Playing Whack-A-Mole With Costs -CMS and Joint Commission Weigh In on Care Transition

Playing Whack-A-Mole With Costs -CMS and Joint Commission Weigh In on Care Transition

Authors Note:  This two-part series deals with the rising costs of post acute-care, particularly with respect to cardiac patients.  Please see  Help! I’ve Fallen and I Can’t Get Up for Part 1.
 

With the rising cost of post-acute care now approaching the cost of in-patient care, it’s no surprise that the world’s largest health insurer, the U.S. Government, has some thoughts on the subject, and those thoughts are being translated into new Joint Commission Quality Metrics.

There is plenty of evidence that the Centers for Medicare and Medicaid (CMS) and the Joint Commission are right to focus on this aspect of care for two reasons:

  1. Good discharge and follow-up procedures can significantly lower cost of care and improve outcomes. In the United States, half of in-patients older than 65 years with congestive heart failure (CHF) are readmitted within 6 months of hospital discharge. CHF is the leading diagnosis related group for acute hospitalization and readmission in this population, with payments totaling 60% of total Medicare reimbursements. Over a wide-range of follow-up interventions (phone calls, increased ambulatory care, and in-home visits) across multiple communities, readmissions fell on average to 43% and costs fell by 12%(1).  
  2. Certain types of post-discharge care, like nursing homes and acute care facilities, are up to six-times more expensive than in-home nursing or family care with ambulatory visits (for details, see my last blog).

The new care-specific guidelines from the Joint Commission, developed in conjunction with the CMS, may take the idea of staying on top of your patients from a “good-to-do” to a “must-do”.

 

 

While, at present, it is optional to become certified in disease-specific care, it affects health systems’ bottom line in multiple ways:

Facilitates marketing, contracting and reimbursement – Certification may provide an advantage in a competitive healthcare marketplace and improve the ability to secure new business.

Improves the quality of patient care by reducing variation in clinical processes – The Joint Commission’s standards and emphasis on clinical practice guidelines help organizations establish a consistent approach to care, reducing the risk of error.

Recognized by select insurers and other third parties – In some markets, certification is becoming a prerequisite to eligibility for insurance reimbursement, or participation for managed care plans and contract bidding.(2)

As the world shifts to value-based purchasing and other forms of fixed payment, the task of implementing these programs can be very difficult, especially following patients outside your system.  Over half the health systems in this country do not employ their physicians, and access to records and appointments is difficult. Additionally, a disproportionate number of the most costly patients end up in nursing homes or other long-term care facilities, and post-discharge care communication is ad hoc at best.  But the benefits outweigh the costs, and those health systems that can track their patients through chronic illness will end-up with a more loyal, healthy, and profitable patient population.


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(1)  Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries, The Journal of American Medical Association, Deborah Peikes, PhD; Arnold Chen, MD, MSc; Jennifer Schore, MS, MSW; Randall Brown, PhD; JAMA. 2009;301(6):603-618. doi:10.1001/jama.2009.126

(2)  Joint Commission Org, , Disease Specific Certification, and Advanced Certification in Heart Failure: Standardized Performance Measures Updated as of December 2014