Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Prospective Payment Systems for Post-Acute Care

12/01/2011

Implementation of a PPS in inpatient acute care facilities in 1983, while exempting most PAC settings,n contributed to the spiraling costs of PAC, as patients were sometimes moved from one facility to another based on reimbursement policies rather than where they might receive the best care. Because of the PPS, there was impetus to move patients out of acute care facilities at a quicker rate. The growth in federally-funded post-acute health care expenditures led to the Balanced Budget Amendment (BBA) of 1997, which required that PPS be created for nursing homes, rehabilitation hospitals, home health care, and long-term care hospitals (LTCHs).15 PPS for these PAC settings, three of which are based on setting-specific assessment instruments, were implemented between 1998 and 2002.

Significant legislative activity since the BBA has included the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999,16 the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000,17 and the Deficit Reduction Act (DRA) of 2005.18 Both BIPA and the DRA contained requirements that HHS develop instruments to assess PAC that would be compatible across settings. BIPA required the Secretary of HHS to report to Congress on the "development of instruments to assess the health and functional status of beneficiaries using post-acute care and other specified services…. The assessment instruments required by BIPA are to have readily comparable, statistically compatible, common data elements and include only those elements necessary to meet program objectives.”19 The BIPA legislation also specified that the standardized instruments developed were to supersede currently-mandated assessment tools:

SEC. 545. DEVELOPMENT OF PATIENT ASSESSMENT INSTRUMENTS.

(a) DEVELOPMENT.--

(1) IN GENERAL.--Not later than January 1, 2005, the Secretary of Health and Human Services shall submit to the Committee on Ways and Means and the Committee on Commerce of the House of Representatives and the Committee on Finance of the Senate a report on the development of standard instruments for the assessment of the health and functional status of patients, for whom items and services described in subsection (b) are furnished, and include in the report a recommendation on the use of such standard instruments for payment purposes.

(2) DESIGN FOR COMPARISON OF COMMON ELEMENTS.--The Secretary shall design such standard instruments in a manner such that--

(A) elements that are common to the items and services described in subsection (b) may be readily comparable and are statistically compatible;

(B) only elements necessary to meet program objectives are collected; and

(C) the standard instruments supersede any other assessment instrument used before that date.

(3) CONSULTATION.--In developing an assessment instrument under paragraph (1), the Secretary shall consult with the Medicare Payment Advisory Commission, the Agency for Healthcare Research and Quality, and qualified organizations representing providers of services and suppliers under Title XVIII.20

The DRA (Section 5008) charged HHS with developing a single comprehensive assessment to be used upon discharge from inpatient hospitals and in all post-acute sites. A demonstration program was to explore uniform patient assessment and develop payment groups based on severity of illness and resource utilization across post-acute settings.21 The Office of Management and Budget (OMB) clearance package supporting the development of the instrument mandated by DRA 2005 claimed: “The lack of a uniform post-acute assessment tool is one of the major limitations to understanding variation in post-acute outcomes, cost-effectiveness, and Medicare payments.”22

Despite regulatory activity, the three currently mandated assessment tools are not likely to be replaced in the very near term due to the fact that each instrument presently supports setting-specific payment methods, and they are considered by representatives of the individual care settings to be best at supporting clinical care decisions, resource-based reimbursement, and quality improvement initiatives.

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