Managing Episodic Length of Stay (ELOS) in skilled nursing facilities (SNFs) is an important strategy to reduce unnecessary costs and improve outcomes during a patient’s episode of care. It is well established that SNF length of stay varies widely between geographic regions and by payer type (fee for service vs. managed Medicare, for example). This variability is perpetuated by a lack of accessible, standardized information about expectations, performance, and outcomes. The SNF Episodic Length of Stay (ELOS) Guidelines seek to address this issue by offering clinical recommendations and data-driven targets for managing SNF length of stay at the bundle level.
How ‘Home-to-Home Time’ Supports the Goals of Bundled Payments
Addressing the tendency of fee-for-service to promote more spending requires changing the metrics that motivate clinician behavior away from volume as a primary focus. The DRG system, an early example of bundled payment, represents an attempt to solve the problem by paying hospitals a set amount for each hospitalization. DRG-based reimbursement incentivizes hospitals to keep costs down by eliminating unnecessary services and by shortening length of stay (LOS). Indeed, in the 30 years following the introduction of the DRG system, average hospital LOS nearly halved, dropping from 10.0 days in 1983 to 5.1 days in 20131,2.
This fix may have had unintended consequences. After adjusting their practices to discharge patients home as soon as it was safe to do so, some hospitals went a step further by transitioning sicker patients to SNFs rather than keeping those patients in-house until they could safely go home. Over the last three decades, the proportion of Medicare patients leaving a hospital who were discharged to a SNF quadrupled from 5% to 20%3,4. This shifting of days from the acute to the post-acute facility setting has several negative consequences: it adds an extra transition, increases the overall time that patients spend in facilities, and increases the cost to Medicare since SNFs are reimbursed by the day whereas hospitals are paid a lump sum for the patient stay. This last point is likely part of the reason that Medicare’s spending per hospital admission on combined inpatient and post-acute facility stays increased by nearly 10% from 2004 to 20115.
Remedy in the News
Remedy continues to be a strong advocate for the BPCI program and using bundled payment models as a path to healthcare transformation.>
CMS proposes changes to CJR: 6 key thoughts on what this means for orthopedic bundled payments
Becker's Spine Review | August 18, 2017
Is HHS’ Proposal to Scale Back Mandatory Bundled Payments a Step Back from Value-Based Care? Many Healthcare Experts Say No
Healthcare Informatics | August 18, 2017
Chris Garcia Named CEO of Remedy Partners
Remedy Partners, the nation’s leading bundled payment company, has named Chris Garcia its chief executive officer, effective July 12, 2017. Remedy is well-positioned for accelerated growth as the healthcare industry continues to adopt bundled payments as a core value-based payment strategy.
One of the most important changes spurred by the practice of value-based care is how physicians may adjust the way they practice. Much of the opportunity to improve value lies in removing needless spending during the period following a hospitalization. For patients, this means spending more time recovering at home and less time in facilities. So what do doctors need to do differently to enable a home recovery?
Hospital-based specialists, generalists (e.g., hospitalists), and surgeons participating in bundled payment programs have tremendous influence over the quality and costs of patient care inside the four walls of the hospital. While many interventions also have effects after discharge, others have more limited post-acute impact. All things being equal, physicians should focus their in-hospital efforts on practices that have a positive effect on patients after they leave the hospital. For example, holding goals of care conversations, early mobilization, prompt discontinuation of urinary and central venous catheters, and asking discharge planners "Why not home?" are but a few of many practices that may improve healthcare value during the post-acute period. In the linked article, I describe how practices that represent 'thinking outside the DRG', or outside the inpatient stay, may improve patient care during recovery from a hospitalization.
Industry publication Fierce Healthcare shared Dr. Win Whitcomb’s strategies for post-acute care in an article published on October 3, 2016 that recapped Dr. Whitcomb’s panel at the CAPG Colloquium 2016.
Dr. Win Whitcomb, Remedy Partners Chief Medical Officer, was featured on a panel at the CAPG Colloquium 2016 held from September 29 through 30 in Washington, DC. CAPG is the leading U.S. trade association for and the voice of accountable physician organizations.
Selecting the optimal next site of care (NSOC) after hospital discharge has emerged as a core skill for physicians in the era of value-based healthcare. The challenge is that few of us have received formal training in post acute care site selection. When I meet with physicians and discuss NSOC selection, they express a clear desire for guidance on discharge planning as they work with patients, caregivers and the healthcare team. Here is a framework to assist physicians in post acute care selection within the BPCI program.
A key element of discharge planning - the selection of the next site of care - is more important and more complex than ever before, due in large part to the advent of the BPCI program and the episodic approach to care. Once the realm of laminated checklists, frayed brochures and quick conversations, hospitals are now finding technology to be a powerful tool to assist them in the selection of an appropriate next site of care.
Gene Huang, Remedy Partners’ Vice President, Business Development, was a featured speaker at the 13th Annual HealthMEDX User Group in St Louis on April 12 - 14, 2016.
Bundled payment programs require effective care coordination encompassing the hospitalization and the post-discharge recovery period. Within this care coordination process, selecting the ‘next site of care’ after hospital discharge is a crucial element in the provision of high value patient care. Why? When looking at large data sets representing aggregate spending, the cost of post-acute care can rival that of the initial inpatient stay.(1) For many bundles, total 90-day episode spending for a patient discharged to a skilled nursing facility can be more than two times that of a patient discharged to home.(2)
Implementing a bundled payment program requires new knowledge, sophistication and skill. In my healthcare career of 40 years focused on managed care and the hospitalist specialty, my work with Remedy and bundled payments again has me facing a steep learning curve. Here I list my Top Ten "Aha!" learnings at Remedy, in no particular order.