Executive Summary

    Five Payer Strategies for Managing Post-Discharge Patients

    For hospitals, post-acute care facilities promise specialized nursing to patients and improved outcomes. For payers, post-acute facilities promise cost-efficiencies. With the industry’s ongoing switch from volume- to value-based compensation, both providers and payers have a strong incentive to make post-acute care work well.

    But a January 2018 survey by HIMSS Media of 100 payers (insurance carriers, third-party payers and health plan administrators) revealed numerous gaps in how hospitals, their post-acute partners and payers collaborate and share information.

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    Tony Tiefenthaler“Gaps in the discharge and referral process cause costly inefficiencies and negatively impact patient care,” said Tony Tiefenthaler, Director of Payer Strategy at Ensocare, which sponsored the January research. Hospital leaders, he said, should look to creating deeper relationships\ with engaged providers – ones investing in technology and processes to manage the post-discharge environment.

    A separate January HIMSS Media survey of 162 healthcare providers revealed that only 26 percent of respondents are partnering with post-acute providers to track patient care, and that more than half (53 percent) are either uncertain or have no real processes in place to manage post-acute providers. For those with processes, just 7 percent make use of automated discharge or referral management software.

    With a focus on closing the care gaps between payers and providers, Ensocare has developed five strategies payers can deploy to successfully manage post-discharge patients.

    1. Explore contractual agreements

    Mirroring the consolidation into larger regional networks among critical-care hospitals 12 to 15 years ago, the post-acute sector is undergoing consolidation, Tiefenthaler observed. Pressed by regulatory and compliance changes that have required them to raise the bar on monitoring of care quality and patient outcomes, smaller post-acute facilities with thin margins are being supplanted by larger entities. These regional players are better able to afford the administrative investments in processes and IT infrastructure needed to measure care quality and patient outcomes. In such an environment, Tiefenthaler said, hospital leaders building relationships with post-acute providers would be wise to reach out to payers to explore new contractual agreements.

    But this opportunity is being missed, according to the HIMSS Media survey. Only 2 out of 10 hospital leaders reach out to payers frequently, and some 40 percent of survey respondents said hospital leaders “never” reach out.

    1. Develop narrow networks or preferential contracts

    To assure high-quality, consistent care, at the lowest possible cost, payers should both narrow and deepen their relationships with these larger, post-acute networks – ones able to quantify their quality metrics, according to Tiefenthaler. This shift is occurring already.

    The survey found that 6 out of 10 payers have built a narrow network or signed preferential contracts with one or more facilities, and 41 percent have developed relationships with two or more facilities. The most popular post-acute types were home health (34 percent), physical therapy (29 percent) and skilled nursing facility (27 percent).

    Provider-Guiding-Patient

    1. Look at quality metrics

    Regarding decisions about which post-acute facilities should receive preferential contracts, payers should look at the providers’ quality metrics.

    “Physicians are aware who the quality players are for specialties like orthopedics and cardiology, and they’re steering patients to these providers,” Tiefenthaler said. Now these primary care physicians are increasingly wanting to identify the better post-acute providers. “Under MACRA, their reimbursement will be reduced if their [post-acute] patients are costing more on a regional or national level,” he said. The survey found that “avoidable ER visits” was by far the top-quality metric when measuring post-acute provider performance, cited by 89 percent of respondents as being very important or somewhat important.

    1. Provide more tools and services

    Payers can help providers gain insight into post-acute quality by providing tools/services, including software tools for the referral process itself, according to Tiefenthaler. The survey found 8 out of 10 payers provide one or more of these items to improve medical management of patients post-discharge, and 67 percent provide two or more tools. Popular tools/services were risk assessment data/predictive analytics (46 percent) and additional or dedicated staff to monitor patients (42 percent), followed by telemedicine services (35 percent), automated phone messaging (32 percent) and a secure cloud-based portal for patients, families and providers (30 percent).

    1. Develop KPIs to measure post-acute provider performance

    While ER readmissions is a valid quality metric, given readmission penalties under Medicare and other managed care plans, the popularity of risk assessment/predictive analytics makes sense, Tiefenthaler said. “Making sure we’re sending the patient to the right location, where there will be the best outcome with the shortest length of stay” is only possible with a referral platform that can help make these predictions accurately, he added.

    Noting that the survey found just under half of payers (and providers) report using this data to better direct patients to post-acute facilities, Tiefenthaler emphasized the opportunities for payers and providers alike to better leverage risk assessment/predictive analytics.

    With these five strategies in place, payers can share information and better coordinate care across the care continuum, which ultimately support cost-effective, improved quality of care.

    Check out the Infographic for more eye-opening findings from the Ensocare and HIMSS Media survey!

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