As nursing home advocates continue to push for ending the 3-day hospital stay requirement, a recently released federal agency report on the use of these waivers by accountable care organizations (ACOs) showcases some of the benefits that they have brought to patients and providers.
Use of waivers by ACOs for a 3-day stay did not result in different outcomes or longer nursing home stays, according to a recent analysis by the Centers for Medicare & Medicaid Services (CMS).
ACOs are made up of groups of doctors, hospitals and other health care providers to collaborate and provide coordinated care to Medicare patients. ACOs are able to leverage certain flexibilities, including waiving the three-day stay rule related to SNF coverage.
Although ACO plans serve a relatively small portion of the nursing home population, the CMS data nevertheless provides a valuable insight on the utility of such waivers. The issue is top of mind for providers, as a blanket waiver enacted during the Covid-19 pandemic is set to end in May, with the expiration of the public health emergency (PHE).
Nursing home leaders said that the CMS analysis backs a position they have long supported.
“For years we have advocated to eliminate this confusing policy barrier by recognizing observation stays as qualifying stays for the purposes of the three-day stay requirement or eliminating the three-day requirement all-together,” the industry’s largest trade group, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), told Skilled Nursing News in a statement.
“It’s time for CMS to expand the three-day stay waivers for all patients receiving Medicare Part A, or eliminate this obsolete beneficiary access barrier permanently,” the advocacy group urged.
In its analysis, CMS examined how providers with ACOs used the SNF waiver over the period of 2014 to 2019. The data shows that health care providers used the waiver only 3% to 5% of the time for SNF stays annually for beneficiaries who did not need to stay three or more days in an inpatient hospital. This figure is similar to how Medicare Advantage (MA) plans would use the waiver, according to experts.
“That adverse outcome rates for waiver stays are lower than or similar to 3-day non-waiver stays provides evidence that ACOs are using the waiver for beneficiaries who are less likely to experience adverse outcomes,” CMS said.
The findings did not surprise but did encourage Mark Price, CEO of Curana Health, which is active in the Medicare Shared Savings Program (MSSP) ACO model, the ACO REACH program and works with skilled nursing and senior living providers in a variety of other value-based and managed care frameworks.
“I was … not surprised to see the CMS data that beneficiaries using the ACO 3-day waiver had lower or similar adverse outcome rates relative to beneficiaries not under the waiver, as we have also seen very good outcomes for patients when we utilize the waiver,” he told SNN.
ACOs’ use of waivers allowed safe management of patients
Fred Bentley of consulting group ATI Advisory told SNN that ACOs were using waivers as a useful way to manage patients, particularly those with less acuity.
“Even given that it’s a few years old, I think [this data] shows that ACOs were leveraging this as a way to more safely and potentially, more effectively, manage patients,” Bentley said.
The top conditions for direct admittance to SNFs were injuries and musculoskeletal conditions, Bentley noted, referring to the data analysis findings. He said that it was noteworthy that often the waiver was used to admit directly to SNFs for less serious conditions such as injuries from falls, for example, but not after suffering a stroke or heart attack.
“The SNF is a valuable landing spot for those (less serious) patients,” Bentley said.
And while for ACOs, SNF stays began rising starting in 2017, when Shared Savings Program ACOs in select tracks were eligible to use the SNF waiver, “very few SNF stays” any year were waiver stays, the CMS report noted.
The data also showed that patients covered by ACO plans were more likely to be referred to a SNF with a waiver from home rather than after a one- or two-day hospital stay.
Bentley said that CMS’ preliminary analysis is “encouraging” toward waiver use and direct admits to SNFs, but more conclusive data with wider implications on outcomes and efficiency would require CMS to do a more rigorous study with regression modeling and controlling for other variables.
Some noteworthy issues pertaining to the impact of quality and costs of care remain unresolved by the data, however.
These findings couldn’t definitively say, for example, that “the patients who came in through the waiver necessarily did better at shorter length of stay than the non-waiver stays … but it is interesting when you look at the data that the average length of stay was a bit lower for the waiver patients,” Bentley said.
