Care-transition program fumbles highlight CMS' reform challenges

The Council on Aging of Southwestern Ohio improved its patient-enrollment rate and managed to keep its CMS Innovation Center demonstration contract. But many other community agencies did not.

The Innovation Center launched a five-year demonstration to test the Community-based Care Transitions Program in 2012. It will spend up to $300 million enlisting community agencies to work with hospitals to help patients build skills and find resources to prevent repeat hospital visits. The center targeted area agencies on aging to participate.

“We were being too nice about allowing people not to sign up,” said Ken Wilson, a vice president at the Cincinnati-based Council on Aging of Southwestern Ohio. So his agency started hiring more persuasive staff. Enrollment jumped from 64% to 98% of eligible patients.

But of 101 participating agencies, roughly one-quarter withdrew or had their contract terminated after the first two-year demonstration contract. “The sites that were not extended failed to achieve performance targets,” the center said in a written statement. There are 72 agencies still participating.

The demonstration's objective was a 20% reduction in the 30-day all-cause readmission rate for traditional Medicare patients at hospitals in the initiative. Separately, agencies were required to reduce 30-day all-cause readmissions for high-risk patients. Agencies are paid an all-inclusive rate for serving eligible patients in a 180-day post-discharge period.

But an evaluation conducted for the Innovation Center by Econometrica found only four of 47 agencies studied succeeded in reducing readmission rates against a comparison group.

The Innovation Center's negative evaluation of the demonstration results and the contract terminations have drawn criticism from some researchers and advocates for community-based care. They say the Innovation Center used unrealistic performance targets and evaluated results too early in the program, using a flawed measure of readmissions. “It's really too early to tell,” said Sandy Markwood, CEO of the National Association of Area Agencies on Aging.

The controversy underscores the challenge CMS officials face as they seek to simultaneously evaluate multiple payment and delivery-reform demonstrations aimed at reducing costs and improving quality of care.

These include Medicare accountable care organizations, bundled-payment initiatives and patient-centered medical home initiatives, all of which the CMS has targeted for rapid expansion.

These payment and delivery-system experiments are seen as central to the Affordable Care Act's goals. The law allows the HHS secretary to implement successful demonstrations in the Medicare program at large, without congressional approval. But results from the demonstrations are emerging more slowly than many experts had hoped, and their results have been mixed so far.

Paul Ginsburg, a health policy expert at the University of Southern California, said evaluating a demonstration is complicated when hospitals are implementing multiple interventions to achieve the objective of reduced readmissions. “Doing a number of things to reach the same goal makes your evaluation process far more challenging if not impossible,” he said.

Dr. Joanne Lynn, director of the Altarum Institute Center for Elder Care and Advanced Illness, called the measure used to track readmissions in the CCTP demonstration “seriously flawed.” She said the evaluators used a hospital's ratio of readmissions to admissions to track progress, but that ratio won't change if community-based assistance reduces both admissions and readmissions.

She urged the Innovation Center to instead measure readmissions at the participating hospital against the rate in the larger community.

No Innovation Center officials were made available to comment.

Current and former participants in the program described the program's performance targets as daunting, and said it took a lot of investment and hard work to launch a community-based care transitions project. Area agencies on aging needed time to build relationships with hospital leaders and discharge planners to provide patient referrals. And some area agencies on aging lacked experience in billing Medicare.

The Innovation Center encouraged area agencies on aging to apply, and they each invested an average of $165,000, according to a survey last October of participating agencies. Nearly all reported that they failed to meet the program's targets for reducing readmissions. But they generally said they had achieved some positive results for patients.

Nick Macchione of the Health and Human Services Agency in San Diego County in California, which won renewal of its contract, said it took time for hospitals to see the value of care-transition programs. “They started to see that (what happened) outside the walls of the hospital was equally as important as the quality of the care inside the hospital,” he said. “That was the big aha.”