WellSky® Submits Comment Letter to Centers for Medicare & Medicaid Services Regarding Proposed Long-Term Care Hospital Payment Rule
June 9, 2023
The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1785-P
P.O. Box 8013
Baltimore, MD 21244–8013
Re: Fiscal Year (FY) 2024 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Proposed Rule (CMS-1785-P)
Dear Administrator Brooks-LaSure:
WellSky appreciates the opportunity to offer our comments in response to the Medicare Program; Proposed Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2024 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Rural Emergency Hospital and Physician-Owned Hospital Requirements; and Provider and Supplier Disclosure of Ownership Proposed Rule (the “Proposed Rule”), which was published in the Federal Register on April, 10, 2023[1]. Founded over 40 years ago, WellSky is a healthcare solutions company that serves 40% of the LTCH market with integrated technology that delivers comprehensive, end-to-end support for the operational and clinical aspects of their organizations.
As the leading solution provider supporting LTCHs that provide specialized programs of care for high-acuity patients who require an extended inpatient hospital stay, we want to express our sincere concern with the Centers for Medicare & Medicaid Services’s (CMS’s) proposed cuts to the program and its providers. The proposed payment adjustments will likely have a devastating impact on Medicare beneficiaries’ access to LTCH services, which have proven to be critically needed, especially for pulmonary patients after a stay in the intensive care unit (ICU) or med-surg unit, and is essential to improving outcomes, reducing readmissions, and managing total costs of care. We have focused our comments on the following key issues: 1) the FY2024 LTCH payment update; 2) the health equity data collection using ICD-10 z-codes; and 3) the LTCH Quality Reporting Program (QRP).
Comments on the Proposed Rule
The Proposed FY2024 Update Threatens Access to LTHC Services
In 2016, CMS began phasing in new patient-level criteria as established by Congress in the Pathway for SGR Reform Act of 2013. For Medicare cases that meet the criteria, LTCHs are paid a standard rate under the LTCH PPS system. For all other Medicare cases, a site-neutral rate is paid, which is the lower of an LTCH’s cost or a comparable amount to what a short-term acute care hospital (STACH) would receive for a similar patient. Once this payment structure is fully implemented, LTCHs will receive approximately half or less of the standard rate for site-neutral cases.
Only a small share of LTCHs were under the full implementation of the site-neutral policy prior to the start of the Public Health Emergency (PHE). The CARES Act of 2022 waived the site-neutral payment policy for cases that do not meet the patient-level criteria. As of May 11, 2023, the PHE waivers have ended and LTCHs are subject to full implementation of the site-neutral payment.
To meet the Pathway for SGR Reform Act payment criteria, an LTCH case must be discharged from a subsection (d) hospital immediately prior to LTCH admission, have spent at least 3 days in an intensive care unit during that subsection (d) stay, or be on a mechanical ventilator for at least 96 hours at the LTCHs. This criterion eliminates patients who can be served in lower acuity post-acute settings and guarantees a severely ill patient population. As some of the nation’s most vulnerable patients, this population requires complex treatment.
The increase proposed to the high-cost outlier (HCO) threshold for standard LTCH cases by 245% from the current $38,518 to $94,378 to achieve the target of paying roughly 8% of aggregate LTCH payments as HCO payments is of great concern[2]. With the HCO threshold increasing so drastically, providers will be forced to shoulder much more of the costs of services. This change, coupled with the CMS projected proposed update for LTCH payment rates, will result in a net decrease of 2.5%, which will threaten access to vital LTCH services. LTCHs deliver necessary hospital-level services to clinically complex patients and have proved to be a vital asset to produce significantly better outcomes for our nation’s sickest patients, therefore a less significant HCO increase should be considered.
LTCH’s focus on treating critically ill patients, especially in rural communities, is threatened when the inflationary payment update is not reflective of the rising costs of delivering care. LTCHs are challenged with rising labor costs as the caregiver shortage continues at crisis levels and medication costs and supply prices increase —all during historic inflation. This significant reduction in LTCH reimbursement inhibits LTCHs’ ability to provide high quality care to high acuity patients, and many LTCHs could be at risk to reduce services.
Proposed Changes to Homelessness-Related Diagnosis Code Severity are Critical to Advancing Health Equity
WellSky supports the Biden Administration’s efforts to advance health equity and improve health outcomes, which we believe can be enhanced by improved harmonization of clinical data standards and use of health information technology. CMS’s proposal to amend the severity level of 3 ICD-10 CM diagnosis codes describing homelessness – unspecified (Z59.00), sheltered homelessness (Z59.01), and unsheltered homelessness (Z59.02), from non-complications/comorbidities (CC) to complications/comorbidities is a welcome change. This proposed change will allow for higher resource utilization, as these patients face additional challenges with subsequent associated costs.
