The American Journal of Managed Care August 2014
Synchronization of Coverage, Benefits, and Payment to Drive Innovation
Table 2 demonstrates that there is substantial variability in CMS’s payment policy waivers across payment models. CMS granted few waivers in the BPCI initiative. Those waivers that were granted may be attached to other requirements (eg, patients transferred from hospitals must go to high-quality SAFs).40 Examples of inconsistencies include: (i) the qualifying 72-hour rule before transfer to a covered skilled-nursing stay is waived for MA plans but waived only with the conditions in the BPCI initiative; (ii) pre-surgery home safety visits are waived for MA plans, while post discharge home visits are waived in the BPCI initiative; (iii) CMS does not waive conditions for Medicare’s traditional telehealth benefit for MA plans, but does expand the telehealth benefit for BPCI awardees; (iv) CMS allows some remote monitoring in MA plans, but not for BPCI awardees. CMS has not had a public discussion of the rationale behind these differing decisions.
This lack of public discussion contrasts sharply with the way CMS approached its 2003 change in payment methodology for IRFs from cost basis to prospective payment (IRF-PPS) and the subsequent revisions to the IRF coverage requirements. CMS made those changes through a multiyear rule making process that vetted the recommendations of a CMS internal working group through opportunities for public comment.41
As a result of the rulemaking process, CMS deleted the coverage guidance previously published in HCFAR 85-2-1 “to reflect changes that have occurred in medical practice during the past 25 years and the implementation of the IRF-PPS.”42
CMS has used various approaches to adapting coverage, benefit, or payment requirements in response to changes in payment methods. Examples are presented in Table 2.
In the MA program, which bases reimbursement on a capitated rate rather than on a fee-for-service amount, CMS has created supplemental benefits. For BPCI awardees, CMS has not relaxed coverage policy requirements. It has, however, granted payment policy waivers to remove certain site-specific payment requirements. When prospective payment was introduced for IRFs, CMS revised requirements for covered admissions through rule making. That is, to introduce a single policy change, CMS has engaged multiple mechanisms. For example, CMS relaxed the requirement to have a qualifying hospital stay of 72 hours before covering a skilled nursing admission as a “supplementary benefit” in the MA program, and as a payment policy waiver in the BPCI initiative.
A Path Forward