Post-acute care, which is care provided to patients after they’re discharged from the hospital, accounts for a large and growing amount of health care costs in the U.S., especially for older adults insured by the Medicare program. PAC costs have risen sharply over the past 15 years and now account for almost 25 percent of the cost for Medicare-managed care health plans. This wouldn’t be a problem if we were getting value for our money, but some estimate that these costs could be reduced by 20 to 25 percent without reducing quality of care. Why is there so much waste in PAC costs? There are three important gaps that lead to unnecessary utilization and costs: medication-related problems; lack of coordinated care and poor communication with patients and health care providers; and overuse of inpatient rehabilitation facilities. The good news is that we know what to do to fix these problems. We just need to make these changes happen.
Cutting costs in PAC can best be achieved by eliminating waste, the use of health care resources that do not improve or maintain the health of the patient. There are three major sources of waste in post-acute care: hospital readmissions, when patients go back to the hospital for treatment, especially when the readmission could have been avoided; admitting patients to skilled nursing facilities, or SNFs, when they could have gone home instead; and keeping people in the SNFs for more days than they need.
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One of the main reasons for readmissions is medication-related problems, or “medication misadventures.” There are many causes for these “misadventures,” including: patients who were not given the right prescriptions; patients confused about what medications to take; patients not being able to get their prescriptions filled; and doctors not explaining why and how to take the medications. Using a process of medication reconciliation, which compares the list of medications the patient was taking before the hospitalization to what was prescribed during the hospital, and clearing things up if there is confusion, can reduce readmission rates by 30 percent or more. Given that Medicare spends over $40 billion a year on readmissions, billions of dollars can be saved by improving medication management.
Another major cause of readmissions is the lack of coordination of care and communication between health care providers as the patient moves from one setting to the next. Every time a patient transition occurs, whether from hospital to SNF, SNF to home or hospital to home, there is a potential loss of information and risk of confusion and/or mistakes that can cause readmissions. When I worked as a doctor in a rehabilitation hospital, I would routinely admit very sick, complex patients, and I didn’t always get accurate information. One very complex patient from a well-known academic center arrived with two medication lists as part of his discharge paperwork, and when I called to find out what the patient should be taking, the doctors and nurses who had cared for the patient had already left, and the covering staff weren’t sure how to answer my questions. This situation is too common. Solutions exist to fix the gaps in communication, like making medical records accessible and ensuring “warm handoffs” where doctors and nurses talk about the patient and don’t just send written records.
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Another major source of waste is overutilization of SNF services. Over the past 15 years, a higher percentage of Medicare patients discharged from hospitals are being sent to SNFs when they could have gone home instead. Not only are more people being sent to SNFs, but when they get there, they stay for longer periods of time. The result is that when an older patient is sent to the emergency room for a work up, it’s akin to sentencing him or her to over a month away from home. When you add up the average length of stay in the hospital — five to six days — and the average length of stay for patients sent to SNFs — 25 to 30 days — it can add up to well over a month away from the comforts of home.
Medicare data from different parts of the country demonstrate that there are significant differences in utilization that are not related to patient needs. In fact, the majority of the difference in Medicare costs per acute episode is due to the differences in PAC costs. In 2015, for example, Medicare spent an average of $2,704 on PAC services for enrollees in Texas, versus only $1,088 for similar enrollees in Minnesota. In other words, older people living in Texas, with the same illnesses and rehabilitation needs as those in other states, are much more likely to be admitted to a SNF and to receive home health services whether they need it or not. Bringing PAC use in Texas to the same level as Minnesota could prevent save billions of dollars and improve the quality of care, since older people in health care facilities have a higher risk of complications like falls or infections.
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Now is the time to reduce and eliminate waste in PAC. Solutions like those outlined above can address the challenges of medication management, lack of coordination and communication, and overuse of inpatient rehabilitation. More progress can be made, and quickly, if health care providers focus on these issues and make the needed changes.
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Solutions for 3 Common Gaps in Post-Acute Care originally appeared on usnews.com
