On October 6, 2014, President Barack Obama signed into law HR 4994, also known as the IMPACT (Improving Medicare Post-Acute Care Transformation) Act[1]. The primary goal of this new law is standardization of Post-Acute Care (PAC) patient data and exchange of information upon patient transfer from setting to setting. The Secretary of the Department of Health and Human Services (HHS) is also ordered to evaluate payment systems in preparation for possible bundled care payments in the future, although the timeline for bundled payments was not set. Home Health Agencies, Skilled Nursing Facilities, Inpatient Rehab Facilities, and Long-Term Care Hospitals are classified as PAC providers.
Currently, PAC entities do not have standardized data sets; and each setting works in a silo-type state. This hampers the tracking of a patient’s progress, including mobility and functional status across care settings. The IMPACT Act puts into motion a series of events that will standardize the collection and exchange of assessment data, data on quality measures, as well as data on resource use (such as the number of therapy visits in each setting, supplies and length of stay) across all post-acute settings. The deadline for PAC entities to implement this standardized assessment and exchange varies per setting, the latest of which is 2019.
Part one of the new law states that PAC providers will report standardized patient assessment data, data on quality measures and data on resource use using assessment instruments that will be created or revised before the implementation of reporting between 2016 and 2019. For HHAs (Home Health Agencies) this instrument is currently the OASIS data set. Skilled Nursing Facilities (SNFs) currently use the Resident Assessment (RA). Inpatient rehabilitation facilities and long-term care facilities do not yet have a standardized assessment, but use Medicare beneficiary assessment instruments instead. The new standardized patient assessment data set will include:
- “Functional Status (Mobility and Self-Care on Admission and before Discharge)
- Cognitive Status (Ability to express ideas, Ability to understand, and Mental Status including Depression and Dementia)
- Special Services, Treatments and Interventions (such as ventilators, dialysis, chemotherapy, total parenteral nutrition or central line placement)
- Medical Conditions and Co-Morbidities (such as Diabetes, CHF or Pressure Ulcers)
- Impairments (such as Incontinence, Hearing, Vision or Swallowing)”[2]
The exchange of this data will help the Centers for Medicare & Medicaid Services (CMS) and providers gauge the complexity of the patient’s condition, as well as view the patient’s progress from onset of illness to transfer to discharge to another health care setting. Currently, this exchange is disjointed at best and is reliant upon each facility or setting’s policy and compliance regarding what is important information to share.
Another long-term goal of CMS is changing the way patient care is paid for by Medicare. Two main themes are explored most frequently: Bundled Payments and Pay for Performance. Bundled payment means that payment is shared across healthcare settings for a patient’s illness or injury from onset until recovery[3]. Pay for performance is based on the total quality of care delivered by the provider. Recent publications by CMS continue to embrace these new payment types.[4] The specifics and dates of implementation are not yet known; but agencies who embrace this thought process and focus on quality of care delivery and accurate patient assessment will be better positioned for success when implementation does occur.
The Quality Measures that will be submitted and monitored with pay for performance will include:
- “Functional Status-Mobility and Self-Care
- Cognitive Status-Ability to express ideas, ability to understand and Mental Status (Depression and Dementia)
- Skin Integrity and changes in Skin Integrity
- Medication Reconciliation
- Incidence of Major Falls
- Accurately communicating the existence of and providing for the transfer of health information and care preferences of an individual to the individual, family caregiver of the individual and providers of service furnishing items and services to the individual when the individual transitions”[5] from health care setting to another or to the patient’s home.
This quality data will be tied to Medicare payment in the future. Providers who provide higher quality outcomes for patients would be paid higher amounts than their under-performing counterparts. Confidential reports on each provider’s performance as compared to other providers, based on these required measures, will be available for review. Arrangements for public reporting (similar to the Home Health Compare web site) of PAC provider performance on quality will also be made available, thus empowering beneficiaries to choose higher performing providers to provide their care.
Another aspect of this new law is that MEDPAC is directed to evaluate PAC payment systems based on the characteristics of the patient rather than where the Medicare Beneficiary receives care. MEDPAC is also tasked with recommending to Congress a prototype for PAC PPS. Resource measures such as total Medicare spending per beneficiary, potentially preventable hospital readmission rates and patients discharged to the community will also be studied. Payment rates for items and services will likely be based on an individual’s characteristics rather than setting for care delivery, clinical appropriateness of items and services, Medicare beneficiary outcomes, greater coordination around a single condition or procedure and integrated hospital systems with PAC providers.
In closing, it is imperative that home health agencies become familiar with and embrace proposed changes long before they are implemented. Failure to be forward-thinking often causes decreased productivity and/or decreased ability to adapt to change when implemented. Home care and post-acute care in general is likely to become more integrated in the future. Embracing this transformation by working on business relationships, quality of patient care and accurate assessment of the patient will often increase the provider’s financial resources in both the near future as well as in the long-term.
For complete details of the IMPACT Act, HR 4994, follow this link: https://www.govtrack.us/congress/bills/113/hr4994/text.
[1] http://www.whitehouse.gov/the-press-office/2014/10/06/statement-press-secretary-hr-4994
[2] https://www.govtrack.us/congress/bills/113/hr4994/text.
[3] http://innovation.cms.gov/initiatives/bundled-payments/
