CD 5540 Medical Speech Language Pathology
Handout Packet # 2
Managed Care

Developed by
Heather M. Clark, Ph.D. CCC/SLP


 
  1. Medical Costs
    1. increase by about 11% per year
    2. US has highest per capita cost of medical care
    3. issues
      1. overutilization and/or misutilization
      2. oversupply of providers
      3. overcapacity (more facilities and beds than needed)
  2. Managed Care
    1. system of payment for medical services which results in fixed (or nearly fixed) costs for the payor-- "prospective payment"
    2. concepts
      1. capitation
        1. provider accepts a designated fee per month to provide services to a group of individuals
        2. risk of overutilization falls on provider, not on payor
      2. health & care rather than medical & cure
      3. value
        1. who can provide the best outcome at the lowest cost
        2. evidence-based practice
  3. Terminology
    1. treatment efficacy
      1. efficacy
        1. study of treatment under optimal conditions
        2. usually addresses change in performance on assessment instruments
      2. effectiveness
        1. study of treatment/services under typical conditions
        2. usually involves functional outcomes
      3. efficiency
        1. assesses the effectiveness given a specific time frame
        2. addresses value
    2. levels of assessment and treatment
      1. impairment
        1. underlying physiologic dysfunction
        2. e.g., weakness, loss of hair cells
      2. disability
        1. effect of impairment on performance (functional)
        2. unintelligible speech, auditory comprehension deficits
      3. handicap
        1. social consequences, effect on quality of life
        2. isolation, unemployment
  4. Evidence-based medicine
    1. model of service delivery that emphasizes providing ONLY those treatments that are DOCUMENTED as effective and most efficient
    2. concepts
      1. process
        1. utilizes literature search and review
        2. provider determines expected
          1. benefits
          2. harm
          3. costs
          4. time
      2. DE-emphasizes clinical judgments based on "personal" experience and anecdotal evidence
      3. benchmarks
        1. sets expected levels of productivity and/or effectiveness
        2. providers will be reimbursed only if demonstrating effectiveness and efficiency
  5. Managed Care and Academia
    1. student clinicians are not efficient (effective?)
    2. supervising clinicians CAN reduce productivity
    3. clinical research is time-consuming and costly
    4. implications for curriculum
      1. concepts of managed care
      2. measurement of treatment outcomes
      3. skill in evidence-based practice
  6. Reimbursement Systems
    1. types
      1. private insurers
        1. group plans (often employer supported)
        2. individual plans
      2. government supported
        1. medicare (federally funded and administrated)
        2. medicaid (federally funded and state administered)
    2. methods
      1. prospective payment
        1. DRG (diagnostic related groups)
          1. inpatient care
          2. payment based on diagnosis
          3. provider benefits from decreased LOS
          4. utilizers
            1. Medicare (Part A--no premium)
              1. 1st 60 days, $768 deductable
              2. days 60-100, $192 per day co-payment
            2. many private insurers
        2. RUG (resource utilization group)
          1. skilled nursing
            1. Medicare Part A
              1. no co-payment for first 20 days
              2. $96 per day for next 80 days
          2. payment based on determined level of rehab care
            1. ultra high
              1. 720 minutes or greater of tx
              2. at least two disciplines
                1. one 5 days
                2. one 3 days
            2. very high
              1. 500 minutes or greater
              2. at least one discipline 5 days
            3. high
              1. 325 minutes or greater
              2. at least one discipline 5 days
            4. medium
              1. 150 minutes or greater
              2. any combination of txs 5 days
            5. low
              1. 45 minutes or greater
              2. any combination 3 days
          3. providers benefit from high-functioning patients
          4. utilizers
            1. Medicare
              1. skilled nursing uses copayments as above
              2. home health has no co-payment
        3. Staff providers
          1. facility employs providers
          2. cost of potential services included in per-day cost to individual payers
      2. retrospective payment
        1. fee for service model
        2. usually involves
          1. deductible
          2. co-payments
            1. set fee per visit
            2. 80/20
          3. fee discounts for payor
        3. utilizers
          1. fewer and fewer private insurers
          2. Medicare
            1. outpatient services
              1. $100 deductible
            2. $1500 cap
              1. 1500 for both PT, SLP
              2. 1500 for OT
              3. hospital-based tx exempt
          3. out-of-pocket
  7. Implications for service delivery
    1. referrals
      1. inpatient
        1. hospital receives no reimbursement for additional services
        2. services considered valuable if they reduce LOS
        3. likely to get more dysphagia referrals
      2. rehab
        1. also functions under DRG
        2. focus now moves more towards functional outcome
        3. will your services reduce ultimate cost of care?
