Mental Health Integration is a Priority for the Rhode Island Legislature

Finding ways to bring more behavioral health services to more residents of Rhode Island is high on the agenda for consideration this year in the Rhode Island Legislature.  The Health and Human Services Committee of the Rhode Island Senate considered a number of bills recommended by the Special Joint Legislative Commission to Study the Integration of Primary Care and Behavioral Health on Tuesday March 25, 2014.  The Commission was created by an Act of the legislature in 2013 and submitted its report in March of 2014.


The Special Joint Commission was empowered to examine “the current behavioral health and primary care system in the Ocean State, and with identifying opportunities to further integrate clinical and payment reform and examine the feasibility of establishing a primary care trust.”   Behavioral health services includes treatments for  mental health conditions, substance abuse, and health-related behaviors. The Special Joint Commission found that (1) additional training of primary care practitioners and behavioral health practitioners is needed to complete integration of the two health care systems, (2) opportunities for collaboration between theses types of providers needs to be embedded in their systems, (3) a strong financing component is needed to achieve success, (4) parity of insurance coverage needs to be achieved in Rhode Island, and (5) better data on behavioral health disorders needs to be collected in Rhode Island.

The Special Joint Commission found that one in five Rhode Island children ages 6 to 17 has a diagnosable mental health or addictive disorder, while one in 10 has a significant functional impairment, and that these kids are not receiving treatment through the schools, communities or clinical settings despite showing symptoms or “action signs.” In addition the Special Joint Commission pointed to an Institute of Medicine report which found that the number of adults over 65 with mental illness is expected to double by the year 2030. Compounding that fact is the rate of growth of this segment of the population over that time period will result in 25 percent of Rhode Island’s residents being 65 or older.   The Special Joint Commission underscored the need for integration, as Rhode Island has the highest rate of adults with serious mental illness at more than 7 percent of the population, which far exceeds the national average of 4.6 percent.


The legislators who were members of this Special Joint Commission introduced a package of bills to address these findings. Primary among them is the Behavioral  Health Reform Act of 2014. This  bill would require behavioral health screenings to be conducted by primary care physicians during primary care exams given to anyone under 21. The screening shall be for psychiatric, psychological, interpersonal, or any other condition.   The Rhode Island Department of Health is to certify appropriate screenings and establish a fee structure for these screenings.  In addition the screenings will be mandated to be covered by  all health insurance providers.

A second bill in the package would require insurers to make a decision on whether to authorize emergency inpatient or residential treatment for mental, emotional, or substance abuse within two hours of receipt of all the necessary paper work having been submitted.  A third bill in the package amends the existing mental health parity law to ensure that substance abuse and other behavioral health issues are covered like other mental health conditions.  All of the bills await further action by the committee.

Integration of care, where behavioral health care providers work within and as part of a primary care team, was the best method of care delivery, the Special Joint Committee found.  Other coordinated care concepts, such as having primary and behavioral health care providers at separate facilities, were found not to be as effective, according to the Special Joint Commission. The lack of appropriate billing codes was found to be a barrier to obtaining behavioral health services, as were wide variations in co-pays and prior authorization requirements for behavioral health services, said the Special Joint Commission.

“We must strive to embrace the cooperative care model of practice, where there is no ‘wrong door’ for full access to comprehensive care,” said Senator Joshua Miller, Co-Chair of the Special Joint Commission. “If a patient enters through an emergency room, doctor’s office, or a clinic the patient should be connected to  health services that include a full range of needed behavioral treatment approaches,” continued Miller.  The Rhode Island Legislature is in session until July and action on all of these proposals is expected before adjournment.

Efforts to Reduce HAIs Meeting with Success

Progress is being made in reducing the number of health care-associated infections (HAIs) according to two reports released by the Center for Disease Control (CDC). An HAI is an infection a person receives while they are in the hospital, in another facility, or under the care of a provider while they are being treated for another condition. Reducing HAIs is a top priority for HHS. In 2009, HHS adopted the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination and since that time CDC has been reporting on the progress towards meeting those goals.

