Fee Reform, COVID-19 Could Derail a Unified Submit-Acute Care Fee System – House Well being Care Information


Now that the mud has settled on the Affected person-Pushed Groupings Mannequin (PDGM), some have returned their consideration towards the concept of one other main reimbursement overhaul: a unified post-acute cost system.

There had been mounting momentum behind a unified cost mannequin for post-acute care suppliers headed into 2020. The continued COVID-19 emergency has derailed plenty of that momentum, however conversations are beginning to decide up once more.

Typically, the post-acute care panorama consists of expert nursing amenities (SNFs), in-patient rehabilitation amenities (IRFs), long-term care hospitals (LTCHs) and, in fact, dwelling well being suppliers.

At present, these suppliers function below setting-specific Medicare reimbursement mechanisms, similar to PDGM within the dwelling well being care and the Affected person-Pushed Fee Mannequin (PDPM) within the SNF area. A unified mannequin would eradicate this separation, creating one cost system for all post-acute suppliers.

It’s an concept that was initially born out of the IMPACT Act, which was handed in 2014.

“The concept was to flatten cost throughout the 4 post-acute care settings,” David Grabowski, a well being care coverage professor at Harvard Medical College, advised House Well being Care Information. “Reasonably than paying totally different cost charges for 4 totally different units of providers, it was an concept that the Medicare program may degree the enjoying area and pay a standard charge for sufferers who could be discharged to any of these 4 settings.”

Along with his function at Harvard, Grabowski was appointed to the unbiased Coronavirus Commission on Safety and Quality in Nursing Homes.

A key profit of getting one post-acute reimbursement system can be having cost tied to a affected person’s situation somewhat than setting, in keeping with Grabowski.

“At present, we have now these distortions the place we have now people that most likely might be cared for in lower-intensity settings, [but they’re] sadly being discharged to institutional settings or going to an LTCH once they might be at a SNF, or getting discharged to a SNF once they might be at a house well being company,” he stated.

As envisioned by the IMPACT Act, there’s additionally a higher emphasis on outcomes as a driver of reimbursement below a unified post-acute cost system, Lisa Grabert, a analysis professor at Marquette and Georgetown universities, advised HHCN.

“It required that all the knowledge that’s reported to CMS throughout the 4 totally different settings be achieved in a constant method,” Grabert stated. “You may doubtlessly make comparisons throughout the settings.”

Making sense of an ‘anomaly of a yr’

Regardless of perceived advantages, there are a variety of potential difficulties in making a unified post-acute cost mannequin.

“Unifying cost additionally means unifying regulation,” Grabowski stated. “It additionally means unifying high quality measurement throughout the 4 settings, and it’s not clear to me that among the guidelines that we’ve had in place work very nicely.”

For instance, within the SNF world, the three-day rule requires a person to have been admitted to the hospital on an in-patient foundation no fewer than three consecutive days in an effort to qualify for fee-for-service reimbursement in a SNF.

Grabowski questioned how a rule similar to this one would persist below a brand new mannequin, particularly in relation to dwelling well being care, the place a lot of people are receiving providers with out prior hospitalization. He identified that exceptions must be made in an effort to proceed.

There may be additionally the COVID-19 emergency to think about.

In some methods, the general public well being emergency shifts post-acute care towards a common cost mannequin, in keeping with Grabowski and Grabert. In different methods, it pushes the phase additional away from it.

It’s essential to keep in mind that 2020 is an anomaly of a yr when it comes to the providers that the Medicare program has delivered within the 4 settings of post-acute care. It might be tough to make use of info gleaned from this yr because the baseline to type the brand new mannequin, in keeping with Grabert.

Moreover, the great cost reforms in each the house well being and SNF settings could additional contribute to those difficulties.

“These two components coupled on high of one another imply that it’s actually tough to determine what had been new modifications and phenomenons of the brand new cost system, versus simply modifications and phenomena related to the pandemic,” Grabert stated. “These two stacked on high of one another could imply that it will likely be a number of years earlier than CMS can determine if they’ve correct sufficient knowledge to maneuver to that unified cost system.”

Help for a unified mannequin

However, the highlight that has been positioned on nursing houses all through the general public well being emergency could play a job in pushing a unified post-acute cost mannequin.

Initially of the month, the Medicare Fee Advisory Fee (MedPAC) had its first assembly of the yr and launched new knowledge that exposed 80% of COVID-19 deaths are within the Medicare inhabitants, and over 40% of deaths are amongst residents of nursing houses and assisted dwelling amenities.

Many policymakers, along with the media, have zeroed within the nursing dwelling area due to this. The general public notion of the nursing dwelling trade, on account of the general public well being emergency, could also be robust sufficient to present CMS the political cowl it wants to make use of its unified cost authority to implement a giant coverage change for nursing houses with none legislative boundaries, in keeping with Grabert.

“On condition that expert nursing amenities make up almost half of the general annual spend within the Medicare post-acute baseline, policymakers could also be tempted to make the most of the unified [post-acute care] mannequin as a coverage instrument to deal with SNF, and presumably broader, reform,” she stated. “Although truly implementing unified cost might have further Congressional motion, the mechanics to really develop cost reform and launch an in depth plan want no additional Congressional motion — an amazing quantity of authority already exists inside the govt department.”

If the Trump administration is reelected, it’s possible officers will likely be taking a look at looming fiscal pressures. The idea of a unified cost system has been on its radar up to now as a cost-savings instrument

In February, the Trump administration launched its proposed budget for the fiscal yr 2021, which projected {that a} unified post-acute care cost mannequin would save $101.5 billion from 2021 to 2030.

Even when a brand new administration is elected, this might nonetheless stay an element.

“If the Biden administration comes into energy, they might be trying once more at this post-acute care area and the concept of unified funds as a [way] to get some financial savings out of the Medicare program,” Grabert stated.

As of now, CMS has solely affirmed its intentions of following the Congressional mandate, in keeping with Grabert.

“There’s nothing actually vital, I might say, popping out of CMS on this subject, apart from the truth that they take the present Congressional mandate of arising with this unified prototype critically, and so they plan on issuing a report back to Congress on time, as is required below present regulation of the IMPACT Act,” she stated.

Congress has additionally begun to posture that it will just like the company to do some oversight and report back to them on how the implementation has been going and presumably gradual issues down on the timeline.

“The proof of that may be a current letter that got here out from [Senators Pat Toomey (R-Pa.) and Michael Bennet (D-Colo.)] to CMS on the IMPACT Act timeline,” Grabert stated. “There’s this Senate letter requesting some oversight of how CMS has applied the underlying regulation, and definitely recommend {that a} delay ought to be thought of right now as a result of pandemic and complete dwelling well being and SNF cost reform.”