Medicare Post-Acute Care: Quality Measurement Final Report. V. CONCLUSIONS AND POLICY IMPLICATIONS


Understanding the quality of post-acute care is more important and has become more challenging than ever before. The multiple and ongoing changes to Medicare post-acute care payment policies create a dynamic environment in which measuring the effect of service delivery is particularly difficult. The statute requires new PPSs for each post-acute care provider type. Each PPS varies in terms of key design features such as the unit of payment (per diem, per discharge, every 60 days), classification schemes (e.g., RUGs, HHRGs, and case mix groups), and patient assessment instruments and processes used for patient classification (e.g., MDS, OASIS, and MDS-PAC). Each of these payment schemes is being phased in on different timetables, and each is being modified in different ways and at different times. How such fragmentation will affect the quality and outcomes of post-acute care is difficult to anticipate.

This project identified a mixture of both global and disease-specific measures that are important in measuring outcomes of post-acute care, based on a consensus of clinicians and researchers, and a review of the literature. The study focused on patients who, following a hospital stay, received post-acute care for conditions that required either intense medical or rehabilitation management. The conditions targeted in this study were CHF, pneumonia, stroke, and back and neck (lumbar spinal stenosis). Through discussions with expert clinicians and researchers, and a review of the literature, post-acute care outcome measures were identified that include traditional measures of physical function, utilization, and mental health, and measures emphasizing symptom relief, specific therapies and other processes of care, satisfaction, and health-related quality of life including role resumption.

Based on input from expert clinicians and researchers, and a review of the literature, the project found that existing administrative data do not contain information needed to measure important outcomes within and across post-acute care settings, and across a span of time over which important post-acute care outcomes may mature. While existing data systems include information needed for some of these measures (e.g., utilization and functional measures) many of the measures identified as important in understanding quality of post-acute care are not included in existing administrative data (e.g., mental health, quality of life, satisfaction, and role resumption). In addition, while existing data systems measure functional status (i.e., information that was considered important across all conditions), existing patient assessment instruments measure functional status in different ways and at different times across post-acute care settings. Further, the differences in patient assessment instruments and processes make it difficult to identify whether similar patients are, in fact, treated across different settings, and if so, what are their relative outcomes of care. Finally, patient assessment data is collected only as long as a patient is treated in any particular post-acute care setting. However, many outcomes that the expert clinicians and researchers identified as important may not be present until after the patient is discharged from the post-acute care setting. Thus, while existing data systems may serve a variety of purposes, they were not found to include information needed to measure post-acute care quality and outcomes.