Progress in General

Based on the most recent data, the CDC reports that one in 25 patients have contracted at least one infection during the course of their hospital stay. In 2011, there were approximately 722,000 according to a report in the New England Journal of Medicine. That number is extrapolated from reported HAIs in 183 hospitals. This number is down from the estimated 1.7 million HAIs estimated in a 2007 report. The report also estimated that about 75,000 people died as a result of their health care-associated infection during 2011. “Although there has been some progress, today and every day, more than 200 Americans with health care-associated infections will die during their hospital stay,” said CDC Director Tom Frieden, M.D., MPH in a statement on the two reports.

The most common HAIs were pneumonia and surgical site infections which each accounted for 22 percent of all HAIs. Urinary tract infections accounted for 13 percent of the HAIs and blood infections accounted for 10 percent of HAIs. The most common germs causing HAIs were C.difficile responsible for 12 percent of HAI infections, Staphylococcus aureus, including MRSA which accounted for 11 percent of HAI infections. Klebsiella and E. coli accounted for 10 and 9 percent respectively of HAI infections.

Patients most likely to acquire an HAI were older, had been in the hospital longer at the time of surgery, were in a larger hospital, had a central line catheter in place, were on a ventilator, or were in critical care, according to the report. Device–associated infections, which have been a major focus of infection prevention in recent decades, accounted for only 25.6 percent of all HAIs. Infections not associated with devices or operations accounted for approximately half of all HAIs.

“Our nation is making progress in preventing healthcare-associated infections through three main mechanisms: financial incentives to improve quality, performance measures and public reporting to improve transparency, and the spreading and scaling of effective interventions,” said Patrick Conway M.D. who is CMS’ Deputy Administrator and CMS’ chief medical officer.  A provision so of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) will impose a 1 percent reduction in payment for the hospitals that are in the top 35 percent of HAIs beginning on October 1, 2015.

Specific Co3nditions

In a second report the CDC said that significant progress has been made in the reduction in a number of HAIs associated with specific procedures. Central line-associated bloodstream infections saw a 44 percent reduction from 2008. Surgical site infections dropped by 20 percent during the same time period for 10 procedures tracked during that time with the most significant reductions in HAIs being associated with cardiac surgeries. There were only small drops of four percent and two percent for hospital-onset MRSA and hospital-onset C. difficle infections respectively. “The most advanced medical care won’t work if clinicians don’t prevent infection through basic things such as regular hand hygiene,” said Frieden.

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Readmission Rates from Post-Acute Care Facilities Similar to Hospitals

The last couple of years have seen lots of attention on the readmission rate of Medicare beneficiaries following a stay in a hospital.  But what about readmission rates from post-acute facilities?  Two recent studies have found that the readmission rate for residents of skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) is about the same as it is for  hospitals.  To reduce the rates of readmission, and hopefully improve care, the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) implemented payment reductions for hospitals that do not meet specific readmission rate targets, and will use hospital readmission rates for IRFs as a national quality indicator.

Readmissions After  SNF Discharges

The readmission rate of SNF residents in North and South Carolina was about 22 percent, according to a recent study reported in the Journal of the American Geriatrics Society.  The study found that “within 30 days of SNF discharge to home 10.3% (5,771 unique participants) had ED visits without hospitalization and 14.7 % (8,303 additional unique participants) were rehospitalized.”  During the period from  January 1, 2010 to August 31, 2011, 12, 349 visits were made to hospitals by SNF residents within 30 days of being discharged from a SNF; this number is slightly higher than the unique participant number because some residents had more than one hospital visit during the 30 days following discharge from the SNF.

The majority of hospital visits happened very soon after discharge from the SNF. The study found that 12 percent of SNF residents had a visit to a hospital’s emergency department or were rehospitalized within 10 days of  being discharged.  On an upbeat note, only 4,538  of the 55,980 Medicare beneficiaries studied  or 8.1 percent died within 90 days of being discharged from a SNF.

Residents of IRFs had a readmission rate of 18.8 percent during the 30 days following discharge, according to a second study reported in the Journal of the American Medical Association.   The study examined 736,536 Medicare beneficiaries who were discharged from 1,365 IRFs between 2006 and 2011.  Mirroring the finding of the SNF study, most readmission following discharge from an IRF happened soon after discharge. “Approximately 50 percent of patients hospitalized within the 30-day period were readmitted within 11 days of discharge,” the study found.

Readmissions After Hospital Discharge

The readmission rate to hospitals within 30 days of discharge has been in the 18 to 19 percent range since 2007.  The Kaiser Family Foundation reports that during the first 8 months of 2013 the hospital readmission rate fell below 18 percent.  In 2012, the readmission rate was 18.5 percent and from 2007 to 2011 it had been 19 percent each year.

