CMS and MedPAC Guidelines and Trends

Analysis: Making smarter decisions about where to recover after hospitalization | HTML

May 15, 2019 6:09 pm

Kaiser Health News is reporting, “Every year, nearly 2 million people on Medicare — most of them older adults — go to a skilled nursing facility to recover after a hospitalization. But choosing the facility can be daunting, according to an emerging body of research. Typically, a nurse or a social worker hands out a list of facilities a day or two — sometimes hours — before a patient is due to leave. The list generally lacks such essential information as the services offered or how the facilities perform on various measures of care quality.

Families scramble to make calls and, if they can find the time, visit a few places. Usually they’re not sure what the plan of care is (what will recovery entail? how long will that take?) or what to expect (will nurses and doctors be readily available? how much therapy will there be?). If asked for a recommendation, hospital staffers typically refuse, citing government regulations that prohibit hospitals from steering patients to particular facilities and that guarantee patients free choice of medical providers. (This is true only for older adults with traditional Medicare; private Medicare Advantage plans can direct members to providers in their networks.) According to a 2018 report from the Medicare Payment Advisory Commission (MedPAC), nearly 84% of Medicare beneficiaries who go to a skilled nursing facility (SNF) after a hospital stay could have selected a higher-rated provider within a 15-mile radius. Where older adults go is important ‘because the quality of care varies widely among providers,’ MedPAC’s report notes, and this affects how fully people recover from surgeries or illnesses, whether they experience complications such as infections or medication mix-ups, and whether they end up going home or to a nursing home for long-term care, among other factors.” 


Managing the transition from acute to post-acute is probably one of the greatest opportunities to improve clinical outcomes, the patient/caregiver experience of care and reduce the total cost of care. And the article is correct, to a certain extent, that the Medicare fee-for-service regs pose a significant, real (and imagined) barrier. Participants in Medicare ACOs and bundled payment models can, and many successful ones do, help their patients select a high-value PAC provider by giving them a rank order list (based on quality and cost metrics) of their options (providers have to make all the options available). In instances where the participating provider has partnered with the PAC provider that can be indicated too. The high-value PAC partners are at the top of the front of the list. The low-value providers are at the bottom of the last page. However, given the complexity of the regs and the potential penalties if one were to get this wrong, it’s not uncommon to encounter organizations participating in qualifying APMs that do use this best practice due to compliance concerns. CMS this week released a care coordination toolkit that provides an example dashboard, which will hopefully allay any remaining concern that providers participating in APMs might have about helping patients select high-value PAC providers who can best meet their needs. Providers who are not participating in a qualifying APM, for the moment, don’t have the same flexibility. However, that will likely change later this yearwhen CMS finalizes its long overdue rule (first proposed in 2015, HFMA summary here) related to the discharge planning requirements in Medicare’s Conditions of Participation. HFMA is running a two-part article profiling the practices of several health systems that have developed a process to ensure that patients are discharged to the correct PAC setting and, when patients need an institutional PAC provider, to help discharge them to a high-value partner.


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