Value-based care and the 90-day post-discharge period: what hospitals should know

The penetration of value-based care models is unstoppable. An impending new rule by CMS suggests that hospitals that are yet to adopt such models need to start preparing now.

During Becker's Hospital Review's 2022 Annual Meeting, in a session sponsored by Sound Physicians, Value-based care and hospitals: an oxymoron or an opportunity?, three of the company's leaders — Robert Bessler, MD, founder and chief executive officer, John Birkmeyer, MD, chief clinical officer, and Paul Merrild, chief growth officer — led a roundtable discussion about value-based care strategies focused on 90-day episodes of care.

Five key takeaways were:

1. The 90-day period after hospital discharge accounts for half of healthcare spend. With the advance of value-based care, many providers are focused on preventing hospital admissions for patients treated in the outpatient setting. Yet, up to 50 percent of healthcare spend occurs from the time a patient shows up in the ER through 90 days after discharge, Dr. Bessler said. Within that 90-day period, inpatient care represents about 35 percent of spending and the other 65 percent goes to post-acute care, including skilled nursing facilities (SNFs) (23 percent) and readmissions (15 percent). 

2. After a hiatus, alternative payment models (APMs) are coming back. The bundled, episode and population-based payment models of Obamacare were halted during the Trump administration and the pandemic. However, CMS is resurrecting them; a preliminary rule is expected this summer regarding these models' next phase.

"MedPAC came down squarely in favor of continuing BPCI [Bundled Payments for Care Improvement]/episode payment models . . . they recommend that BPCI needs to move from voluntary to mandatory. We fully expect that to happen," Dr. Birkmeyer said. The return of APMs has implications for how providers manage the critical 90-day post-discharge period.

3. Organizations recognize the cost and quality concerns associated with post-discharge care. While these costs may not be a concern in a fee-for-service model, entering into a risk-based agreement changes perspective. "We dipped our toes in with the total knees and total hips bundle, and it was eye-opening," one participant said. "I thought the cost was so much based on inpatient care and then you realize the amount we were sending to SNFs are incredible. Now we send so few." 

Another attendee noted that participating in a value-based program helped her organization identify areas for improvement beyond the hospital that may have a bearing on readmissions. "It helped us identify the SNFs that we were sending people to and that needed to provide better clinical oversight." 

Poor SNF quality indicators should be viewed like a black box warning. "The mindset shift of the physician needing to think about the nursing home like a prescription is a big mindset change," a participant said.

4. Nurturing a high-quality post-acute network is essential for success with APMs. To avoid sending patients to suboptimal post-acute care facilities, care teams need to start planning discharge dispositions the moment patients are admitted. "The vast majority can go home if you provide the right wraparound services," one attendee observed, referring to home health services that can replace more expensive, but not necessarily better, SNF care.

Bringing telemedicine into SNFs is another way to improve post-acute services and prevent readmissions without incurring the high costs associated with staffing SNFs with physicians or sending residents to the ER. Other cost- and readmission-lowering measures include improved PCP handoff and initiating advanced care planning discussions early.

5. For smooth transition to value-based care models, follow these steps. Sound Physicians has identified five key levers or behaviors that support the shift to APMs that provider organizations can adopt. 

  • Align incentives.
  • Support a consistent practice.
  • Embed technology.
  • Focus on the right patients by putting meaningful data in the hands of physicians.
  • Strive for getting patients home from the hospital/SNF or keeping them home (Sound's "home-home-home" program).

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