In the RCS-1 proposal document, CMS states that the CMI weights were calculated to make RCS "budget neutral":
Another assumption made for these impacts is that, as with prior system transitions, we would implement the RCS-I case-mix system, along with the other policy changes discussed in section III of this ANPRM, in a budget neutral manner through application of a parity adjustment to the case-mix weights under the RCS-I model under consideration, as further discussed below.
Notice, they don't say this will be budget neutral. They also make it clear that budget neutrality is not necessary the goal AND it's up for debate:
However, as we would not be required to implement RCS-I in a budget neutral manner, we solicit comment on whether we should consider implementing RCS-I in a manner that is not budget neutral.
So that part is up in the air. What other forces will be acting on RCS regarding budget neutrality? I can think of two:
- Bundled payment: Bundled payment pushes SNFs towards lower length of stays. It's a competitive advantage to get patients to a lower cost environment (home, assisted living, etc) as quickly as possible. Shorter stay = lower cost.
- The use of modified ADL scoring system in RCS: Extensive assistance is the most used self category for all 4 late loss ADLs. (See table 26 in the technical document.) Under RCS only 3 of the 4 are used and for two of those, toileting and transfers, limited assistance will increase case-mix index over extensive assistance. This is one of the few ways facilities can still influence payment. Over time, they will.
So my question is: Why RCS and why now? Bundled payment exists without RCS so those impacts are happening either way. The modified ADL score slowly increasing cost feels like an accident to me. What's the point of this?
The stated purpose of the entire project according to CMS is:
The proposed rule proposes policies that continue a commitment to shift Medicare payments from volume to value, with continued implementation of the SNF Value-based Purchasing (VBP) program.
It isn't clear to me how RCS can accomplish that goal. The main thing RCS seems likely to do is shift the power & money from therapy to SNFs. We'll be spending about as much, but doing a lot less therapy. (Unless there is some type of accountability I have yet to find in any of the documentation yet.)
Here's an idea: why don't we make two payments: one when the patient arrives based on the patient status (like RCS but without the flawed ADL part) and another when a patient can meet objective goals set by CMS based on that same patient status and actuarial tables. Whether the patient has reached the goal would be determined by a disinterested third party like an auditor.
Next we publish the percentage of patients that hit the goals for all SNFs and put that data on nursing home compare for everyone to see.
That would be paying for value over volume.