Will the MDS ever go away?
Maria Arellano, MS, RN
Here's a question on many people's minds: Will OASIS and MDS merge? For assessments: maybe; for payment: not likely. Will the MDS be replaced by the CARE Tool? It is possible, even likely. Will it be partially or completely replaced? The complete answer remains unknown for now.
As the industry moves from fee-for-service to the episodic world of care, much emphasis has been placed on understanding how payment systems work over the past couple of decades. This view evaluates outcomes at the close of an episode, before the checks get cut. But what about at the beginning? Can a common assessment language set the stage for better outcomes across the continuum? Can this common assessment tool downstream lead to savings for the taxpayer?
Introducing the CARE Tool: The CARE (Continuity Assessment Record and Evaluation) tool is an Internet-based, single, comprehensive patient assessment instrument that could be used in acute care hospitals and the four PAC settings of interest (LTACs, IRFs, SNFs, and Home Care Agencies). CARE was called for by Congress, as part of the 2005 Deficit Reduction Act, and chartered CMS to conduct a Post-Acute Care Payment Reform Demonstration (PAC-PRD). As described in the report, Medicare has different payment systems post-acute providers, each with its own case-mix groups, payment units, associated payment rates, and incentive structures. The variability in case-mix measurement and payment methodologies, including both units and adjustment approaches, makes it difficult to compare patient or facility cost differences in a standard way across settings and to create consistent incentives across payment systems. Congress is also concerned about paying for overlapping services across an episode in the fee for service world.
The study, which included 140 participating providers included 15 acute care hospitals, 15 LTCHs, 26 IRFs, 43 SNFs, and 41 HHAs; was just published in January 2012. The estimated provider burden was 30 minutes to one hour per assessment, and was the same as or 10 minutes less than the estimated burden of the current CMS assessment tools, such as the MDS and OASIS.
Key Study Findings:
1) The development of Case Mix Systems using uniform definitions and measures of patient acuity between different settings is possible and can be accomplished with a limited set of common patient acuity items.
2) Post Acute Care payment systems can be improved by:
- The inclusion of patient acuity measures that are not included in current payment systems.
- Separately examining and modeling the routine, therapy, and non-therapy ancillary aspects of patient- specific resource use.
3) Multiple approaches to the unit of payment are possible. The choice of payment unit will be largely driven by policy considerations rather than empirical results.
4) Evidence supports the potential for development of a common payment system for the three inpatient PAC settings: LTCHs, IRFs, and SNFs. Evidence also supports modeling home health routine service use separately from the other PAC settings.
5) Using the same acuity measures with the same weights and base rates, consistent payment models predicting patient specific use of therapy services can be created for SNFs and IRFs with minimal levels of over or under estimation. Therapy models that include all three PAC inpatient settings including LTCHs show promise for future development.
6) Due in part to the nature of home health service provision of care, a payment model combining home health with the other types of PAC providers is not supported by the analysis.
7) After controlling for the patient acuity measures, provider type is a statistically significant predictor in the models of change in self care functional ability from admission to discharge.
- IRF stays were associated with a small but statistically significant impact on improving self care functional ability from admission to discharge
- HHA stays are associated with a statistically significant positive impact on improving self care functional ability from admission to discharge
8) After controlling for patient acuity differences, LTCH patients appear to have significantly lower probabilities of being readmitted to an ACH within 30 days of discharge relative to a SNF setting. The interpretation of this result should be made with consideration of the capacity of LTCHs, as hospital-level providers, to deal with higher severity patients.
Key Finding for the CARE Tool itself:
- The implementation of CARE within the demonstration was successful. All five settings were able to use CARE to collect information in a consistent, reliable, and comprehensive manner for their Medicare populations.
- Participant feedback on CARE was generally positive, particularly regarding the functional status items.
- Reliability testing for CARE showed positive results that are consistent with reliability standards used for previous CMS mandated patient assessment instruments. Overall, the inter-rater reliability results showed very good agreement on most items, suggesting these items could be used to measure a patient's progress in a standardized way across an episode of care.
What does this mean to us?
What does that mean for the MDS itself? Will the CARE Tool replace the MDS completely or just at admission and discharge? Will the schedule for assessments change? While the “how” and “when” are still unknown we can only speculate on these variables. We can, however; conclude that with these positive findings, CMS will move forward with the CARE Tool and payment reform and the details will unfold over time.
The CARE Tool and the MDS 3.0 are similar in many ways but are not a 100% match. To most clinicians in the industry, the thought of yet another new tool causes their heart to skip a beat. However, looking at the positive side, the benefits of a single assessment tool across the post-acute continuum may include:
1) Efficiency: helps to improve transitions of care as the data shared is consistent
2) Quality: standardizes quality measures and goals, regardless of care setting
3) Economic: from a taxpayer's perspective, helps prevent care providers from charging for redundancies
4) One version of the truth: CARE accelerates the need for an interoperable EHR, to minimize redundancies
5) Reduced data entry & better accuracy: through increased interoperability
6) Eliminate patients having to tell their story over and over again which reduces the chances of missing information.
To read the entire report with details on the study design and specific outcomes, download the report at http://www.cms.gov/Reports/Downloads/Flood_PACPRD_RTC_CMS_Report_Jan_2012.pdf.
Maria Arellano, MS, RN, is a Clinical Designer at American HealthTech and member of CMS's CARE (Continuity Assessment Record and Evaluation) Technical Expert Panel (TEP)