Medicare Severe Wound Care: Spending Declines May Reflect Site of Care Changes; Limited Information Is Available on Quality

What GAO Found

GAO’s analysis of Department of Health and Human Services (HHS) Centers for Medicare & Medicaid Services (CMS) data show that in fiscal year 2018, 287,547 Medicare fee-for-service beneficiaries had inpatient stays that included care for severe wounds. These wounds include those where the base of the wound is covered by dead tissue or non-healing surgical wounds. About 73 percent of the inpatient stays occurred in acute care hospitals (ACH), and a smaller percentage of stays occurred in post-acute care facilities. Specifically, about 16 percent of stays were at skilled nursing facilities (SNF), and about 7 percent were at long-term care hospitals (LTCH).

CMS data show that Medicare spending on stays for severe wound care was $2.01 billion in fiscal year 2018, representing a decline of about 2 percent from fiscal year 2016, when spending was about $2.06 billion. Spending declined as a result of decreases in both the total number of these stays, as well as spending per stay, which both decreased by about 1 percent. The decrease in per stay spending was likely driven, in part, by a change in where beneficiaries received care. CMS data show fewer severe wound care stays in LTCHs, which tend to be paid higher payment rates. At the same time, more severe wound care stays were at two other types of facilities that tend to be paid lower payment rates: ACHs and inpatient rehabilitation facilities.

GAO’s analysis of CMS data also show that, while the number of LTCHs that billed Medicare for severe wound care decreased by about 7 percent from fiscal years 2016 to 2018, Medicare beneficiaries continued to have access to other severe wound care providers. For example, CMS data show that most beneficiaries resided within 10 miles of an ACH or SNF that provided severe wound care in fiscal year 2018.

Figure: Percentage of Medicare Fee-for-Service Beneficiaries Residing within 10 Miles of a Health Care Facility That Provided Any Severe Wound Care, by Facility Type, Fiscal Year 2018

Note: The “other” category includes facilities such as psychiatric hospitals or units.

There is limited information on how or whether the decrease in LTCH care for severe wounds may have affected the quality of severe wound care Medicare beneficiaries receive. For example, CMS collects information on the percentage of patients with new or worsened pressure ulcers at post-acute care facilities, but it does not measure the quality of care they receive.

Why GAO Did This Study

Medicare beneficiaries with serious health conditions, such as strokes, are prone to developing severe wounds due to complications that often lead to immobility and prolonged pressure on the skin. These beneficiaries may require a long-term inpatient stay at an ACH or a post-acute care facility, such as an LTCH. LTCHs treat patients who require care for longer than 25 days, on average. In 2018, LTCHs represented about $4.2 billion in Medicare expenditures.

Prior to fiscal year 2016, LTCHs received a higher payment rate for treating Medicare beneficiaries than ACHs. Beginning in fiscal year 2016, a dual payment system was phased in that paid LTCHs a rate similar to ACHs for some beneficiaries and a higher rate for beneficiaries that met certain criteria. As this payment system has moved from partial to full implementation, lawmakers had questions about how it may affect beneficiaries’ severe wound care.

The 21st Century Cures Act included a provision for GAO to review severe wound care provided to Medicare beneficiaries. This report describes facilities where Medicare beneficiaries received severe wound care, Medicare severe wound care spending, and what is known about the dual payment system’s effect on access and quality. GAO analyzed Medicare severe wound care access and spending data for fiscal years 2016 and 2018 (the most recent data available); reviewed reports; and interviewed CMS officials, researchers, and national wound care stakeholders.

HHS provided technical comments on a draft of this report, which were incorporated as appropriate.

For more information, contact James Cosgrove at (202) 512-7114 or cosgrovej@gao.gov.

