Even though a new, unified payment system has been discussed for several years, the mere mention of it in President Trump’s budget proposal jolted observers in February.

The budget specifically said a new system is needed due to “excessive payment” currently going to post-acute providers.

Such a system would be based on resident/patient need instead of the care setting — be it skilled nursing facilities, home health agencies, inpatient rehabilitation facilities or long term care hospitals.

The Medicare Payment Advisory Commission was expected to make a recommendation to Congress about a unified payment system in its March report. The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT) requires the com- mission to develop a prospective payment system covering the four PAC settings.

Trump’s budget also calls for allowing accountable care organizations to cover primary care visits in order to encourage Medicare beneficiaries to use the ACO’s providers.

One of providers’ biggest concerns about the budget is support shown for Medicaid per-capita caps or block grants that would replace the current funding, starting in fiscal 2020.

Another concern for some observers is that the budget calls for expanded use of State Section 1115 Medicaid Waiver authority to “foster state-level Medicaid reform.”