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Postacute Centers Want Patient Income Weighed in CMS Metrics

By Kerry Young, CQ Roll Call

July 5, 2016 -- Specialty medical centers are pressuring Medicare administrators to factor the socioeconomic status of patients into judgments about the quality of care provided to people recovering from serious illnesses and injuries.

The Centers for Medicare and Medicaid Services (CMS) is shaping a framework intended to allow better comparisons of post-acute care provided in four different settings. A roughly $60 billion annual expense for Medicare, the field involves the work of home health agencies, long-term care hospitals, skilled nursing centers and specialty inpatient rehabilitation facilities. 

The IMPACT Act (PL 113-185) of 2014 ordered CMS to do the groundwork for eventually moving to a unified payment system. The agency is handling the initial steps through the four annual payment rules that cover post-acute care. CMS in April released the draft rules for skilled nursing centers, inpatient rehabilitation facilities and long-term care hospitals that are updated each fiscal year. Last month, it released the proposed rule for home health agencies, for which payment policies are changed each calendar year.

Many post-acute care organizations are asking CMS to account for differences in patient populations. For example, one measure CMS proposed in assessing if a hospital readmission could have been avoided would weigh medical risks that increase the odds of a patient in a skilled nursing facility (SNF) having to return to the hospital. But it would not make an adjustment for socioeconomic factors, according to Vickie R. Kunz, senior director for health finance for the Michigan Health and Hospital Association.

"This is vital for ensuring that SNFs caring for large numbers of poor, vulnerable patients are not disproportionately penalized," Kunz wrote in a June 26 comment to CMS.

Without an adjustment for socioeconomic status, the data collected from the new measures will not offer a valid comparison of the results provided by different organizations, wrote Patty Haggen, executive director of rehabilitation services at the John Muir Medical Center in Walnut Creek, Calif., in a June 20 comment on the inpatient rehabilitation facilities (IRFs) draft rule.

"IRFs that serve individuals with limited resources will be unfairly penalized for factors beyond their control," Haggen and colleagues wrote.

CMS said in the draft home health rule that Medicare officials understand the role that "sociodemographic status, beyond age, plays in the care of patients," but said they have concerns about creating different standards for the outcomes due to patients' socioeconomic status.

We "do not want to mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations," CMS officials wrote, echoing a phrase repeated in other rules regarding requests for factoring patients' incomes into quality measures.

In the draft home health rule, CMS also noted that the nonprofit National Quality Forum is in the midst of a trial period of new measures to determine if adjusting for so-called sociodemographic factors is appropriate. In addition, the Office of the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services is conducting research to examine the effect of socioeconomic status on quality measures for Medicare, CMS said. This work will factor into the agencies' deliberations on socioeconomic factors, the agency said.

Medicare officials and lawmakers have been wrestling broadly with the question of how to measure the quality of hospitals and specialty clinics that have many poor patients. The House on June 7 passed by voice vote a package of relatively small changes to Medicare policy (HR 5273) that includes a provision meant to address concerns about how hospitals that serve many poor customers are hit by readmission penalties. 

Rep. Charles B. Rangel, D-N.Y., questioned at a May markup whether this provision would have the effect of lowering the standards for hospitals that serve the poor. He argued that the priority should be to make sure that hospitals serving low-income communities have the resources they need to prevent admissions of their patients, rather than rejiggering the penalty. Still, Rangel agreed with a need to preserve the funding for medical centers serving the poor.

"I don't want these hospitals to be put out of business just because we don't provide the funds for them to do the right thing," Rangel said.

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