Washington, D.C.—Hello, ProviderNation. One of the greatest minor characters in all of literature is Mr. Salter in Evelyn Waugh’s glorious “Scoop.”* So terrified is he of his terrifying, press baron boss that poor Salter can only answer in the affirmative by saying, “Definitely, Lord Copper” and in the negative by saying, “Up to a point, Lord Copper.”
But you’ll just have to forgive AHCA’s Dan Ciolek if, dealing with the media reaction to yesterday’s inspector general’s report on Medicare’s therapy margins, he feels that the Salter character is an outrage of his own copyright.
For the past 36 hours or so, Ciolek has had conversations that go something like this:
Reporter: The OIG says that skilled nursing centers made 29 percent profit margins on therapy in fiscal 2012, right?
Dan: Definitely, Lord Copper.
Reporter: The OIG also says that high RUG charges cost Medicare $1.1 billion in fiscal 2012 and 2013, right?
Dan: Definitely, Lord Copper.
Reporter: So we need across-the-board cuts to Medicare therapy rates, right?
Dan: Up to a point, Lord Copper.
As OIG itself noted, AHCA (in the form of Ciolek and others) has been up front in arguing that Medicare has to stop rewarding volume and start rewarding value. So it’s a little bit more than irritating to see some folks read the inspector general’s report—in essence, proof that volume-based payment is flawed—to argue that the only solution is to reduce the amount of payments, regardless of outcomes.
“We have been supportive of a shift away from the volume of service,” Ciolek tells me. “We want to be paid based on what we do in our centers, and in good outcomes. The challenge is to get data on quality and outcomes. That’s why we supported IMPACT and have been developing outcome measures as part of our quality initiative.”
The problem with OIG’s report is that “it doesn’t say whether the quality of the care or the outcomes were better, worse, or indifferent.”
“We care about outcomes,” Ciolek says. “The discussion should be, is the therapy valuable or not? We shouldn’t pay for what is done in rehab, we should pay for the results of rehab.”
Poor Ciolek is trying to thread a needle in the middle of a hurricane. He makes (or tries to make) the following points:
- That, first, the far-famed Omnibus Budget Reconciliation Act of 1987 requires skilled nursing centers to help residents “attain and maintain [their] highest practicable physical, mental, and psychosocial well-being.”
- That, second, federal regulators themselves have acknowledged, in the Jimmo settlement, that therapy services can’t arbitrarily be withheld for folks of any age of condition… “even when a chronic, progressive, degenerative, or terminal condition exists.”
- That, third, regulators are already gathering the kind of data, under IMPACT, that will answer all sorts of questions about value and quality.
- That, fourth, you can’t kinda be data-driven. If it emerges that Medicare is spending too much for therapy without demonstrating value, then the data will answer that definitively.
- That, fifth, until the data comes in, any precipitous moves are also premature.
“The core issue is that beneficiaries need services to get stable, to get better, and to get home, quickly,” Ciolek says. “A lot of the focus is on the margins and the actuarial stuff. The system needs to get rid of minute-driven models. But don’t lose sight of the fact that these folks need care.”
So, Ciolek’s measured, thoughtful approach will get the media to rewrite the standard-issue, hackneyed narrative about “nursing homes gaming the system,” right?
Up to a point, Lord Copper.
*Your Humble Correspondent, having served as a foreign correspondent, will take his oath that there is nothing satirical about “Scoop.” It is an understated work of pitiless realism.