Long-Term Care has a Shorter Time Frame Due to ACA, CMS

May 04, 2016 - The Affordable Care Act has impacted a variety of aspects of the health insurance landscape as well as the healthcare delivery system. The Patient Protection and Affordable Care Act also led to the Center for Medicare & Medicaid Innovation where accountable care organizations and the Medicare Shared Savings Program was formed. Long-term care is another arena in which the Affordable Care Act played a role.

The Kaiser Family Foundation reports that the Affordable Care Act led to new options for state Medicaid programs to renovate their long-term care infrastructures and create more options for home and community-based services. Some of these possibilities have come from the Balancing Incentive Program and the Community First Choice state plan option.

Jane Gabbidon, a corporate clinical consultant and former long-term care nurse, spoke with HealthPayerIntelligence.com about some of the other aspects related to the Affordable Care Act and long-term care services.

“There are changes [in long-term care after the ACA]. For me as long-term care nurse, our focus is always on the regulations. The state and the federal government governs what we do. They come into our facilities to survey and, of course, our focus is always on ensuring that we are in compliance with their regulations in all areas of care,” Gabbidon began.

“The only area of billing that we focus on - Medicare and Medicaid are our primary payers. Of course, they tie into all of these changes. The changes impact us only in the sense that we now know that when our clientele come in, as in the past, they were coming in for predominantly long-term care and with the change from these insurance giants to Medicare and Medicaid to a more managed care plan, we know that we now have a shorter window,” she continued.

It seems that new public and private insurance options are requiring long-term care facilities to improve the wellbeing of the disabled and the elderly in much shorter time frames than before.

“They are now coming in for the short term. Our goal is always to get them back on their feet as quickly as possible while complying with all the regulations for all areas of care. We work to get them back out into the community and to the ACOs,” Gabbidon explained.

“Our timeframe is limited now as opposed to in the past when we figured we had residents coming in for 400 days to get them full therapy. No, we now know that most of the managed care insurance like HMOs, Medicare, and Medicaid are saying we have two weeks or four weeks to get them the optimal care and get them back on their feet.”

When it comes to the proliferation of accountable care organizations and the Medicare Shared Savings Program, geriatric care has been taken from a long-term services position to a managed care system.

“In terms of Medicare changes, most residents from a long-term care aspect in our environment or geriatric residents who have Medicare or Medicaid, recent changes have transformed how they are all managed through ACOs,” she continued. “Now that they are all on the managed care system, they’re being operated similarly to the way the private insurance giants operate. The time frame of every aspect is limited. The timed window that you have to provide care to clientele is limited.”

“The services that were once readily available now have a limited timeframe. The payments to skilled nursing facilities have decreased in the sense that the timeframe has decreased and the government has cut the rates for skilled nursing facilities. They are significantly impacted by all of these changes,” she clarified.

Both the Affordable Care Act and other healthcare industry reforms have brought significant transformations for payer-provider reimbursement policies. Many health payers as well as the Centers for Medicare & Medicaid Services (CMS) have opted to focus on value-based care reimbursement and move away from the fee-for-service payment system. Gabbidon explained how CMS and health payers have brought those new payment structures to long-term care.

“CMS has made significant changes in terms of payment and in terms of long-term care,” she mentioned. “There is a correlation between the hospitals and the nursing homes. If Medicare patients are readmitted to hospitals in under 30 days, they are fined. Of course, their goal based on their payment system is to ensure that patients get quality care in the least amount of time as possible and to get them to the skilled nursing facilities.”

“The skilled nursing facilities must now ensure that patients are not readmitted to the hospitals in 30 days as it affects the SNFs payment. Right now, nursing homes are not being fined, but over time, nursing homes will be fined,” she continued.

“The overall relationship between hospitals and nursing homes now come into question because the hospitals are going to look at the nursing homes that are repeat offenders that keep sending back their clientele within 30 days for complications of the same condition. Yes, it will affect that relationship. CMS also focuses changes on providing quality care while cutting expenses at the same time,” Gabbidon concluded.

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