A recommendation to eliminate the three-day hospital stay requirement for Medicare skilled nursing coverage was welcome news to long term and post-acute care advocates when it appeared in the final report of the Commission on Long Term Care in September. 

In addition to topping the to-do lists of many health care lobbyists, it turns out that eradicating the pesky rule also was a “no brainer” for the commissioners as well, says Stephen Guillard, commission appointee and health care consultant who served as chief operating officer of HCR ManorCare for a number of years.
“On the three-day stay recommendation, everyone felt that we’ve reached a point where this can be considered an irrational barrier,” he said in an interview one day after the group met for the last time to issue its final recommendations.

Given the commission’s diverse makeup, Guillard was heartened by its ability to see the benefit of the three-day rule recommendation. “I think people came to appreciate that there is an absurdity in the current system that is basing payments on site of care versus what the needs are of an individual. And there was a belief that we are spending money in such a way that could be allocated in a more judicious, rational, and appropriate method,” says Guillard.

The concept of site-neutral payment structures for post-acute care settings made its way onto the commission’s list of recommendations, as did observation days counting toward the three-day hospital stay requirement. “I think they looked at this observation stay issue in the same context,” says Guillard, “because it creates arbitrary or inefficient barriers and obstructions to a smooth, effective system. So I think we were fortunate to bring that to the forefront.”

Long term care is a very difficult, complex, problematic issue, he adds.

“And to think that a commission being comprised of the members that this commission had could accomplish a significant amount of work on a such a complex problem in 100 days was a bit optimistic, in my opinion,” says Guillard.

Serving on the commission along with Guillard was long term care colleague Neill Pruitt Jr., chairman and chief executive officer of UHS-Pruitt, Norcross, Ga. Similar to Guillard, Pruitt was sanguine about the ability of the group to work together. “It was an honor to serve on the commission and play a small role in effectuating some structural, meaningful changes to the long-term health of these programs. Each of my colleagues brought a unique perspective to long term care’s most challenging issues,” said Pruitt after the final report was released.

Guillard, however, was slightly less politic about the commission’s daunting task. “I think they did as good a job as could be accomplished given the constraints and the complexities of the issues,” he said, hinting at the group’s partisan makeup. “There were significant differences where certain members of the commission favored an approach that was wholly different from other members of the commission,” says Guillard. “Some members felt we should look at this problem in a social insurance context, expand entitlement programs, and provide more services to more people—and they felt that in a very focused way. There were others that felt we really needed to approach this in a procedural kind of way and look first and foremost at how we could streamline or increase efficiency in the current system.”

While only time will tell what the commission’s work really accomplished, both Guillard and Pruitt were honored to have served on the panel, and both were optimistic about how the final report illuminated a number of concerns specific to post-acute care.

Following the report’s release, the panel’s Republican appointees issued a letter to Congress detailing concerns that they felt were not addressed in the final report, while the Democratic appointees issued an “alternative report” that it says is “difference in vision and recommended action plan from the commission majority.”

The final report of the commission can be accessed here: www.ltccommission.senate.gov/index.cfm.