A Medicare beneficiary falls down and breaks a hip, landing in a hospital. Two days later, the hospital sends that beneficiary to a local nursing home to receive follow-up care. Does Medicare pay the bill or does the beneficiary? Most people would answer that the beneficiary will end up paying. Here’s another scenario: a Medicare beneficiary experiences chest pain and goes to the hospital. The hospital keeps the beneficiary for three days of observation. Who pays the nursing home bill? Once again, under current rules it would be the patient. That’s because the Centers for Medicare and Medicaid Services (CMS) has a statutory requirement that a patient spend at least three consecutive days in a hospital as an inpatient in order to qualify for Medicare coverage of a subsequent stay in a skilled nursing facility. However, that may change. A Medicare pilot project is testing whether eliminating that rule will reduce costs.
Part of the Affordable Care Act (also known as the ACA or as Obamacare) included a provision to develop ways to reduce or hold costs. As one part of that, CMS is exempting patients at dozens of hospitals from the three-day hospital stay requirement. Although a nursing home stay is expensive, a hospital stay is even more so. The three-day inpatient hospital stay has frustrated beneficiaries probably since its inception but only Congress can change the rule and so far there hasn’t been any interest in doing so.
Under the pilot, more than half a million seniors at more than 170 hospitals have qualified for Medicare’s nursing home benefit. Patients cannot ask to be placed on the program so there’s little anyone can actively do to change their status as regards this pilot program.
Another pilot program looking at costs pays a bundled payment rather than the customary fee-for-service model. In that program, Medicare pays a set fee for any of 48 specific procedures (including knee and hip replacement) in about 70 hospitals across the country. Hospitals, doctors, nursing homes and other care providers then share the reimbursement. Just as in the other pilot program, the three-day rule can be waived. Medicare beneficiaries expecting to undergo a procedure should contact the hospital ahead of time to see if the hospital is participating in the pilot program.
Another pilot program that CMS is offering involves hospice care. People familiar with hospice know that those individuals that choose hospice care must forego any curative care. Only about 44 percent of terminally ill patients choose hospice and most only do so at the very end of their lives. The pilot program will look at whether people will select hospice care if they are not required to give up curative care. Hospice care providers under the Medicare Care Choices Model receive $400 a month per beneficiary. Because of the low reimbursement rate, many hospices are not choosing to apply for the program. Medicare beneficiaries should contact their local hospices to see if they are participating.