By Anne Tumlinson Innovations
For frail older adults with complex care needs, an inpatient hospital stay is destabilizing and often marks the beginning of a decline in functioning. For these older adults and their families, the post-hospital period is a risky, confusing, and stressful time.
Medicare covers a range of “post-acute” care settings that support and rehabilitate patients as they make the journey home. The problem for patients and family caregivers is that not only are there different types of providers in nearly every market (e.g., skilled nursing facilities, rehab hospitals, home health agencies), but also that there are dozens of providers within each type and no obvious way for consumers or their medical providers to determine the best options.
The tools for comparing and selecting providers often lack the information that matters most to patients and their families. Measures of post-acute care provider quality and performance are severely limited — making it difficult for hospitals, health plans, and families to discern differences in providers’ value. In fact, we see evidence of market confusion in the Medicare fee-for-service claims data, which shows that in many markets, hospitals are sending patients to dozens of different post-acute providers, with widely varying quality ratings.
Remember the promise of value-based care to create incentives under which hospitals would form clinically integrated, narrow networks with high-quality post-acute care providers? That hasn’t yet happened in any significant way, and the promise of value-based care is probably the farthest from fulfillment in the area of post-acute care.
Post-acute care remains a commodity service in most markets, which is problematic for all participants in the system:
- For patients and family caregivers: our health care system fails our most complex patients at a particularly vulnerable time in a care episode, leading to higher overall care costs throughout their lifetimes and faster functional decline.
- For post-acute providers: investment in quality is not rewarded by the market. Providers that do invest in quality may not see a return and will be less likely to continue making investments in improved care and outcomes.
- For the Medicare program: continued post-acute care spending variation suggests significant overpayment and varied outcomes for similar services and care.
We cannot continue to ignore this problem, particularly with the country’s shifting demographics. The Kaiser Family Foundation projects that the 80+ population, the patient population most likely to use post-acute care, will grow by 47 percent from 2020 to 2030. As growth in the size of the 80+ population accelerates, our deficient system will create enormous problems for patients and families and payers.
The good news is that payment systems and performance measurement in post-acute care are evolving to improve the ability of post-acute care providers to deliver high-quality care to more clinically complex patients. Starting on October 1 this year, Medicare will pay both skilled nursing facilities and home health agencies based on patient characteristics instead of the amount of therapy they deliver. The changes will better align payment with the needs of hospitals looking to find strong clinical programming for patients with clinically complex needs. There’s never been a better time for hospitals and post-acute care providers to operate in a more clinically integrated manner. How do you do that and where do you start?
Here are a few ideas:
- Reduce the disconnect between inpatient and post-acute care settings through provider relationships. Hospitals and payers are not going to find perfect post-acute care providers; but hospitals and payers can find organizations with whom they can develop long-lasting, productive clinical partnerships. Committing the time and attention to developing these partnerships can foster a more seamless care delivery experience for patients and families and increase value over time. Interview the clinical and financial leadership of post-acute care organizations in the same way you would interview any other potential partner — look for alignment of values and the ability to build trust.
- Employ high-tech/high-touch solutions for discharge decision-making. Helping patients and their families select the best option requires two things: reliable quality and performance information you cannot get from government tools; and experienced case managers who work collaboratively with the full range of providers and payers involved in patient care. The entire discharge planning function needs to be organized and resourced differently. While the Medicare Payment Advisory Commission continues to present options to Congress on helping hospital discharge planners identify higher quality providers, it will be years before government tools will help. In the meantime, it will be worth the cost to develop the tools that would deliver powerful support to the case managers helping patients and families navigate their transition out of the hospital.
- Explore value-based contracts that include post-acute providers. In the end, payment incentives must align with performance. Post-acute care providers are mightily motivated by volume, but they will really deliver quality outcomes if they are full partners in sharing the risk and the reward for delivering improved patient care. Including them in the value they help create is good business for all parties.
There are post-acute providers who have made investments to innovate their care delivery models and to manage and improve care for their patients. It’s time for payers, hospitals, and health systems to find and partner with these providers.