Unintended Consequences of Measures to Reduce Readmissions and Reform Payment - Threats to Vulnerable Older Adults

1. Unintended Consequences of
Measures to Reduce Readmissions
and Reform Payment—Threats to
Vulnerable Older Adults
by
Mary D. Naylor, Ellen T. Kurtzman, David C. Grabowski, Charlene
Harrington, Mark B. McClellan & Susan C. Reinhard

2. Engelberg Center for Health Care Reform
Brookings Institution
Mission:
• Work with a broad range of stakeholders to develop data-
driven, practical policy solutions that promote broad
access to high-quality, affordable, and innovative care in
the United States.
– Conduct research and evaluations
– Make policy recommendations
– Provide technical support and
– Facilitate the development of consensus around evidence-based
health care solutions.
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3. Engelberg Center for Health Care Reform
Brookings Institution
Projects and partnerships supporting comprehensive health care
reform:
• Financing + delivery reforms
– Accountable Care Organization (ACO) Learning Network,
Academic Medical Centers, Beacon Communities, Bundled
Payments, Value-Based Insurance Design
• Implementing quality and cost measures to support higher value care
– Quality Alliance Steering Committee (QASC), Performance
Measurement Implementation, Long Term Quality Alliance (LTQA)
focusing across acute, PAC, and LTC parts of the system
• Biomedical innovation and personalized care
• Guiding the health care reform debate
– Bending the curve
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4. Long Term Services and Supports (LTSS)
» Defined as assistance with ADLs or IADLs
» Growing population of frail, older people require LTSS
 10-11 million community-based residents, half of whom are
older adults
 1.8 million nursing home residents, most of whom are older
adults
» Recipients of LTSS experience frequent changes in health and
multiple transitions
» Represent disproportionate share of spending—15% of
Medicare beneficiaries have both chronic illnesses and LTSS
needs but account for 30% of spending
» Much of this spending and associated care may be avoidable
(e.g., repeat hospitalizations for uncontrolled conditions)

5. Impact of Transitions on Older Adults
Receiving LTSS
Poor health outcomes—accelerated cognitive and
physical functional decline
Higher rates of iatrogenic events such as hospital-
acquired conditions, medical errors
Unmet needs, lower patient satisfaction, higher
caregiver burden
Excessive and often avoidable use of costly health
services such as emergency department (ED) visits and
hospitalizations
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6. Evidence of Effective Transitional Care
» 21 RCTs of 587 diverse “hospital to home” innovations
targeting chronically ill older adults
» 9 of 21 had positive impact on at least one measure of
rehospitalization plus other health outcomes
» Multicomponent interventions that address gaps in
care, promote effective hand-offs/root causes of poor
outcomes
» Reliance on in-person home visits, patient self-
management, connecting acute and primary care
» Nurses as “hubs”—clinical managers or leaders
» Interventions averaged 9+ weeks
Naylor, Aiken, Kurtzman, Olds, & Hirschman. Health Affairs. 2011; 30(4):746-754.

7. State of Reform
» New ACA policies and programs illustrate opportunities
to enhance transitional care among Medicare population
» Potential for older adult population receiving LTSS to
benefit
 Hospital Readmissions Reduction Program (Section
3025)
 National Pilot Program on Payment Bundling (Section
3023)
 Community-Based Care Transitions Program (Section
3026)

