In a recent discussion someone pointed out to me one of the real challenges of HCAPHS and reducing hospital readmissions. After the 60 days (or 90 days in some cases), hospitals don’t care if the patient is readmitted. What does this do? It creates a cliff where the patient is no longer followed, tracked, or supported by the hospital. The hospital doesn’t financially care any more since if you get readmitted to the hospital after 60 days, then it doesn’t count against their readmission score and they get reimbursed for another hospital visit. In fact, you could argue that it’s in a hospital’s best interest to have you readmitted after the 60 days since that’s more revenue for the hospital. The reality for many hospitals is that they need their beds full to run their business.
We’re already seeing this cliff in hospital readmissions, but I wonder if we’re going to see similar cliffs across all of the value based reimbursement programs that are to come. I think we probably will, but we’ll see what the final programs look like.
In some ways it makes sense why you’d want to set an arbitrary number of days after which a hospital readmission (or whatever health event you’re tracking) should not count against that hospital. It’s not like we can expect a hospital to prevent a patient from being readmitted forever. Or can we…at least for a specific condition?
It all gets really complicated and messy with thousands of nuances and variations. This is why I’m scared about what’s happening with value based reimbursement. Does anyone trust the government to dive into enough detail to make sure that the program rewards the right efforts and doesn’t penalize the organizations that are trying to do the right thing for the patient? Sometimes it feels like we’re just trying to move around deck chairs on the Titanic.
What does excite me is that we’re going to have much more data available to quantify the work that’s being done. We’re going to have much better ways to communicate with the patient. Patients are going to likely demand more transparency from their doctor. These are all movements in the right direction. I just don’t think patients are going to be happy with what they find. I know most doctors I know aren’t happy with it either.
I know they won’t be happy if they’re the patient that falls off the 60 day “cliff.” Patients will aptly ask, “So, you only care about my health for 60 days?”
The method behind the madness is based on the fact that avoidable readmissions are clustered within 30 days of discharge and this risk can be mitigated, not just pushed back in time, by effective care management. I have not seen a study to reinforce this point, but one could easily be assembled. So in theory the process does not kick the can down the road and create set of health care cliffs. The same logic applies to bundled care programs. Over time the 30d -90 d risk envelope will expand to full risk as many larger health systems are moving in this direction, so continuous care for high risk patients may be come a reality and remove the lumpiness you are referring to.
Tom,
I agree that it makes some sense if you’re trying to treat the largest percentage and make the most improvement. The solution is to move fully to a full risk model. I just fear that we’ll never actually make it to the full risk model and we’ll be stuck in this partial world with a lot of cliffs for a long time. We’ll see.
The fact is that most (> 95%) of healthcare organizations are only scratching the surface with VBC (< 5%). There are two sets of compensation structures to change here. The first one determines how money moves from the insurer to the delivery organization and the second the determines how money moves from the delivery organization to the physicians. While the payers might be forcing the systems to change to VBC through mandates and other interventions. The systems themselves have to handle the second stage of this transaction and move away from volume/RVUs. I share the fear that this might end up not serving the patient in the end at all.