The House Ways and Means Health Subcommittee held a hearing on ways to improve access to quality post-acute care.
Millions of Medicare enrollees require care after a hospital stay, such as rehabilitation, hospice, and home health care, and quality and access have suffered over the years, the panelists said.
Consolidation, mergers, and acquisitions by national chains have reduced competition in the $60B post-acute care industry, witnesses told the subcommittee. Medicare reimbursement models that do not reflect actual cost of advanced long-term care, and models focused on rehabilitation do not adequately reduce hospital readmittance.
Complicated cases that require costly and extended care can cause facilities to operate at a loss, which discourages caretakers from admitting patients most in need of specialized care.
“From a provider and patient perspective…when [the high-cost outlier threshold was lower], we were able to allow more patients who would enter into the facility who we knew would become high-cost outliers, because that fixed loss amount was such that we could manage that and still make a relatively small margin within our long-term care hospital,” Paul Congilli, a Nebraska hospital leader told the subcommittee.
The panel at the March 14 hearing discussed possible remedies such as expansion of telehealth services, implementation of a unified payment system, and implementation of a pay-for-performance system modeled on private-sector programs.
High-Cost Outliers
Patients with complex or difficult-to-treat conditions who need post-acute care can impose an outsized financial burden on facilities and staffing, says Linda Gorman, director of health care policy at The Independence Institute.
“There are well-known reasons for staffing problems,” said Gorman. “The first is that the payers—primarily Medicare and Medicaid—pay at below cost. If one is operating a facility with high fixed costs, staffing is where one cuts back, with hours, numbers of hires, or quality of hires.
“This is just basic economics,” said Gorman. “Given that, perhaps the most significant moment in the subcommittee hearing was the discussion of the increase in the high-cost outlier threshold and its effect on margins.”
The dwindling margins have caused many long-term acute care (LTAC) and skilled nursing facilities (SNFs) to limit services required by high-cost outlier patients. For example, patients in Texas, home to two of the five largest metropolitan areas in the United States, can only find one SNF actively accepting patients who need both hemodialysis and invasive ventilation. Having one such facility in a state as large as Texas could cause patients and their families a great deal of inconvenience, as this writer has experienced.
Telehealth Debate
While the concept of telehealth gained a great deal of currency during the COVID-19 pandemic, one witness, Dana Madison, a Texas home health administrator, advocated how the practice could be helpful now in easing LTAC staffing shortages.
“In Lubbock, Texas, six years ago we did a study, and at that point, we were a city of 260,000,” said Madison. “We were 1,000 [registered nurses] short and 1,000 [licensed vocational nurse] short, and that’s a hole that you can never backfill enough. We are dealing with it right now.
“Telehealth would help with that tremendously,” said Madison. “If we could do telehealth visits, one particular nurse could make 20 visits a day instead of the normal eight that they make. For those patients that don’t need to actually have hands-on care that day, I think telehealth would be a great way to take care of those patients.”
Telehealth and home care will not ease staffing problems, says Gorman.
“There are cases that can best be handled in nursing homes because of severity, scale, organizational, and continuity problems,” said Gorman. “That is why the nursing home industry developed.”
Pay-for-Performance Support
Jonathan Fleece, a Florida home-based care provider, testified that tying Medicare reimbursement to the quality of care provided, a practice already embraced by the private sector, could incentivize health providers to improve performance.
“If you look at the current star rating system that is prevalent in Medicare today, it is one that does not adequately pay for performance for the providers,” said Fleece. “We would certainly advocate that for those organizations that have higher star ratings, that they get paid more under the reimbursement system. That would be one model of a pay for performance.”
Star ratings have had limited value, says health care economist Devon Herrick.
“The metrics for what constitutes quality performance are hard to measure,” said Herrick. “Yet, Medicare should claw back reimbursements when costs are driven up by poor-quality care.”
Priority Call
Post-acute care in public health programs should actively engage patients in health care choices and prioritize care for those most in need, says Gorman.
“The people who know about quality are the patients and those supervising their care.” said Gorman. “But as Medicare/Medicaid are currently constructed, patients or their agents have little say in how government health money is spent, particularly if they are in managed care.”
Quality care costs more, says Gorman.
“Since there is a limit to the amount of money that is available for health care, it is important to ensure the public programs put paying for the care of people who have serious medical problems at the top of their list,” said Gorman. “This may mean cutting other nice but nonessential things. Paying for medical care for the seriously ill, for example, is more important than paying for coverage for able-bodied, mostly healthy people that is seldom used.”
Kevin Stone ([email protected]) writes from Arlington, Texas.
