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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. For hospitalized patients, generally speaking, it's great news to hear you're being discharged and going home at last. But years of evidence have shown that this transitional period is particularly fraught. Countless factors from incomplete instructions, lack of continuity in care, and delayed follow-up can lead to serious setbacks and even harm like falls, infections, or medication errors.
Rob Lott:These in turn can lead some patients right back in the hospital again. Is it possible to reduce the risks associated with such transitions? That's the subject of today's Health Odyssey. I'm here with Doctor. Mackenzie L.
Rob Lott:Hughes, a psychologist and senior research scientist at NORC at the University of Chicago. Together with co authors, Doctor. Hughes conducted a study whose findings are published in the June issue of Health Affairs. Its title is also its main finding. Transitional care management associated with more healthy days at home, lower spending after hospital discharge.
Rob Lott:And I'm really excited to hear more about the paper, so let's just dig in. Doctor. Mackenzie L. Hughes, welcome to The Health Odyssey.
MacKenzie Hughes:Thank you. Thanks for having me.
Rob Lott:So let's start with some background. What do we mean when we talk about transitional care? I alluded to a little bit of that in the introduction. Did I do a good job of describing most people's experience of transitional care? What does that typically involve?
Rob Lott:Where are people transitioning from and to and who's involved?
MacKenzie Hughes:Yeah. Yeah. Your introduction was a nice overview of kind of what we're talking about here. And this is a good place to start. So, you know, when we're referring to care transitions, we're really talking about this movement that a patient undergoes when they are moving between health care providers or between different settings.
MacKenzie Hughes:And this movement typically happens as a patient's health care needs change. So in our paper, we refer to care transitions. Kind of what we're really talking about is the transition that a patient would make from the hospital setting to a community setting. And for for many people, this would look like, you know, for example, going home from the hospital.
Rob Lott:Okay. And traditionally, these transitions have been associated with bad outcomes and high costs. Why is that?
MacKenzie Hughes:Yeah. So you yeah. You mentioned a few of those outcomes in your introduction. So, you know, a a patient's transition from the hospital to home or to some other community setting can really kind of put them in a vulnerable spot in terms of their risk for rehospitalization and these other kind of poor outcomes. And, you know, as I mentioned earlier, these transitions during these transitions, a patient might experience changes in their health care settings or changes in the individuals that are responsible for their care.
MacKenzie Hughes:So really to successfully coordinate these transitions and to avoid those bad outcomes and to avoid the high costs, information needs to be shared with the patient and with the individuals that are involved in the patient's care. So this can look like, you know, communication between the patient's health care providers. That's really critical here. I can also, it's important that patients and their caregivers have the information that they need to manage, you know, the patient's health condition and their medications as they're going home.
Rob Lott:So the scenario I'm envisioning is someone's in the hospital, they're typically being cared for, or at least their care is overseen by a hospitalist, someone who's sort of managing their in the moment in the hospital care, then they're sent home and they usually say, follow-up with your primary care provider in two days or something like that. Is that sort of a typical transition and is often, I imagine there's some loss typically of information when the basically, the report goes from the hospital to the primary care provider. Is that fair?
MacKenzie Hughes:Yes. Yeah. So, you know, maybe the patient has been seeing one doctor, maybe they're a specialist, and now their care will be managed by someone else. Maybe it's their primary care provider. And, you know, what we know with, and we can dig in a little bit more about these, you know, TCM or transitional care management codes is in in many cases, it's the primary care provider that's providing the services.
MacKenzie Hughes:So yeah, that scenario that you described, I think is a good one here.
Rob Lott:Against this backdrop, let's say policymakers kind of looked at the situation, they said this is a problem area. So let's have Medicare reimburse clinicians to manage these transitions. I think this started in 2013. Can you say a little bit about the theory driving that policy change around the reimbursement? Was it simply a case of policymakers saying, well, the reason these transitions go badly is because no one has an incentive to manage them?
Rob Lott:Or did we know more about what was kind of going on under the hood at that point?
MacKenzie Hughes:Yeah. There were a few things going on around that time that Medicare had introduced these transitional care management codes. So kind of looking back on on what was going on, pre 2012, thirty day rehospitalization rates were pretty high. And vulnerable patients were kind of revolving from the hospital to the community and back. And, obviously, that's that's not ideal.
MacKenzie Hughes:And so this prompted Medicare to make a couple of policy changes. So in the fall of twenty twelve, Medicare introduced the hospital readmissions reduction program. And that program incentivizes hospitals to pay attention to, you know, how and where they were discharging patients. And then just a few months later, so in 2013, Medicare had introduced the transitional care management codes and those codes are and those codes are are meant to incentivize the practitioners to better care for their patients after discharge. I should mention, you know, before these transitional care management codes were introduced, Medicare did not pay for any non kind of face to face services that the patients needed during their care transitions, like medication reconciliation, scheduling follow-up visits and referrals, or helping patients access community resources and support services.
