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Medicare Payment Panel Debates Postacute Care

By Kerry Young, CQ Roll Call

September 11, 2015 -- Advisers to Congress are wrestling with how to judge the quality of treatment provided to elderly and disabled people recovering after serious illness and surgeries.

Facing a June 2016 deadline to deliver a mandated report to Congress, members of the Medicare Payment Advisory Commission (MedPAC) on Thursday delved into the complexities of comparing treatments delivered in different settings to people who still need medical care after being discharged from hospitals. The panel is tasked with looking at four settings: inpatient rehabilitation centers, skilled nursing facilities, long-term care hospitals, and patients' homes, where care is provided with the help of aides. People served in these settings often are recovering from strokes or hip replacements.

The wishes of people in need of such postacute care should factor heavily in these assessments, said Rita Redberg, a MedPAC member and cardiologist from the University of California at San Francisco.

"In my experience taking care of people the last 30 years, most people want to go home," she said. "They always want to go home if that is a reasonable option."

Too often, though, they may end up admitted as patients to treatment centers, she said. These can prove more costly than home care, but haven't been shown to provide a clear benefit to patients in many cases. Redberg also suggested that hospice should be considered among the options for post-acute care, as some of the people admitted to long-term care hospitals are nearing death.

But that would be beyond the scope of the mandate given to MedPAC through a 2014 law known as the IMPACT Act (PL 113-185), noted Mark E. Miller, executive director of the panel, while indicating some openness otherwise to the suggestion.

There's bipartisan agreement among lawmakers for the need to overhaul post-acute care, despite deep rancor on other medical issues, such as the implementation of the 2010 health law.

The IMPACT Act was cleared by the Senate by unanimous consent on Sept. 14, 2014, two days after the House agreed to it by voice vote. Medicare in 2013 paid for 9.6 million episodes of postacute care, and the cost to the program for the field of medicine roughly doubled between 2001 and 2012, according to MedPAC.  "Yet despite this heavy investment, the need for [post-acute care] is not well defined, and Medicare gives providers considerable latitude in delineating which patients they admit among the patients referred to them by hospitals," the panel said in its March 2015 report to Congress.

The decision on how to treat a person in need of post-acute care often is made for reasons besides medical rationales, including local practice patterns, the availability of care in a market, patient and family preferences, and financial arrangements between a provider and the referring hospital, according to the commission.

Medicare and Congress have worked for years to better understand the field. The IMPACT Act, for example, directs MedPAC to build on data from a postacute care research that was authorized by the 2005 Deficit Reduction Act (PL 109–171).

Several MedPAC members expressed frustration with the lack of data available to aid in making comparisons about different sites of care. The panel is charged with putting ideas to aid in creating "a payment model that is in the spirit of site neutral payments,"  said Katherine Baicker of the Harvard School of Public Health. Yet commissioners still want to know more about why "patients who look very much the same" and obtain similar results from their care "get treated in settings that have very different costs," she said.

Baicker and other panelists noted the challenges ahead, including avoiding overpaying for home health services simply because they look inexpensive compared to more costly options. Miller said that MedPAC members would continue to discuss postacute care, one of the more complex topics facing the panel, at several meetings before the June deadline.

"Some of the issues we get, when we are lucky, are kind of dichotomous, like taking a left and taking a right," said MedPAC Chairman Francis J. Crosson. "This one I think requires a GPS because there's so many twists and turns here."

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