FutureFocus June 27, 2018 Discharge Planning: CMS Guidance Needed

Lisa Remington

In this week's FutureFocus, are new discussions about discharge planning practices. The June MedPAC report urges CMS to provide more guidance.  CMS’s current regulatory guidance, reflects “the prohibitions” of a law more than two decades old, the Balanced Budget Act (BBA) of 1997, which states “a hospital ‘may not specify or otherwise limit the PAC providers made available to beneficiaries. (Medicare Advantage allows plans to establish their own networks; these plans’ enrollees must select a provider that is in their plan’s network.)” The BBA also requires “that hospitals provide a list of HHAs or SNFs that are near the beneficiary’s residence for patients identified as needing these services.” We provide updates and insights.

Lisa Remington, President, Remington Health Strategy Group

By: Ronald M. Schwartz, Contributing Writer, The Remington Report 

Medicare should allow hospital discharge planners to recommend specific post-acute care providers based on the quality of care. That’s a key takeaway in the Medicare Payment Advisory Commission (MedPAC) June 2018 Report to the Congress: Medicare and the Health Care Delivery System.

The advisory panel to Congress and the administration devotes one of its 10 chapters in this annual report to “Encouraging Medicare beneficiaries to use higher-quality post-acute care providers.” “Helping beneficiaries to identify better quality PAC providers should be a goal of a reformed hospital discharge planning process,” MedPAC urges. However, “current regulations do not permit discharge planners to recommend specific PAC providers to beneficiaries.” The problem largely hinges on the failure of the Centers for Medicare & Medicaid Services (CMS) to finalize regulations called for in The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This law “requires hospitals to include quality data when informing beneficiaries about their options,” says MedPAC. MedPAC’s report could put pressure on CMS to finalize the regulations for which the IMPACT Act specified a Jan. 1, 2016 deadline. 

“Many Discharge Planners Cautious” About Advising Beneficiaries  

However, notes MedPAC, CMS’s current regulatory guidance, reflects “the prohibitions” of a law more than two decades old, the Balanced Budget Act (BBA) of 1997, which states “a hospital ‘may not specify or otherwise limit’ the PAC providers made available to beneficiaries. (Medicare Advantage allows plans to establish their own networks; these plans’ enrollees must select a provider that is in their plan’s network.)” The BBA also requires “that hospitals provide a list of HHAs or SNFs that are near the beneficiary’s residence for patients identified as needing these services.” “The list is not required to include quality or performance information,” adds MedPAC. “In practice, many discharge planners are cautious about providing advice to beneficiaries because they do not want to be seen as limiting patient choice” (citing two studies in 2015 and 2017).

"The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) law “requires hospitals to include quality data when informing beneficiaries about their options,” says MedPAC."

To understand the 1997 law, one must appreciate the environment in which it was crafted, when the process called “steering” received much attention. That year, the HHS Office of Inspector General released the report “Medicare Hospital Discharge Planning,” reviewing discharges to SNFs and HHAs. It found that “hospital ownership does seem to have influence on which home health agencies patients are referred to. Discharge planners from hospitals which own home health agencies report that hospital ownership is a factor in their referral process to home health agencies.”

What About Quality Data Available Today to Consumers? 

The MedPAC report notes that a 2016 study “found minimal impact” of the HHA data available through Medicare.gov. “On average, the best performing agencies might have increased their market share by less than 1 percent (Jung, J. K., B. Wu, H. Kim, et al. 2016. The effect of publicized quality information on home health agency choice. Medical Care Research and Review 73, no. 6 (December): 703–723).” Other studies have indicated that “patients are often unaware of this information or that they have limited or no access to online services when hospitalized. Patients who are hospitalized may be too distracted or sick to conduct detailed research about their PAC provider options, and a beneficiary’s family member or other caregiver may also have difficulty finding and using this information.” “In practice, beneficiaries report soliciting the views of physicians, family members, or other associates to recommend a PAC provider.” 

MedPAC Suggestions for Quality Guidance 

The selection of a PAC provider today can be “crucial because the quality of care varies widely among providers,” concludes MedPAC.  Among the options, MedPAC suggests that Medicare could expand the authority of discharge planners to recommend higher quality PAC providers in a number of different ways. These range “from prescriptive approaches that provide specific metrics that hospitals must use, to more flexible approaches that allow hospitals to decide on the metrics they use to identify high-quality PAC providers. Ultimately, beneficiaries should retain freedom of choice, but have better information to make that choice.”