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PTAC OKs New Nursing Facility Payment Model

News  |  By MedPage Today  
   March 30, 2018

The model aims to reduce avoidable emergency department visits, provide timely access to physician care, and lower costs for nursing home patients.

This article first appeared March 29, 2018 on Medpage Today.

By Shannon Firth

WASHINGTON -- A new payment model to improve care for nursing home residents will make its way to the secretary of the U.S. Department of Health and Human Services (HHS).

The Physician-focused Payment Model Technical Advisory Committee (PTAC) voted 10-0 on Tuesday to recommend full-scale implementation of Intensive Care Management in Skilled Nursing Facility Alternative Payment Model (ICM SNF APM). The model aims to reduce avoidable emergency department visits, provide timely access to physician care, and lower costs for nursing home patients (one PTAC member was absent for the vote).

"I think we're actually very close to something implementable on a wide scale," said Tim Ferris MD, MPH, a practicing internist and CEO of the Massachusetts General Physicians Organization in Boston. While he said he had misgivings about the level of accountability in the model, he stated that it wasn't "rocket science" to improve that element.

Grace Terrell, MD, an internist and CEO of Envision Genomics in Huntsville, Alabama, stressed that finding ways to improve care in nursing homes "ought to be considered an emergency." She voted for full implementation "with high priority."

The proposed model involves a geriatrician-led care team, which might include a nurse, social worker and pharmacist, working with the attending primary care provider (PCP) in partnership with a nursing home or skilled nursing facility. The care team provides 24/7 support via telehealth, mentorship, and "management of care transitions."

The model was put forth by Avera Health of Sioux Falls, South Dakota, based on its own Avera eLong Term Care (Avera eLTC) program. The model from the regional health system suggested two possible payment pathways: a performance-based payment and a shared savings model.

While PTAC got behind the model, members did express some reservations. Robert Berenson, MD, internist and institute fellow at the Urban Institute here, and Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform in Pittsburgh, expressed concerns over the shared savings pathway, which would overlay substantial financial risk on care for patients with a high chance of dying.

"The very cheapest patient of all is the patient who dies," Miller said, emphasizing the need to provide protections against stinting and inappropriately keeping patients out of the hospital.

Another concern was the model's ability to work in smaller settings. Avera serves 5,000 residents daily, according to its proposal. Joseph Rees, MD, a hospitalist at Avera McKennan Hospital, said the model could be implemented in smaller, rural geriatrician practices "if they have a really good interdisciplinary team."

Others at the meeting pointed out the model's advantages.

Joshua Hofmeyer, Avera eCare senior care officer, said the program improved staff retention at that facility. Also, staff felt they had time to serve patients, instead of constantly "putting out fires," he said.

David Basel, MD, vice president of Clinical Quality for Avera, noted that as the care team provides direct care, they are also training and mentoring nursing home staff. In addition, by providing a backstop for overburdened PCPs, the model also keeps relationships between PCPs and patients intact, Basel noted.

While the model's lack of risk adjustment is a shortcoming, a preliminary review team told the committee, PTAC members acknowledged that there currently aren't well-validated risk adjustment tools for the long-term care population.

Ferris said that performance measures should be enhanced and evaluated more quickly -- a 2-year reporting period before pay-for-performance kicks in seemed "generous," he said.

He also stressed that the letter to the HHS secretary should include explicit plans for goals of care.


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