The IMPACT Act of 2014 won’t generate dramatic headlines. With an acronym that stands for Improving Medicare Post-Acute Care Transformation, the act is focused on enhancing and standardizing clinical data and assessments across post-acute care (PAC) settings, developing new quality and resource measures for PAC providers, and facilitating the comparison of outcomes among providers and settings—all in the service of creating an infrastructure for site-neutral payment reforms in a not-too-distant future.
Introduced in late June by Rep. Dave Camp (R-Mich.), the IMPACT Act might have broken laws of physics and entrenched partisanship on Capitol Hill as it sped through the House of Representatives on a voice vote last September, passed the Senate two days later by unanimous consent, and was signed into law on Oct. 6 by President Obama.

Act Will Have Impact

Though it took just 40 days to go from introduction to public law, the act was the culmination of months of bipartisan work among lawmakers and their staff, according to Rep. Sander Levin (D-Mich.), who spoke on the House floor just before the bill’s passage.

Despite a rare smooth sailing and the absence of controversy, and despite being described by one lawmaker as “innocuous,” the IMPACT Act is far from a trifle.

It has in fact been heralded as a post-acute care milestone, one that lays the groundwork for significant payment reforms.

Even before broader reforms materialize, the act is expected to boost skilled nursing facilities’ (SNFs’) ability to demonstrate their value as high-quality, cost-effective therapy providers through the creation of standardized assessments and quality measures, says Daniel Ciolek, senior director of therapy advocacy for the American Health Care Association (AHCA).

This is particularly important as providers reach out to policymakers—whose perception of nursing facilities may still be rooted in the 1970s—in an effort to convey (often through a facility tour) the sophisticated level of care that’s provided in today’s SNFs.

Under A Microscope

SNFs have been scrutinized and sometimes criticized for the rising volume and intensity of the therapy they provide, Ciolek says.

Correlating therapy utilization to resident acuity and outcomes has been an uphill battle, primarily due to a data gap that the IMPACT Act has the potential to close, he adds.

“The current clinical and functional data gathered through the MDS [minimum data set] patient assessments are inadequate to reflect true patient complexity and degree of positive functional and other care-related outcomes obtained from SNF rehabilitation services,” he says.

By refining and standardizing post-acute care assessments and implementing quality measures across settings, the IMPACT Act mandates filling data gaps and creating a more accurate view of resident needs and outcomes.

As an agent of change and transformation, the IMPACT Act is “the most important thing to happen to therapy” since Medicare began covering services, Ciolek says.

Breaking Ground

Drawing on broad support from provider and beneficiary groups, as well as quality organizations, the statute breaks new ground by requiring standardized patient assessment data to be reported at admission and discharge across SNFs, inpatient rehabilitation facilities, long term care hospitals, and home health agencies (HHAs). All but home health agencies must report uniform assessment data by Oct. 1, 2018, with HHAs following on Jan. 1, 2019.

The statute also calls for new quality measures to be created in five domains: functional status, which includes mobility and self-care; skin integrity; medication reconciliation; major falls; and patient preference regarding treatment and discharge.

Reporting on the measures will be phased in beginning Oct. 1, 2016, for all but HHAs, which will start in 2017.

Therapy touches nearly all of those measures, Ciolek says, as therapists are engaged in boosting mobility, preventing falls and skin breakdowns, and making community discharge possible.

By Oct. 1, 2016, providers will be required to report new measures of resource use, including Medicare spending per beneficiary, rates of discharge to the community, and rates of potentially preventable hospital readmissions.

A Tale Of Two SNFs

At any given time, a typical 100-bed skilled nursing facility has 86 long-term residents, whose average length of stay is more than a year, and 14 short-term residents receiving post-acute care for an average stay of 27 days, according to AHCA. Over the course of a year, the same facility will serve 189 short-stay residents, comprising nearly 69 percent of its annual population, and 86 individuals requiring extended long term care services.

“Today’s SNFs care for two distinct populations,” AHCA said in its August 2013 PAC reform response to the Senate Finance and House Ways and Means committees (see box).

In 2009, only 854,000, or 23 percent of the 3.7 million individuals who received care in a nursing facility, stayed for at least a year, AHCA reported.

