The CMS has issued guidance on processing claims from accountable care organizations that use a waiver to send Medicare patients to skilled-nursing facilities faster as a way to avoid costly hospital visits and provide tailored care.
But as the logistics surrounding the waiver raise concerns, the three-day mandate itself is being questioned.
Beginning in 2017, providers can ask to waive the required three-day hospital visit before Medicare payments kick in if they send patients to nursing homes that carry at least three stars on Medicare's five-star quality ratings.
The CMS' guidance outlines the technical claims process necessary for eligible providers to utilize the waiver.
There's concern that few if any ACOs will use the waiver since it's only available to those participating in track three, the riskiest of the three alternative payment options. Track three also has the greatest potential for reward—if providers in the ACO successfully reduce medical spending and improve quality. But they also face the greatest risk of being penalized under this model if they fail to do so.
Applications to either utilize the waiver or become a track three ACO and get the waiver are due July 29. So far there's been limited interest. Of the 433 Medicare ACOs, 95% were track one as of January 2016, according to the CMS.
“While this waiver is doing something good, how many patients is it really going to impact?” asked Kara Gainer, a senior research and policy analyst at the law firm Drinker Biddle.
The CMS' rationale for limiting use of the waiver is to see if it will dramatically drive up SNF use without lowering the overall cost of care of beneficiaries, according to Jeffery Spight, president of Collaborative Health Systems, which operates 24 Medicare ACOs.
The waiver could provide ACOs the flexibility to deliver care based on individual patient needs rather than Medicare eligibility criteria, said Josh Seidman, senior vice president at Avalere Health.
“As care improvements and efficiencies are gained—and as hospital average length of stay continues to decline—the relevance of the three-day rule as a clinical tool disappears,” said James Michel, senior director of Medicare reimbursement and policy at the American Health Care Association, a not-for-profit federation of state health organizations.
Michel hopes the three-day rule will be eliminated from the Medicare program altogether and that the CMS will use SNFs as a low-cost alternative to hospitals.
A potential downside of the waiver is that patients in track three ACOs may push providers to send patients to SNFs earlier than they should.
“If beneficiaries know there is a waiver, they or their families may pressure the physician to admit and discharge to SNF,” said Jackie Birmingham, a vice president of clinical leadership at Curaspan, a healthcare IT company that advises clients on care transitions for patients.
Medicare fee-for-service spending for SNFs was $28.6 billion in 2014, down from $31.3 billion in 2011 according to federal data. ACOs have also failed to earn savings bonuses. Only one out of four of roughly 200 ACOs earned a bonus. One owed Medicare $4 million.