      3. skilled nursing
        1. facilities will be looking to admit high-rehab potential patients
        2. tx services will be reimbursed ONLY for those with high RUGs
      4. long-term care
        1. staff providers may be too costly to maintain
      5. outpatient
        1. may have to choose between walking and talking
        2. may result in more out-of-pocket expenses
    2. goal selection
      1. emphasis on functional outcomes
        1. stress independence
        2. safety
  8. Documentation (Stierwalt, 1998)
    1. The Glass is...
      1. Terminology issues
        1. words/phrases used can impact the likelihood of payment
        2. Sets the tone for expectation of progress, or necessity of skilled services
      2. Tx can be provided in the following areas (for medicare)
        1. speech
        2. language
        3. swallowing
        4. voice
    2. Half empty...
      1. Poor cognitive skills
      2. Pt. not oriented to time or place
      3. Status unchanged
      4. Maintenance tx
      5. Monitored during mealtime
      6. Pt. Confused
      7. No significant difficulties noted
      8. Oral motor exercises were stressed
    3. Half full...
      1. New skill acquired
      2. Designed and established a functional maintenance program
      3. Pt. ready for next step in tx
      4. Ability to generalize noted
      5. Higher level language skills noted
      6. Training and instruction
      7. Functional vocabulary increased
      8. Deficits require skilled tx
    4. Treatment Goals
      1. Measurable
      2. Functional
      3. Pt. Related
      4. Focused on the areas reimbursed at least 50%
  9. Evaluations: Questions reviewers will ask when viewing eval docs.
      1. What happened
      2. When
      3. Premorbid skill level
      4. Current presenting problems
      5. Prognosis for improvement
      6. Skilled tx required?
      7. Recommendations include functional outcomes?
    1. What happened
      1. reviewers will look for medical diagnosis
      2. associated with a specific ICD code.
      3. ICD Codes
        1. Primary Codes
          1. CVA - 436.0
        2. Tx Codes
          1. Apraxia - 784.69
          2. Aphasia - 784.3
          3. Dysarthria - 784.5
          4. Agnosia - 784.69
          5. Dysphagia - 787.2
        3. Tx codes must be in line with diagnostic codes, or it may be basis for denial of payment
        4. Codes would be on Tx plan
    2. Premorbid Skills
      1. Premorbid abilities
      2. previous CVAs
      3. other neurologic events
      4. normal functioning
      5. Cannot set goals higher than the prior level of function
    3. Current functioning
      1. make sure to describe deficits so that reviewer can see that it is a covered aspect of speech/language and swallowing
      2. Deficit statements
        1. Because of dysarthria the patient is unable to produce understandable speech to communicate wants and needs. Speech intelligibility is currently at the 20% level of effectiveness.
        2. The aphasia has produced a symbolic dysfunction that interferes with the patient's ability to recall and use single words to communicate wants and needs. This ability is currently at the 30% level of effectiveness.
      3. Although these are acceptable statements according to Medicare guidelines, a clinician should question them. What's wrong with these statements? You must provide the basis for your observations
        1. Standardized tests
          1. requires skilled administration
        2. Informal observation
          1. requires skilled interpretations
    4. Summary of Evaluation
      1. State the medical diagnosis
      2. Specify the date of occurrence or change in condition
      3. Describe the conditions the you are qualified to treat
      4. Explain why speech services are needed
      5. Specific training and instruction that needs to be conducted
      6. Functional levels of independence
  10. Progress Notes
    1. Home health and Skilled Nursing
      1. MDS (minimum data set) completed by
        1. day 7: covers 14 days
        2. day 14: covers 16 days
        3. day 21: covers 30 days (care plan due)
        4. day 60, etc: covers 30 days
    2. General guidelines
      1. Functional goals addressed
      2. Knowledge and training of a professional is necessary
      3. Progress must be related to functional progress toward established goals
      4. Comparison statements must be included in the documentation
      5. Positive expectation for continued progress
    3. Medicare Denial Criteria
      1. Services are not reasonable nor are they necessary
      2. Services are not considered skilled services
  11. Other Documentation Issues
    1. Acute Care Documentation
      1. typically hand written
      2. immediately following the visit with the patient
      3. location in the medical chart
        1. progress notes
        2. Consult reports
    2. Rehabilitation
      1. typically dictated
      2. follows a universal temporal pattern
        1. referral received
        2. within 24 hours of receiving a referral
          1. Evaluation report
        3. three days following referral
          1. inpatient progress notes
            1. one per week following the evaluation
          2. outpatient progress notes
          3. one per month following discharge or from start date.
        4. Procedure reports
          1. Within 24 hours of procedure
        5. Discharge Summaries
          1. Within three days of discharge
    3. Miscellaneous
      1. Preauthorization and/or reauthorization
        1. letters to document the need for service
        2. historically, seldom necessary
        3. more frequently needed in the growing managed care market
      2. Justification letters
        1. letters to attempt to reverse denial of payment