Short-stay residents are also driving a growing rate of discharge to the community. Among AHCA members, for example, 61 percent of residents are currently returning to their communities, up from 58 percent last year, according to data from LTC Trend Tracker, a Web-based tool available to AHCA members. Trend Track allows users to track a wide range of metrics and compare their performance to that of other providers.

Rehab A Major Factor In Restored Health

The majority of people served in SNFs today “need rehabilitation or skilled nursing care to complete their course of care following an acute illness,” AHCA said. As a result, “both the range of services provided in SNFs and the acuity of illness of persons served have significantly increased over time.”

The ability of providers to convey this trend, however, has been hampered by data-gathering and -reporting processes that are out of step with the evolving role of SNFs, their demographics, and the clinical needs of residents, says AHCA’s Ciolek.

The IMPACT Act’s requirement for the assessment of functional status at the time of admission and discharge is critical to gaining a more accurate view of SNF residents’ initial abilities and changes that occur after receiving therapy, he adds.

“The current MDS items related to function were designed for the needs of long-term residents, and are neither specific nor sensitive enough to adequately address the functional needs of the resident at admission or reflect functional improvement through a therapy episode,” Ciolek says.

Furthermore, the timing of the initial MDS assessment, which is completed within five to eight days of admission, is not responsive to short-stay residents who, by the time the assessment is done, may be a third of the way through their stay and have already made significant functional gains that will be missed on the MDS, Ciolek says.

Data Matter

Data on acute-care hospital trends suggest that patients are leaving sooner and, presumably, with more intensive needs at discharge. According to the Centers for Medicare & Medicaid Services 2014 Statistics, the average length of a Medicare hospital stay has decreased significantly over time, from 9.0 days in 1990 to 5.0 days in 2012, a 44 percent decline.

In its annual data book released last June, the Medicare Payment Advisory Commission (MedPAC) reported that from 2006 through 2012, the average length of an inpatient stay for Medicare beneficiaries fell nearly 7 percent, from 4.93 days to 4.59 days.

“Medicare length of stay declined at an average annual rate of approximately 1.2 percent during this period,” MedPAC reported, while the length of stay for non-Medicare inpatients remained “nearly unchanged” for the period, at 3.9 days.

Despite such findings, policymakers remain skeptical that acuity among residents entering a SNF has changed significantly, or that increased frailty and acuity justified therapy utilization increases over the past decade, Ciolek says.

Numbers Controversial

Last March, MedPAC reported that between 2002 and 2012, the share of SNF days that were classified into “rehabilitation case-mix groups increased from 78 percent to 93 percent,” while the share of “intensive therapy days as a share of total rose from 29 percent to 77 percent.”

The panel conceded that “shorter hospital stays could have shifted some therapy provision from the hospital to the SNF sector,” pointing out that between 2008 and 2012, “hospital lengths of stay decreased 9 percent on average for the five highest-volume diagnosis-related groups discharged to SNFs.”

Nevertheless, MedPAC maintained that during the same period, “the increase in the most intensive therapy days (18 percent) far outpaces the changes in patient characteristics,” the commission said.
The conundrum underscores the need for SNFs to gather and report “standardized, meaningful data on patients’ condition, function, and outcomes,” Ciolek says.

Getting Proactive On PAC Reform

AHCA has not been waiting in the wings for post-acute reform to arrive.

The organization has been active in developing a payment reform proposal based on two key elements: a SNF-stay bundle of care, which would cover all Part A services from admission to discharge, and the reduction of some administrative and regulatory burdens, including a partial phase-out of the three-day prior hospital stay required for Medicare SNF coverage.

The organization is embracing reform, and Ciolek expresses confidence in its members’ ability to meet a new era of post-acute care. “The bottom line is that we’re improving residents’ function and demonstrating that we are meeting the goals we’ve set,” he says.

“We are sending people home and, ultimately, saving the system a lot of money.”

Ciolek says he looks forward to the transformation that will result from the IMPACT Act and payment reforms that “incentivize and validate the great outcomes we achieve,” while spurring less successful providers to improve.
Lynn Wagner is a freelance writer based in Shepherdstown, W.Va.