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Managing Post-Acute Care and Other Extended Care Services (2010 Updated)
Apollo Managed Care Consultants, Feb 2010, Pages: 604
Policies and procedures for quality-based, cost effective clinical review criteria and case management strategies for post-acute care in a subacute unit, SNF, hospice, ambulatory care and/or the home. Review criteria guidelines/benefit ‘interps’. Resources include numerous forms, coverage information, Medicare average LOS by DRG, authoritative references, and stroke, cardiac and pulmonary rehabilitation guidelines.
Preface - Volume I
The focus of this manual is entirely related to the management of the care of health plan members who require extended care services for the management of a condition in a contracted and authorized location for a defined period of time as a common Medicare risk health plan covered benefit. Medicare benefit determinations are the ‘gold standard’ for these determinations. Many health plans offer additional benefits in the Certificates of Coverage, either as a marketing tool at no additional cost to the member or at an added premium.
Therefore, all policies, procedures, benefit interpretations and the like throughout this manual need to be carefully reviewed for applicability to the population served by each managed care organization (MCO), whether a health plan, PSO, a capitated medical group, a MSO, PHO or another managed care entity.
This manual has been compiled in recognition of the need for objective guidelines, policies and procedures for the management of post-acute transitional care inpatient, skilled nursing facility and rehabilitation hospital as well as outpatient integrated rehabilitation medicine programs providing physical, occupational and speech therapy. Standards for the review of requests for services are an integral part of the management of these services. The observations are based on the experience of many Health Maintenance Organizations, capitated multi-specialty medical groups, behavioral health care providers and the literature. Specific standards for the review of occupational, physical and speech therapy can be found in Apollo’s Managed PT/OT and Rehabilitation Care Manual.
This manual provides a model for common, acceptable, customary, reasonable and necessary managed care contract benefit interpretations and objective evidence-based review for the management and authorization (or denial) of services. Each must be reviewed by physician and other members of the medical policy committee of the health plan or contracted/delegated medical group and modified and adapted as appropriate to the circumstances of care in their community and as provided in their contracts.
Quality care is cost effective care – cost and cost-effectiveness may be quite different.
Cost effective health care is necessarily quality driven (true quality, that is; not excessive care under the guise of ‘quality’). Attention must always be focused on the issues that will result in optimal medical/surgical outcomes in the specific local medical environment. No item is more costly than the treatment of an avoidable complication, whether secondary to a treatment or procedure or due to the lack of adequate care (commission vs. omission).
‘Right time, right place, right reason and right provider’ has been used as a definition of appropriate, quality-based necessary care. Low-technology (and usually cost) interventions are not necessarily cost effective, and high-technology interventions are not necessarily cost ineffective. Applying the most appropriate, timely and needed clinical interventions for prevention, diagnosis, and treatment (‘do it right the first time’) is a critical key to the most cost-effective care. For example, the use of coronary artery bypass surgery instead of medication for patients with left main coronary artery disease results in a cost-effectiveness ratio of about $2300 to $5600 per year of life saved. At the other end of the spectrum, use of this surgery for other patients with less critical coronary artery disease does not deliver a savings or equivalent ‘bang for the buck’. Refer to Deyo, R. A.: Cost-effectiveness of primary care. J of the Am Board of Family Practice (13) #1:47-54, 2000 and other cost-effective care references in the References and Resources section near the end of this manual.
The proactive delivery of audited high quality preventive health care services will reduce costs for a given population or community of patients over time. A recent example relating to Merrill Lynch employees and retirees was published in the Wall Street Journal on May 23, 2000.
Preface - Volume II
This ‘single topic’ medical guideline and review criteria has been developed to provide a representative model for common, acceptable, customary, reasonable and necessary managed care contract benefit interpretations and objective evidence-based review for authorization (or denial) of services in the context of clinical information. Each guideline must be reviewed by the medical policy committee of the health plan or contracted/delegated medical group, modified and adapted as appropriate. It is strongly recommended that all applicable documents that will be used to manage medical care in the organization be sent to affected providers for review and comment prior to implementation. This will always promote an understanding of the guideline, avoid compliance issues, and frequently improve the document by additional input. Cost effective health care is quality driven (true quality, that is; not excessive care) and attention must always be focused on the issues that will result in optimal medical/surgical outcomes in a specific local medical environment.
Once adopted, all policies, procedures, guidelines, protocols, benefit interpretations, review criteria, pathways and the like should be reviewed at least every two years and preferably at annual intervals. In some cases, even more frequently, as clinically significant changes occur due to new technology, medications or practices entering the medical mainstream. The sources of the information in a guideline, whenever possible, should be included as a reference or footnote.
Use clear and unambiguous language in a stated policy or procedure. Avoid any implications of guaranteed clinical results or outcomes as a result of following a particular guideline. All policies, procedures, guidelines and similar criteria should be followed consistently, significant variations noted with justification, and be a written form available for dissemination.
When using this single topic publication, it should be noted that the policies/guidelines are all subject to contractual limitations and changes that occur periodically based on objective studies in the medical literature, recommendations by national bodies such as the AMA, ACP, HCFA and/or other objective sources of new information. The benefit determination should have been accomplished in an initial and prior step as a separate consideration prior to any review for authorization on the basis of medical necessity.
To assure an organized process for the compilation, approval and distribution of medical policy, procedures, guidelines and related information - all policies or guidelines proposed for use by any physician or medical organization should be submitted to the Medical Director or Vice President, Medical Services for a detailed review, circulation to others in the organization and specific approval prior to implementation.
A review of clinical information to make a benefit and/or medical necessity determination should not be confused with a ‘second opinion’. The reviewer has no actual or potential role in the care of the patient. The determination resulting from the review process relates only to payment (or non-payment) for services rendered.
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