Challenges in Post-Acute Care (PAC)

in the United States

Alan M. Jette, PT, PhD

Boston University School of Public Health

Goals for this Lecture

• Describe the changing demographics in the US impacting post-acute care (PAC)

• Describe the current picture of and challenges facing PAC in the US

• Discuss steps being taken to address PAC reform

The Demographic Imperative

PAC Funding in the US • Medicare: A federal system of health insurance for people over

65 years of age and for certain younger people with disabilities and people with End-Stage Renal Disease .

• Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

• Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

• Medicare Advantage: A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.

• Medicaid: A joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

The Current PAC Picture in the US

What is Post-Acute Care?

• …skilled nursing and therapy services for patients recovering form an acute illness (typically but not always after an acute hospital stay), provided by skilled nursing facilities, home health agencies, inpatient rehabilitation hospitals, long-term care hospitals, and outpatient practices.

• PAC accounted for about 10% of total Medicare outlays in 2013

• In 2013, fee-for-service Medicare spent $59 billion on post acute care, more than double what it spent in 2001.

Supply of PAC providers in the US

• 29,000 PAC providers in the US

• 12,461 HHA providers

• 15,173 SNFs

• 1,177 IRFs

• 422 LTCHs

Estimates of Use of Rehab Services by 65+

Service Setting US(2013)* US (2014)*

Inpt. Rehab. 4.9% 4.2%

Home Care 8.0% 6.0%

Outpatient 10.0%**

Other

*Kaiser Family Fdn. 2015; 45,095,565 Medicare beneficiaries 65+

** MedPac, 2011, 4.9 million Medicare beneficiaries used outpatient rehab

• From 2008 – 2013, the % of Medicare patients discharged form a hospital to LTCH, IRF, SNF, or HHA increased from 37.5% to 42%.

• More often than not, patients use multiple PAC settings.

Factors Influencing PAC Setting

Clinical factors • Patient’s diagnosis

• Acuity level

• Functional status

Non-Clinical factors

• PAC options in a community

• Bed availability

• Relationships between referring hospitals and PAC choices

• Family preference

Medicare admissions criteria

PAC Placement

• Limited evidence base to guide PAC placement decisions

• Discharge tools being used to guide post-hospital planning to reduce readmissions, reduce variation and cost by selecting the most cost effective, clinically appropriate setting.

• NaviHealth

Payment for PAC Services

• Since 1997 CMS has phased in prospective payment into PAC settings

• Medicare pays PAC providers a fee based on estimates of the national average cost of providing covered care over a specific period of time.

• Payment in institutional PAC is by the episode at discharge but in increments of 60 days in HHA

• Medicare beneficiaries are responsible for cost sharing amounts

• For example, in 2008, a patient with congestive heart failure:

• Cost $2,500 for HHA care for 30 days

• $10,700 for those discharged to a SNF,

• $15,000 for those care for in an IRH.

Challenges Driving PAC Change in the US

PAC Challenges

• There is considerable overlap in services and expertise across PAC providers in different settings

• Patients face dramatically different costs depending on the PAC setting in which s/he is treated

• There is an absence of evidence regarding the appropriateness of care or outcomes across different settings

• PAC providers not evenly distributed across states and regions of the US

• Payments may considerably exceed provider costs

• Case mix measures are inadequate

• Payment is uniform regardless of appropriateness or quality

Legislative efforts to control PAC costs

• Balanced Budget Act of 1997: mandated phased-in prospective payment of PAC services

• Patient Protection & Affordable Care Act of 2010 Contained several important provisions that affected the Medicare Program’s PAC payment systems.

• Improving Medicare PAC Transformation Act of 2014

Bundled Payments and PAC • In this model, a designated entity is responsible for a targeted

spending level that covers the costs of all services in an episode of care.

• If spending is below the targeted level, the at-risk entity keeps the difference

• If spending is above the targeted level, the at risk entity needs to return the difference to the payer.

• Bundled payments create incentives for coordinating PAC and lower costs… concern that needed care may be with held to reduce costs, needs to be monitored carefully.

Total Joint Surgery

• CMS has instituted a mandatory, hospital-led bundled payment model for joint replacement cases.

• In this model, PAC provides share potential gains and loses with the hospital awardee.

What Needs to be Done to Address PAC Challenges?

• Strengthen the evidence base for PAC delivery system reform through further demonstration research

• Improve Hospital to PAC Discharges

• Streamline Data Collection Requirements for PAC Providers

• Include risk adjustment including education, poverty, housing, as well as medical/functional factors

• Develop uniform assessment across PAC settings

Challenge of Uniform PAC Assessment

CARE (Continuity Assessment Record & Evaluation)

Self Care

• Eating

• Oral hygiene

• Toileting hygiene

• Shower/bathe self

• Upper body dressing

• Lower body dressing

• Putting on/taking off footwear

Mobility

• Roll left & right

• Sit to lying

• Lying to sitting on side of the bed

• Sit to stand

• Chair/bed-to-chair transfer

• Toilet transfer

• Car transfer

• Walk 10 feet

• Walk 50 feet

• Walk 150 feet

Mobility:

• Walk 10 ft on uneven surface

• 1 Step (curb)

• 4 steps

• 12 steps

• Picking up an object

• Wheel 50 ft. with 2 turns

• Wheel 150 ft.

THANK YOU