I may have mentioned this before: I am a beekeeper. A hobbyist, really. I started out five years ago with one hive intending to keep it a light hobby, something interesting for weekend relaxation and perhaps some honey to boot.
It didn’t stay that way for very long. Keeping bees becomes more attractive the longer you do it.
Last season, I had eight hives in various locations around where I live. Being busy with “regular” work, that many hives were a stretch for me. It’s hard work at times, but I have gotten a taste of the sweet reward, and it is worth it.
Last summer, we all got a taste of where the Centers for Medicare & Medicaid Services is heading regarding a unified payment system for Medicare-covered post-acute care (PAC). RTI International published a report to Congress, mandated by the IMPACT Act titled, “Unified Payment for Medicare Post-Acute Care.” It’s worth a look.
Medicare PAC services are provided to beneficiaries by PAC providers defined as skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs) and home health agencies (HHAs).
The Secretary of the Department of Health and Human Services was mandated by the IMPACT Act to submit a report to Congress with recommendations and a technical prototype for a Unified Post-Acute Care Prospective Payment System (UPAC PPS) that would,
- set payment according to individual beneficiary characteristics (such as cognitive function, motor function, and impairments), rather than PAC type;
- account for the clinical appropriateness of services furnished and beneficiary outcomes;
- be designed to incorporate standardized patient assessment data as described under Section 1899B of the Social Security Act; and
- further clinical integration, such as by motivating greater coordination around a single condition or procedure to integrate hospital systems with PAC providers. (1)
As with the Patient Drive Payment Model, the UPAC payment system prototype relies heavily on data mined from the assessment tools. The data necessary to develop this initial UPAC PPS prototype came from Hospital and PAC claims as well as the assessment tools that each PAC provider uses (HH – OASIS, LTACH – LCDS, SNF – MDS and IRF – IRF PAI).
It was from these assessment tools that much of the stratification or end splitting was derived. In fact, the UPAC PPS report to Congress indicates that, “In connection with the IMPACT Act, selected standardized self-care and mobility assessment data were collected and submitted to CMS …” (1)
Using these and other assessment data, CMS created several variables for the prototype analysis including;
- a motor (i.e., physical) function score calculated using data from the standardized self-care and mobility data elements,
- indicators of bladder and bowel incontinence, and
- a cognitive and communication function score calculated using data from the assessment data elements. (1)
Only the self-care and mobility items were considered Standardized Patient Assessment Elements or SPADEs, when this prototype was developed. These have been a standard item set consistently reported in each assessment type. In the end, they also had a more significant effect on the cost of care than the other elements.
The other items like cognition, communication and incontinence were not standardized elements at the time of prototype development and were not consistently reported. They also did not appear to have significant impact on cost of care in the initial analysis completed for the UPAC PPS prototype. In fact, they were relegated to a subsequent phase of the prototype’s case-mix adjustment focused on comorbidities.
While the initial UPAC PPS prototype is a start RTI acknowledged that, “… universal implementation of a unified PAC payment system could not be done under CMS’s existing statutory authority.” (1) They also acknowledged that additional analyses need to be done. Part of that analysis will surely be a more robust SPADE configuration among the various assessment tools, which has begun.
We have a tremendous responsibility when completing the MDS to ensure that the data we code is accurate and reliable. Now that we have the final MDS 3.0 v. 1.18.11 with new and expanded items, as well as the DRAFT RAI Manual that goes along with it, our task is all the more important.
In a statement related to the RAI Manual release, CMS stated, “This version of the MDS 3.0 RAI Manual contains substantial revisions related to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which requires that standardized assessment items be collected across post-acute care (PAC) settings. Standardized data will enable cross-setting data collection, outcome comparison, exchangeability of data, and comparison of quality within and across PAC settings.” (3)
FYI, most of the data elements that are necessary to accomplish this will be complete with MDS 3.0 v1.18.11 implementation. We may soon see health equity measures, hinted at in the FY 2023 SNF PPS final rule, come to fruition. Social Determinants of Health SPADEs seem to be opening that door.
Remember also that “A goal of unified PAC payment is to base the payment on patient characteristics instead of the PAC setting. This framework applies a uniform approach to case-mix adjustment across Medicare beneficiaries receiving PAC services for different types of PAC providers while accounting for factors independent of patient need that are important drivers of cost across PAC providers.” (2)
And then this: “The unified approach to case-mix adjustment includes standardized patient assessment data collected by the four PAC providers.” (2)
FYI, most of these data elements are already in place in the current set of PAC assessment tools. Stay tuned for UPAC PPS 2.0.
The phrase, “bee’s knees” means something excellent or wonderful. Remember, PDPM is largely a result of past MDS data. Consider the effect that the MDS has had on past payment system development.
April is the month that I get to pick up the bees I have purchased from a local beekeeping supply store and install them in my hives. I look forward to this task every year. For a beekeeper, it is one of the many “bee’s knees” experiences we get to enjoy.
It is true that the opportunity we have to shape a future PAC PPS is significant. The MDS can be an excellent and wonderfully powerful tool in that process — the “bee’s knees” — if we will see it that way. In the end, the sweet reward will bee worth it.
Quotation sources:
- Unified Payment for Medicare Post-Acute Care
- IMPACT Act Spotlight and Announcements
- CMS Email announcement about the DRAFT RAI Manual v1.18.11 release
Joel VanEaton, BSN, RN, RAC-CT, RAC-CTA, is a master teacher and the executive vice president of PAC Regulatory Affairs and Education at Broad River Rehabilitation.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
