Kill inpatient rule, use functional criteria to determine Medicare coverage for skilled nursing, leading geriatrician says

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The Centers for Medicare & Medicaid Services should consider providing Medicare skilled nursing coverage for a person with certain functional limitations, regardless of whether that person has been hospitalized, according to a new “Viewpoint” article in Journal of the American Medical Association. 

Currently, a Medicare beneficiary only receives SNF coverage after spending three midnights as a hospital inpatient. There is “little empirical evidence” that eliminating this unpopular rule will improve care without increasing costs, but there is “justifiable concern” about its bad effects, wrote Harvard Medical School Professor Lewis A. Lipsitz, M.D., chief of gerontology at Beth Israel Deaconess Medical Center and director of the Institute for Aging Research.

The current rule incentivizes SNFs to admit residents to the hospital to benefit from subsequent Medicare reimbursements after the resident returns, and poses problems for beneficiaries who need skilled care but don't necessarily need to be admitted as a hospital inpatient, Lipsitz stated, echoing many high-profile critics of the inpatient rule. These include former acting CMS administrator Donald Berwick, M.D.

Lipsitz noted CMS could set specific functional criteria for skilled nursing care, such as the presence of delirium.

Some observers say the groundswell against the current situation is reaching a critical point, and the inpatient rule is doomed. Dale Zaletel, a senior operations consultant and post-acute development strategist, told a webcast audience at McKnight's Fall Online Expo that he expects the rule to be scrapped within a year.

Click here to access Lipsitz's JAMA article.