MedPAC approves draft LTCH recommendations

Standardized admission criteria proposed

If your hospital is not classified as a long-term care hospital (LTCH), you may not be paying attention to the questions being asked by the Centers for Medicare & Medicaid Services (CMS) and some politicians about the need for this level of care. But rehab advocates say you should, because the debate over long-term care ties in with the 75% rule.

The basic question in all of these issues is: Where should patients with differing levels of rehabilitation needs be treated? LTCHs are distributed unevenly around the United States, but the patients still exist. They’ll have to be seen somewhere. So will patients who get squeezed out of inpatient rehabilitation facilities because of the 75% rule.

"In a way, this examination of LTCHs and trying to distinguish them is similar to the discussion over the 75% rule with respect to inpatient rehab facilities and distinguishing them from acute care facilities," says Carolyn Zollar, JD, vice president for government relations and policy development at the American Medical Rehabilitation Providers Association (AMRPA) in Washington, DC.

In April, the Medicare Payment Advisory Commission (MedPAC) voted unanimously to approve a set of draft recommendations that would urge Congress and the secretary of Health and Human Services to establish new criteria for LTCHs.

The criteria would delineate the types of patients who are treated appropriately in LTCHs and ensure those patients are medically complex and have a good chance for improvement.

MedPAC completed a study on LTCHs that was prompted by the commissioners’ concern at the huge growth and uneven geographic distribution of LTCHs in recent years.

The role of LTCHs

The study asked questions about the role of LTCHs, how patients are treated in areas where there are no LTCHs, and how Medicare spending and outcomes compare for patients who use LTCHs and those who are treated in alternative settings. The study included:

  • Thirty-four structured interviews with physicians, hospital administrators, nurses and discharge planners in two market areas with LTCHs and two market areas without them.
  • Commissioner and staff site visits to LTCHs in three cities that have multiple LTCHs.
  • A comparison of characteristics of patients treated in markets with and without LTCHs and examination of the impact of LTCH use on Medicare spending and outcomes.

Sally Kaplan, PhD, the MedPAC research director who led the study, reported to the commissioners that patients in market areas with LTCHs had similar acute hospital lengths of stay whether or not they used LTCHs.

She said LTCH patients were three to five times less likely to use skilled nursing facilities (SNFs), "suggesting that SNFs and long-term care hospitals may be substitutes." LTCH patients had higher mortality rates and cost Medicare more that patients using alternative settings. However, LTCH patients had lower readmission rates than similar patients in alternative settings.

"The main conclusions from our study are that when admissions to long-term care hospitals are largely unrestricted, long-term care hospitals tend to cost Medicare more than patients treated in alternative settings," Kaplan told commissioners.

The recommendations include:

  1. Requiring a uniform patient review process that screens patients prior to admission, periodically assesses the patient throughout the stay, and assesses the available options when the patient no longer meets the continued stay criteria.
  2. Instituting a uniform patient assessment tool across the industry that would emphasize clinical assessment of the patient.
  3. Requiring multidisciplinary care treatment planning that establishes patient-specific care plans. LTCHs would be expected to have such services as wound care experts, respiratory therapists, end-of-life counseling and home ventilator training depending on their patient mix.
  4. Retaining the current average length-of-stay requirement with the option to reevaluate over time.
  5. Requiring daily physician presence that would include care planning, daily patient assessments, and medical interventions when needed.
  6. Developing criteria for a weaning success rate for ventilator dependent patients.
  7. Developing national admission and discharge criteria for each major category of patients. The criteria would specify clinical characteristics such as blood pressure, respiratory insufficiency, and the presence and severity of open wounds.
  8. Developing discharge criteria for patients depending on their discharge destination.
  9. Requiring that a high share of patients, possibly 85%, be classified into major categories of patients. Possible categories include respiratory, complex medical, wound care, ventilator weaning, infectious disease, and cardiovascular. A high share of the patients would also need to have a high severity level.
  10. Requiring a minimum number of nursing hours per patient day, possibly 6½ hours.

Kaplan told the commissioners that the above criteria are not the only measures needed.

"We also want to point out that it will be important in the longer term to make refinements to existing PPSs [prospective payment systems] for acute care hospitals and SNFs. As currently designed, these payment systems may have had the unintended consequence of encouraging long-term care hospital growth," she pointed out.

Kaplan also urged the development of strong rules regarding hospitals within hospitals "to ensure that hospitals do not discharge patients prematurely for financial gain."

Zollar says the AMRPA is following this issue closely, even though LTCHs make up a minority of its membership.

"We are watching MedPAC’s actions very carefully. I think it represents a concern in various policy thinkers here in DC that if Medicare is paying for excluded hospitals based on different and more costly payment systems, that it wants to be certain there is a difference in the nature of the hospitals and patients," she adds.

The American Hospital Association (AHA) also is following the issue. "The MedPAC staff are doing a good job with the LTCH research," says Rochelle Archuleta, the AHA’s senior associate director for policy.

"If the commission’s recommendations to develop and implement facility and patient characteristics for LTCHs are acted upon by Congress and CMS, it would be appropriate to convene an independent panel of clinical experts, perhaps under the auspices of the Institute of Medicine, to establish a clinical consensus on the content of these standards, rather than have CMS oversee the effort," she adds.

"We concur with the commissioners who stated that a moratorium on certification of LTCH hospitals within hospitals is premature," she explains.

What are the long-term goals?

Archuleta says the long-term goal for looking at how the various PPSs work together is wise.

"They’re looking at developing a greater understanding about the connection between the PPSs to ensure they are devised appropriately," she says. "We feel there are some protections in place now to be sure patients are treated appropriately, but we feel the long-term approach is reasonable."

Standard outcomes measurements also would be welcome, Archuleta says.

"We think it would be wonderful to ensure the outcomes measurements would be comparable with the outcomes measurements of other systems, which is not the case now. Right now the outcomes generated in a skilled nursing facility are not comparable to those generated in an inpatient rehab facility. Those segments do have patient assessment instruments; LTCHs aren’t quite there yet," she adds.

Another long-term goal the AHA would like to see concerns patient access. "One MedPAC goal that is very important is to ensure that the skilled nursing facility PPS does not discourage access to care for medically complex patients," Archuleta says. "The regulations should ensure that medically complex patients are reimbursed appropriately, which is widely agreed at this point to not be the case. We’re strongly in favor of that. That’s a major issue we’ve been pushing on for years."

(For more information, the transcripts from the March and April meetings concerning LTCHs can be found on the MedPAC web site:

Need more information?

  • Rochelle Archuleta, Senior Associate Director, Policy, American Hospital Assoc., 325 7th St. N.W., Washington, DC 20004. Phone: (202) 638-1100.
  • Sally Kaplan, Research Director, Medicare Payment Advisory Commission, 601 New Jersey Ave. N.W., Suite 9000, Washington, DC 20001. Phone: (202) 220-3717.
  • Carolyn C. Zollar, JD, Vice President, Government Relations & Policy Development, American Medical Rehabilitation Providers Assoc., 1710 N St. N.W., Washington, DC 20036-2907. Phone: (202) 223-1920. E-mail: