Beyond Hospitals and Primary Care: How Risk-Bearing Entities Can Think About Post-Acute

As more health systems and provider groups take on risks for their patient lives and the total cost of care, all areas of the health continuum are coming under scrutiny in an effort to increase the value of dollars spent. In 2020 there were 517 accountable care organizations (ACOs) in the Medicare Shared Savings Program alone, with ~11 million lives covered, representing roughly 30% of all traditional fee-for-service beneficiaries.

In my last role as Chief Medical Officer at Caravan Health, I worked with ACO medical directors across the country to make sense of their claims data, using analytics to parse opportunities to better serve patients and reduce the cost of care. With a view into claims data of a million Medicare lives, it was an opportunity to see national and regional trends and make recommendations on targeted improvements within hospital systems and their partners.

Quality and Cost Can Vary Widely in Post-Acute, But There Are Savings To Be Had

One area of near universal interest has been post-acute care providers and the spending associated with these services. This has been in part due to recognition that a large driver of variation in cost of care has been driven by variation in utilization of post-acute services. The costs of these services (Skilled Nursing, Home Health, Inpatient Rehabilitation) per beneficiary peaked in 2011 at $1541.¹ Hospice is for a variety of reasons seen as a separate service, though one could argue in the new world of value, most of these services can be separated from trigger of an acute admission for eligibility.

So how does a population health leader look at their claims data on post-acute services and the continuum to meet the needs of their patients with a serious illness? There are several guiding principles:

1. No one service is an island. You must look at the continuum to get the whole picture. If you have a long length of stay or high cost per beneficiary in home health, for example, this may mean excessive use, but it also may be that there has been a push to send people home on home health rather than send them to SNF. It also helps to look at corresponding hospice use. If that is low, this may indicate a tendency to use home health when hospice is the more appropriate service.
2. Look at the data in hospice: When evaluating hospice agencies, measures I found helpful to benchmark against known national metrics were: average and median length of stay, the average cost per day, and ER visits per episode. This gave me a sense of the types of patients each agency admitted and how skilled they were at appropriately gauging eligibility, the ability to provide different levels of care (General Inpatient, Continuous, Respite, and Routine), and the ability to manage symptoms.
3. Length of Stay in Skilled Nursing may not tell the whole story, but cost and quality were good indicators: SNF data was remarkably consistent, in that the length of stay was always around the 20 days Medicare covered without a patient co-pay, but the ability to compare variation in cost per episode and length of stay – coupled with quality data from CMS and other sources – was a powerful way to start conversations about preferred partners and 3-Day waiver participants.
4. Ultimately, data is only data. You can read the tea leaves only so far, and then conversations are needed. These discussions may be with discharge planners, care coordinators, or physicians to know how they experience and gauge the quality of various post-acute vendors. Maybe that hospice agency with the high GIP utilization rates takes the most complex oncology patients or has an open access program.

Value is Coming, and Post-Acute Can Help

The Affordable Care Act not only provided opportunities for more Americans to be insured, it also laid the framework for a move to value in healthcare, not just more volume. The Medicare Shared Savings Program was the first broad scale program to provide claims data to physicians and hospital members. Having the data to understand where and how your patients are getting care is eye-opening and powerful. I don’t think I ever worked with a group who wasn’t shocked at something they discovered. But having this transparency, and the ability to design programs that truly meet patients’ needs has been a game changer. When selecting a hospice provider, it can make a significant difference in achieving shared savings.

Sources

1: Trends in Postacute Care Spending Growth During the Medicare Spending Slowdown

About the Author: Anna Loengard, M.D. is the Chief Medical Officer of AccentCare®, Inc. She is a highly accomplished physician executive with significant experience in both geriatric medicine and value-based care models. Previously, Anna served as Chief Medical Officer for Queen’s Healthcare System and as Chief Medical Officer at St. Francis Healthcare System in Honolulu focusing on post-acute care. She received her doctor of medicine degree from State University of New York at Stony Brook in New York City and completed her residency in Internal Medicine at Harvard Medical School, Beth Israel Deaconess Medical Center (BIDMC) in Boston, and her Geriatrics Fellowship at the University of Arizona in Tucson. She earned a Bachelor of Arts in Political Science and French from the University of California, San Diego.