A big push from the House of Representatives to present the first possible permanent fix to the Sustainable Growth Formula and avoid a 21 percent reduction in payment to the Physician Fee Scheduled as early as April 1, 2015, came to a grinding halt when S. 810 was left to discuss after the Senate's spring break. Having all possibilities covered, CMS acted early and released a statement on what they were prepared to do should a final vote not be completed in time.
Mediware Rehabilitation Blog
In the absence of obvious issues that require immediate redress, where does the nurse leader go with the data? How should the nurse leader prioritize? Using the acronym ‘Peter Says Lion Eats Snails’ (PSLES), the nurse leader can look for areas of prioritization. As the reader may recall, this is the same acronym used to memorize Maslow’s hierarchy of needs. In this case the concept is the same, we move from lowest priority to highest, but the words are different.
The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105–33) to advise the U.S. Congress on issues affecting the Medicare program. MedPAC publishes and shares their recommendations with Congress each March and June in hopes that the 17 member commission imparts wisdom to guide regulatory process and change. There is no better time than NOW for inpatient rehabilitation hospitals and hospital units to refute MedPAC's continued insistence that resources and care are equal between an IRF level of care and SNF level of care. If this were true, long ago specialty management and concentrated rehabilitation programs with a 24/7 emphasis on nursing, medical management and therapy interdisciplinary care would not have been supported at a hospital level of care.
If we are not careful in demonstrating the differences, a commission like MedPAC, who has informed congress that care is the SAME and should be paid the same, will support a notion that site neutral payments will solve Medicare short falls and everyone, including the beneficiaries, will have access to appropriate levels of service.
In part 1 of this 3 part series, we examined the 4 big challenges nursing leaders need to take into account when looking at data on productivity, quality measures, census data and trends, fall rates, turnover rates, patient satisfaction scores and more. Once the nursing leader has the numbers, considered the rates and benchmarks, established a pattern rather than making generalizations on short term data, and determined causation, what next? How should a nurse leader prioritize? Looking at the data, there may be one piece of information that is so far off the benchmark that it creates cause for alarm that cannot be ignored. When those events happen, they force nurse leaders to pay attention to that issue and make it the highest priority.
I have all this data, but I do not know what to do with it.” This is a direct quote from a nurse manager at a rehabilitation hospital several years ago. Have you ever felt this way? Nurse Managers are usually inundated with data on productivity, quality measures, census data and trends, fall rates, turnover rates, patient satisfaction scores and more. Increasingly, numbers are used by payers, hospital leaders and the public to make decisions about where, how and when to provide care. It is, therefore, of paramount importance that the nurse leader understand what the numbers mean, and how to prioritize.
“Site-neutral” may have been replaced with “efficient care in the most appropriate setting” language in the President’s FY2016 budget, but it was prominently discussed in Washington this past week as the American Medical Rehabilitation Providers Association (AMRPA) hosted its annual Spring Executive Forum. Presentations, followed by visits to the Hill to meet with Congressional leaders, drove focus upon how the care and result of managing impairment and functional restoration differed in settings where rehabilitation services are provided.
Imagine going to your computer, logging on to the Internet, putting your patient’s name into a search engine and getting immediate access to everything that was done for that patient to treat current and previous medical problems. With one or two more clicks, you would access summary information, comparing your patient to an appropriately matched population of like patients cared for with conditions and problems matching your patient. Then, another click and a quick analysis of the data would predict best-fit care strategies matched to your patient’s requirement and resources.
On Feb. 2, 2015, the President released his 2016 Presidential Budget Reform documents. In looking back over the past four years when first covering this topic in a blog, I attempted to see what might be in store for post-acute care and in particular, Inpatient Rehabilitation Facilities. Perhaps less is MORE but I'm beginning to wonder how the numbers all add up because, in comparison at best, some savings look fictitious as a 'guestimate' of inconsistency. Let's review...
I left blog #3 in this series with this thought, "Applying site-neutral payment lacks real insight into regulatory realities that have placed IRF access and costs where they are today." Why continue to support more SNF PAC beds in the matrix when regulations have forced most IRFs to be at 60-70 percent capacity or less?
Patients deserving IRF level of care have payment possibilities in the PRESENT IRF PPS payment tool. These payments are less than both SNF and IRF experiences published in the June MedPAC report. I urge you to tell this story to your lawmakers!
Have regulatory changes that steered rehabilitation patients of lesser CMG values away from IRF fueled the growth of other post acute care venues? Have the shifts that occurred made good financial sense to CMS? Have acute care practices and lengths of stay changed over the past 20 years necessitating more robust post-acute care readiness? The answer to these questions hold the key to what lawmakers need to consider when it comes to recommending site-neutral payment in IRFs and SNFs, even for limited orthopedic conditions.
Let's review these concepts in Blog 3 of the series on site-neutral payment and why now more than ever a specialized level of rehabilitation care (IRF) should not be considered comparable in services or payment to a SNF level of care. If patients are screened and directed appropriately based on their real medical and functional needs, there would be no need to concoct 'site- neutral' relationships.
Resources federally mandated to admit and care for patients at a rehabilitation ‘burden of care’ facility and payment based on the IRF PAI driven assessment has historically created acuity payments in higher CMGs. This reality is what fueled the experience noted in the June MedPAC study that, ‘on average’, payments to IRFs, when compared to SNFs, can be higher. In this second discussion on site-neutral payment, and why it should not be considered at this time in Congress, let's review the present possibilities of payments and why we should access those first before paying a site-neutral payment that is not always commensurate with the real burden of care for a patient treated in an IRF.Let's also say that when a patient admitted to an IRF has a lower acuity, the payment available and paid will follow that experience too! Yes, even in an IRF.
Site-neutral payment has been garnering a lot of attention lately, with various government agencies discussing equal pay for equal treatment, and then using actual data files within CMS to make arguments for equal pay. Meeting the Three AIMS of CMS to obtain better value for dollars paid in healthcare is important; however, these studies attempt to neutralize real differences that, in hindsight, cannot be made vanilla in the ways they have applied rationale to make comparisons.
To defend medical necessity, IRF resources, outcomes and patient types have moved to higher acuity. Comparing real costs may show that it costs more, on average, to treat patients in an IRF; however, on average, IRFs do not have the same population of patients they ‘signed up for’ when IRF PPS payment began in 2002. Unless consideration is given to what has caused this shift, discussions on site neutral payment needs to be stopped in its tracks (if it is not too late already) and we need to educate lawmakers about how they got IRFs to realize the differences they are seeing when real patient data is compared.