Prior to the CMS' declaration in the fall, there was no guidance with respect to what it took to be considered "primarily engaged" or to count as an inpatient provider.
If smaller hospitals are not deemed to be primarily engaged in inpatient care, they may be prohibited from providing medical services or be paid at a lower rate for free-standing facilities, according to Brian Jent, an attorney at Hall, Render, Killian, Heath & Lyman.
He is pleased that there is finally guidance on the meaning of "primarily engaged," but concerned that some may not be able to meet the clarified standard, largely due to the shift to outpatient services. "As hospitals decrease the number of inpatient beds, maintaining an average daily census of two may become difficult in some areas," Jent said.
David Muhlestein, chief research officer at Leavitt Partners, agreed that these facilities' focus on outpatient care could have consequences. "This could lead to some of these facilities closing," Muhlestein said.
Officials from Emerus Holdings, the nation's first and largest operator of micro-hospitals, had mixed reactions to the new surveyor guidance. While they were happy that the CMS clarified the meaning of "primarily engaged in inpatient care," calling the guidance much needed and long awaited, they had concerns about the two-patient requirement. It's unclear if the same two patients have to be observed during the survey window.
"We believe the appropriate measure should be the number of inpatient admissions during the survey, rather than just at the moment a surveyor appears on site, as surveys typically takes two to three days," said Richard Bonnin, an Emerus spokesman. Emerus, which has more than 27 facilities nationwide, partners with local systems to build micro-hospitals. The company in October inked a joint venture with Allegheny Health Network, part of Highmark Health, to open at least four facilities in Western Pennsylvania.
Other concerns are that the guidance was released without a public comment period, is effective immediately, and has a 12-month look-back period for compliance when there was not any clear guidance on expectations. That could affect the validity of surveys already performed.
The better approach would be to have 12 months to comply with the new guidance, then apply a 12-month look back, Bonnin said.
