MedPAC Debates Troubling Post-Acute Referral Patterns

You can lead patients to a high-quality post-acute care (PAC) provider, but you can’t make them decide to go there.

That was a primary takeaway in a wide-ranging discussion at the Medicare Payment Advisory Commission’s (MedPAC) March public meeting that focused on how to steer beneficiaries into higher-quality PAC facilities.

“Medicare statute provides beneficiaries with the freedom to choose their PAC provider, and the laws state that hospitals may not recommend providers,” MedPAC senior analyst Evan Christman noted in his presentation. “The IMPACT Act created a new requirement that hospitals use quality data during the discharge planning process and provide it to beneficiaries. But regulations implementing this new requirement have not been finalized.”


Perhaps because of this uncertainty, PAC provider quality information often isn’t provided to patients discharged from the hospital, one Health Affairs study found. Patients are provided with a list of a hospital’s preferred providers that lacks information about those facilities, according to interviews with hospital and skilled nursing facility staff members.

MedPAC conducted an analysis of SNF and home health patients in 2014 that compared the quality of a provider used by beneficiaries to the quality of nearby providers and found that most beneficiaries had a nearby provider that was higher quality than the one used. Of SNF patients, about 85% had at least one better choice nearby, while about 47% had five or more.

Christman’s presentation examined a variety of pathways to get patients into higher-quality facilities. These included:


1. A “flexible” approach that lets hospitals define quality measures, performance level and other information

2. A “prescriptive” approach that uses Medicare-defined criteria for quality measures and levels of performance

3. A “revised prescriptive” approach that allows for variation in PAC quality throughout different markets

Under the flexible approach, hospitals would have to collect and review data on PAC provider performance and maintain a formal record of the process. While it would allow hospitals to set the standards they see as most appropriate for the patient, it could lead to multiple quality standards in a market, with the higher-quality designation varying from hospital to hospital, Christman noted.

The commissioners had some disagreement on the approaches; Dr. David Grabowski, one of the commissioners present at the March meeting, disdained the flexible path, saying it would “end up as business as usual… with a lot of hospitals throwing up their hands.”

On the other hand, there is some alignment between hospitals and beneficiaries on where to go for PAC, Dr. Paul Ginsburg, another commissioner, argued.

“I’d like to open up not only…drawing on these measurements for quality, but using other information such as…we work well with this SNF, you know, we really feel it’s been valuable in reducing readmissions,” he said in pushing back against the prescriptive approach.

The problem of Medicare Advantage beneficiaries being more likely to enroll in lower-starred nursing homes, as rated by CMS, was documented in Health Affairs in January by researchers from Brown University. That research was cited by Grabowski in the meeting, and there was debate over whether patients were simply using different measures to select a nursing home than the quality information provided by CMS.

Another potential issue was whether discharge planners at a hospital felt free to provide some kinds of information to patients.

“Maybe discharge planners are in a situation right now which is conflicted for them in the sense that they may know things about individual providers that they would like to be able to emphasize to patients,” Dr. Francis Crosson, the commissioner who served as chair, said in the meeting. “But they feel like they’re under a legal proscription to do that, and that’s an uncomfortable result of the current regulatory environment. And if it’s possible, we’d like to be able to find a way to relieve them of that pressure.”

The committee ultimately decided to put together a June chapter to further discuss the issues raised by the presentation, “without trying to resolve them.”

Written by Maggie Flynn

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