Concerns about lack of skilled nursing access for cancer patients, as well as oncology-related costs borne by skilled nursing facilities, have prompted operators to call for action from the Centers for Medicare & Medicaid Services (CMS).
Several nursing home professionals raised this issue in comments to CMS’ proposed Medicare payment update for 2024. One oncology nurse commenter said it’s very difficult to get an oncology patient into a SNF, despite it being “imperative” that such patients receive rehabilitation in this setting in order to improve their performance status – and in turn qualify for certain treatments and tolerate the treatments better.
Discriminatory treatment stems from costly oncology drugs, the nurse said, adding that CMS should review and add expensive chemotherapy and other oncology medications to the list of exempt consolidated billing medications.
Top on the list are: Denosumab, Leuprolide and Keytruda, among other regimens.
“I think everyone is trying to figure out the associated cost under consolidated billing with a number of different items, including chemotherapy, including PET scans, including transportation … there’s also radiation treatment,” said Tim Fields, CEO and co-founder of Ignite Medical Resorts.
Cost of care often exceeds the reimbursement rate, with oncology medications valued at tens of thousands of dollars.
Through consolidated billing, a SNF under Medicare Part A or managed care receives a “fee” from Medicare to cover everything under that stay, Fields said.
“All of your pharmacy, your medical supplies, your therapy – everything that would be covered that way, you would need to take care of the patient all under that one fee that you get, we as an industry bill a per diem,” he said.
The per diem rate is based on a managed care plan or the PDPM score. And pharmacy, as well as medical supplies and food, are the three largest costs a SNF has aside from labor.
Stuck between cost of care and access issues
Meanwhile, some skilled nursing facilities are asking clinicians on the acute care side to hold any cancer treatment for patients in rehab to avoid high consolidated billing costs.
“Delaying oncology treatment leads to patients and families having to balance the risks of a progressive and debilitating disease with the need to receive therapies for increased strength, endurance, and safety to return to their home setting,” Clarissa Cox told Skilled Nursing News in an email; Cox is system vice president of care management at Minneapolis-based acute care system Allina Health.
Marcia Lindig, transitional rehab program director for Courage Kenny Rehabilitation Institute, said in an email to SNN that staffing constraints already affect the number of admissions nursing homes can take – facilities can’t afford to accept referrals with low reimbursement and high expense.
Courage, a SNF, is part of Allina.
Associations including the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) have advocated for solutions to the SNF consolidated billing requirements, so that new, high-cost drugs and services can be implemented in a timely manner.
Regulatory rulemaking can be a more time-effective solution than updating statutory exclusions, AHCA/NCAL said in an emailed statement to Skilled Nursing News.
“We encourage Congress to address this issue so seniors can access this life-saving care,” AHCA/NCAL said. “By working together, we can ensure that oncology patients receive the care they need while alleviating the financial burden on families and nursing homes.”
Acute care systems like Allina advocate for expanding the “J-Code exclusion list” to include oncology medications. This would allow SNFs to be reimbursed for oncology medications outside of consolidated billing, Cox said.
“The list of chemotherapy medications that are excluded from consolidated billing has grown slowly over time,” added Lindig. “Allina Health has requested that CMS establish a formalized process where people (patients, providers and entities) can submit considerations for the exclusion list.”
Better hospital partnerships, advanced programs
Solutions also lie with aligned partnerships between SNF operators and hospital systems, Fields said.
A “workaround” for an operator would allow a resident to go through cancer treatment in a hospital as an inpatient, he said. The patient would be admitted to the nursing home first for rehabilitation, to get stronger mobility and endurance – essentially become a healthier patient before they’re admitted to the hospital for their cancer treatment.
Once the treatment is done, they could be discharged back to the nursing home for additional rehab and therapy, then eventually could go home and receive follow up care with outpatient centers.
Operators would do well to work with the hospital physicians to avoid heavy financial burdens associated with cancer drug costs.
That’s what Ignite does for oncology patients who need services, but there could be more advanced programs specifically for this type of patient that could better align cancer treatments at the hospital and rehabilitation initiatives through post-acute care, Fields said.
“Unfortunately, the way that consolidated billing works, [cancer patients] just get admitted to [SNFs], and then they’re getting all their treatments while they’re still an inpatient with us, all those costs fall on the facility,” said Fields. “It’s not feasible, when they’re going through super expensive testing and treatments.”
Cox and Fields agree that oncology patients make up a small and underserved population for the SNF industry – Cox believes this is because the patient population is forced to choose between cancer treatment and short-term rehabilitation.
“Our hope with advocating for change is that patients could access the right level of care and still receive oncology treatment,” said Cox.
Appropriately billed SNFs would in turn increase access for such patients needing rehab, especially when both rehab and chemotherapy are recommended at the same time.
“This will also alleviate the emotional and financial burden of patients and families previously forced to make the difficult decision of rehabilitation or oncology intervention,” said Cox.
Barriers to advanced oncology programs, and different pathways
Leaders in the SNF space must look to specialized programs around heart failure and COPD, wound care and other high acuity services, Fields said. Such programs are well aligned with acute care systems, with communication and protocols in place for smooth transitions in care.
“We’ve got a program, we have protocols and communication, maybe the cardiologist or pulmonologist is rounding in a facility – they need to do something like that. That’s pretty advanced,” said Fields.
That would mean a cancer center physician, group or oncologist would be educating partner SNFs on how to better take care of these patients, show clinicians what to look for.
Convincing managed care plans to sign on for such a program is a whole other challenge, Fields said – it’s extremely difficult to have extended SNF stays approved for a typical resident, let alone a patient that needs costly cancer medications.
Long-stay residents wouldn’t have the same issues, he added, but they also wouldn’t be covered for therapy under Medicaid. Consolidated billing is specifically a Medicare issue.
With a long-stay patient, they would be considered a Medicare beneficiary as soon as they go to the hospital for a PET scan or something similar, and then once they’re discharged to the SNF where they live, they get aggressive therapy under Medicare, he said.
Ideally, such patients would already have dual eligibility for both Medicare and Medicaid.
Companies featured in this article:
AHCA/NCAL, Allina Health, Courage Kenny Rehabilitation Institute, Ignite Medical Resorts
