Carespring Health Care Management Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule

WASHINGTON, May 30 -- Chris Chirumbolo, CEO of Carespring Health Care Management, Cincinnati, Ohio, has issued a public comment on the Centers for Medicare and Medicaid Services proposed rule entitled "Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022". The comment was written on May 19, 2021, and posted on May 26, 2021:

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I am writing to provide comments on the proposed rule (NPRM) CMS-1746-P - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2022 that was published in the Federal Register on April 15, 2021. CMS requested comments, therefore we would like to specifically address the discussion on recalibrating the SNF patient driven payment model (PDPM).

One of the primary goals of PDPM was to capture the entirety of the patient's medical needs and assure reimbursement was tied to the specificity of these needs, not just to a therapy value or nursing value. We feel this system more effectively captured and reflected the patient's care needs better than the prior RUG system did. It is difficult for any person to exclude or understand the full impact of the pandemic on PDPM related CMI. The new PDPM was only in place for a short time before the entire industry changed due to COVID 19. Since March 2020, patient needs, and medical complexity have changed. Limitation of visitors and restrictions on socialization have not only impacted mood status but mobility as well. Communal eating limitations have impacted PO intake and a potential relationship to weight loss - need for diet modifications, possible skin integrity changes. The end result,patients who were treated and recovered from COVID presented more complexity than can be fully captured through PDPM. PDPM moved us in the right direction. Now we need to take the appropriate next step.

Going forward, as the CEO, I am concerned about the continuing impact of the pandemic and the operational challenges facing our Skilled Nursing Facilities. As of today, our SNF occupancy remains 13% behind pre-pandemic levels and Skilled Nursing patient revenue, without stimulus funds, is down over 15%. Additionally, our labor and other expense costs-skyrocketed as a result of the (1) pandemic and (2) one of the worst labor shortages in our 35-yearhistory as a provider. We must be able to pay our workforce more and that requires commitment from CMS to understand and support the initiative.

* With pandemic expenses included, the average cost per Medicare A patient day increased over $13.00 per patient per day calendar year 2019 to calendar year 2020. The total with pandemic expenses increased another $48.00 per patient per day in the quarter ended March 31, 2021.

* Excluding pandemic expenses, the average cost remained the same for the from 2019 to 2020. First quarter 2021 costs increased by $30.00 PPD.

Based on these facts, we request CMS to approve the full market basket index within the MPPR adjustment and cancel plans for the 5% PDPM "correction" for FY 2022. I am concerned how the implementation of a 5% percent rate cut will create significant revenue losses for an industry that is devoted to caring for a frail elderly population with intense healthcare needs. The COVID-19 pandemic permanently impacted how we provide care and the increased costs to provide skilled care continues regardless of a COVID-positive diagnosis. Many of these additional costs will continue to be incurred by SNF providers for a sustained period due to changes in patient care delivery, infection control, reporting requirements, and other necessary costs.

Without a fair and predictable SNF PPS payment rate going forward, SNF providers will face additional financial losses on the heels of the PHE. Consequently, our ability to provide the high-quality care that CMS expects and our patients require and deserve will be extraordinarily compromised.

Given these recent and ongoing challenges during the COVID-19 PHE and that are anticipated as the nation recovers, I encourage CMS to proceed in a thoughtful manner and to adopt the following recommendations:

* More time is needed to thoroughly evaluate all data related to the pandemic's impact on SNF utilization in FY2020 before making a final determination of whether a PDPM parity adjustment is warranted, and if so, by how much.

* I strongly recommend that if CMS implements a PDPM parity adjustment, that the blended approach is applied, including a delayed implementation of two years, and then a phased-in implementation of no more than a one percent reduction per year be applied until parity is achieved.

* Other comments related to specific sections of the NPRM are offered on the next page.

Sincerely,

Chris Chirumbolo

CEO

Carespring Health Care Management

390 Wards Corner

Cincinnati, Ohio 45140

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Further comments related to specific sections of the NPRM

1. CMS must recognize that Medicare A - Fee for Service rates cannot be considered without addressing the systematically gross underfunding of Medicaid. Coupled with the increasing challenges with Medicare Advantage Organizations with their ostensible goals to decrease volume or payment, typically both under the guise of "value". The pandemic exposed the fragility of the financial support system of care, the overall nursing home system is unsustainable for most providers.

a. Medicaid - Our facilities' census are comprised of 60-70% Medicaid. Medicaid is reimbursing our resident care at 75% of the actual cost. Medicaid needs to cover the cost of care which would include reimbursement for the capital component for providers with newer physical plants.

b. Managed Care Organizations-They are becoming the next generation of underfunding as like Medicaid they are not covering the cost of care. CMS must require that Medicare Advantage Organizations/ Medicare Replacement Plans to pay commensurate rates to Providers. We have had our rates reduced by two large providers during the pandemic that are now below our costs of providing skilled care. While we realize that the relationship between CMS and these insurance companies is contractual, the difference between FFS rates and MAO rates paid to providers is substantial and continues to widen.

2. PDPM, as a more holistic payment methodology compared to RUGS IV, was the better approach during the global pandemic. However, multiple additional costs which will likely persist are not captured in the PDPM. A few of those services include - labs (hematological assays, oxygen saturation, d-dimer), x-rays (predominantly chest), respiratory treatments that are short lived (not seven days), need for airborne precautions that cannot be captured due to cohorting or suspected infection, weight loss, etc.

* PDPM demonstrates a multidimensional application for capturing the complexity of the patient with some pointed shortcomings: Labs, x-rays, respiratory treatments (less than daily), isolation while cohorted, high cost medications that are not IV, dysphagia/aphasia/apraxia not due to cerebrovascular disease are a few patient characteristics not captured adequately via PDPM.

3. An inadequacy of COVID / Isolation Coding under PDPM. A large volume of patients with epidemiologically significant active infections (COVID 19 and C-diff etc.), airborne precautions, and restricted mobility due to in room isolation were unable to qualify for isolation coding on the MDS due to being cohorted with a roommate suffering from the same affliction. The cost for these patients was the same if not higher than those in a room by themselves. Facilities that found themselves with high volumes of infected patients (had to cohort) and no private rooms received NO additional compensation for this high level of care. There should be full compensation for the highly technical and therapeutically burdened need for all isolation patients including those not in a room alone.

4. Consolidated Billing exclusions remain inadequate and should be revised.

* There continue to be outlier drug costs that need to be considered for exclusion from consolidated billing.

* Certain classes of drugs considered "Specialty" drugs are the largest exposure items for SNFs and need to be evaluated by CMS.

* Many pharmaceutical therapies in use today were not in existence at the time that consolidated billing PPDs were created. Therefore, they cannot be considered "included" within the Medicare A FFS rate.

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The proposed rule can be viewed at: https://www.regulations.gov/document/CMS-2021-0062-0002

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