The issue of waivers and their utility is important to the nursing home industry in alleviating bottlenecks at hospitals while allowing nursing home providers to overcome an intermediary step that many advocates in the sector have deemed unnecessary, especially for less acute older adults.
During the pandemic, the 3-day hospital stay requirement for nursing home residents was waived by CMS to ease access to care. This waiver will expire once the PHE ends on May 11.
CMS’ data on waiver use by ACOs can be useful in shedding some light on the PHE waiver’s potential utility, although perhaps only in a limited way, given the particular frameworks that ACOs operate under versus other types of health care provider organizations, experts said.
For example, Curana’s Price noted that ACOs “most likely” had approval processes for reviewing and approving use of the 3-day stay waiver. Ending the waiver without requiring such approval processes could result in different outcomes.
Furthermore, ACOs are incentivized to spend less since CMS monitors to see if the ACOs spent more or less than a benchmark amount on its assigned beneficiaries.
As a preliminary effort, however, CMS’ analysis can help allay fears that involvement of ACOs would increase Medicare costs.
“My takeaway is that it’s a valuable tool in the tool chest for value-based care providers,” said Bentley, adding that the numbers suggest that SNFs are still largely going to be used for what they have always been used for, and “that the direct admits aren’t necessarily going [to] become a major referral source.”
Making the 3-day stay waiver permanent
SNF advocates say the 3-day hospital stay policy needs to be relinquished.
“The recent CMS ACO analysis confirms our position that physicians, providers, and the beneficiaries themselves are in the best position to understand what care a person needs and when shortening or avoiding a hospital stay prior to a SNF admission is appropriate,” AHCA/NCAL told SNN.
Meanwhile, LeadingAge, which represents more than 5,000 nonprofit aging services providers, sent letters last week to Congressional leaders and federal officials calling for doing away with the 3-day stay policy, terming the requirement, “an outdated policy that presents unnecessary barriers to care.”
“This analysis supports why the 3-day stay should be eliminated,” Janine Finck-Boyle, VP of Health Policy at LeadingAge, told SNN in an emailed statement.
LeadingAge also previously noted in a release that Medicare administrative contractor audits conducted to safeguard against inappropriate SNF admissions did not identify issues that necessitated suspension of the 3-day stay waiver. Moreover, related quality measure data also showed no negative impact on patient outcomes.
“In fact, the adverse outcomes of admitted nursing home residents shows that an unnecessary hospital stay could cause a plethora of issues such as infection, wounds, decline in activities of daily living and possibly transfer trauma,” Finck-Boyle explained. “A direct admit to a SNF for the care in one episode could alleviate any of that,” she said, adding that much of the routine care at hospitals can be provided in nursing homes too. “These real-world practicalities make mandatory stays an anachronism.”
ACOs plan to use waiver beyond PHE
Programs such as ACO REACH and Medicare Advantage ISNPs can all take advantage of the SNF 3-day waiver even beyond the PHE, and Curana intends to do so.
“We believe this is a great option that offers significant benefits for patients, ACOs, and for SNFs,” Curana’s CEO Price told SNN.
Before the pandemic, the ACO 3-day stay waiver was significantly “under-utilized,” with only a small number of innovative ACOs fully using it given that SNFs and long-term care facilities were historically not eligible for the ACO 3-day stay waiver, according to Price.
It is noteworthy too that among conditions CMS places on ACOs for using waivers at SNFs is that the facilities have to possess a rating of 3 stars or higher.
CMS has taken steps to increase the prevalence of ACOs. The agency previously announced an expansion to certain ACO initiatives in 2023, doubling down on efforts to have all patients with traditional Medicare in an ACO relationship by 2030.
More than 700,000 health care providers, including nursing homes, will participate in at least one of three expanded initiatives.
One key to the success of ACOs and other value-based care models is the ability to provide services for patients in the lowest-cost setting that is still appropriate for their needs, and Price views 3-day stay flexibility as supporting that goal.
“The CMS memo you shared mentioned providing the ‘right care to the right patient in the right place’ and that is exactly how we think about it as well,” he said.
Companies featured in this article:
AHCA/NCAL, ATI Advisory, Centers for Medicare & Medicaid Services, Curana Health, LeadingAge