The Hospital Readmission Reduction Program (HRRP) began assessing reductions in payments to hospitals that did not achieve their readmission goal beginning with payments for calendar year 2013.  In the first year of the program 2,213 hospitals were fined for not meeting their readmission rate goals.  In the second year of the program 2,225 hospitals were penalized for not meeting their goals.  Penalties in the first year could have been as high as 1 percent  and a 2 percent reduction was applied during the second year.  A reduction as much as 3 percent  could  apply during the third year of the program.  Only a small number of hospitals are receiving the full reduction. Of the 2,225  hospitals receiving a reduction in 2014, only 18 are received the full 2 percent reduction and another 154 will be receiving a 1 percent reduction. The majority of hospitals that are receiving a reduction in 2014 will be receiving a reduction of less than 1 percent. Kaiser said that the total reduction will result in a loss of $227 million to all hospitals in 2014.

CMS has stated that rehospitalization can be a sign of low-quality care and it has been taking action with hospitals to help drive down the rate of readmissions to a hospital.  These studies show that the post-acute care settings of SNFs and IRFs have a  readmission rate similar to hospitals, which might lead one to wonder if similar carrot and stick incentives will be applied to these facilities to drive down the rates of readmission to a hospital following discharge.


Congressmen Urge Sebelius to Fix RAC Backlog

In a letter to HHS Secretary Kathleen Sebelius, 111 congressmen urged HHS to deploy additional resources to resolve the backlog of appeals of overpayments determined by Recovery Audit Contractors (RACs), to implement reforms in the RAC process, and consider alternative payment methods used to reimburse RACs. The number of appeals of RAC overpayment determinations has ballooned to such a degree that it is overwhelming the entire Medicare appeals process. In addition, this large number of appeals is resulting in a significant amount of money being paid to hospitals as reimbursement for Medicare services that are in dispute. Medicare beneficiaries are also feeling the impact, as they are often required to pay higher out-of-pocket costs for Part B services and sometimes held financially responsible for post-acute care services, according to the congressmen’s letter.

RAC Program

The RAC program was approved by Congress in the Tax Relief and Health Care Act of 2006 (P.L. 109-432). This act expanded the RAC demonstration project approved in the Medicare Modernization Act of 2003 (MMA) (P.L. 108-173) to the entire country. RACs are permitted to look back at claims that are as much as three years old and apply the same Medicare policies and rules to identify improper payments as do Medicare administrative contractors that process claims for payments. If an overpayment is identified the overpayment is recouped and the RAC retains a portion of the amount recouped as its fee. The commission amount ranges from 9 to 12 percent of the amount recouped.

Appeals Backlog

Hospitals and other providers can appeal a RAC determination that an overpayment has been made. One step in the process is to request a hearing before an administrative law judge (ALJ) appealing the overpayment determination. In a memo from Nancy Griswold, the Chief Administrative Law Judge for HHS’ Office of Medicare Hearings and Appeals (OMHA) it was stated that there was a back-log of 375,000 requests for a hearing before an ALJ. Ms. Griswold stated that “in just under two years, the OMHA backlog has grown from pending appeals involving 92,000 claims for services and entitlements to appeals involving over 460,000 claims for services and entitlements.”  She went on to state that in one week her office received 15,000 requests for an appeal hearing before an ALJ.

This large number of appeals may in part be due to the fact that 70 percent of hospital appeals of Part A claims that are heard before an ALJ are overturned in favor of the hospital, according to report from the American Hospital Association (AHA). In a letter to CMS Administrator Marilyn Tavenner, the AHA claimed that $1.5 billion worth of claims are currently being appealed and a significant amount of that money would be returned to hospitals based on the success of appeals.

AHA Recommendations

In its letter the AHA recommended that: (1) CMS should not hold funds at issue in hospital disputes until the ALJ determination; (2) statutory deadlines for appeals should be enforced through the utilization of automatic default judgments; (3) CMS should address systemic issues within RACs, which lead to erroneous denials; (4) additional documentation request limits should be lowered, which would in turn decrease the number of claims reviewed; and (5) RAC deadlines should be enforced by a waiver of RAC contingency fees in any cases where a RAC misses a deadline to make a decision.