8. ACA’s Impact on
Transitions Among Older
Adults Receiving LTSS
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9. Hospital Readmissions Reduction Program
» Beginning October 2012, hospitals with excessive, severity-
adjusted rehospitalization rates (30 day) will be financially
penalized
» Initially limited to three target conditions—
pneumonia, HF, and AMI—with expansion to other
conditions in 2015
» Within 2 years of law’s enactment, quality improvement
support will be provided to hospitals through Patient Safety
Organizations (PSOs)
» Should motivate behaviors that reduce preventable
rehospitalizations and improve outcomes for all
beneficiaries, including frail elders receiving LTSS
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10. Hospital Readmissions Reductions—
Barriers
» Common reasons for hospitalization among older adults
receiving LTSS do not fully synch with those targeted by the
law
» Restriction of PSO quality improvement opportunities to
hospitals
» Coordination between acute care and LTSS providers not
guaranteed
» Preventing rehospitalizations is known to be costly
» Losses from penalties may not be offset by income that
would be generated from rehospitalizations
» Penalty cap could incentive providers to bear the penalty
rather than assume costs for prevention
» Use of coding to avoid measurement of some
rehospitalizations (e.g., observation stays)
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11. National Pilot Program
on Payment Bundling
» Five year pilot program established by January 2013 to
evaluate an episode-based, integrated care delivery and
payment program
» Structured around an acute care hospitalization
» Longest “episode” covered—three days before hospital
admission and through 30 or 90 days post-hospital discharge
» Bundled payment pays for
inpatient, physician, outpatient, and postacute care
» Should reduce costs and improve quality—incentives will
exist to deliver care in the lowest-cost setting, maximize
operating margins, and avoid expensive postacute stays and
preventable rehospitalizations
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12. Hospital Readmissions Reductions—
Barriers
» Pilot excludes LTSS as part of the “bundle”
» Little incentive exists to coordinate care before or beyond the
episode
» Fails to create the type of integration among
acute, postacute, and primary care and community- and
institutionally based LTSS
» Hospitals likely to limit referral networks which may
incentivize nursing homes to specialize in postacute care
rather than LTSS
» May incentivize withholding or denying care and shifting
costs to the postbundle period
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13. Community-Based Care Transitions
(CCTP)
» $500 million available to community-based organizations
(CBOs) + one or more hospitals with high readmission rates
to provide transitional care services
» Implementation of evidence-based care transition services
(e.g., timely post-discharge follow up, self-management
support, comprehensive medication review and
management)
» Target high risk Medicare beneficiaries—those who have
been diagnosed with multiple chronic conditions or possess
other factors, such as cognitive impairment, depression, or a
history of multiple readmissions, that others place them at
risk
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14. Community-Based Care Transitions—
Barriers
» Hospitals as “hub” of care transitions—some frail older
adults receiving LTSS are likely to be “missed” if they are not
hospitalized and/or live outside geographic region
» Patients may lack the required physical, mental, functional
disabilities or other determinants for eligibility
» Medicare-only benefit without any specific mandate to
align, integrate, or coordinate with Medicaid or private
insurers
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15. Policy Recommendations
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16. Going Beyond the
Affordable Care Act
» Anticipate unintended consequences
 Identify negative effects through warning signs
 Longitudinally monitor consequences
 Enhance existing performance measures and available
data
» Advance payment policies that integrate care
 Reform needs to incorporate LTSS
 Shorter-term, immediate pathways that build on existing
programs (e.g., extend readmissions penalties to LTSS)
» Promote needed delivery system reforms
 Support for providers in their implementation of these
provisions
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17. Reforming the Delivery System
» Bring together Acute, Post-Acute and Long Term Care
Communities to implement health care reforms that improve
health and lower costs, particularly for patients with
complex needs, including new support for:
 Providers
 Consumers
 Payers
 Purchasers
» Examples: Aligned provider payment and benefit design
reforms for Accountable Care Organizations, Medical
Homes, Episode Payments
» Major upcoming focus of Brookings reform efforts
» LTQA can facilitate educational and other reform initiatives
that advance developing comprehensive reforms
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18. Conclusion
Selected provisions of the
Affordable Care Act inadequately address
the unique needs of
older adults receiving LTSS and
may introduce unintended consequences.
Policy action is needed to address these
potential emerging risks.
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19. To Become Involved
Contact
• Dr. Barbara Gage at the Brookings Institution:
bgage@brookings.edu
Or
• Mr. Doug Pace at the LTQA:
Dpace@LeadingAge.org
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