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Postacute Care Overhaul Timeline Questioned by MedPAC Members

By Kerry Young, CQ Roll Call

March 3, 2016 -- Medicare officials should look for opportunities through administrative action to speed changes in the program’s highly fragmented approach to paying for care of the elderly and disabled after hospital stays, advisers to Congress said.

A 2014 law envisions leaving the current system largely in place through 2026 or 2027, said MedPAC commissioner Kathy Buto, a veteran federal health adviser. Despite congressional interest in overhauling the system, shepherding legislation through Congress to change that timeline significantly will be a challenge.

"We are talking 10 years before we will see anything new," said Buto at the panel’s Thursday meeting.

Buto asked if there is any way to encourage the use of existing Centers for Medicare and Medicaid Services tools to more quickly establish a "glide path" toward an overhaul of the payment system, such as the use of demonstration projects.

MedPAC is preparing to vote next month on material for a highly anticipated report in which it will advise Congress on how to move toward a unified payment system for post-hospital care. Medicare paid $59 billion in 2013 for such care, more than double the amount in 2001, according to MedPAC.

Medicare has different reimbursements for patients with often similar conditions treated in four settings. Those are skilled nursing homes, specialty inpatient rehabilitation centers, long-term care hospitals and at-home care with the help of aides. There's often little evidence to guide frail people recovering after strokes and surgeries as to which approach to care might help them most. The fragmentation adds to the stress that many families face as relatives are discharged from hospitals.

A 2014 law (PL 113-185) championed by now Ways and Means Chairman Kevin Brady, R-Texas, is intended to both simplify the payment system and gather evidence on how different approaches to post-hospital care work. The law set a June 2016 deadline for MedPAC’s first report on the post-hospital care payment overhaul. This measure sets in place a series of subsequent deadlines, which currently would push out the timing of a payment overhaul as Buto outlined.

Lawmakers in both parties remain interested in overhauling the post-acute care system, eyeing potential savings that could be used as offsets in future budget agreements. That political pressure could speed the pace of the overhaul ahead of the IMPACT Act's timeframe.

Warner Thomas, a MedPAC member and the chief executive officer of the Ochsner Health System in New Orleans, also called for encouraging CMS to use demonstration projects to jumpstart changes within the field of post-hospital care. "There is real opportunity for folks that want to innovate," he said Thursday.

CMS already has several major demonstration projects underway in other fields of care to try to reward hospitals and medical practices for better coordinating the care of patients. Among these are a test that will put hospitals in 67 regions of the country at financial risk if patients don't fare well after undergoing hip and knee replacements. Another program is seeking to better coordinate the care of cancer patients.

MedPAC members also discussed Thursday how judgments would be made about the quality of care provided under a more unified Medicare approach to payments for post-hospital services.

"Maybe we should have higher expectations" such as monitoring how well patients fare 90 days after an admission instead of 60 days, said Mary Naylor, a MedPAC member and professor at University of Pennsylvania School of Nursing.

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