Wide Variations in Post-Acute Care Utilization Suggest Opportunities

​Regional variations in post-acute care utilization account for 73% of regional spending differences in Medicare per-beneficiary reimbursement.¹ Recently, Greg Sacks, MD, MPH and colleagues analyzed the patterns of 217 hospitals with 112,620 surgery patients.² Utilization of inpatient, post-acute care such as skilled nursing facilities and inpatient rehab facilities ranges from 2.7% to 39.7% of discharges and utilization of home health ranges from 3.1% to 57.8%.² These extreme ranges exist after adjusting for preoperative risk factors, operation type, occurrence of pre-discharge complications, as well as hospital ownership, size, teaching status, rural versus urban, and region. Wide variations like this typically suggest underutilization, overutilization, or both. Congress has recognized the potential for cost savings and improved patient care that could come from providing more evidence-based guidelines for when to make referrals to post-acute care and to which setting.¹

​Inpatient, post-acute care costs more than home health when used as the first post-discharge care setting. For instance, for hip replacements (MS-DRG 470), compared to the average cost of skilled nursing facilities (SNF) and inpatient rehab facilities (IRF), Medicare saves $12,131 when home health is the first post-acute care setting. For MS-DRG 291 (heart failure and shock with MCC), Medicare saves $16,777 compared to SNF and IRF rehab.³ This being the case, it would make sense that the thought process for site selection would be to first consider home health, and then consider inpatient options for patients requiring more care than the Medicare home health benefit delivers. However, Dr. Sacks’ large study could not find persistent evidence of such patterns. From 2007 to 2009, comparing home health, SNF, IRF, and long-term care hospitals, discharges to inpatient rehabilitation happened 61.3% of the time while home health was the first post-acute care setting in 38.7% of discharges. This suggests some potential for greater utilization of home health.³

​When deciding between sites of non-acute care, the first thing to keep in mind is that when patients are safe for intermittent care and the home environment, home health achieves outcomes on par with inpatient rehabilitation if not better (because the home health care delivery model provides advantages in modifying patient lifestyle, improving adherence at home, and allowing for follow-up visits). In Dr. Sack’s study, the hospitals that utilized inpatient post-acute care more had more rehospitalizations. Other than that, even after risk-adjusting the data, inpatient-utilizing hospitals have no advantages or disadvantages compared to home-health-utilizing hospitals in terms of mortality or complications. Other studies have demonstrated that, in cases of lower-extremity joint replacement, cardiac rehab, osteoarthritis rehab, and stroke, the inpatient rehab setting does not ensure superior therapy compared to fully-staffed home health with nursing, physical, occupational, and speech therapy.⁴⁻¹⁰ The advantage that inpatient settings provide is more support with activities of daily living, more constant nursing supervision, the availability of more than one physical therapy session per day, and the availability of more than two nursing visits per day. If the care plan does not require any of that, most postdischarge care objectives can be achieved readily in the home environment. Please let us know if you would like more information on how home health can help with a particular case or a particular category of cases of interest to you.

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​References:

1. Newhouse J, Garber A. Geographic variation in Medicare services. N Engl J Med. 2013; 368: 1465- 1468.
2. Sacks G, Lawson E, Dawes A, et al. Variation in hospital use of postacute care after surgery and the association with care quality. Medical Care. 54 (2): 2016: 172-79.
3. Dobson A, DaVanzo J, El-Gamil A, et al. Clinically appropriated and cost-effective placement (CACEP): Improving health care quality and efficiency: Final report. Dobson DaVanzo & Associates, LLC. 2010; Vienna VA.
4. Mahomed N, Davis A, Hawker G, et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008; 90: 1673-80.
5. Tribe K, Lapsley H, Cross M, et al. Selection of patients for inpatient rehabilitation or direct home discharge following total joint replacement surgery: a comparison of health status and out-of-pocket expenditure of patients undergoing hip and knee arthroplasty for osteoarthritis. Chronic Illness. 2005; 1: 289-302.
6. Mahomed N, Koo Seen Lin M, Levesque J, et al. Determinants and outcome of inpatient versus home based rehabilitation following elective hip and knee replacement. J Rheumatol. 2000; 27: 1753-8.
7. Fransen M, McConnell S, Harmer A, et al. Exercise for osteoarthritis of the knee. Br J Sports Med. 2015; 49 (24): 1554-1557.
8. Mallinson T, Bateman J, Tseng H, et al. A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lowerextremity joint replacement surgery. Arch Phys Med Rehabil. 2011; 92 (5): 712-20.
9. Duncan P, Sullivan K, Behrman A, et al. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med. 2011; 364: 2026-2036.
10. Jolly K, Taylor R, Lip G, Stevens A. “Home-based cardiac rehabilitation compared with centre-based rehabilitation and usual care: A systematic review and meta-analysis.” International Journal of Cardiology. 2006; 111: 343-51.