Measuring a patient’s job is a significant obstacle to finding fair wages after acute

As an advisory board in Congress wrestles with how to subject all post-acute providers to a single payment system, the use of self-reported data continues to cast doubt on the ability to accurately measure patient outcomes.

Members of the Medicare Payments Advisory Committee on Thursday directed staff to continue evaluating the proposed potential payment system with a focus on improving how they measure patient function.

She was one of several post-acute subjects at the two-day MedPAC meeting; Members also discussed the minimum level of skilled nursing staff and the reliability of that data in the afternoon session (see below). But a large part of the morning was devoted to the continuous development of the PPS model.

“In addition to just coordinating payments, I think there is real value in this exercise in coordinating cost-sharing, harmonizing quality measures, and harmonizing regulations across different PAC settings. MedPAC member and Harvard healthcare policy expert David Graboswki, Ph.D., said,” I think that will have value wherever this type of model ends up.”

Grabowski added that differences in how functional status and outcomes are assessed make it difficult to compare the settings and care provided there “from apples to apples.”

He and several other commissioners expressed specific concerns about the patient’s job classification. Early research into the emergence of the patient-driven payment model has shown that nursing homes significantly treatment decreased minutes, while their assessment of the individual patient’s needs, or characteristics, “go up significantly,” Grabowski said.

“How much of this is real? We believe very little based on the hospital’s claims. We believe a lot of that is being updated,” he said. “So since we rely on coding from various post-acute providers, let’s make sure it’s accurate. That’s really the tension: how much we can get from hospital claims, and how much we have to rely on it to tell us what the characteristics are. I’m very skeptical based on what happened.” In the PDPM we will have accurate information.”

MedPAC is following up on the 2014 requirements for the design of a uniform payment The system that would advance and evaluate care provided by skilled nursing, inpatient rehabilitation facilities, long-term care hospitals, and home health agencies.

Staff are currently working on their next report, due in June 2023, in which it evaluates the system proposed by the Secretary of Health and Human Services earlier this year.

This work looks to update the analysis and design features, particularly in light of changes in provider and recipient behaviors during the pandemic; Compare the prototype to the features MedPAC previously said it would prefer; assess whether additional diagnoses are needed; and analyze how the system will be implemented, and whether reimbursement levels are needed for a transitional period.

MedPAC will review the entire report for the first time in March and vote on the final draft in April.

Carol Carter, the panel’s principal analyst, said the researchers were looking to better understand how and when a job is recorded in various PAC settings, particularly when it is linked to payment.

“There are incentives to rate patients as lower than they really are to set payment at a higher rate, so we are concerned about the quality of the information as much as we miss the data,” she said.

Member Dana Gilge Safran of the National Quality Forum noted that nursing homes were not the only place that might produce biased information, adding that home health patients can provide inaccurate information about themselves due to cognitive issues.

Member Robert Sherry, MD, chief medical and quality officer at UCLA Health, echoed Grabowski’s concerns about measuring functional status across settings. He wants regulators eventually to make functional results a “mandatory report” so that nursing homes and other places have to present the information using a common methodology that is less prone to coding.

“These functional outcomes are really crucial in determining whether or not the payment is appropriate,” he said. “At the end of the day, it’s really important to understand what we’re paying for what we’re getting.”

Stimulating increased hiring?

Also on Thursday, MedPAC members received a quick analysis of their payroll employment data. In light of the Centers for Medicare and Medicaid Services’ study of potential minimum staffing, committee staff wanted to know how members might want to use this data to inform future policy efforts.

Among the key findings was the fact that contract employment nearly tripled during the pandemic, from 3% in the first quarter of 2019 to 8.4% in the fourth quarter of 2021 (latest data included).

Members noted that the total number of employee hours decreased in the same time period, narrowing the gap between available workers and residents’ needs. While that may not sound like a crisis to fellow MedPAC members, Grabowski emphasized that the reduced hours have occurred even as residents have presented themselves as more medically complex, and are demanding more care.

He noted how objective payroll-based data was better than previous self-reported metrics, and encouraged MedPAC to pursue a position that better stimulated higher employment levels.

“They have this great metric now,” he said, “and they should weigh that down even more (on Care Compare)”. “I strongly support recommending this to CMS.”

Grabowsky also said that MedPAC should evaluate the hours physical therapists spend caring for residents, while another member encouraged staff to determine how often doctors are in nursing homes and how this might be linked to quality.

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