Post-acute payment bundling system appears ominous

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Nursing homes have cause to worry about the prospect of a Medicare post-acute payment bundling system. If it pans out, facilities may end up on the losing side of the equation.

That is just one of my takeaways from a panel discussion held during this week’s American College of Health Care Administrators' annual conference in Providence, RI. The four panelists, who represented long-term care associations, providers and academia, covered some of the big issues of the day.

Besides the bundling system, they covered topics including the Five-Star Quality Rating System, which still seems like a bad idea; Employee Free Choice Act (no, it’s not going away); and MDS 3.0.

Perhaps the biggest issue on the table was post-acute bundling, which appears in President Obama’s budget proposal. While it is still in the discussion stage in Washington, it already has raised lots of concern and questions in the hospital and long-term care communities.

The idea behind the plan, the speakers explained, is to reduce the number of rehospitalizations and create more accountability for hospitals. To do that, the Centers for Medicare & Medicaid Services would allocate a certain amount of money for post-acute episodes to hospitals, which would be responsible for distributing the money to the appropriate provider, such as skilled nursing facilities. The bundling would cover 30 days of post-acute care—the time when many patients are vulnerable to being rehospitalized.

Not surprisingly, the whole proposal raises a red flag for the post-acute community. What would be the incentive for hospitals to give away the funding? But hospitals, like skilled nursing facilities, are not wild about the concept, the experts said. They don’t necessarily want the responsibility of handling the funding and decision-making for each post-acute “episode.”

Skilled nursing facilities are concerned because post-acute care has become an important revenue stream. There’s a fear that hospitals will retain the more short-term patients and discharge the ones with multiple co-morbidities, who likely will need long-term care, back to skilled nursing facilities. Very plausible. Then again, it’s been shown that it’s cheaper to send post-acute patients to SNFs for rehab. So who knows?

“If we prepare ourselves I think we can be competitive,” said panelist Lane Bowen, president of the Health Services Division at Kindred Healthcare.

That remains to be seen, judging by what the panelists offered.

Besides Bowen, the panelists were Vincent Mor, chair of the Department of Community Health and professor of Medical Science at Brown University; Angelo Rotella, former chair of the American Health Care Association; and Dave Kyllo, executive director of the National Center for Assisted Living. Moderating the talk was Randy Lindner, president and CEO of the National Association of Boards of Long Term Care Administrator Boards (NAB).

Five-Star criticism

The panel also offered some important points about the Five-Star rating system and the Employee Free Choice Act during the Sunday session. Panelists, such as Mor and Rotella, were not shy about berating Five-Star, a ranking system on the Nursing Home Compare Web site, that started in December. Nursing homes can receive between one and five stars, based on health inspections, staffing and quality measures.

Rotella talked about how it misleads consumers and could actually be detrimental to the businesses of nursing homes with low-star rankings.

“We’re talking about snapshots instead of moving pictures and the snapshot gets old very quickly,” Rotella noted.

Mor is pushing for a dual ranking system: one that ranks rehab in nursing homes and another that ranks facilities as a place to live, a la long-term care.

Regarding the Employee Free Choice Act, NCAL’s Kyllo mentioned that with the current opposition fighting it, it likely won’t go anywhere in its current version. Still, a milder form likely will pass.

Bright spots

The discussion, all in all, was educational and illuminating. Here are a few other (by no means all) highlights of the conference:

- Rev. Monsignor Charles J. Fahey, an icon of the long-term care field, offered a frank lecture about aging and long-term care. Using his recent hip and cataract surgeries as a point of reference, he talked about the inevitability of aging. Nursing homes should stop denying the reality of death and talk about themselves as good places for end-of-life care, he said.

- Philip Dubois, an administrator at Market Square Health Care Center in South Paris, ME, delivered a moving presentation during an education session on Sunday. A horrific car accident that killed three family members forced him to live as a resident at his facility. He talked about the experience and what he learned from the perspective of a resident.

- Perhaps the best part of the conference is that many attendees left with a bit more knowledge, a sense of collegiality with others in their profession and a renewed sense of purpose. More than 400 people attended on Sunday and 100 vendors exhibited.

Mark Jacobs, administrator of the 47-bed Victorian Villa in Canton, ME, summed up what the conference means to him. Being in rural western Maine, he said he sometimes feels cut off from the long-term care community and wonders what is happening in other facilities. (In case you’re curious about how remote Canton is, his facility touts that it has a new cell phone tower, according to its Web site.)

Being at the conference allowed Jacobs to talk and share experiences with his counterparts from the rest of the country.

“It makes you feel like you’re back in the loop,” he said, smiling.
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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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