Determining Medical Necessity and Appropriateness of Care at Medicare Long Term Care Hospitals (LTCHS)

Section 114 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (PL 110-173) requires that the Secretary of Health and Human Services conduct a study on the establishment of national long-term care hospital, facility, and patient criteria for determining medical necessity, appropriateness of admission, and continued stay and discharge from long-term care hospitals. The results of the study are to be reported to Congress, together with recommendations for legislation and administrative action, including timelines for implementation of patient criteria, or other appropriate action by June 30, 2009. The contractor will describe any additional research studies that are needed to answer the research/policy questions raised by the mandate. The research areas to be considered cover Medicare policy areas such as facility classification and conditions of participation, payment systems (including patient classification issues and "bundled" models across individual payment systems), quality of care, and other related topics. Innovative approaches to addressing the key research questions and policy concerns are encouraged. The contractor will provide a discussion of the rationale and methodology proposed for each study. A full research design for additional analyses will be presented after the Report to Congress has been submitted. Data analyses for these additional research analyses will be performed in project years 2 and 3. The contractor shall address, but not limit itself, to examination of the following research questions: - What facility/patient criteria can be used to uniquely define LTCHs and patients that are appropriate for care in LTCHs? - What facility criteria are needed to ensure appropriate provisions of care in LTCHs? - What criteria are needed to determine appropriateness of admissions, discharges, and treatment modalities, medical complexity, quality of care, and improvement potential for patients commonly treated in LTCHs? - What criteria/reforms are needed to ensure parity in Medicare payments, access to care, and quality of care between patients treated in LTCHs and patients with similar conditions treated in other settings?