Room for Improvement in Hospital Maternity Care

Rates of early induction of labor have declined in U.S. acute care and pediatric hospitals, but rates of episiotomies  remain unacceptably high in many hospitals, according to a 2014 survey released by the Leapfrog Group and developed by Castlight Health.  The survey results also reflected little change in the number of hospitals meeting Leapfrog’s standards for high-risk deliveries since 2013.  The American Congress of Obstetricians and Gynecologists (ACOG) has long advised limiting both elective inductions prior to 39 weeks’ gestation and the use of episiotomies.  Leapfrog has made suggestions for improvement to hospitals, and existing CMS programs seem to support the advice as far  as inductions are concerned.

Elective Inductions

Definitions of “full term” range from 39 weeks’ gestation to 40 weeks and six days.  However, according to Leapfrog, rates of elective inductions, those with no medical basis, prior to 39 weeks, increased from 9.5 percent in 1990 to 32.9 percent in 2009.  Providers and patients may choose early inductions for nonmedical reasons le convenience, perceived liability, or relief of pregnancy symptoms.  However, infants born at 36 to 38 weeks are more likely than full-term infants to have lung problems and other medical issues, often requiring treatment in the neonatal intensive care unit (NICU).  Long-term effects on academic achievement resulting from preterm birth may also be seen.  Mothers whose labor is induced are more likely to undergo cesarean sections (C-sections) than women who are not induced, and they may be at higher risk of other postpartum complications.  In addition, Leapfrog cited a study finding that the early deliveries cost up to 17.4 percent more than full term early deliveries.  If early term delivery were reduced to 1.7 percent, the report suggests, the U.S. could  save $1 billion annually, much of which results from a reduction in days spent in the NICU.

Leapfrog has defined its standard for early elective deliveries as a rate of scheduled C-sections or inductions before 39 weeks no greater than 5 percent.  In 2010, only 30 percent of hospitals responding to the survey met the standard.  The rate increased  over time, to 71 percent in 2013 and 78 percent in 2014.  The numbers are positive; however, significant variation exists among hospitals, with 17 hospitals reporting early elective delivery rates of 30 percent or more.

Recognizing the dangers of elective inductions, and perhaps the financial costs associated with them, CMS launched  the Strong Start for Mothers and Newborns initiative in  2012, which promotes awareness, spreads best practices, and promotes transparency.  In an August 2012 final rule, CMS added a measure to the Inpatient Quality Reporting (IQR) Program that is effective for fiscal year (FY) 2015: Elective delivery prior to 39 completed weeks of gestation, which will link quality of care with payment.  In December 2013, the agency updated its Hospital Compare website to include voluntary reports of the measure. CMS also created the Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid and CHIP to explore opportunities that could not only result in better care and outcomes, but reduce the cost of care for mothers and infants enrolled in Medicaid and the Children’s Health Insurance Program. The recommendations, in part, led to the creation of the Maternal and Infant Health Initiative.

Episiotomies

Episiotomies are incisions made in the perineum–the area between the vagina and the anus–during childbirth.  The procedure was formerly a routine part of childbirth intended to prevent worse tears of the perineum.  However, they have been linked to worse tears, bladder and fecal incontinence, pelvic floor defects, and painful recoveries.  The Mayo Clinic notes that episiotomies may be warranted in certain cases, such as when a physician anticipates “extensive vaginal tearing,” the baby is an abnormal position, or the baby needs to be delivered quickly. Leapfrog’s standard rate for episiotomies is less than or equal to 12 percent. Sixty-five percent of reporting hospitals achieved the standard in 2014 and the national average was 11.3 percent, down less than two percentage points from 2012. However, dramatic variations were seen.  Twenty-five hospitals reported rates of less than or equal to 1 percent, but 12 reported rates of 40 percent or greater. To further encourage a decrease in episiotomies, Leapfrog plans to lower its standard from less than or equal to 12 percent to less than or equal to 5 percent; only 27 percent of hospitals reporting in the 2014 survey would meet that standard.

