Managed care is an all-encompassing term that covers a variety of methods to pay for healthcare outside the norm of fee-for-service. Medicare Advantage (MA) plans are a form of managed care, as are Managed Medicaid plans. Accountable Care Organizations (ACOs) also fall under this umbrella. With the exception of MA, managed care is a relatively new idea in terms of health care financing. Generally, with managed care, payments flow through a risk-bearing third-party company to health care providers. The third party’s goal is to manage a patient’s total cost of care so that the total payment made by the third party is smaller than the initial bill. How this system is regulated is still evolving; CMS is committed to moving away from traditional fee-for-service payments, and managed care has a role to play in attaining that goal.
All Medicare-certified skilled nursing facilities are subject to the Five-Star Quality Rating System and Nursing Home Compare, which were established, implemented, and maintained by the Centers for Medicare and Medicaid (CMS). Both programs use metrics to judge the quality of skilled nursing properties. Nursing Home Compare is a website where consumers can gather information about quality metrics for every eligible skilled nursing property to use for comparison shopping. Most of the quality metrics displayed on Nursing Home Compare are used as part of the input to establish a skilled nursing property’s Five-Star rating, with five-star facilities considered the highest quality.
Home health, which provides post-acute medical services directly in a patient’s home, increasingly plays two interesting roles in the post-acute industry: as skilled nursing competitor and potential ally. And as the Centers for Medicare and Medicaid (CMS) pushes for care coordination and value-based purchasing, skilled nursing providers increasingly are forming relationships with home health agencies.
The challenge facing the skilled nursing sector, Ray Thivierge explained during a recent interview with NIC, is that a massive realignment is taking place as the health care system shifts from a fee-for-service to value-based reimbursements.