Proposed hospital payment measures do not consider post-acute care sufficiently, AHCA tells CMS

A potential new Medicare payment measure for hip and knee replacements needs to be revised, or it could limit patients’ access to care, according to the American Health Care Association/National Center for Assisted Living.

The nation’s largest long-term care association laid out its concerns to the Centers for Medicare & Medicaid Services on Nov. 21. CMS requested comments on two reports released in September, which described progress in developing a way to measure the costs of total hip and/or knee arthroplasty (THA/TKA). The government is interested in a measure that would take into account hospital case mix, geographic payment differences and other variables, in order to get an idea of what a reasonable cost is to achieve high-quality outcomes. The measure could be used in setting payment levels in bundled payment systems and similar models.

One concern is that an expert panel was surprised that post-acute services account for 60% of THA/TKA payments. This suggests that the expert panel evaluating the proposed measure might be lacking members with post-acute expertise, AHCA/NCAL Senior Director of Therapy Advocacy Daniel E. Ciolek wrote in the organization’s comment.

Additionally, the measure does not adjust for where hospital patients come from or where they go post-surgery, Ciolek wrote. For instance, costs might be predictably lower for a person coming from and going back to a long-term care setting, as compared with someone who will undertake more rigorous post-acute therapy in order to return to “a two-story walkup home.”

“AHCA is concerned that if the hospital-level, risk-standardized payment measure associated with a 90-day episode of care for elective THA/TKA does not address these cost-predictive variables, and if the measure is adopted for quality or payment policy purposes in the future, then patient access to such services may be compromised,” Ciolek wrote.

The worry is that if risk adjustment is not adequate, hospitals might avoid performing procedures on patients who require more complex and costly rehab, or these patients might not have access to the needed level of post-acute therapy, according to Ciolek.