High-Risk Deliveries

Infants who weigh less than 3 pounds, 4.91 ounces should be cared for in a NICU.  They have a higher likelihood of survival and better prognoses when they are born at hospitals with experienced, on-site NICUs. Leapfrog deems hospitals to meet standards for high-risk deliveries if they ensure that at least 80 percent of mothers receive antenatal steroids prior to delivery, which can reduce the incidence and severity of respiratory distress syndrome (RDS) in infants, as other well as other issues, including mortality; and either (1) deliver at least 50 “very low” birth weight babies each year or (2) maintain a lower than average morbidity/mortality rate for very low birth weight babies. In 2014, 24.4 percent of reporting hospitals met this standard, which is only an increase of 0.4 percent since 2013, although some hospitals are making “substantial progress.”  Hospitals in 24 states reported on this standard.  Strikingly, no hospitals in Georgia, Missouri, or South Carolina met Leapfrog’s high-risk delivery standard; only 4 percent of hospitals  reporting from New York met the standard.

Looking Forward

While the survey results reflect improvement, there is clearly room for improvement.  In addition, variations among suggest that standards are not being consistently achieved across hospitals.  Leapfrog will continue to assess hospitals’ compliance with its maternity standards and report again in 2016.

Kusserow on Compliance: Recovery Audit Program Update

On virtually the last day of 2014, CMS announced new recovery audit contracts and changes to the Recovery Audit Program. It awarded the Region 5 Recovery Audit contract to Connolly, LLC, for identification and correction of improper payments related to durable medical equipment, prosthetics, orthotics and supplies (DMEPOS); and home health and hospice claims submitted to CMS (national contract). However, CMS has suspended work under the contract due to a post-award protest filed with the Government Accountability Office (GAO). New Recovery Auditor contracts for Regions 1, 2, and 4 remain under “a pre-award protest,” which is expected to continue into the summer. Additionally, the procurement process will continue for Region 3.

The changes to the Recovery Audit Program include improvements to reduce provider burden and increase transparency in the program. The changes will be effective with each new contract award and include, but are not limited to:

  1. The look-back period for patient status reviews is restricted to six months after the date of service, if the hospital has submitted its claim within three months of the date of service;
  2. Additional documentation requests (ADR) limits will correspond with providers’ compliance with Medicare rules; providers with lower denial rates will have lower ADR limits and providers with higher denial rates will have higher ADR limits;
  3. ADR limits will be diversified across all claim types of a facility (i.e., inpatient, outpatient) to ensure that a provider with multiple claim types is not disproportionately affected by a recovery audit review in one claim type;
  4. Recovery Auditors will not receive a contingency fee until after the second level of appeal is exhausted;
  5. Recovery Auditors must wait 30 days to allow for a discussion request before sending the claim to the Medicare Administrative Contractor for adjustment; and
  6. Recovery Auditors will be required to maintain an overturn rate of less than 10 percent at the first level of appeal, or be subject to a corrective action plan.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

“Biggest Loser” and Similar Employer Wellness Programs Harm More Than Help

Employer wellness programs targeting employees’ weight control have resulted in no demonstrated positive effect, according to a paper published in the American Journal of Managed Care. Even with the use of financial incentives and penalties, the paper noted that there is no published evidence of savings resulting from long-term weight loss, nor a reduction in inpatient admissions associated with obesity and suggested that employers should abandon their weight control programs.

The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) has spurred an influx of wellness programs in larger organizations, as the health reform law gives corporations the opportunity to make up to 30 percent of health insurance premiums dependent on participation in a corporate wellness program and/or on achievement of positive health outcomes. The paper notes that smoking and overweight status are the most common targets of corporate wellness programs.

