A Valuable Perk from Medicare. Medicare beneficiaries can get direct access to a skilled nursing facility, sometimes without a recent hospitalization.
The lowdown on skilled nursing facilities. Patients are sent to a skilled nursing facility to manage their post-acute care and begin the slow and uncomfortable process of recovery. Historically speaking, patients were routinely sent to SNFs after a surgery, whether they needed that level of care or not. As it turns out, SNF care was often a waste of patients’ time and money (I refer to patients’ money here, because health insurance costs get passed to the consumer, and we all need to remember that!). Major healthcare reform initiatives, like the CJR Model, have shown that for certain types of surgeries, we could dramatically reduce SNF care without harming patient outcomes, and save a bunch of money.
So how do we match SNF care to only those patients who need it? Well, one way to is to require a prior hospitalization of three days or more – this is how Medicare rolls and it’s called the 3-day rule. The idea is that if a patient is hospitalized for that length of time, then that patient’s condition is probably serious enough to justify a SNF. A lot of folks, clinicians and patients alike, are not happy with this rule. I won’t dive deep into this topic, but you can find some good details here. Anyways, Medicare allows this rule to waived under certain conditions, and that means a patient can be admitted to a SNF after spending 1 or 2 days in a hospital, or even with no prior hospitalization – as long as a physician gives the go ahead (and accompanying documentation).
From a value perspective, the flexibility of the SNF three-day rule waiver can improve the patient experience (and reduce healthcare expenditures) by avoiding unnecessary hospitalizations. A common, and expensive, sequence of care for many patients is to show up in the emergency room, get put under observation status, spend a few days in the inpatient wing, and end up spending the next few weeks in a skilled nursing facility. But through the waiver, patients can skip the visit to the ER (and the hospitalization!) and get sent directly to the SNF. The key point here is that SNF care might be the only type of care that’s needed, and your doctor can make that decision.
Taking advantage of the rule waiver. The first thing is to be aware of your local ACO. If you haven’t heard this acronym before it stands for Accountable Care Organization, and it’s a very big deal in healthcare right now. ACOs represent a major national effort to reign in healthcare spending, by holding doctors and hospitals (ACO entities) responsible for the annual cost of care for their Medicare FFS patients.
Medicare operates several types of ACOs, and many of them have access to the SNF three-day rule waiver. To find out if you fall under the management of a Medicare ACO, simply ask your primary care doctor whether he or she participates in a Medicare ACO and if you are “aligned” to that ACO. Now for technical reasons, your primary care doctor may participate in a Medicare ACO, but as a patient, you may not be eligible for the rule waiver. If that’s the case your next step is to ask your doctor about ‘voluntary alignment’. Voluntary alignment is a path for patients to declare that a particular ACO is responsible for their care management. One last point: if you get Medicare benefits through a Medicare Advantage plan, then you cannot access the rule waiver – there’s no way around this.
The Medicare rules on waiver access are always subject to change, and I will try to keep this post updated with the latest details.
Happy Readings
~ James
