Aging in Place: CMS Reports Success in Reducing Medicare Cost for Long-term Care Residents by Reducing Hospitalizations

Infringing on the autonomy of Medicare patients to seek quality care is paying off in massive dollar savings for the federal government.   This blog previously reported on the controversial sign-off rule that prevents Medicare patients discharged from hospitals to nursing facilities from returning easily to the hospital for necessary care.  Before the rule, if you were discharged to a nursing home, but later felt that hospital care was necessary, you could simply ask to be transported back to the hospital.  Your wife, your health care proxy, or the nursing home could transport you back to the hospital.

After implementation of the rule, not even the nursing home, if it believes the hospital  is better able to care for you, can return you to the hospital, unless there is a life-threatening condition, or a doctor first examines you and "signs off" on the the transfer.   The nursing home industry objected to this hard-to-justify restriction on its authority and discretion. 

Since 1984, the federal policy of reducing the hospital stays of Medicare patients, which some have characterized as "quicker and sicker," has increasingly transitioned elderly health care from hospitals to highly regulated skilled nursing facilities in order to reduce the cost of Medicare.  There is increasing evidence that there are significant resulting adverse outcome outcomes.  Now, the federal government implies that these same facilities cannot be trusted to make decisions regarding choice of care. Physicians are relegated to gatekeepers for more expensive care, even where necessary. 
   

In the first assessment since the controversial rule was implemented, the Centers for Medicare & Medicaid Services (CMS) reported that the rate of potentially avoidable hospitalizations among dual-eligible long-term care residents fell by nearly a third in recent years.  In a data brief posted on the CMS blog, officials documented the “real progress” made in reducing cases of potentially preventable hospitalizations among long-term care residents over the last decade. Overall, the hospitalization rate for beneficiaries eligible for both Medicare and Medicaid — including those outside of long-term care facilities — fell 13% between 2010 and 2015.

In that same five-year timespan, the rates of hospitalizations among dual-eligible long-term care residents caused by potentially avoidable conditions, such as dehydration, urinary tract infections and skin ulcers, dropped 31%. That decrease was widespread, with improvement documented in all 50 states. In total, the decrease meant dually-eligible residents avoided 133,000 hospitalizations between 2010 and 2015.  The brief does not, however, report that the overall incidence of avoidable conditions decreased — only that hospitalizations for the conditions decreased.    In fact, the only reported reduction in incidence (i.e., improvement in actual health outcomes), appears to have come from the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care, which "significantly reduced catheter-associated urinary tract infections in hundreds of participating long-term care facilities nationwide."  This 2001 project helped prevent a recognized cause of hospitalizations in residents of these facilities.  One can assume that the absence of reported reductions in other potentially avoidable conditions means that there was no significant reduction attained.

CMS is applauding its ability to reduce expensive hospitalizations, but is tacitly acknowledging that these weren't achieved by better quality care, but rather from impediments and disincentives to more expensive, higher quality care. There is nothing in the recent report that suggests overall  improvements in healthcare outcomes for the nation's elderly.     

Blog authors Niall Brennan, chief data officer for CMS, and Tim Engelhardt, director of CMS' Federal Coordinated Health Care Office, attributed the decrease to the “committed work by those who directly serve older adults and people with disabilities,” as well as programs such as the agency's “Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents.” The post also highlighted CMS' Hospital Readmission Reduction Program, Accountable Care Organizations and bundled payments as drivers behind the hospitalization rate drop.

This article was inspired by an article in McKnights, the original of which can be found here.