Lack of results

Despite the expected correlation between obesity reduction savings and wellness savings, corporations have with wellness programs are not reaping any benefits. No studies of such programs have documented savings, according to the paper in one case, even in one particular case that experienced a significant reduction in hospital admissions for reasons such as heart attacks. In addition to a lack of financial results, companies with wellness programs also saw a lack of results in weight loss itself. The paper highlighted that the only major population cohort that showed a reduction in obesity was young children. Comparatively, Medicare and Medicaid populations, who often do not have access to wellness programs, are benefitting from declines in wellness-sensitive medical events requiring hospitalization.

More harmful than helpful results

The paper stresses that corporate wellness programs for weight loss should be discontinued, as these and other programs harm morale and corporate culture through surveys, weigh-ins, and screens, which tend to encourage “employee revolts.” Obesity programs also cause health hazards due to overdiagnosis and overtreatment, and “biggest loser” contests can humiliate employees and spur unhealthy crash dieting. As an alternative to wellness programs such as these, the paper suggests that employers subsidize healthy food options in workplace cafeterias, reimburse fitness memberships, and allow extra breaks for exercise.

With 5 State Proposals Approved, What is the Future of Medicaid Waivers?

While 29 states plus the District of Columbia have chosen to expand Medicaid under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), five other states have proposed and been approved for Medicaid waivers. A Kaiser Family Foundation (KFF) Issue Brief explained that these waiver programs have been implemented in these states as they are seen as a “politically viable way to implement expansion in order to expand coverage and capture federal dollars.” As such, many other states are considering and have proposed demonstration projects in the form of Medicaid waiver programs.

Section 1115 Waivers

Under section 1115 of the ACA, states may choose to expand Medicaid coverage without following the expansion spelled out in the ACA, yet still receive funding available under the ACA through the creation and administration of a demonstration project. These waivers must be approved by CMS and, thus far, five states have submitted waivers that have been approved by the agency—Arkansas, Iowa, Michigan, Pennsylvania, and Indiana. These states have been allowed to administer a more flexible version of Medicaid expansion while still receiving 100 percent of the funding for the program from those found to be eligible between 2014 through 2016 and 90 percent of the costs of the program starting in 2020.

The KFF brief describes the shared features of the alternative Medicaid expansion models in the five states this way: “While the waivers are each unique, they include some common provisions such as implementing the Medicaid expansion through a premium assistance model, charging premiums, eliminating certain required benefits (most notably non-emergency medical transportation), and healthy behavior incentives.”

Indiana

The KFF Brief highlighted the most recently approved waiver in Indiana due to its unique characteristics (see Amendment of Healthy Indiana Plan implements Medicaid expansion, February, 11, 2015). The provisions that are present in the Indiana waiver that were not included in other waivers include: (1) no retroactive eligibility; (2) effective dates of coverage beginning on the date of the first premium payment (rather than the application date); and (3) a bar on enrollment for adults re-enrolling in coverage for a time period of six months if that individual is dis-enrolled for unpaid premiums. Indiana also is allowed to charge higher cost-sharing rates for non-emergency use of the emergency room under a separate waiver pursuant to section 1916(f) of the ACA.

The Future of Waivers

In addition to approved waivers in the five states, KFF noted that many states have waiver proposals in the works. Most notably, both Tennessee and Utah have engaged in negotiations with CMS for waiver approval, yet these proposals also will need to be approved by the respective state legislatures. In February of 2015, the Wyoming alternative model, called SHARE, was rejected in the state Senate (see Wyoming legislature leaves ‘working poor without coverage,’ February 11, 2015). In New Hampshire, a state which already expanded Medicaid under the ACA, a waiver with CMS based on a premium assistance model is also pending. For those waivers that CMS has denied, KFF states the following as reasons for the denials: (1) conditional work requirements; (2) premiums for individuals that have incomes less than 100 percent of the federal poverty line; and (3) requirements to provide certain wrap-around benefits to the extent that the Health Insurance Marketplace does not offer such coverage.

KFF concludes its Brief by considering the future of other waivers, such as those that will be made available to states under section 1322. In 2017, explains KFF, states will be allowed to apply for waiver of Marketplace coverage provisions and to combine those with Medicaid expansion waivers.