Physicians and Nurses.
The Affordable Care Act also requires the Department of Health and Human Services to develop and implement a plan by 2013 that would lead to reporting physician-level quality measure data on the new Physician Compare website (www.medicare.gov/physiciancompare/search.html?AspxAutoDetectCookieSupport=1), including measures of the quality of care transitions. CMS has until 2019 to decide whether to conduct a demonstration giving Medicare beneficiaries financial incentives to seek care from physicians who score highly on these measures.
The law also creates a $200 million, 4-year workforce development demonstration aimed at increasing the number of advanced practice registered nurses trained in care transition services, chronic care management, preventive care, primary care, and other services appropriate for Medicare beneficiaries.
Taken as a whole, the inclusion in the Affordable Care Act of these carrots and sticks aimed at different types of providers suggests a tension over whom to pay and how to pay them to improve care transitions. On the one hand, the payment cuts that high-readmission hospitals nationwide will soon face create an expectation that hospitals take responsibility for improving care transitions using existing resources. But the fact that another program will provide new care transitions payments to hospitals and community-based organizations suggests that they may require additional resources to provide these services.
And although physicians’ performance on care transitions quality measures will be reported on Physician Compare, no provision in the Affordable Care Act requires hospitals to alert physicians when their patients are discharged, typically the needed first step before a physician can become involved in a care transition.
Other Policy Options
If these Affordable Care Act provisions fail to improve care transitions or if CMS decides to pursue other policies, the agency’s statutory authority gives it some additional options, as follows:
• Pay physicians for care transition services. Under the Medicare physician fee schedule, CMS could create a new billing code that would enable physicians to bill for delivery of care transition services. In a proposed rule issued in July 2012, CMS would create a code to bill for care transition services delivered to Medicare beneficiaries in the 30 days following a discharge from a hospital, skilled nursing facility, or community mental health center. The code would apply to Medicare patients whose medical or psychosocial problems, or both, require moderate or high complexity medical decision making.
To qualify for the new payment, physicians would have to obtain and review a patient’s hospital discharge summary, update the patient’s medical records to reflect changes in health conditions and ongoing treatments, and establish or adjust a patient’s care plan. Physicians would be required to communicate with a beneficiary or their caregiver within 2 business days of discharge to resolve medication discrepancies and inform them about possible complications. Whether physicians will consider the payment level assigned to this billing code adequate for the effort required, however, remains unclear.
• Track whether hospitals transmit records to physicians. Another policy option would be to add a care transitions measure to Medicare’s Hospital Inpatient Quality Reporting program, a pay-for-reporting program. Adding such a measure would create a modest incentive for hospitals to better communicate with physicians about patients’ hospitalizations, especially if CMS chose to include that measure in the subset that is displayed on the Hospital Compare website (www.medicare.gov/physiciancompare/search.html?AspxAutoDetectCookieSupport=1).
If CMS wanted to further elevate hospitals’ focus on this measure, it could include it in the subset of measures it uses in the Hospital Value-Based Purchasing Program, the new pay-for-performance program for hospitals created in the Affordable Care Act and scheduled to go into effect in October 2012.
A hospital-related care transitions measure has been developed by a group of physician specialty societies and endorsed by the National Quality Forum, a nonprofit organization that works with providers, consumer groups, and governments to establish and build consensus for specific health care quality and efficiency measures. This indicator, called Timely Transmission of Transition Record (measure no. 0648), measures how often a hospital sends a transition record to a patient’s physician within 24 hours of discharge. Having this information would allow primary care physicians to identify which patients needed follow-up care.
However, hospitals may not welcome this additional reporting burden because transmittal of such records to outpatient physicians is not a billable hospital service, which means claims data cannot be used to easily calculate how often such transmittals occur. Instead, for hospitals that don’t have good electronic health record systems, labor-intensive chart reviews would be required to calculate such a measure.
