To begin to answer this question, Congress has authorized a CMS-led post-acute-care payment reform demonstration project. As the CMS states, the project is designed to lead to a patient-focused post-acute-care delivery system.
This long overdue demonstration will involve a uniform assessment tool and quite possibly would result in a modified payment system. It involves assessing the outcomes of patients treated in long-term acute-care hospitals, inpatient rehabilitation facilities, skilled-nursing facilities and home health agencies.
We believe that if implemented appropriately, this project would help the CMS and the entire industry understand the importance of each care setting. If administered properly, the demonstration would recognize that each care setting serves a different role by treating different patient complexities and needs. However, there is a significant risk that, in the interest of reducing overall spending for post-acute-care services, the CMS would fail to collect the complex data required to differentiate why some patients are inappropriate for certain post-acute-care settings.
For example, some skilled-nursing facilities provide ventilator weaning as do many long-term acute-care hospitals. Would the lower costs generally experienced in the skilled-nursing facilities setting outweigh a hypothetical finding of superior results in the long-term acute-care hospitals? Would the system be sufficiently responsive to the clinical judgments of healthcare professionals?
Many providers are concerned that the CMS is merely trying to cut costs by creating a single payment method that would apply to all post-acute settings. While all parts of the Medicare program are being scrutinized for possible cutbacks, this demonstration project should not be viewed simply as an ax. It is very likely that it would result in payment changes based on more information on the case-mix severity of Medicare patients; it is unlikely that a single payment based on post-acute diagnosis alone is in the near future.
Yet the fact remains that the current post-acute-care delivery system involves too many assessment instruments and payment methodologies that are understood only by individuals and providers completely immersed in each care setting. This needless complexity hinders acute-care hospital systems from creating a global continuum of care involving multiple care settings.
The primary obstruction to a uniform patient delivery system is found in the assessment tools used to determine payments to post-acute-care providers. Three of the post-acute-care prospective payment systems rely on standardized data collected by providers using different assessment tools developed for multiple purposes, including assessment, quality improvement and payment. Currently, long-term acute-care hospitals are not required to use an assessment tool.
Since there is no uniform assessment instrument for the entire post-acute-care delivery system, all data is collected in different formats and are often incompatible.
Because there is little consistency between assessment instruments, it is very difficult to aggregate the data from all post-acute-care settings in a reliable format. Consequently, it is not possible to accurately compare quality of care received in each type of post-acute-care venue. Without this information, payment rates would continue to fluctuate, and the industry would not have the ability to justify its continued differentiation of significant components of the healthcare system.
To enable the industry to compare apples to apples, CMS has devised a multiphase approach to the demonstration. During phase I, which is already in progress, the CMS is developing and refining the Continuity Assessment Record and Evaluation, or CARE, tool. This would measure the health and functional status of Medicare acute discharges and the changes in severity and other outcomes for post-acute-care patients. Phase I also involves the creation of a cost and resource use, or CRU, tool, which would measure staff and ancillary resources associated with different types of patients. As it should, the CRU would identify fixed and variable costs associated with each post-acute-care setting.
If the CARE tool and the CRU tool are accurate and thorough, the overall results of the demonstration would likely confirm that certain post-acute-care settings provide better care to individual patients but at a cost that is unique to the setting. These better outcomes may come at an unsustainable price to the Medicare system.
Complex and critical questions about the future of post-acute care are being studied. In phase II of the demonstration, providers in 10 geographically different market areas would be selected to participate in the study. Though the CMS would not say how many providers are involved or where the test markets would be, it did say that the sample would be statistically significant. However, given the import of this study and the wide diversity of multiple factors in this industry, the selection of participant markets should be broadened and additional numbers of providers should participate in the project.
Inclusion of more willing providers in more markets would ensure that the results are viewed as meaningful so that the demonstration serves as the impetus to sustainable quality improvement in post-acute care.