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

Publicly available quality data is rarely a factor in Medicare beneficiary choice of a post-acute care (PAC) provider, according to Medicare Senior Policy Analyst Evan Christman.

“In practice, beneficiaries report relying on information from trusted sources like health care providers, families, or others that may have experience with PAC,” Christman told the Medicare Payment Advisory Commission (MedPAC) March meeting in Washington.

“These trusted intermediaries are often considered by beneficiaries to be more important sources of information than Medicare's publicly reported quality data,” such as available on Nursing Home Compare and Home Health Compare. “Factors such as distance from a beneficiary's home and community reputation are commonly cited by beneficiaries as important when selecting a provider. Beneficiaries report that they would like to receive more advice” from hospital discharge planners, but “discharge planners cannot make recommendations.”

"The Balanced Budget Act of 1997 requires hospitals to provide beneficiaries with a list of SNFs and HHAs nearby, but the list is not required to include quality information." 

Most SNF and HHA users had a nearby provider of higher quality, according to a study by MedPAC staff. For each patient selected, it was determined how many providers with a better performance on a composite measure were operating within 15 miles of the beneficiary's residence:

  • SNF: 84.3 percent of beneficiaries had at least one higher-quality SNF nearby; 46.8 percent had 5 or more.
  • HHA: 94.5 percent of beneficiaries had at least one higher-quality HHA nearby; 69.5 percent had 5 or more.
  • Beneficiaries in urban areas generally had more higher-quality options nearby.

Higher-quality providers “had meaningful differences” compared to other providers, such as significant differences in re-hospitalization rates. “This has real consequences for beneficiaries, as those served by low-quality providers will have more hospitalizations and likely have worse clinical outcomes.”

Christman added that “for some conditions, it will also mean that hospitals face steeper penalties under programs like the Hospital Readmissions Reduction Program.  And, in addition, Medicare receives less value for the PAC care it buys, and spends more on re-hospitalizations than it should have to.”

Could Be Corrected by IMPACT Act, but No Regs Yet

The Balanced Budget Act of 1997 requires hospitals to provide beneficiaries with a list of SNFs and HHAs nearby, but the list is not required to include quality information. “Medicare statute provides beneficiaries with the freedom to choose their PAC provider, and the laws states that hospitals may not recommend providers,” Christman noted.

The IMPACT Act (Improving Medicare Post-Acute Care Transformation Act of 2014) created a new requirement that hospitals use quality data during the discharge planning process and provide it to beneficiaries. But regulations implementing this new requirement have not been finalized.

MedPAC Commissioners discussed two options for providing this authority: a “flexible approach” whereby hospitals would collect and provide quality data on PAC providers; and, a “prescriptive approach” in which Medicare would develop a single quality standard and would notify hospitals and beneficiaries of qualifying PAC providers.

MedPAC plans to include discussion of this topic, and possible solutions, in its June 2018 report to Congress on Medicare and the Health Care Delivery System.

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