By Kerry Young, CQ Roll Call
November 9, 2015 -- A key health policy goal of the new Ways and Means chairman—changes to the treatment of people recovering from serious illnesses, injuries, and surgeries—is moving forward in an influential advisory panel. The work ultimately could result in an overhaul of one of Medicare's fastest-growing expenses.
An overhaul of so-called post-acute care, a roughly $60 billion annual expense for Medicare, has been a top priority for Rep. Kevin Brady, R-Texas, and has the support of the Obama administration. Medicare's spending on post-acute care more than doubled between 2001 and 2012, with different payment rates set for the four main settings for this treatment. Lawmakers are looking for ways to better direct people toward the best sites for post-acute care, while also keeping this spending in check by flattening payments. Decisions about post-care settings now often are based on factors such as a hospital's relationship with a particular center, according to the Medicare Payment Advisory Commission.
MedPAC staff on Nov. 6 said it would be possible to develop a "reasonably accurate" unified payment system for post-acute care, but noted there are some thorny issues to resolve. Lawmakers have been looking for MedPAC's guidance in this effort. The IMPACT Act (PL 113-85), which Brady helped passed last year, ordered MedPAC to provide Congress with a report by June 2016 on creating a new unified payment for post-acute payment.
Among the ideas being considered for the report is whether to create new coordinating agencies that would work to direct patients into the best rehabilitation settings for them. These navigators could stand to profit, or lose money, based on how well patients fare.
The transition from hospital to post-acute settings now is often stressful and chaotic. Frail people recovering from strokes and other serious illnesses and their family members often are confused and frustrated while attempting to sort out different options for recovery care.
Craig Sammit, chief clinical officer at insurer Anthem Inc. and a MedPAC member, objected to the idea of bringing in a new third-party to coordinate care, saying it would add another "layer of complexity" to these cases. Instead, Medicare should be looking to bolster the ability of primary-care doctors to guide their patients through recoveries, or to rely on accountable care organizations more for this work, he said.
"I am not comfortable with the creation of yet another layer," Sammit said. "I don't think we have given enough opportunity to see that the layers that currently exist, when held accountable, can manage this."
Other panel members concurred with his view that adding coordinators would add complexity to a field of care that leaves many patients and their families bewildered.
Still, MedPAC Executive Director Mark E. Miller said there appears to be a need for navigators of some kind for post-acute care, although how this role is filled may not be clear yet.
"You are at once saying 'I need coordination. It's the most concerning thing that any family talks about.' And I hear this all of time, too," Miller said, summarizing the discussion. "But you don't want anybody to enter the picture."
The coordinator approach had been proposed by Rep. David McKinley, R-W.Va., in his bill (HR 1458), for which he has three cosponsors.
MedPAC and Congress have given themselves a long time-frame for addressing payments for post-acute care. While serving as chairman of the Ways and Means health subcommittee, Brady last year pushed for the IMPACT Act (PL 113–185) that requires the different providers of post-acute care to use a uniform tool to judge how well people fare in the different care settings. That would put a new PAC payment system in place by 2023 at the earliest, by MedPAC's estimate.
But Congress and Medicare officials could accelerate that schedule. In an interview last week with CQ RollCall, Brady outlined an ambitious goal for pressing ahead on Medicare legislation in the year ahead, even with the inevitable tensions surrounding the 2016 elections likely to disrupt much of the work of Congress.
"I am hopeful that we can move a package of hospital reforms, including post-acute reforms and a number of bipartisan health care priorities here over the next six months," Brady said.
The Obama administration also is seeking an overhaul of post-acute care. It estimated in its fiscal 2016 budget request that $9.6 billion could be saved over a decade from the creation of a bundled payment.