Imagine you are a hospital patient getting released to a skilled nursing facility to recover from a hip fracture or heart failure, and upon arriving at the facility discovered your bed isn't ready. Let's say you arrive at night and hurting because your pain medicine is wearing off, but the doctor and pharmacist had left for the day. On top of it, you haven't eaten in hours and feel despaired. Instead of giving you a bed, something to eat, your prescribed pain medicine and next steps to get you well, the facility bounces you back to the hospital.
Five competing Massachusetts accountable care organizations (ACO) are working together to reduce incidences like these and other snafus that can hinder the care of, and jack up costs for, patients who require some level of post-acute care after leaving the hospital. Together, the five ACOs provide medical care to 40 percent of the state's Medicare beneficiaries; they are trying to tame a part of the health care system that has become Medicare's Achilles Heel.
"We're all looking to improve the quality of care, cost efficiency and patient experience," says Dr. Mark Krivopal, vice president and medical director for clinical integration at Steward Health Care System. The five so-called pioneer ACOs—sponsored by Steward, Partners Healthcare, Atrius Health, Mount Auburn Cambridge Independent Practice Association and Beth Israel Deaconess Physician Organization—have contracted with Medicare to coordinate care for patients across care settings.
Medicare pays pioneers differently. If an ACO saves money, it can split the savings with Medicare -- as long as it hits 33 quality and performance measures -- or share in any losses. As a result, the five Boston-area health care systems have stopped scrapping for market share. Instead of filling hospital beds, the ACOs are working to reinvent patient care to reduce barriers rife in the current fee-for-service system, including widely varying experiences and issues that older patients face in skilled nursing facilities (SNF), home health services, rehabilitation hospitals and other sub-acute settings. ACOs are one of the ways Medicare, commercial and other payers nationwide are trying to make care better and less expensive.
"The Massachusetts effort is unique in its deep level of collaboration across health systems and skilled nursing facility partners," says Dr. Clay Ackerly, associate medical director for population health and continuing care for Partners HealthCare. The players are creating a series of guidelines on how patients who get discharged from the hospital and require some level of post-acute care should be treated -- common standards that are currently lacking in the industry.
The parties, which include post-acute care provider representatives, have rolled out initial standards around SNF staffing levels and minimal use of temp-agency personnel, warm handoffs (ensuring hospital and post-acute care clinicians communicate with one another about a patient's care), prompt patient in-take screening, and providing patients with clear and reconciled medication lists and instructions as they enter and leave post-acute care settings. The guidelines also direct that doctors see patients within two days of SNF admission, highlight care planning practices, and order facilities to conduct consistent interdisciplinary team meetings to discuss patient care.
"We're creating a breakthrough moment here," says Richard Bane, president and CEO of Bane Care and past chairman of the Massachusetts Senior Care Association. The effort started informally last fall and the group meets regularly. The collaborative has produced "aspirational goals and standards around transitions of care," says Bane. Implementation is occurring on a facility-by-facility basis.
While many ACOs nationwide are focused on coordinating upfront care and care their Medicare beneficiaries receive once they get home from the hospital, Massachusetts ACOs are taking a bigger step in reorganizing post-acute care. By doing so, the Massachusetts ACOs stand to reduce widely varying patient care experiences, start paying for post-acute care based on performance rather than the number of services they generate, put some out of business and provide a model to other communities looking to reshape health care delivery.
In 2012, Medicare's post-acute care bill in the traditional fee-for-service program totaled $62 billion, more than double the $26 billion the program paid in 2000. About 43 percent of all Medicare beneficiaries discharged from hospitals in 2011 required some form of post-acute care, according to the Medicare Payment Advisory Commission (MedPAC).
In July, the esteemed Institute of Medicine issued a report that showed variation in Medicare spending across the nation is driven largely by differences in post-acute care. "If regional variation in post-acute care did not exist, Medicare spending variation would fall by 73 percent," the IOM said. Even among beneficiaries with similar care needs, spending varies more than three-fold, according to MedPAC, and at the extremes can ping pong by as much as 800 percent.
After-hospital care decisions often are driven by proximity of services, patient preference or financial or contractual relationships between providers, according to Mark Miller, executive director of MedPAC, which provides Congress with technical advice about running Medicare. Miller blames fee-for-service payment, which rewards any post-acute care providers for services provided, without discerning which setting or provider is deemed most efficient or effective in delivering the right amount of needed care.
"The use of outpatient therapy is similarly vexed by the lack of guidelines about when and how much therapy is appropriate for a given condition," Miller told a congressional panel in June. Miller and the IOM cited payment reforms, such as ACOs, as a key fix.
"It will be incredibly helpful" to have standardized protocols in place, says Bane. It's a two-way street, he says, as hospitals under fee-for-service drop patients like hot potatoes once they leave the hospital, which can lead to mix-ups. "Membership is welcoming the standards so we don't have to play under five different sets of rules."
Now, the players are broaching trickier territory, attaching metrics to the guidelines. "We do need to identify facilities that are high quality," says Ackerly, adding the initiative is "laying the groundwork for advancements in quality measurement and care improvement." Bane says re-hospitalization rates and "critically important" patient satisfaction rates will be included. When it comes to length-of-stay measures, Bane says, they must be adjusted on a case-by-case basis. A healthy person recuperating from a hip replacement is very different from a hip-replacement patient suffering a chronic illness.
With guidelines and measures in place, payment changes will likely follow for post-acute providers that so far have been paid exclusively on a fee-for-service basis. "We're discussing piloting some value-based [payment] system," says Bane. This could ultimately lead to some facilities specializing in certain types of care or patient conditions, rather than being jacks of all trades.
"The response was really positive" to the guidelines, says Elissa Sherman, president of LeadingAge Massachusetts, which represents not-for-profit providers of post-acute care. The road ahead, she acknowledges, will change. "The ACOs will be reducing the number of SNFs to which they refer," she says. "They will want to be working with SNFs that are able to meet the quality standards and that are able to reduce length of stay. This may mean a reduction in Medicare post-acute business for SNFs who are not able to meet the standards and reduction in length of stay. Some facilities that see a major decrease in Medicare revenue may ultimately have a hard time staying in business."
From Medicare's perspective, that may not be a bad thing.
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