The OIG, in Advisory Opinion 19-03 issued on March 1, 2019, found it acceptable for a medical center to provide follow-up care in patients’ homes at no charge for individuals with congestive heart failure and chronic obstructive pulmonary disease who are considered to be at high risk of readmission to the medical center (the “Program”). Specifically, the OIG determined it would not impose sanctions based on the Program under the civil monetary penalty provision prohibiting inducements to beneficiaries.
The medical center established criteria for eligibility for the Program, including (i) a specific diagnosis, (ii) current inpatient or readmitted inpatient status, (iii) a determination of high risk of readmission based on a risk assessment tool recognized in the health care industry to predict unplanned readmissions or emergency room visits, (iv) a decision by the patient to obtain follow-up services from the medical center, (v) the patient’s choice to enroll in the Program, and (vi) the patient residing in the service area in a home or assisted living facility.
The Program consists of in-home follow-up care by a community paramedic with two visits per week, with each visit lasting approximately 60 minutes. The visits could include services, such as monitoring vitals, reviewing medication, monitoring compliance with the discharge plan and performing a home safety inspection. The paramedic will also evaluate the need for the patient to have follow-up appointments.
The medical center certified that it would not bill the patient or any government program for the services provided through the Program.
The OIG concluded that the complimentary services were remuneration to the patients who received the services and that the remuneration could influence a patient to seek additional care from the medical center. The OIG further concluded that the complimentary care did not fall within the CMP exception for “promoting access to care” because not all of the services provided by the paramedic improve access to care (e.g., the home safety inspection).
Despite the fact that the Program did not fall within a CMP exception, the OIG determined that it would not impose sanctions for the following stated reasons:
- The benefits to the Program outweigh the risk that the Program will inappropriately influence the patient to choose the medical center for future care—because only those patients who have selected the medical center are eligible for the Program;
- The patient has freedom of choice for selecting a provider for other services;
- The fact that the paramedic may suggest that a patient contact the medical center if additional care is needed furthers care management and integrated care, all of which are important for patients with chronic diseases;
- The Program is unlikely to increase costs to a federal health care program through overutilization or inappropriate utilization—any increase in utilization results from the patient seeking appropriate care;
- The Program is not advertised to the public;
- The medical center is not seeking reimbursement from the patient or a federal program for services provided under the Program;
- The Program could result in savings to federal programs if the Program is successful in improving patient health and reducing hospital admissions;
- The risk that the Program will interfere with clinical decision making is low; and
- The scope and duration of the Program appears designed to achieve the goals of improving patient compliance with discharge planning, improving patient health and reducing patient admissions.
The OIG emphasized three reasons for its decision to okay the arrangement. The OIG concluded that the Program would (a) likely help the medical center achieve its laudable goal to reduce readmissions and improve patient health; (b) not negatively impact the patient’s freedom to select his or her provider, and (c) not result in increased costs to any federal health care program. The Opinion also suggests that it was critical to the OIG that the patients had chronic diseases making them at high risk for readmission.