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    At the state and federal levels, GAO found weaknesses in the oversight of Medicaid managed long-term services and supports (MLTSS), which assist individuals with basic needs like bathing or eating. Through various monitoring approaches, six selected states identified significant problems in their MLTSS programs with managed care organization (MCO) performance of care management, which includes assessing beneficiary needs, authorizing services, and monitoring service provision to ensure quality and access to care. State efforts may not be identifying all care management problems due to limitations in the information they use to monitor MCOs, allowing some performance problems to continue over multiple years. Performance Problems in Managed Care Organization (MCO) Care Management, Identified by Selected States GAO found that the Centers for Medicare & Medicaid Services' (CMS) oversight of state implementation of its 2016 requirements, and of access and quality in MLTSS more broadly, was limited. This hinders the agency's ability to hold states and MCOs accountable for quality and access problems beneficiaries may face. Oversight did not detect quality and access problems. GAO identified cases where CMS learned about problems not through its regular oversight, but instead from beneficiary complaints, media reports, or GAO. CMS officials said that states had not reported these problems to the agency. Lack of national oversight strategy and assessment of problems in MLTSS. Weaknesses in oversight reflect a broader area of concern—namely, that CMS lacks a strategy for oversight. CMS also has not assessed the nature and extent of access and quality problems across states. Without a strategy and more robust information, CMS risks being unable to identify and help address problems facing beneficiaries. As of July 2020, CMS had convened a new workgroup focused on MLTSS oversight, though the goals and time frames for its work were unclear. An increasing number of states are using managed care to deliver long-term services and supports in their Medicaid programs, thus delegating decisions around the amounts and types of care beneficiaries receive to MCOs. Federal guidance requires that MLTSS programs include monitoring procedures to ensure the appropriateness of those decisions for this complex population, which includes adults and children who may have physical, cognitive, and mental disabilities. GAO was asked to review care management in MLTSS programs. Among other things, this report examines state monitoring of care management, and CMS oversight of state implementation of 2016 requirements related to MLTSS quality and access. GAO examined documentation of monitoring procedures and problems identified in six states selected for variation in program age and location. GAO reviewed federal regulations and oversight documents, interviewed state and federal Medicaid officials, and assessed CMS's policies and procedures against federal internal control standards. GAO is making two recommendations to CMS to (1) develop a national strategy for overseeing MLTSS, and (2) assess the nature and prevalence of MLTSS quality and access problems across states. CMS did not concur with the recommendations. GAO maintains the recommendations are warranted, as discussed in this report. For more information, contact at (202) 512-7114 or yocomc@gao.gov.
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  • Climate Change: A Climate Migration Pilot Program Could Enhance the Nation’s Resilience and Reduce Federal Fiscal Exposure
    In U.S GAO News
    GAO identified few communities in the United States that have considered climate migration as a resilience strategy, and two—Newtok, Alaska, and Isle de Jean Charles, Louisiana—that moved forward with relocation. Newtok, for example, faced imminent danger from shoreline erosion due to thawing permafrost and storm surge (see figure). Literature and experts suggest that many more communities will need to consider relocating in coming decades. Shoreline Erosion at Newtok, Alaska, from July 2007 to October 2019. Federal programs provide limited support to climate migration efforts because they are designed to address other priorities, according to literature GAO reviewed and interviews with stakeholders and federal officials. Federal programs generally are not designed to address the scale and complexity of community relocation and generally fund acquisition of properties at high risk of damage from disasters in response to a specific event such as a hurricane. Unclear federal leadership is the key challenge to climate migration as a resilience strategy. Because no federal agency has the authority to lead federal assistance for climate migration, support for climate migration efforts has been provided on an ad hoc basis. For example, it has taken over 30 years to begin relocating Newtok and more than 20 years for Isle de Jean Charles, in part because no federal entity has the authority to coordinate assistance, according to stakeholders in Alaska and Louisiana. These and other communities will rely on post-disaster assistance if no action is taken beforehand—this increases federal fiscal exposure. Risk management best practices and GAO's 2019 Disaster Resilience Framework suggest that federal agencies should manage such risks before a disaster hits. A well-designed climate migration pilot program that is based on project management best practices could improve federal institutional capability. For example, the interagency National Mitigation Investment Strategy—the national strategy to improve resilience to disasters—recommends that federal agencies use pilot programs to demonstrate the value of resilience projects. As GAO reported in October 2019, a strategic and iterative risk-informed approach for identifying and prioritizing climate resilience projects could help target federal resources to the nation's most significant climate risks. A climate migration pilot program could be a key part of this approach, enhancing the nation's climate resilience and reducing federal fiscal exposure. According to the 13-agency United States Global Change Research Program, relocation due to climate change will be unavoidable in some coastal areas in all but the very lowest sea level rise projections. One way to reduce the risks to these communities is to improve their climate resilience by planning and preparing for potential hazards related to climate change such as sea level rise. Climate migration—the preemptive movement of people and property away from areas experiencing severe impacts—is one way to improve climate resilience. GAO was asked to review federal support for climate migration. This report examines (1) the use of climate migration as a resilience strategy; (2) federal support for climate migration; and (3) key challenges to climate migration and how the federal government can address them. GAO conducted a literature review of over 52 sources and interviewed 12 climate resilience experts. In addition, GAO selected and interviewed 46 stakeholders in four communities that have considered relocation: Newtok, Alaska; Santa Rosa, California; Isle de Jean Charles, Louisiana; and Smith Island, Maryland. Congress should consider establishing a pilot program with clear federal leadership to identify and provide assistance to communities that express affirmative interest in relocation as a resilience strategy. The Departments of Homeland Security and Housing and Urban Development provided technical comments that GAO incorporated as appropriate. For more information, contact Alfredo Gómez at (202) 512-3841 or gomezj@gao.gov.
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  • Former City Officials Sentenced for Accepting Bribes in Exchange for Cannabis Dispensary Permit
    In Crime News
    Two California men were each sentenced today to two years in prison for accepting bribes in return for a guarantee of a city permit to open a commercial cannabis dispensary.
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  • Wife of “El Chapo” Pleads Guilty to Drug Trafficking and Money Laundering
    In Crime News
    The wife of Joaquin “El Chapo” Guzman Loera, leader of the Mexican drug trafficking organization known as the Sinaloa Cartel, pleaded guilty today to charges related to international drug trafficking, money laundering, and a criminal violation of the Foreign Narcotics Kingpin Designation Act (the Kingpin Act). 
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