November 08, 2016
Fixing Gaps in Care: Broad Trends for Three Key Approaches

Since the Affordable Care Act was passed, all roads lead to patient-centered, quality-driven, cost-efficient care. To that end, the Centers for Medicare and Medicaid Services (CMS) are increasingly focusing on joining up access to medical care, care coordination and communication — in particular where there are gaps in care.

These gaps can arise due to population factors such geography, socioeconomic status and ethnic background, but the result across the board is disparities in quality and quantity of treatment. In practical terms, this means hospitals face longer patient inpatient stays, higher readmission rates, increased use of services, higher costs, and lower patient satisfaction of care — not to mention reimbursement penalties from CMS.

Addressing the specific issues that arise from the gaps in care can contribute to greater gains on all sides (patient, provider, and hospital). Here are three key routes by which to address gaps in care and increase reimbursement success.

1. Removing rural restrictions

Patients who live in rural areas face additional hurdles to accessing medical care, particularly long distances to travel, simply to be examined by a provider. This can decrease the frequency, quality and sustainability of treatment; increase the chances of readmission due to reduced follow-up or patient monitoring; and lower patient incentive to seek medical care until it is critical.

CMS has rolled out the Frontier Community Health Integration Project (FCHIP) Demonstration to find ways to increase healthcare access and improve healthcare quality for people from areas with limited healthcare access due to long distances from healthcare providers. Ten critical access hospitals in Montana, Nevada, and North Dakota will participate in the program over a span of three years. The program will focus on three points:

1. Supporting these hospitals in finding ways to keep patients within their local health system and prevent them from traveling further distances for treatment (e.g. transfers).

2. Testing different payment schemes to assess access to care, increased healthcare provider coordination, and reduced admissions, readmissions and transfer.

3. Testing the effectiveness of nursing care, telemedicine and ambulance services among the participating hospitals.

2. Minimizing socioeconomic barriers

Socioeconomically disadvantaged populations may face high costs, inability to travel or maintain self-care for an ongoing condition, or lack adequate information/health literacy about their condition. These factors can actually lead to patients requiring more care that they are unable to afford or engage in. This puts hospitals that treat low-income patients at an apparent disadvantage compared to other hospitals, resulting in higher costs and greater reimbursement losses, because Medicare’s formula for calculating penalties does not account for the patient population’s socioeconomic status.

A study from the Missouri Hospital Association claims that readmission rates improve from 43–88% after adjustment for socioeconomic conditions. Many hospitals in low-income areas and proponents of incorporating socioeconomic adjustment factors are advocating for a change in the penalty calculation, and CMS is listening. In collaboration with the National Quality Forum, the government body is investigating whether and how readjustment of the parameters used for penalty calculation could help hospitals that care for poorer patient groups.

Telemedicine is also being examined from a new angle. Largely in use for solving the issue of treatment in rural areas, the technology for communicating with and treating patients remotely is now being tested for its effectiveness in improving health outcomes for low-income urban populations. A collaboration between the Rutgers School of Nursing, Rutgers Business School, and device company, SmartCareDoc, aims to demonstrate the feasibility of telemedicine to increase communication and monitoring of medical conditions in underserved populations.

3. Addressing transitions between hospital and home

The transition between acute and post-acute care — a crucial time filled with variables for previously critically-ill patients — is a period where patients of any stripe may fall through the cracks. Key strategies for reducing readmission rates include improving documentation, coordinating care, educating and empowering patients in their own health, and diligently following up.

What does this look like in practice? A program at the University of Colorado focuses on transitions by following the patient for the first month after hospital discharge. Notable measures include:

  • Periodic check-ups on a patient by a social worker and nurse
  • Improved communication and planning of continued treatment with a patient’s primary care physician
  • Increased use of technologies such as telemedicine or patient apps to track patient status in real time
  • Coordination between hospitals and community groups to ensure meal deliveries, patient transportation and social services, among other things.

The key to tackling this transitional gap in care and avoiding negative repercussions is to discuss and anticipate what is needed for long-term care so as to provide patient support and seamlessly linked care that avoids repetitions in treatment (e.g. readmissions or tests for the same preventable complications) that lead to excess costs.