MacKenzie Hughes:So, you know, through these TCM codes, Medicare started to pay practitioners. And again, I think primary care physicians for their time spent on care coordination, care transition activities that go beyond that office visit. And then, you know, one more thing was going on around that time. So, you know, around the time that Medicare had introduced those TCM codes, they also started implementing alternative payment models, which I'm, of course, happy to talk about in more detail. But, you know, these models were also helping to address better delivery of whole person care while reducing spending.
MacKenzie Hughes:And so our work and the work of others has shown that these alternative payment models adopt TCM or transitional care management as a key strategy for coordinating care during that post discharge period where, you know, a patient is transitioning from the hospital back to the community.
Rob Lott:Gotcha. So what I I think you're hinting at is that the ACOs and other alternative payment models have sort of included this transitional care management as sort of like one strategy of a menu of strategies that they're using. And that it's fair to see the transitional care management reimbursement as sort of a piece of this kind of larger vision and not just a standalone fix that someone has said, let's flip the switch and things will get better.
MacKenzie Hughes:Sure. Yeah. We yeah. What we're finding is, these accountable care organizations and others are that are participating in these alternative payment models are are more likely to adopt these care transition, you know, management services.
Rob Lott:Great. Well, in just a I wanna ask you about the findings of your study. But before we do, let's go to a quick break. And we're back. I'm here with Doctor.
Rob Lott:Mackenzie L. Hughes talking about her paper on transitional care management and its association with increased healthy days at home and lower spending after hospital discharge. I kind of spoiled the end here, but I wanted to ask you about the findings of your paper. I just hinted at them with the title of that paper, but can you tell us a little more about the outcomes that you studied and what you found?
MacKenzie Hughes:Yes. So our analysis focused on examining the associations of transitional care management and alternative payment models on four quality and cost outcomes. So those were readmissions, mortality, healthy days at home, and then total Medicare spending, and specifically during the thirty one to sixty day period after the patient was discharged from the hospital. And so before I talk about our main findings, I just quickly wanna mention, you know, that we had categorized hospital discharges into kind of in a couple of different ways. we had categorized discharges into those that received TCM and those that did not receive TCM.
MacKenzie Hughes:And again, TCM is the transitional care management. So you can kind of think of these as the treatment and comparison groups, you know. And then we also categorized the discharges into those that were aligned with alternative payment models and those that were not aligned with an alternative payment model. And so, you know, really what we were trying to get at here was if you kind of imagine yourself as a patient, you know, if you received TCM services after leaving the hospital and you were aligned with an alternative payment model, you know, are your outcomes better and are your costs lower compared to someone else who also received TCM, but maybe, you know, after leaving the hospital, but but they were not aligned with an APM. So I'll share kind of our our main findings, which I know are also in our title.
MacKenzie Hughes:But with the healthy days at home outcome, we found that the association between TCM receipt and healthy days at home was more pronounced in the patients that were aligned with alternative payment models compared to those that were not aligned with an alternative payment model. So, you know, basically, if you focus on only the patients that received TCM, the patients that were aligned with the alternative payment model had more healthy days at home compared to those that were not aligned with an APM. If you look, you know, at our results, you know, we are talking about a difference in the a fraction of a day during that thirty one to sixty day period following hospital discharge. But I think, as a patient who has been ill or has had to undergo treatment in the hospital, having any additional healthy time at home and being out of the hospital is meaningful. So we were excited to see that result.
MacKenzie Hughes:And then in terms of costs, the association between TCM and total Medicare spending was also more pronounced among the patients that were aligned with the alternative payment models. So again, if you focus only on the patients that received TCM, the patients that were aligned with an alternative payment model had lower spending compared to those that were not aligned to an alternative payment model. So those were the the two main findings, and those findings, you know, were incorporated in the title of our paper.
Rob Lott:Great. And what do we know about the sociodemographic factors at play? Were there segments of the population that were more likely to see the benefits of transitional care management? Or what other sort of variation did you see that might be illuminating?
MacKenzie Hughes:Yeah. Our findings did show that certain groups of people were less likely to receive transitional care management. So for example, black and African American beneficiaries and those who are dually eligible for Medicare and Medicaid were less likely to receive transitional care management. And then we also found the beneficiaries who are female and white were more likely to receive transitional care management. And these findings are consistent with prior research and with the literature showing sociodemographic differences in access to health care.
MacKenzie Hughes:And this is a area of future work, I think. You know, we need to better understand the impact of this uneven delivery of TCM services and how it might impact health disparities.
