CARE:
Standardizing Data, Improving Payment
Barbara Gage, PhD
Dianne Munevar, MPP (presenter)
RTI, International
Project Officer: Shannon Flood
Funding Source: CMS Contracts No. 500-2005-0029I TO 5
AcademyHealth Annual Meeting
Chicago, IL
June 30, 2009
www.rti.org
RTI International is a trade name of Research Triangle Institute
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Overview
•
The Issue: Inconsistent payment incentives across PAC Prospective Payment
Systems (“PPS”)
•
The Reason: History, different payment methods, different case-mix systems,
leading to poor ability to measure beneficiary case-mix characteristics
consistently
•
The Result: Very different average payments across settings for potentially
similar patients
•
What is Needed:
– Standardized case-mix information to measure differences in costs across
different post acute care settings
– Work towards site-neutral payments for clinically similar patients
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The Problem
• Similar services provided in settings with very different
payment rates and case mix measurement methods*
• In order to compare costs, resource use, and outcomes -need to control for differences in case mix
• Requires similar measurement of medical, functional,
cognitive impairments, and other factors that affect site of
care decisions (i.e., social support)
* Sources: Gage et al, 2005; Cotterill and Gage, 2004; MedPAC, ProPAC
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Project Description
The Post Acute Care Payment Reform Demonstration
(“PAC PRD”) is a 4-year effort to examine the following:
– Appropriate payment methods for services across an episode of care,
– Variation in costs associated with treatment in each PAC setting and
across an episode of care,
– Appropriate placement of patients following acute hospital discharge,
– Variation in outcomes achieved across different post-acute care sites
controlling for case mix differences.
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Current Payment Models
IPPS
LTCH
Acute
inpatient.
medical or
surgical
Acute
inpatient,
medically
complex
IRF
Acute
inpatient,
medically
stable w/
rehab needs
1983
2002
2002
1998
Payment Unit
Discharge
Discharge
Discharge
Day
Case-mix Groups
(number)
MS-DRGs
(738)
LTCH MSDRGs (738)
RICS
(21)
RUGs
(53)
60-day
episode
HHUGs
(80)
$5,128
$39,114
$13,038
NA
NA
Intended Treatment
Population
Year PPS went into
effect
FY 2009
Base Rate/Discharge
SNF
HH
Inpatient,
Homebound,
medically
w/ skilled
stable w/
nursing
skilled nursing
or rehab
or rehab needs
needs
2000
(case w/ weight=1.00)
Sources: Federal Register
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Examples of Similar Patients, Different Settings
DRG
209: Major Joint & Limb Reattachment Procedures of
Lower Extremity
Total
Percent of Discharges to First Site of
Percent
Hospital
of Acute
PAC
Discharges Discharges
for PAC
Using
Users
PAC
IRF SNF LTCH HHA OP/B2
16,793
89.2
32.4
31.3
0.6
27.0
8.6
089: Simple Pneumonia & Pleurisy Age >17 w CC
5,052
33.1
3.0
50.2
1.9
39.8
5.1
014: Specific Cerebrovascular Disorders except TIA
4,967
65.0
33.5
39.8
2.5
16.5
7.8
127: Heart Failure & Shock
4,926
32.4
3.4
40.3
1.3
50.5
4.5
210: Hip & Femur Procedures except Major Joint Age
>17 w CC
3,943
87.6
24.0
64.9
1.7
8.0
1.3
Source: A New Era: Post Acute Use Under PPS, B. Gage, M. Morley, and J. Green, forthcoming. MedPar 2004.
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Current Assessment Instruments
• Can distinguish populations at highest end of severity
• But overlap at lowest end of severity
– Simple knees treated at IRFs and SNFs
– Ventilator weaning of “healthier” patients at LTCHs and IRFs
• Payment per discharge differs dramatically by site of care’s
PPS
– Substantial differences in base rates
– Sometimes but not always reflective of differences in patient needs
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Measuring Patients Across Medicare Settings
• Inpatient Rehabilitation Facilities  IRF-PAI
• Skilled Nursing Facilities  MDS
• Home Health Agencies  OASIS
• Long-Term Care Hospitals  no standard tool
• Outpatient Providers/Therapy Offices  no standard tool
• Acute Hospitals  no standard tool
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Common Domains in Assessment Instruments
• Administrative Information
• Social Support Information
• Medical Diagnosis/Conditions
• Functional Limitations
– Physical
– Cognitive
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Differences in Functional Scales
IRF-PAI
7= Complete independence
MDS
0= Independent
6=Modified (device)
1= Supervision
5=Supervision
2= Limited Asst. (guided
maneuvering)
4=Minimal Assistance 25%
3= Extensive Asst
(3+ times/week)
4= Total Dependence
3= Moderate Assistance
50%
2=Maximal Asst. 25%
1= Total Asst.
0= Activity NA
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8= Activity NA
OASIS
0= bathe independent
tub/shower
1= with devices,
independent
2= with person
(reminders, access, reach
difficult areas
3= participates but req.
other person
4= unable, bathes in
bed/chair
5= totally bathed by other
Unknown
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Differences in Assessment Periods
Tools
No. of
Functional
Items
Scale Levels
IRF-PAI
18
7
Past 3 days
MDS
13
5
Past 7 days
OASIS
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varies
Assessment Periods
Assessment day
Source: Gage and Green, 2006. Chapter 2. The State of the Art: Current CMS PAC Instruments in
Uniform Patient Assessment for Post-Acute Care, CMS Report, Contract #IFMC 500-02IA03.
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Objectives of the PAC PRD
• Provide standardized patient information across PAC
settings
• Compare resource use across settings
– Fixed and variable
• Compute case-mix standardized costs per patient
across settings
• Develop relative resource weights applicable across
settings
– Fixed and variable
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Why Standardize Case-Mix Across PPS?
• Standardized measurement items are needed to compare:
– Costs across similar patients
– Outcomes analysis of similar patients
• Necessary for considering whether different types of facilities
are paid equitably for treating similar types of patients
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Conclusion
• Current PAC payment systems’ use of multiple
measures of medical, functional, and cognitive measures
leads to different payment amounts per patient with
same costs and treatment needs
• Standardized measurement items are necessary if we
are to develop site-neutral case-mix payments for
clinically similar patients
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For More Information…
Please contact:
Barbara Gage, Ph.D.
Principal Investigator at RTI
(781) 434-1717 or bgage@rti.org,
or
Dianne Munevar
Health Policy Analyst at RTI
(781) 434-1712 or dmunevar@rti.org.
To learn more about the PAC PRD,
visit the project website at www.pacdemo.rti.org.
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