Patterns of meeting the minimum number of minutes to qualify for higher reimbursement rates were seen in 4 states: Texas, Mississippi, Arkansas, and Indiana. CMS said it will refer this matter to auditors for review.
CMS on Wednesday released data on payment and utilization rates for skilled nursing facilities, of SNFs, a healthcare delivery area that has received more attention in recent years as the federal government looks to rein in costs.
The report covered data from 15,055 facilities, involving more than 2.5 million stays and nearly $27 billion in Medicare payments for 2013. Data are “de-identified” so no individual patient information is available.
Along with the overall data, CMS provided information on 2 categories of resource utilization groups, or RUGs. CMS has noted that that in these groups, the amount of therapy provided to patients frequently comes very close to the minimum thresholds needed to qualify patients for higher reimbursement: the “Very High” level requires at least 500 minutes per week, and the “Ultra High” requires 720 minutes per week.
CMS notes that by coming within 10 minutes of the minimum threshold, the facility can receive a Medicare per diem of up to 25% higher for these patients. As reimbursement moves toward value-based incentives, rather than a fee-for-service system, these kinds of patterns are under greater scrutiny.
“CMS strives to ensure that patient needs, rather than payment system incentives, are driving the provision of therapy services,” said Shantanu Agrawal, MD, deputy administrator and director of the Center for Program Integrity. “These concerns have prompted us to refer this issue to the Recovery Auditor Contractors for further investigation.”
The federal government has taken a hard look at SNFs not only because they represent a heavy area of spending on their own, but also because they can reflect broader problems with quality care. In May 2015, researchers from MIT and Vanderbilt published a paper that linked high use of SNFs with poorer health outcomes and higher rates of downstream spending.
Texas, Arkansas, Mississippi, and Indiana stood out from other states as having patterns of patients qualifying for the higher payment threshold based on amounts within 10 minutes of the minimum. Of these, Texas, Mississippi and Indiana, have the highest range for average Medicare standardized payments per stay at SNFs, according to Healthcare Dive.
Spending at SNFs has long bedeviled CMS despite efforts to control it. In 2014, Susan Dentzer wrote in The American Journal of Accountable Care how federal officials were surprised at early results from Pioneer Accountable Care Organizations, which saw spending on SNFs increase significantly—along with spending on home health agencies—in the early days of this model.
There was some speculation that providers or plans swapped out stays at SNFs for days in acute care. But the patterns revealed with Wednesday’s data suggest a connection to reimbursement.