CMS seeks comment on new post-acute admission policies for accountable care organizations

Share this content:
Specially trained RNs could help reduce avoidable hospitalizations, results suggest.
Specially trained RNs could help reduce avoidable hospitalizations, results suggest.

The Centers for Medicare & Medicaid Services is considering giving accountable care organizations more flexibility in how their patients can access post-acute care. The agency described these policies in a proposed rule announced Monday and requested that stakeholders submit comments by Feb. 6.

CMS is considering waiving the requirement that beneficiaries spend three days as a hospital inpatient before qualifying for subsequent skilled nursing coverage, according to the document. This waiver would potentially apply to ACOs in the Medicare Shared Savings Program under two-sided risk — that is, they are eligible for financial rewards but also penalties, if they don't meet performance and cost benchmarks. There currently are more than 330 ACOs in the Shared Savings Program, according to CMS, and their results have been mixed.

The government also wants input on how this waiver might work, such as whether it should only apply to skilled nursing facilities that are part of the particular ACO. Another question is whether the forthcoming skilled nursing facility 30-day all-cause hospital readmission measure should be one of the quality indicators that ACOs have to meet. If the hospitals, physicians and other providers in an ACO meet quality and cost-saving goals, they are eligible to receive a portion of the savings to the Medicare program.

Hospitals also have said that they would like to be able to steer patients to SNFs that they deem high quality, but they are worried about running afoul of Medicare rules that beneficiaries must have freedom of choice in selecting a post-acute provider. CMS believes that existing statutes, regulations and guidance are clear enough on this issue, according to the proposed rule. However, the agency did float the possibility of waiving the requirement that hospitals “not specify or otherwise limit the qualified provider which may provide post-hospital home services.”

The proposed rule contains other information relevant to post-acute care, including whether certain codes for SNF services should be defined as primary care. The 429-page document also puts forward large-scale changes to the ACO program. These include a three-year extension of the time period in which an ACO can earn financial rewards without being at risk for penalties.

Another proposed change would take local market conditions more into account when calculating financial performance benchmarks. Some critics of ACOs have said this is necessary for the system to be viable in the long term. Earlier this year, leaders of a Pioneer ACO in California cited a lack of regional adjustment as a main reason they dropped out of the program.

Click here to access the CMS press release, which links to a fact sheet and the full proposed rule.