Is Site-neutral Payment for SNFs and IRFs Another Kludge in the American Kludgocracy?

Transcription

1 Is Site-neutral Payment for SNFs and IRFs Another Kludge in the American Kludgocracy? National Health Policy Forum on Site-Neutral Payments for Post-acute and Ambulatory Care Services Washington, DC June 5, Gerben DeJong, PhD, FACRM MedStar National Rehabilitation Hospital Department of Rehabilitation Medicine Georgetown University School of Medicine Washington, DC

2 Disclosures Financial: Remains associated with his former employer, MedStar National Rehabilitation Hospital Receives a consulting fee and expenses from navihealth Nonfinancial: Speaking as an academic, a researcher, a policy wonk Not as an advocate for any post-acute industry Committed to evidence-based policy and practice while being mindful of the larger policy goals we are seeking to achieve. 2

3 Research evidence Considerable overlap in the types of pts served in SNFs and IRFs Not a lot of daylight in risk-adjusted patient outcomes between SNFs and IRFs In the case of orthopedic patients, e.g., joint replacement, IRFs are only marginally more effective overall but not dramatically so. Is this a setting effect? Is this a therapy intensity effect? Many SNFs are as effective as IRFs but greater variation in practice and outcome among SNFs Smaller, low-volume SNFs perform less well Need to look at within-setting variation as well as between-setting variation. The case for IRFs is stronger for patients with neurologic conditions, e.g., stroke, TBI, SCI. 3

4 Research evidence Davanzo, et al. (2014) study Took a different approach Used Medicare FFS claims data ( ) Used propensity scoring to match 100,000 IRF-SNF pairs from 13 conditions Evaluated 2-yr outcomes with respect to readmissions, mortality, longevity Largest differences seen among pts with brain injury, stroke, amputation, and cardiac disorders Smallest difference among pts who had hip or knee replacement 4

5 Research evidence Percentage Point Differences in Mortality Rates 5

6 Research evidence This is one time when a MedPAC report comes up short Given differences between populations, we would expect patients treated in SNFs to be more likely to die within two years compared with patients treated in IRFS (p. 167). Given the differences in ages and comorbidities between patients treated in IRFs and SNFs, the study unsurprisingly found that IRFs had lower mortality rates and more days alive (p. 169). Observations overlook study s propensity-score matching. 6

7 Need to take a step back There are larger questions to ask apart from the evidence for, and against, SNF and IRF outcome and cost differences. Are we asking the right question? Do we really want to overlay SNF s dysfunctional RUGs pymt system into the IRF world? A pymt system that MedPAC has repeatedly called for reform or replacement? A pymt system prone to upcoding? A pymt system that encourages overutilization? Do we really want to add another layer of complexity on a group of providers who struggle to remain compliant with existing pymt systems, medical necessity rules, and audit regimes that accompany them? 7

8 Need to take a step back Why do we want to limit site-neutral payment to SNFs and IRFs? Many patients, e.g., joint replacement pts, do not need a bedservice facility They can go directly home (with or without home health) or directly to outpatient care. Why not also include these settings in a site neutral pymt system? 8

9 Need to take a step back IRF-SNF site-neutral pymt issue is a case of policy nearsightedness Where is American health care and post-acute care going long-term? Pretty clear: Look at the ACA, the IMPACT Act, the proposed BACPAC legislation Moving toward episode-based or bundled pymt and population health Bundled pymt 9

10 Need to take a step back Inputs Episodes Populations FFS Volume Bundled pym t & ACOs Quality reporting Capitation Value No risk Shared risk Full risk Higher cost settings Lower cost settings Prestige competition Price + quality competition

11 Need to take a step back Bundled pymt is the ultimate site-neutral pymt system We have over 400 Medicare bundled pymt demos and over Medicare 400 ACOs Let s learn from them: What works and does not work How these demos are reinventing post-acute care This is where we need to put our analytic energy What are the building blocks of an effective site-neutral bundled pymt system? 11

12 Need to take a step back 12

13 Need to take a step back Ask: How much money are we really saving in moving to the site-neutral world envisioned by MedPAC? MedPAC estimates: 7% (not really sure what 7% represents) MedPAC proposes a 3-yr. phase in. Is this really worth it when the solution is going to be so shortlived? When we have bigger issues to solve given the overall direction of American health care? 13

14 Is site-neutral pymt a kludge? A kludge, according to the Oxford English Dictionary, says Teles, is a clumsy but temporarily effective solution to a particular fault or problem. Steven Teles [It] is an inelegant patch put in place to solve an unexpected problem and designed to be backward-compatible with the rest of an existing system. When you add up enough kludges, you get a very complicated program that has no clear organizing principle, is exceedingly difficult to understand, and is subject to crashes. Any user of Microsoft Windows will immediately grasp the concept. Teles S. Kludgeocracy in America. National Affairs 2013;(17):

15 Is site-neutral pymt a kludge? Kludges are a product of our very incremental approach to problem solving in American public policy In this instance, however, we have an opportunity to ask: Where does site-neutral payment fit, or does it fit at all as presently conceived, given post-acute s long-term policy and payment trajectory? 15

16 Payment drives practice Tell me how you are going to pay me and I will tell you how I am going to practice

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18 Contact Information Gerben DeJong, PhD Senior Fellow for Health Policy & Post-acute Care MedStar National Rehabilitation Network Professor Department of Rehabilitation Medicine Georgetown University School of Medicine 102 Irving Street, NW Washington, DC (office) (mobile) 18