Despite the managed care movement of the 1990s, traditional Medicare and Medicaid remain the biggest payers in the post-acute continuum.
Today, federal government policies are shifting people away from traditional Medicare and Medicaid to Medicare Advantage and Managed Medicaid programs. The result is that health plans, accountable care organizations (ACOs), and bundled payment demonstrations are now contractually accountable to financial and quality specific outcomes.
These expectations of transparency, improved outcomes and fiscal responsibility are occurring at the same time the Affordable Care Act is bringing more people into the system. With the majority of this group going into the health plan market, combined with the “graying” of America, post-acute use by non-government payers is quickly growing.
As this historic shift continues, private plans are replacing the government as the operator of Medicaid and Medicare. Federal and state regulations are creating an environment promoting standardized measures and processes, accountability for outcomes, sharing of performance metrics, innovation and information based consumer choice.
These regulations and trends have also contributed to a shift in the role of data in the post-acute space. Health plans, ACOs and hospitals are now ready to partner with skilled nursing facilities and home health agencies. Transparency of data is becoming the foundation of these partnerships.
Payers and hospitals want to help make their SNF and HHA partners successful by giving them the patients that they are able to manage effectively. New, collaborative models require sharing of standardized outcome data, often collected and analyzed by a third-party vendor, to facilitate ease of transfer, minimize the cost of data sharing, and align both providers’ and payers’ expectations for success in achieving enhanced quality care and enabling outcomes based financial reward systems.
More than just collecting data, providers need to use standardized, nationally recognized measures. In the past, many individual providers used their own methodology to create their own “data driven” story.
These proprietary measures are now of little to no value because they block effective comparison of performance among competitors. Today, the post-acute industry is leading this shift towards standard measures to ensure that providers are evaluated fairly.
The National Quality Forum has validated and endorsed the standard measure in rehospitalization. Now with clear definitions and standard methodologies, research findings can drive practice. For example, a recent study at PointRight found that among all Medicare residents in CY 2014 that were rehospitalized within 30 days of post-acute discharge, 13.3% were at the end of life. Armed with information like this, there is a clear path for reducing unnecessary rehospitalization by addressing the resident’s end of life wishes.
With standardized measurement reshaping the healthcare landscape, providers need to understand what their data says about their performance. A delay in embracing this market shift and acting on insights from the analysis, may result in a lose-lose situation: poor outcomes that will inhibit opportunities for participating in payer networks and result in penalties handed down from the Centers for Medicare & Medicaid Services. It is time to modify your current strategies; transparency, outcomes, and data sharing mark the start of a new trend.
Providers need to deliver superior risk-adjusted outcomes or be left behind in the marketplace. Fortunately for post-acute providers, there are experts that have been turning analytics into answers for years. Look for the experienced organizations if you need assistance.
Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.