Patients who are experiencing homelessness often have multiple social factors impacting their overall wellness. They face challenges associated with safe discharges and access to care—especially early interventions—which leads to more complex symptoms and worse outcomes when they do receive timely care. Lack of access to prescription medication, improper nutrition, and exposure to extreme climate conditions heighten the risk of being exposed to communicable diseases. All efforts to encourage providers to use standards including ICD-10-CM Z codes to identify nonmedical factors that may influence a patient’s health status help advance interoperability as we work toward a digital health environment.
As the leading technology partner for organizations across the post-acute care spectrum, WellSky fully supports methods to incentivize documenting and reporting diagnosis codes describing social and economic conditions. Utilizing existing standards allows for functional exchange of health information for all providers who serve long term and post-acute care (LTPAC), behavioral health, and other providers left out of the incentives from the The Health Information Technology for Economic and Clinical Health (HITECH) Act, who are in different stages of health IT adoption. Sharing social determinants of health data can aid with risk prediction and subsequently inform caregivers with proactive interventions to promote improved outcomes.
LTCH Quality Reporting Program (QRP): For FY2024 Proposed Changes
As a provider of innovative technology, WellSky supports the collection and submission for all the CMS identified items sets, which includes the LTCH CARE data set. WellSky welcomes the proposed cross-setting measure to adopt a Functional Discharge Score (DC Function) measure, which assesses the percentage of LTCH patients who meet or exceed an expected discharge function score. The DC Function measure would replace the current measure, Percent of LTCH Patients with an Admission and Discharge Functional Assessment, and a Care Plan that is considered topped-out. Collecting measures in a way that least burdens hospitals for reporting while maintaining high quality results and allows for data sharing is ideal.
WellSky appreciates CMS’s desire for input on principles for selecting and prioritizing LTCH Quality Reporting Program quality measures to improve assessment-based quality measures and measure concepts for future years. The areas identified for future years address important issues in the lives of the patients LTCH providers serve. We encourage CMS to support testing and review of any proposed measures, especially the patient reported outcome measures, through the National Quality Forum (NQF) to ensure they demonstrate importance, scientific acceptability, feasibility, and usability, and do not conflict with or duplicate existing measures.
We promote the collection and reporting of measures LTCHs can directly impact that will improve the quality of care for their patients. We encourage measures that account for the high acuity patient population LTCHs serve to ensure the compatibility of the patient population. By stratifying the data, we can identify disparities to improve outcomes. As previously mentioned, collection of all future measures that can be done in a way that is least burdensome to the hospital, obtaining from current data sources to include claims’ data, current LTCH CARE data set, and NHSN/CDC data. Where new collection may be necessary, measurement should support the instruments and assessments hospitals already use in clinical practice.
We fully appreciate how challenging it is to align the standardized patient assessment data required for reporting under the Improving Post-Acute Care Transformation (IMPACT) Act that are applicable for the full spectrum of patient acuities in the LTPAC space. Existing questions and responses from the Data Element Library (DEL) allow for functional exchange of health information, but create additional administrative burden when questions don’t pertain to the setting. Adding additional skip logic to bypass such questions would streamline data collection.
WellSky would be pleased to offer expert guidance within CMS’s downstream analysis of outcome measure integration with current EHR standards of care, as we work collaboratively to support providers and the patients they serve with innovative approaches to the evolution of healthcare. This data would allow for clear and future analysis of specific relationships between the cause and effect on outcomes generated. WellSky firmly believes innovation will be needed to solve the challenge of an ever-changing healthcare landscape. Our objective is to help providers achieve the top outcome within the most efficient, effective, and compliant use of resources and technology.
Conclusion
WellSky appreciates the opportunity to comment on the Proposed Rule. And, again, we urge CMS to work with the LTCH industry to avoid the unintended consequences of the proposed 4.7% decrease in high-cost outlier payments adjustments. We also appreciate CMS’s review of these comments. We stand ready to address any questions you may have regarding these comments and the negative impact the Proposed Rule could have on the LTCH industry.
[1] 88 Fed. Reg. 26658 (May 1, 2023).https://www.cms.gov/medicare/acute-inpatient-pps/fy-2024-ipps-proposed-rule-home-page
[2] CMS Releases FY 2024 LTCH Prospective Payment System Proposed Rule