If CMS were to pay hospitals to develop discharge plans, discuss them with patients, and transmit them to outpatient physicians for follow-up care, the hospitals would have a greater incentive to perform these crucial activities. CMS could also then use the hospitals’ billing records for these services to calculate quality measures assessing how often the hospitals performed these important services.
However, in the current strained federal fiscal environment, offering a new carrot to hospitals may have little appeal for policymakers. Indeed, because Medicare already gives hospitals lump-sum payments to cover all the costs associated with a hospitalization and because Medicare’s conditions of participation require hospitals to have a discharge planning process in place, policymakers may feel hospitals are already being paid for care transition services but are simply not performing them as routinely as they should be.
• Strengthen hospital do-not-pay policies. Another policy stick would be to further limit payment for hospital readmissions. For example, CMS could extend its current policy of not paying for Medicare readmissions that occur within 24 hours of a hospital discharge for the same condition to 72 hours, or even 15 or 30 days, postdischarge. Doing so would require carefully defining which readmissions would be ineligible for payments and how to account for co-occurring conditions. Already, hospitals as a group are upset about CMS’s decision to penalize them for certain planned readmissions because they do not think it adequately distinguishes between readmissions that are truly necessary compared to readmissions that are truly preventable.
Given the current budgetary environment and the fact that Medicare is estimated to spend $12 billion per year on potentially preventable hospital readmissions, interest in improving care transitions to reduce Medicare spending is likely only to grow.
Although some care transitions interventions have generated cost savings, uncertainty remains over how best to encourage providers to use these approaches. Evaluation of the changes brought about by the Affordable Care Act will begin filling gaps in our knowledge. And if the health care law’s approaches fail to make a strong enough case for providers to pay attention to care transitions, policymakers may want to explore bigger carrots and sticks.
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The Women’s and Children’s Health Policy Center.
1Health Policy Brief: Care Transitions, Health Affairs, September 13, 2012. Written by Rachel Burton, Research Associate, Urban Institute. Editorial review by Eric Coleman, Division Head Health Care Policy and Research, University of Colorado Medical Campus; Debra J. Lipson, Senior Researcher, Mathematica Policy Research; Ted Agres, Senior Editor for Special Content, Health Affairs; Anne Schwartz, Deputy Editor, Health Affairs; and Susan Dentzer, Editor-in-Chief, Health Affairs. Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation. Reprinted with permission.
Take the identified healthcare policy from thread one. Identify both obvious and non-obvious stakeholders. Also identify stakeholders that you have the potential to influence.
In our discussion question #2, take the health care policy that you identified in thread one that needed revision. Can you discuss both the obvious and the non-obvious stakeholders? Which stakeholders to you have the potential to influence? What barriers do you face with reaching stakeholders and allowing them to buy in?
This week’s graded topics relate to the following Course Outcomes (COs).
- Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (PO #9).
- Analyze legislative process and the impact of special interest lobbies (PO #9
- How have you seen the diverse interests of healthcare stakeholders impact patient care in your nursing practice or in the practice of other nurses?
- In general, do you think political action committees (PACs) and special interest groups (SIGs) contribute to or detract from improvements in patient healthcare? Provide an example to illustrate your thoughts.
- What role should politics play in healthcare reform? What role should the DNP-prepared nurse play in the political process that impacts healthcare reform?
Policy & Politics in Nursing and Health Care
Diana J. Mason, PhD, RN, FAAN
Rudin Professor of Nursing
DIANA J. MASON, PhD, RN, FAAN, is the Rudin Professor of Nursing and Co-Founder and Co-Director of the Center for Health, Media, and Policy (CHMP) at Hunter College and Professor at the City University of New York. She served as President of the American Academy of Nursing (2013-2015) and as Strategic Adviser for the Campaign for Action, an initiative to implement the recommendations from the Institute of Medicine’s Future of Nursing report, to which she contributed. From 2012 to 2015 she served as Co-President of the Hermann Biggs Society, an interdisciplinary health policy salon in New York City.
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