Care-tran­si­tion pro­gram fum­bles high­light CMS’ re­form chal­lenges

Modern Healthcare - - REGIONAL NEWS - By Me­lanie Evans

The Coun­cil on Aging of South­west­ern Ohio im­proved its pa­tient-en­roll­ment rate and man­aged to keep its CMS In­no­va­tion Cen­ter demon­stra­tion con­tract. But many other com­mu­nity agen­cies did not.

The In­no­va­tion Cen­ter launched a five-year demon­stra­tion to test the Com­mu­nity-based Care Tran­si­tions Pro­gram in 2012. It will spend up to $300 mil­lion en­list­ing com­mu­nity agen­cies to work with hos­pi­tals to help pa­tients build skills and find re­sources to pre­vent re­peat hos­pi­tal vis­its. The cen­ter tar­geted area agen­cies on aging to par­tic­i­pate.

“We were be­ing too nice about al­low­ing peo­ple not to sign up,” said Ken Wil­son, a vice pres­i­dent at the Cincin­nati-based Coun­cil on Aging of South­west­ern Ohio. So his agency started hir­ing more per­sua­sive staff. En­roll­ment jumped from 64% to 98% of el­i­gi­ble pa­tients.

But of 101 par­tic­i­pat­ing agen­cies, roughly one-quar­ter with­drew or had their con­tract ter­mi­nated af­ter the first two-year demon­stra­tion con­tract. “The sites that were not ex­tended failed to achieve per­for­mance tar­gets,” the cen­ter said in a writ­ten state­ment. There are 72 agen­cies still par­tic­i­pat­ing.

The demon­stra­tion’s ob­jec­tive was a 20% re­duc­tion in the 30-day all-cause read­mis­sion rate for tra­di­tional Medi­care pa­tients at hos­pi­tals in the ini­tia­tive. Separately, agen­cies were re­quired to re­duce 30-day all-cause read­mis­sions for high-risk pa­tients. Agen­cies are paid an all-in­clu­sive rate for serv­ing el­i­gi­ble pa­tients in a 180day post-dis­charge pe­riod.

But an eval­u­a­tion con­ducted for the In­no­va­tion Cen­ter by Econo­met­rica found only four of 47 agen­cies stud­ied suc­ceeded in re­duc­ing read­mis­sion rates against a com­par­i­son group.

The In­no­va­tion Cen­ter’s neg­a­tive eval­u­a­tion of the demon­stra­tion re­sults and the con­tract ter­mi­na­tions have drawn crit­i­cism from some re­searchers and ad­vo­cates for com­mu­ni­ty­based care. They say the In­no­va­tion Cen­ter used un­re­al­is­tic per­for­mance tar­gets and eval­u­ated re­sults too early in the pro­gram, us­ing a flawed mea­sure of read­mis­sions. “It’s re­ally too early to tell,” said Sandy Mark­wood, CEO of the Na­tional As­so­ci­a­tion of Area Agen­cies on Aging.

The con­tro­versy un­der­scores the chal­lenge CMS of­fi­cials face as they seek to si­mul­ta­ne­ously eval­u­ate mul­ti­ple pay­ment and de­liv­ery-re­form demon­stra­tions aimed at re­duc­ing costs and im­prov­ing qual­ity of care.

Th­ese in­clude Medi­care accountable care or­ga­ni­za­tions, bun­dled-pay­ment ini­tia­tives and pa­tient­cen­tered med­i­cal home ini­tia­tives, all of which the CMS has tar­geted for rapid ex­pan­sion.

Th­ese pay­ment and de­liv­ery-sys­tem ex­per­i­ments are seen as cen­tral to the Af­ford­able Care Act’s goals. The law al­lows the HHS sec­re­tary to im­ple­ment suc­cess­ful demon­stra­tions in the Medi­care pro­gram at large, with­out con­gres­sional ap­proval. But re­sults from the demon­stra­tions are emerg­ing more slowly than many ex­perts had hoped, and their re­sults have been mixed so far.

Paul Gins­burg, a health pol­icy ex­pert at the Uni­ver­sity of South­ern Cal­i­for­nia, said eval­u­at­ing a demon­stra­tion is com­pli­cated when hos­pi­tals are im­ple­ment­ing mul­ti­ple in­ter­ven­tions to achieve the ob­jec­tive of re­duced read­mis­sions. “Do­ing a num­ber of things to reach the same goal makes your eval­u­a­tion process far more chal­leng­ing if not im­pos­si­ble,” he said.

Dr. Joanne Lynn, direc­tor of the Al­tarum In­sti­tute Cen­ter for El­der Care and Ad­vanced Ill­ness, called the mea­sure used to track read­mis­sions in the CCTP demon­stra­tion “se­ri­ously flawed.” She said the eval­u­a­tors used a hos­pi­tal’s ra­tio of read­mis­sions to ad­mis­sions to track progress, but that ra­tio won’t change if com­mu­nity-based as­sis­tance re­duces both ad­mis­sions and read­mis­sions. She urged the In­no­va­tion Cen­ter to in­stead mea­sure read­mis­sions at the par­tic­i­pat­ing hos­pi­tal against the rate in the larger com­mu­nity.

No In­no­va­tion Cen­ter of­fi­cials were made avail­able to com­ment.

Cur­rent and for­mer par­tic­i­pants in the pro­gram de­scribed the pro­gram’s per­for­mance tar­gets as daunt­ing, and said it took a lot of in­vest­ment and hard work to launch a com­mu­nity-based care tran­si­tions project. Area agen­cies on aging needed time to build re­la­tion­ships with hos­pi­tal lead­ers and dis­charge plan­ners to pro­vide pa­tient re­fer­rals. And some area agen­cies on aging lacked ex­pe­ri­ence in billing Medi­care.

The In­no­va­tion Cen­ter en­cour­aged area agen­cies on aging to ap­ply, and they each in­vested an av­er­age of $165,000, ac­cord­ing to a sur­vey last Oc­to­ber of par­tic­i­pat­ing agen­cies. Nearly all re­ported that they failed to meet the pro­gram’s tar­gets for re­duc­ing read­mis­sions. But they gen­er­ally said they had achieved some pos­i­tive re­sults for pa­tients.

Nick Mac­chione of the Health and Hu­man Ser­vices Agency in San Diego County in Cal­i­for­nia, which won re­newal of its con­tract, said it took time for hos­pi­tals to see the value of care-tran­si­tion pro­grams. “They started to see that (what hap­pened) out­side the walls of the hos­pi­tal was equally as im­por­tant as the qual­ity of the care in­side the hos­pi­tal,” he said. “That was the big aha.”

“They started to see that (what hap­pened) out­side the walls of the hos­pi­tal was equally as im­por­tant as the qual­ity of the care in­side the hos­pi­tal. That was the big aha.” Nick Mac­chione Health and Hu­man Ser­vices Agency San Diego County

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