As healthcare providers and analysts continue to digest more than 1,400 pages of the CMS' recent inpatient prospective payment proposed rule, they are analyzing how the agency would implement a new payment methodology for Medicare disproportionate-share hospital (DSH) payments next year.
The 2010 Patient Protection and Affordable Care Act decreases Medicaid and Medicare DSH payments—which community and safety net hospitals use to provide uncompensated care—starting in 2014, based on the belief that the law's coverage expansions will lower the number of uninsured and underinsured Americans.
Starting next year, the law lowers the base Medicare DSH payment to 25% of current levels. Disproportionate share hospitals will then receive the remaining amount of what would have been paid—about 75%—after the amount is reduced to reflect changes in the percentage of people who are uninsured. The CMS expects the changes to reduce payments by 0.9% compared with current payments.
Xiaoyi Huang, assistant vice president for policy at the National Association of Public Hospitals and Health Systems,said the organization's early read of the draft rule has the association frustrated that the CMS will use inpatient days for Medicaid and low-income Medicare patients as a proxy for uncompensated care, one of three factors in a complex formula the CMS will use to calculate the payments.
“The proxy CMS uses does not account for uninsured, period,” Huang said. The method also does not take into account that a lot of hospital care is delivered in outpatient settings. The NAPH plans to issue a report this month highlighting the effects the DSH payment changes would have on hospitals, Huang said.
The American Hospital Association is also studying the DSH provision and has created a working group led by Teri Fontenot, CEO of Woman's Hospital in Baton Rouge, La.
Erik Johnson, senior vice president at consulting firm Avalere Health, said hospitals could have fared worse in the proposed rule.
Another factor of the proposed DSH calculation calls for a 2 percentage point decline in the rate of uninsured, Johnson said, which is half what some in the industry had expected based on estimates from the Congressional Budget Office.
“On DSH, I have the sense they are being a little more cautious and not introducing a lot of radical things into the IPPS right now,” Johnson said. “They want to reserve the right to iterate how the DSH payment will get paid in future years.”