Oy is right. Those 100 days of skilled nursing may be a mirage thanks to new Medicare Initiative.

Oy

During this journey, I have felt as if I keep tripping over new information – critical information that families should be made aware of, but instead I find out the info by accident.  Apparently just a couple of months ago – a.k.a. before my dad fell and broke his hip but AFTER he fell and fractured his pelvis – Medicare expanded a new initiative they had started a couple of years ago.  This year, the expansion INCLUDED orthopedic practices and specifically hip and knee replacements.

The way it USED to work is when you fell and had to have hip replacement surgery, you would receive up to 100 days of skilled care, as long as you were making progress in therapy (and also assuming you had been out of the system for 60 full days – see prior blog post).

Now, with this new initiative, Medicare has decided in advance roughly how long it should take to rehab a person who has hip or knee replacement surgery.  Medicare takes the time they think it takes a 90-year-old and the time it takes a 50-year-old and then averages the period into something in the middle. They do not take into consideration any co-morbid conditions, which most 90-year-olds have, nor do they consider the additional complication of Dementia.

So, for the purposes of this explanation, let’s assume Medicare says it should take a person 20 days of rehab to recover from hip surgery….if the nursing home disagrees, and keeps a patient on for longer, then the Orthopaedic practice gets less money.  Next time they have a patient to send, perhaps they won’t choose that nursing home.  The nursing home, which was trying to do the right thing now goes out of business. Furthermore, this is a system that ultimately does not benefit the patient.

Let me explain further.  In a bundled payment environment, Medicare has decided, in advance, how much a hip replacement should cost, including hospitalization, skilled nursing, and home care. The physician’s practice is given a bundled payment for all of those services and then they hire a management firm (in my case, Remedy out of CT) to manage the various vendors involved in my father’s care. The incentive on paper is to make sure that no one is keeping my father on too long to milk the system (I am guessing).  The sad byproduct of this, of course, is that patients like my father, who may need a bit more time than the average, due to his co-morbid conditions, will end up two ways:

  1. He will be pushed out of skilled care before he is fully ready and,
  2. The nursing home, which has done an excellent job with my dad will be penalized if they keep him on until he is fully ready

And the real victim, of course, is the patient:  my dad.  If they discharge him before he is ready, he will be back into the system sooner than later.