About this time last year, as the cold winter temperatures were giving way to a spring thaw, a bout with a bad strain of pneumonia landed my dad in the hospital. What followed was an introduction to a part of the health care system I knew in name but had yet to experience first-hand: that of post-acute care. When we received the happy news that my dad would be discharged from the hospital, admittedly my family and I were surprised to learn he would transition to a post-acute care setting before returning home. To aid in our decision-making, his care coordinator shared a (very long) list of facilities from which to choose, arranged geographically. After several harrowing weeks in the hospital, we were now met with making a difficult and time sensitive decision. Somehow, we summoned the wherewithal to ask about the quality of these facilities. We were referred to the available Medicare quality data, which we poured over in the limited time we had before he was discharged.
Months after my personal introduction to post-acute care, AcademyHealth hosted an invitational meeting in December 2016 as part of our Research Insights project on current strategies to improve care and lower costs for post-acute and chronic care. The far-ranging meeting discussion examined new payment models and other initiatives designed to coordinate and integrate post-acute and chronic care services more effectively, and I felt my own personal experience echoed throughout much of the discussion.
As the American population continues to age, those with chronic conditions will assume greater importance in the health care system, and patients may cycle between post-acute and chronic care services as they manage their conditions. Spending for post-acute and long-term care is high and evidence about their quality remains uneven. In response to an increased emphasis on moving from volume to value in health care, there are numerous payment and delivery system models for managing post-acute and chronic care currently underway:
Innovations in Post-Acute Care
- Hospital Readmissions Reduction Program (HRRP)
- Bundled Payments for Care Improvement (BPCI) initiative
- Accountable Care Organizations (ACOs)
- IMPACT Act of 2014
- Medicare Advantage care coordination and development of post-acute care provider networks
Innovations in Chronic Care
- Medicaid managed care and Medicaid waiver programs for long-term services and supports
- Financial Alignment Initiative (FAI) demonstrations
- Program of All-Inclusive Care for the Elderly (PACE) programs
- Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs)
Yet, much of the early evidence from these programs has been mixed. Participants in the December 2016 meeting identified important policy considerations and research needs emerging from these demonstrations.
Financial Incentives
The post-acute care demonstrations test a range of payment and delivery system innovations, but meeting participants agreed that more research is needed to determine how providers respond to the various combinations of upside and downside risk for both outcomes and costs in order to better calibrate payment formulas.
Consumer Engagement and Behavior
Discussants also pointed out that consumers faced with the need for post-acute care often do not have adequate time or information to make choices. Most are unfamiliar with available options or with the advantages and disadvantages of each, and providers are reluctant to engage in any behavior that could be perceived as “steering” patients to post-acute care providers. I know when my family asked the hospital staff for recommendations for post-acute care providers, we were told they couldn’t be made.
Limited Evidence Base
The chronic care demonstrations have been plagued by a lack of definitive evidence regarding the efficacy of popular approaches already in use. Several speakers highlighted difficulties associated with finding appropriate control groups for studies of programs that enroll providers and/or patients on a voluntary basis (e.g. ACOs, FAI).
Social and Support Services
Speakers also suggested that policymakers think not only about the services in place now for people with chronic conditions, but also about other social services and supports that should be available to meet the needs of a rapidly aging population: greater financial support for family caregivers; easier access to care workers and in-home services; adapted housing for people with disabilities; greater use of telemedicine and remote monitoring, etc.
Future Research Directions
As health care remains in the national spotlight, with a particular focus on improving value, post-acute and chronic care is an area ripe for future research. Meeting participants highlighted several areas that would be particularly important to policymakers, including: deeper understanding of the effects of care coordination on outcomes as well as competition and anti-trust concerns; comparative cost and quality information from different post-acute and chronic care settings; and understanding how providers respond to various combinations of upside and downside risk.
Many more issues were discussed at the December Research Insights meeting. For more, read the full meeting report here.