{"id":8191,"date":"2014-12-11T21:14:55","date_gmt":"2014-12-11T21:14:55","guid":{"rendered":"http:\/\/www.medicareadvocacy.org\/?p=8191"},"modified":"2021-08-10T16:56:35","modified_gmt":"2021-08-10T20:56:35","slug":"no-site-neutral-payments-for-inpatient-rehabilitation-facilities-and-skilled-nursing-facilities","status":"publish","type":"post","link":"https:\/\/medicareadvocacy.org\/no-site-neutral-payments-for-inpatient-rehabilitation-facilities-and-skilled-nursing-facilities\/","title":{"rendered":"No Site Neutral Payments for Inpatient Rehabilitation Facilities and Skilled Nursing Facilities"},"content":{"rendered":"

The Medicare Payment Advisory Commission (MedPAC), the nonpartisan government agency that advises Congress on Medicare policy, indicated at its November 7, 2014 public meeting that, at its next public meeting in December, it would recommend (1) phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) for 17 conditions, which it has not publicly identified and (2) loosening regulatory requirements for IRFs so that they might continue to provide care to Medicare beneficiaries after their Medicare reimbursement rates are reduced.[1]<\/a>  MedPAC will recommend deleting IRF requirements that physicians see patients at least three times per week and that IRFs provide intensive therapy to patients each day.  The Center for Medicare Advocacy says to MedPAC: Don't do it.<\/strong> <\/p>\n

The fundamental premise of MedPAC's recommendations is flawed.  IRFs and SNFs do not provide the same level of care to their patients and, consequently, their patients do not have the same health outcomes, contrary to MedPAC's presumption that patient outcomes in both settings are similar enough to justify site-neutral payments.  Multiple studies find that patients who are able to tolerate the higher amount of therapy provided by IRFs have better outcomes than residents who receive their post-acute care in SNFs.<\/strong>  Watering down IRF requirements so that they resemble SNF requirements will jeopardize, if not eliminate, the higher IRF level of care that some Medicare patients need and can benefit from.  Moreover, the HHS Inspector General's report on adverse events in SNFs,[2]<\/a> described below, found that many Medicare beneficiaries were harmed when they received post-acute care in a SNF for, on average, 15.5 days.  This certainly does not support MedPAC's recommendation to make IRFs look like SNFs.  The costs, in both financial and human terms, are too high. <\/p>\n

MedPAC projects that site-neutral payments will result in savings to the Medicare program of almost $500 million, 7% of IRF spending.[3]<\/a>  The Center questions whether MedPAC has taken into account the additional costs to the Medicare and Medicaid programs that could result from site-neutral payments.  Higher rates of rehospitalization as well as physician services, durable medical equipment, and other Medicare-covered health care costs, in addition to Medicaid costs for dually-eligible beneficiaries who remain in SNFs under Medicaid after their Medicare coverage ends, could all lead to higher total health care spending for patients who are denied medically necessary and appropriate IRF coverage.  The projected savings from site-neutral payments could evaporate.<\/p>\n

IRFs and SNFs Provide Different Care<\/strong><\/p>\n

IRFs, a category of acute care hospitals, are currently required to have significantly higher staffing levels than SNFs and to provide more direct care to their patients each day.  The following chart reflects requirements for the two care settings, as identified by MedPAC in November 2014.[4]<\/a> <\/p>\n\n\n\n\n\n\n
\n

Requirement<\/strong><\/p>\n<\/td>\n

\n

IRFs<\/strong><\/p>\n<\/td>\n

\n

SNFs<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Physician oversight<\/p>\n<\/td>\n

\n

Rehabilitation physicians must see patients at least three times per week<\/p>\n<\/td>\n

\n

Physicians must see residents within 14 days of admission and then every 30 days<\/p>\n<\/td>\n<\/tr>\n

\n

Registered nurse staffing<\/p>\n<\/td>\n

\n

24 hours per day<\/p>\n<\/td>\n

\n

Eight hours per day<\/p>\n<\/td>\n<\/tr>\n

\n

Therapy services<\/p>\n<\/td>\n

\n

Intensive; often described as at least three hours per day<\/p>\n<\/td>\n

\n

No requirements; Medicare reimbursement rate depends on amount of therapy SNF says it provided<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

HHS Inspector General Found High Levels of Adverse Events in SNFs for Medicare Beneficiaries<\/strong><\/p>\n

A recent report by the HHS Office of Inspector General (OIG) underscores why patients should not be inappropriately shifted to SNFs for post-acute care.  Earlier this year, in the first analysis of adverse events in SNFs, OIG reported that nearly one in three Medicare beneficiaries who went to a SNF for 35 days or fewer in August 2011 (and who spent an average of 15.5 days in the SNF) experienced an adverse event or other harm, including falls, avoidable infections, pressure sores, improper medication dosing, hospitalizations, and death.[5]<\/a> <\/p>\n

Physicians who conducted the reviews for OIG found that 59% of the adverse events and incidents of temporary harm were "clearly or likely preventable" and that "many events were the result of failure by SNF staff to monitor residents or staff delay in providing necessary medical care."[6]<\/a>  Factors contributing to these poor outcomes for residents included "substandard treatment, inadequate resident monitoring, and failing to provide treatments."[7]<\/a><\/p>\n

OIG reported that more than half of the residents who experienced harm were hospitalized, "with an estimated cost to Medicare of $208 million in August 2011."[8]<\/a>  In addition, "[A]n estimated 1.5 percent of Medicare SNF residents [1,538 individuals] experienced events that contributed to their deaths"[9]<\/a> in August 2011.  For most of these residents, death was "likely not an expected outcome."[10]<\/a><\/p>\n

Studies Find Better Health Outcomes for IRF Patients than for SNF Residents<\/strong><\/p>\n

Many studies comparing health outcomes for patients in IRFs and SNFs find that patients have better outcomes when they receive post-acute care in IRFs. <\/p>\n