Health Affairs

From Health Affairs

For Vulnerable Older Adults, the Affordable Care Act Could Fall Short Without Changes in Health Care Delivery and Payment Systems

Bethesda, MD -- One of the goals of the Affordable Care Act (ACA) is to reduce the fragmentation of services for patients. The problems of fragmentation are magnified for the six million Americans receiving long-term services. New analysis, released as a Web First by Health Affairs, examines the impact on this population of three provisions of the ACA—the Hospital Readmissions Reduction Program (Section 3025), the National Pilot Program on Payment Bundling (Section 3023), and the Community-Based Care Transitions Program (Section 3026). It found that these provisions inadequately address the unique needs of Americans receiving long-term services, and, in some instances, produce unintended consequences that contribute to avoidable poor outcomes. The study is part of Health Affairs’ series of occasional articles on The Care Span, supported by the SCAN Foundation.

The authors selected these three provisions because each is designed to enhance transitional care and prevent avoidable poor outcomes among the Medicare population. Here are the findings about each of the three programs:

• Hospital Readmission Reduction Program. The program was designed to provide incentives for improvements in outcomes. However, because some frail older adults suffer from multiple conditions, and therefore have a higher possibility of being readmitted, hospitals could respond by limiting access to this population. Alternatively, the authors say that hospitals could also respond by redesigning care processes that benefit all patients.
  
  
• National Pilot Program on Payment Bundling. Bundled payments are designed to motivate providers to deliver care in the lowest-cost setting while avoiding expensive post-acute stays. However, the pilot program excludes long-term services and support as part of the “bundle,” so the authors point out that providers may simply withhold services to this group past the bundled payment period to realize savings.
  
  
• Community-Based Care Transitions. At the moment, thirty sites are participating in a program linking community-based organizations with hospitals to improve outcomes and reduce rehospitalizations. However, the authors point out that many frail older adults might not have been hospitalized or may not live in geographic regions served by these organizations.

“Because the Affordable Care Act may introduce unintended consequences for older adults receiving long-term services and supports, we suggest additional policies that may address these potential emerging risks,” conclude the authors. “Without retooling the payment and delivery systems, reform could fall short of its transformational promise.”

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically and health policy briefs published twice monthly at www.healthaffairs.org. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download weekly Narrative Matters podcasts on iTunes.

The full text of each Health Affairs Web First paper is available free of charge to all Web-site visitors for a two-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund.