In addition to lower level nervous  system functioning, spinal cord injury patients may develop secondary  medical complications that can further decrease functional independence  and quality of life, including, but not limited to:
Autonomic dysreflexia: a condition that may result in life threatening  hypertension—high blood pressure—due to impaired nervous system  response, below the level of spinal cord injury. LTCHs are paid under  the LTCH PPS. Since the two qualifying  hospitals are currently only excepted from the statutory two-tiered  payment structure for cost reporting periods beginning during fiscal years  2018 and 2019, these two hospitals must also meet the statutory 50  percent threshold in fiscal year 2020 and beyond in order to receive the  standard rate for any future discharges until reinstated. The Two Qualifying Hospitals: Craig Hospital and Shepherd Center

Two LTCHs have qualified for the temporary exception to site-neutral  payments, according to CMS officials. Most Medicare Beneficiaries Who Receive Services at the Two Qualifying Hospitals Need Specialized Follow- Up Care to Manage Long-Term Effects of Catastrophic Injury

We found that most Medicare beneficiaries at the two qualifying hospitals  need specialized services to manage the chronic, long-term effects of a  catastrophic spinal cord or brain injury. Medicare Policies May Have Modest Effects on Payments to the Two Qualifying Hospitals Depending on the Types of Patients Treated and Other Factors

		Simulations of Medicare Payments to Qualifying Hospitals Illustrate Potential Effects of Payment Policies

Simulations of Medicare payments illustrate the potential effects of  Medicare’s site-neutral payment policies, which were required by law, on  the qualifying hospitals. Severity of patient conditions: Medicare payment is typically higher  for more severe injuries, such as a traumatic injury with major  comorbidities or complications, relative to less severe injuries. 2. Our simulations reflect that in the two baseline years, about  23 percent of the fiscal year 2013 discharges and about 40 percent of  the fiscal year 2016 discharges met the criteria to receive the  standard rate for Shepherd Center; and about 8 percent of the fiscal  year 2013 discharges and about 20 percent of the fiscal year 2016  discharges met the criteria for Craig Hospital. 3. When the temporary exception expires after fiscal  year 2019, hospital officials expected that these patients will not qualify  for the standard rate. MedPAC officials and some stakeholders—a specialty association and  health care providers with experience treating patients with similar  conditions at other LTCHs—told us that some LTCHs have changed the  services they offer and the patients they treat to increase the proportion of  discharges that qualify for the standard rate. Similarities and Differences May Exist Between the Two Qualifying Hospitals and Other Facilities that Treat Medicare Patients with Spinal Cord and Brain Injuries

		The Two Qualifying Hospitals Treat Patients with Conditions Different Than Those at Most Other LTCHs, and Treat Fewer Medicare Patients

Our review of Medicare claims data, other information, and interviews  with stakeholders indicated the two qualifying hospitals treated Medicare  beneficiaries with different conditions than most of those treated at other  LTCHs. While patients with spinal cord and brain injuries may receive care in  other LTCHs, most stakeholders we interviewed also suggested the two  qualifying hospitals treat patients that are different from those treated at  most other LTCHs, and can offer specialized care. According to CMS officials, IRFs are specifically  designed to provide post-acute rehabilitation services to patients with  spinal cord injuries, brain injuries, and other neuromuscular conditions. Medicare uses separate payment systems to pay LTCHs and  IRFs, for care provided to beneficiaries. LTCHs are paid pre-determined  fixed amounts for care provided to Medicare beneficiaries, under the  LTCH PPS. Some Information Suggests Similarities and Differences Between Qualifying Hospitals and IRFs that Specialize in Spinal Cord and Brain Injuries

While data limitations make a direct comparison difficult, based on our  review of other data and information, and interviews with stakeholders,  we identified similarities and differences between the qualifying hospitals  and certain IRFs that provide specialty treatment for catastrophic spinal  cord injuries, acquired brain injuries, or other paralyzing neuromuscular  conditions. Specialized programs and services. Other services provided. Agency Comments

We provided a draft of this report to HHS. HHS provided technical  comments, which we incorporated as appropriate. We also provided the  two qualifying hospitals summaries of information we collected from them,  to confirm the accuracy of statements included in our draft report. We  incorporated their comments, as appropriate. To identify how to appropriately calculate the long-term care hospital  (LTCH) payment for each of these discharges in future payment years,  we reviewed applicable federal regulation and documents from the  Centers for Medicare & Medicaid Services (CMS) and the Medicare  Payment Advisory Commission (MedPAC), and interviewed officials from  both organizations. The site-neutral payment policy did not apply to discharges from the  fiscal year 2013 baseline year.
Why GAO Did This Study

The Centers for Medicare & Medicaid Services pays LTCHs for care provided to Medicare beneficiaries. There were about 400 LTCHs across the nation in 2016.
The 21st Century Cures Act included a provision for GAO to examine certain issues pertaining to LTCHs. This report examines (1) the health care needs of Medicare beneficiaries who receive services from the two qualifying hospitals; (2) how Medicare LTCH payment polices could affect the two qualifying hospitals; and (3) how the two qualifying hospitals compare with other LTCHs and other facilities that may treat Medicare patients with similar conditions.
GAO analyzed the most recently available Medicare claims and other data for the two qualifying hospitals and other facilities that treat patients with spinal cord injuries. GAO also interviewed HHS officials and stakeholders from the qualifying hospitals, other facilities that treat spinal cord patients, specialty associations, and others.
GAO provided a draft of this report to HHS. HHS provided technical comments, which were incorporated as appropriate. We also provided the two qualifying hospitals summaries of information we collected from them, to confirm the accuracy of statements included in our draft report. We incorporated their comments, as appropriate.

What GAO Found

Spinal cord injuries may result in secondary complications that often lead to decreased functional independence and quality of life. The 21st Century Cures Act changed how Medicare pays certain long-term care hospitals (LTCH) that provide spinal cord specialty treatment. For these hospitals, the act included a temporary exception from how Medicare pays other LTCHs. Two LTCHs—Craig Hospital in Englewood, Colorado and Shepherd Center in Atlanta, Georgia—have qualified for this exception. GAO found that most Medicare beneficiaries treated at these two hospitals typically receive specialized care for multiple chronic conditions and other long-term complications that develop after initial injuries, such as pressure ulcers that can result in life-threatening infection. The two hospitals also provide specialty care for acquired brain injuries, such as traumatic brain injuries.
GAO's simulations of Medicare payments to these two hospitals using claims data from two baseline years—fiscal years 2013 and 2016—illustrate potential effects of payment policies. LTCHs are paid under a two-tiered system for care provided to beneficiaries: they receive the LTCH standard federal payment rate—or standard rate—for certain patients discharged from the LTCH, and a generally lower rate—known as a “site-neutral” rate—for all other discharges. Under the temporary exception, Craig Hospital and Shepherd Center receive the standard rate for all discharges during fiscal years 2018 and 2019. Assuming their types of discharges remain the same as in fiscal years 2013 and 2016, GAO's simulations of Medicare payments in the baseline years indicate:
Most of the discharges we examined would not qualify for the standard rate, if the exception did not apply.
Medicare payments would generally decrease under fiscal year 2020 payment policy, once the exception expires.
However, the actual effects of Medicare's payment policies on these two hospitals could vary based on factors, including the severity of patient conditions (e.g., Medicare payment is typically higher for more severe injuries), and whether hospitals' discharges meet criteria for the standard rate.
Similarities and differences may exist between the two qualifying hospitals and other facilities that treat Medicare patients with spinal cord and brain injuries. Patients with spinal cord and brain injuries may receive care in other LTCHs, but GAO found that most Medicare beneficiaries at these other LTCHs are treated for conditions other than spinal cord and brain injuries. Certain inpatient rehabilitation facilities (IRF) also provide post-acute rehabilitation services to patients with spinal cord and brain injuries. While data limitations make a direct comparison between these facilities and the two qualifying hospitals difficult, GAO identified some similarities and differences. For example, officials from some IRFs we interviewed reported providing several of the same programs and services as the two qualifying hospitals to medically complex patients, but the availability of services and complexity of patients varied. Among other reasons, the different Medicare payment requirements that apply to LTCHs and IRFs affect the types of services they provide and the patients they treat.