Medicare has a huge and growing problem caring for patients after they have been discharged from the hospital. After years of talk, Congress may be about to take a modest but important first step toward cleaning up the mess, and making sure that patients get care that gives them the best chance to live a healthy and active life after a surgery or acute medical episode such as a stroke.
A wide-range of treatment and rehabilitation services live under the umbrella of Medicare post-acute care. That itself is a big part of the problem. Remarkably, the top Democrats and Republicans on both the House Ways & Means Committee and the Senate Finance Committee—who have been unable to agree on anything for years—are sponsoring a bill aimed at starting to fix the tangle of problems that bedevils the post-acute system.
Their proposal is exceedingly modest, but it is an important start.
A bit of background: Post-acute care patients may get care in a skilled nursing facility (SNF), a hospital-based inpatient rehabilitation facility (IRF), a long-term care hospital (LTCH), or from a home health agency.
Each operates under its own set of enormously complicated rules. There is no standard way to assess the quality of care patients receive or manage transitions from one setting to another. Medicare pays these facilities different rates for what is effectively the same care. And decisions on where a patient is sent after being discharged from the hospital are too often based on financial decisions rather than her best interests.
On top of all that, as a result of Medicare’s aggressive effort to curb hospital admissions in favor of observations (where a patient may spend up to several days in a hospital without ever being formally admitted) growing numbers of seniors must pay for their post-acute care out of pocket .
This mess forces patients and their families to make a mind-numbing set of important decisions under enormous pressure and with little useful information–just as they are being discharged from a hospital. Besides the advice of their doctor, they often need a care manager and a lawyer to figure out what to do.
The Affordable Care Act and ongoing market changes are already changing the post-acute world by encouraging hospitals, nursing homes, home health agencies, and other providers to partner in new risk-based models of managed care. In those designs, such as Accountable Care Organizations, bundled payments, and the like, providers work together to provide a full range of treatment after an illness or injury.
Imagine, for example, your mom falls and breaks her hip. She is taken to a hospital emergency room, admitted to hospital, has surgery to repair her fracture, is discharged to a skilled nursing facility for rehabilitation, and is finally discharged back home for additional therapy. In new risk-based models, the hospital, surgeon, SNF, home health agency, and physical therapists all team up to provide care for a single, fixed payment. They share the money–and the responsibility.
Properly designed, such a model can fix much of the post-acute mess. But for now, most care for mom’s hip fracture is still provided in the traditional fee-for-service system, where each provider is paid based on how much he does. The challenge is how to better organize that care.
To start to fix those problems, Senate Finance Committee Chairman Ron Wyden (D-OR) and senior Republican Orrin Hatch (R-UT) have teamed with Ways & Means panel chair Dave Camp (R-MI) and senior Democrat Sandy Levin (D-MI) to introduce the Improving Medicare Post-Acute Care Transformation (IMPACT) Act.
Their measure mostly focuses on those assessments. It would require all post-acute facilities to report common information regardless of their setting. One key reform would require providers to report on standard quality measures for their patients. Just getting all these providers talking to one another in the same language would be very helpful.
The bill would set a fairly long timeline for developing a standard assessment tool that could eventually lead to a new payment model. By the time that happens, in 2022, today’s managed care models are likely to be refined and much more widely used.
Still, the bill would be an important step for both providers and for patients. In the current political environment, it is impossible to say when Congress might act, but given who backs it, the measure has a better shot than most.
It would be nice if they talked to one another. However, they miss the real point that most post-acute goes home. The paucity of effective homecare from an agency is appalling. Should we not focus on education the unpaid family caregiving in the 85% of care that is not care but practical problem solving (so you know in advance of bedside discharge if you need a GCM. ElderLaw Atty. or a real caregiver advocate) at your bedside. 8 years from now, there will be millions more unpaid family caregivers trying to deal with ” bundles” or whatever value-based care has morphed to, but it still leaves the unpaid family caregiver in the same quandary they are today. Seems to me it is a “pyrrhic victory” at best.
Keep up the good work,