Rob Lott:Your data ends in 2020, which as we know is sort of the early phases of COVID. And do you have a sense of whether or not the pandemic's impact is manifest in this data and maybe how the results might have changed if your data extended another additional two or three years?
MacKenzie Hughes:Yeah, this is a good question. I'm glad you're bringing this up. And it's an important point to clarify for our paper. So eligible hospital discharges that were included in our analysis were taken from 2018 and 2019 data. And like I mentioned before, our study outcomes were measured between thirty one and sixty days following hospital discharge.
MacKenzie Hughes:And I'm saying all this because the latest possible follow-up data included in the analysis would have been from 03/01/2020, which is still, you know, prior to when the COVID nineteen pandemic began in The US. You know? So we cut it close, but all of the outcome data included in the analysis were from before the pandemic. But, you know, regarding your the part of your question about how our results may have been different had our data overlapped with the pandemic. You know, of course, the pandemic introduced all kinds of challenges on the health care system, and it's hard to know how our results would have been different.
MacKenzie Hughes:But what I will say is TCM is really focused on follow-up care and contacting patients and their care caregivers after they leave the hospital. And these follow ups can actually be made using telehealth, like a telephone call or email. So there's flexibility in how the TCM follow-up contacts are made with patients. And then on top of that, we also know that alternative payment models have been kind of at the forefront of adopting telehealth supported by Medicare waivers. So kind of considering these details, I'm going to guess that our results may not have been all that different had we done this same analysis using data from a couple years into the pandemic.
MacKenzie Hughes:But, you know, this is sort of my best guess. I think there's you know, this is a good area of future work kind of looking at how results might be different. We're using data from, you know, 2020 to 2022, for example.
Rob Lott:Okay. Let's assume you have maybe a few members of congress on your email distribution list, and, one of them is really interested in, their aging constituents. The rising costs associated with the aging US population, their care, the fact that our system seems to be consistently failing them. They read this paper and they come back to you with something along the lines of, well, you know, what do we do now? So based on the findings of your paper, where would you recommend that a policymaker, whether at the federal level or the state level, go forward in terms of potential policy changes inspired by your findings?
MacKenzie Hughes:Yeah. So our results indicated that beyond the overall benefits, TCM may be a useful strategy within alternative payment models to help reduce spending while maintaining or improving quality. So there may be complementary effects between TCM and these alternative payment models or, you know, these two policies may be reinforcing. That's really what our results can say. Our study did not focus specifically on identifying areas for, you know, practice and policy recommendations within TCM or APMs.
MacKenzie Hughes:But, you know, given our results, I'll say a few ideas. So practice leaders should consider both strategies, TCM and alternative payment models together in care redesign initiatives. policymakers could consider harmonizing across TCM and alternative payment model policy as Medicare continues to work towards its goal of treating all Medicare beneficiaries through these accountable care relationships. And then you know, our findings showed that TCM services may not have been used or or delivered for many beneficiaries who may have benefited from them. So, again, our findings can't speak to this directly, but given the promising results associated with these transitional care management codes, I think there are efforts that could be made to increase uptake of the services.
MacKenzie Hughes:So for example, policymakers could consider making adjustments to TCM. The current codes only allow one health care professional, either a physician or a qualified nonphysician practitioner to bill for TCM services for each beneficiary. And the codes don't really incentivize, like, a co ownership of patients across multiple providers, and they don't account for the number of team members that could be involved in delivering the services. So I think, you know, policymakers could consider opportunities to expand the codes to increase adoption by allowing groups of clinicians to receive reimbursement, to promote, you know, team based care or expanding the codes to more so that more nonphysicians could provide and and receive payment for for TCM. And then one other kind of adjustment I think maybe policymakers could consider is figuring out how to reduce some of the administrative burden that is associated with TCM delivery.
MacKenzie Hughes:So there's some evidence showing that, you know, it can be a burden to billings. I think especially billing for TCM codes has been play has placed a lot of administrative burden on on staff. So, you know, those are just a few ideas that, you know, we have in terms of, you know, what do we do now, what's next for this work? But again, know, our paper was really focused on understanding how the two policies might be working together.
Rob Lott:Great. A great road map for potential policy changes going forward. That's a good spot to stop. Thanks so much for joining us here today. Really appreciate it.
MacKenzie Hughes:Thanks so much for having me.
Rob Lott:Absolutely. To our listeners, thanks for tuning in. If you enjoyed this episode, leave a review, recommend it to a friend, and smash that subscribe button. We'll talk to you next week. Thanks for listening.
Rob Lott:If you enjoyed today's episode, I hope you'll tell a friend about a health policy.