS) protocols as enunciated by the Telligen reviewer or “use” criteria relating to discharge policies and procedures including follow-up.

Respondent physicians and institutions implicated during this process have pointed to regulatory limitations on the ability to subject patients to involuntary admission or administration of psychotropic medication, and regulations restricting admission to acute care hospitals where alternative facilities would otherwise provide sufficient care. Respondents have also cited American Psychiatric Association (APA) guidelines relating to the need to treat patients through alternative community programs where possible. They also argued that many of the subject patients had significant social risk factors compounding discharge planning and follow-up care.

Many of the institutions cited will face significant challenges because they operate under slim financial margins compared to other institutions. In several recent cases pursued by Telligen, institutions felt compelled to adopt corrective action plans for which they lacked adequate staff and resources because of the draconian nature of the sanctions that could be imposed.

Independent research conducted by the Commonwealth Fund supports the respondents’ concerns. Commonwealth Fund studies suggest that safety-net hospitals are 30 percent more likely to have 30-day readmission rates above the national average. Hospitals serving large numbers of low-income patients are more likely to have the lowest adjustment factors and receive the maximum penalty of 1 percent under HRRP. The same institutions are at risk to not receive Medicare and Medicaid incentive payments under HITECH and face potential imposition of penalties under that legislation if their failure to comply continues through 2015. Further imposition of sanctions by QIOs for failure to meet “meaningful use” criteria, not yet implemented and evaluated by CMS, compounds an already complicated regulatory picture for hospitals in general, and for safety-net institutions in particular.

Safety-net institutions handle a disproportionate share of vulnerable populations that include low-income insureds, underinsureds or patients on Medicaid. Safety-net hospital patients have substantially higher rates of chronic health problems, disability, mental illness and substance abuse compared to the general population. They also have disproportionate personal and social needs adversely affecting their health and otherwise imposing roadblocks to coordinated care. These include homelessness, unsafe housing, unstable employment and lack of family support. This population requires significant enabling and support services and transitional care post-discharge, which may well be beyond safety-net institutions’ ability to provide.

QIOs should be circumspect in sanctioning physicians and covered institutions for violation of “meaningful use” criteria that has yet to be implemented or fully evaluated by CMS. QIOs may need to consider application of a “sliding scale” assessment, at least initially, as it relates to application of “meaningful use” criteria during care reviews, to allow nonuniversity based hospitals as well as safety-net institutions, the necessary time to bring themselves into compliance with evolving EHR, CDS and discharge planning and care requirements incorporated into recently passed healthcare legislation.

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