This presentation presents the challenges to swing bed reimbursement and discusses swing beds vs. SNFs; readmissions; length of stay; disposition; and transitions of care programs

1. Presented by:
Martie Ross, JD
Principal
NATIONAL RURAL HEALTH ASSOCIATION CRITICAL ACCESS HOSPITAL CONFERENCE
Demonstrating the Value of Swing Beds
September 28, 2018

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Agenda
1. Challenges
2. Data Analysis
3. Strategies

3. 1. Challenges
OIG, MedPAC, Rural Extenders, and Alternative Payment Models

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“We estimated that Medicare could
have saved $4.1 billion over a 6-year
period if payments for swing-bed
services at CAHs were made using
SNF PPS rates.”
Average
CAH per
diem
payment
per swing
bed day
Average
SNF
payment
per day
Number of
CAH swing
bed days

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 OIG failed to account for impact of fixed cost allocation to swing-bed days
 Fewer inpatient days over which to allocate fixed costs = higher cost per
acute inpatient day
 Cost savings calculations should use actual payment vs. per diem payment
 OIG’s cost savings estimate 3x too high
Average
CAH
ACTUAL
payment
per swing
bed day

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“Medicare pays substantially more
for a post-acute day in a CAH swing
bed than a [SNF]. In 2013, Medicare
paid the median CAH $1800 per
post-acute swing bed day. This
amount is $1,400 higher than the
$400 per day paid to SNFs on
average.”

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Bipartisan Budget Act of 2018
 Rural Extenders
 Renewal of Medicare Dependent Hospital Program
 Renewal of enhanced Low-Volume Adjustment Program
 Renewal of ambulance add-on payment program
 Repeal of payment cap on therapy services
 Removal of rental cap for DME for speech-generating devices
 Extension on a permanent basis of MA special needs plans
 Extension of work geographic practice cost index floor
 Extension of Home Health rural add-on payment
 Extension of funding for FQHCs
 Extension of funding for National Health Service Corps, Teaching Health Center GME, Family-to-
Family Health Information Centers, Sexual Risk Avoidance Education Program, the Personal
Responsibility Education Program
 Payment Mechanism
 Earlier version of legislation in the House included reducing swing bed payments to SNF
PPS rates
 Final package included cuts to the ACA’s Prevention and Public Health Fund, modifications to
long-term care hospital payments, and cancellation of unspent money in Medicare and Medicaid
improvement funds
 What happens next time?

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Alternative Payment Models

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10. 2. Data Analysis
2015 Medicare Part A Limited Data Set Files –
Missouri and Kansas
MSSP Claims Data

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Missouri and Kansas
461 SNFs
35 CAH Swing Beds
285 SNFs
42 CAH Swing Beds

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Methodology
Identify Swing Bed and SNF stays
Find prior inpatient admission for each Swing
Bed or SNF stay – Anchor Admission
Include all Part A services within 90 days of
inpatient discharge - Episode
Compare Swing Bed and SNF episodes –
Total Cost of Care, ALOS, Readmission,
Discharge Disposition

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Missouri – Top 15 Diagnoses

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Kansas- Top 15 Diagnoses

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MO: Regional Comparison–ALOS Per Discharge
Swing Bed stays are ~14 days less than SNF stays

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KS: Regional Comparison – ALOS Per Discharge
Swing Bed stays are ~14 days less than SNF stays

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MO: Regional Comparison – Readmission Rate
Swing Beds have ~5% lower readmission rates than SNFs

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KS: Regional Comparison – Readmission Rate
Swing Beds have ~7% lower readmission rates than SNFs
11% 11% 11%
12%
14%
19% 19% 19%
20%
22%
Southwest South Central Southeast Northeast Northwest
Swing Bed

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MO: Discharge Disposition Comparison
Discharged Home 49% 40%
Discharged to Home Health
Discharged to General Hospital
Other
Swing Bed
20% 11%
5% 11%
26% 39%
SNF

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Discharged Home 60% 51%
KS: Discharge Disposition Comparison
Discharged to Home Health
Discharged to General Hospital
Other
Swing Bed
8% 8%
4% 15%
28% 26%
SNF

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MO: Facility Comparison
21% of CAHs
outperform SNF peers
Total Cost of Care
71% of CAHs
outperform SNF peers
Readmission Rates
100% of CAHs
outperform SNF peers
Average Length of Stay

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KS: Facility Comparison
29% of CAHs
outperform SNF
peers
Total Cost of Care
86% of CAHs
outperform SNF
peers
Readmission Rates
98% of CAHs
outperform SNF
peers
Average Length of Stay

23. 3. Strategies
Swing Bed Value Proposition
Continuum of Care – Preferred Provider Relationships

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SNF Quality Measures
 SNF Quality Reporting Program
 Requires SNFs to submit standardized and interoperable patient
assessment data (MDS 3.0)
 Failure to submit = reduce Annual Payment Update by 2 percentage points
 Does not apply to CAH swing beds
 SNF Value-Based Purchasing Program
 SNF 30-Day All-Cause Readmission Measure
 2% withhold re-distributed based on performance
 Does not apply to CAH swing beds
 Nursing Home Compare
 Does not include CAH swing beds

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Swing Bed Value Equation
 Hospital readmission
 Return to community
 Functional status
 Need for assistance with activities of daily living – initial assessment vs. discharge
 Average LOS
 Beneficiary out-of-pocket
 Process of care/teamwork
 Staffing levels
 Lab and radiology
 Patient experience of care/patient satisfaction
 Adverse events (infections, falls, pressure ulcers, use of antipsychotic
medications )

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Continuum of Care
 PPS hospitals’ competing priorities
 Reduce Medicare bed days beyond mean geometric LOS
 Reduce readmissions
 Post-Acute Care Transfer Policy
 When PPS hospital patient with LOS < geometric mean is transferred,
hospital receives per-diem rate (for specified MS-DRGs)
 Skilled nursing facilities
 Inpatient rehab facilities and units
 Long-term care hospitals
 Psychiatric hospitals and units
 Children’s and Cancer hospitals
 Home with a home health plan of care that begins within 3 days
 Hospice care (effective 10/1/18)
 Transfer to swing bed not included

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Swing Bed Transitional Care
 High-quality post-acute care for challenging patient
populations
 Wound care, respiratory support, intravenous treatment, cardiac
monitoring, pain management, complex tube feedings
 Benefits
 Community hospital setting (vs. nursing home)
 Closer to family and friends
 Focus on successful return to home
 Integration with referring acute care hospital

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Engagement
 Self-assessment of performance
 Self-assessment of capabilities
 Market analysis
 Business plan
 Partner recruitment

29. Remember to
complete
your survey
before you
leave this
session.
Thank you!

30. PYA, P.C.
800.270.9629 | www.pyapc.com
Martie Ross
Consulting Principal
(800) 270-9629
mross@pyapc.com