Over the past decade, Congress and the Centers for Medicare and Medicaid Services (CMS) have touted the benefits of implementing a single post-acute care assessment instrument for healthcare reimbursement. Yet, despite the rhetoric, these two organizations are getting ready to release a tool that is not scientifically proven and that will make it harder, and more expensive, to achieve this goal.

Earlier this year, the Senate Finance Committee and the House Ways and Means Committee, in a rare move of bipartisan and bicameral unity, released the IMPACT Act, draft legislation that reforms the way that CMS pays for care in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health agencies.


As the committees receive comments on their effort, they must address one gaping hole: CMS’s current plan to roll out the CARE tool, which is the agency’s attempt to create a functional measurement tool that can be used throughout the entire industry.

The creation of a workable standardized measurement tool for post-acute care has been a longstanding goal of CMS. Such a tool would facilitate “apples-to-apples” comparisons between facilities in terms of the effectiveness of their care and their resource utilization. The tool also would allow interested parties – be they patients, doctors or the government – to determine whether and when one facility is more appropriate than another.

Unfortunately, the early reviews of the CARE tool have been poor. Facilities testing the tool report a steep learning curve and significant implementation challenges. Rather than simplify the data collection and reporting process, the new tool forces facilities to spend more time and money on paperwork and less on patient care.

In addition, many of the measures in the draft specifications CMS has issued have not been scientifically tested for reliability and validity, making many in the industry wonder whether the CARE tool will function as promised.

If this were not bad enough, the IMPACT Act gives CMS a loophole that will allow it to push the CARE tool out on the industry, whether it works or not.

In the Act, Congress gives the Secretary of Health and Human Services the ability to waive the National Quality Forum’s Measure Application Partnership (MAP) Process for the CARE tool, a task Congress required in the Affordable Care Act. The Forum has been contracted to review quality standards and give independent validation to CMS’s work.

Given the problems so far with the CARE tool, exempting it from the review process is a serious omission that not only lacks transparency, but also will likely make post-acute care more expensive, not less.

Congress has two potential solutions.

First, it can remove the loophole. However, this option is likely to expose the flaws in the tool and require CMS either to go back and make expensive, time-consuming fixes or to shelve the program.

Second, it can do what it should have done in the first place and require CMS to look at existing tools that could complete the desired task at a lower cost to taxpayers and a lower learning curve for the industry.

UDSMR’s FIM instrument, which has been scientifically tested for reliability and validity for more than 25 years, is one alternative. CMS has used the FIM instrument since 2002, and it the tool is currently used by all the nation’s IRFs as part of the Medicare IRF Prospective Payment System, along with many SNFs and LTCHs. It already has been submitted to the Forum for endorsement and has been offered to CMS for ongoing use on a royalty-free basis.

Whether CMS fixes the CARE tool or uses an off-the-shelf technology, giving the agency the option to skip independent evaluation, is bad public policy. It is better for Congress to remove the loophole and force CMS to make sure the CARE tool actually works as promised.

Granger is executive director emeritus of Uniform Data System for Medical Rehabilitation (UDSMR), a division of UB Foundation Activities, the not-for-profit arm of the University at Buffalo.  The views expressed here are his own.