June 17, 2025 • 21 mins
Health Affairs' Rob Lott interviews MacKenzie Hughes of NORC at the University of Chicago about her recent paper reviewing how transitional care management was associated with healthier days at home and lower spending after hospital discharges for patients.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. For hospitalizedpatients, generally speaking,
it's great news to hear you'rebeing discharged and going home
at last. But years of evidencehave shown that this
transitional period isparticularly fraught. Countless
(00:27):
factors from incompleteinstructions, lack of continuity
in care, and delayed follow-upcan lead to serious setbacks and
even harm like falls,infections, or medication
errors.
These in turn can lead somepatients right back in the
hospital again. Is it possibleto reduce the risks associated
(00:50):
with such transitions? That'sthe subject of today's Health
Odyssey. I'm here with Doctor.Mackenzie L.
Hughes, a psychologist andsenior research scientist at
NORC at the University ofChicago. Together with co
authors, Doctor. Hughesconducted a study whose findings
are published in the June issueof Health Affairs. Its title is
(01:14):
also its main finding.Transitional care management
associated with more healthydays at home, lower spending
after hospital discharge.
And I'm really excited to hearmore about the paper, so let's
just dig in. Doctor. MackenzieL. Hughes, welcome to The Health
Odyssey.
MacKenzie Hughes (01:34):
Thank you. Thanks for having me.
Rob Lott (01:36):
So let's start with some background. What do we mean
when we talk about transitionalcare? I alluded to a little bit
of that in the introduction. DidI do a good job of describing
most people's experience oftransitional care? What does
that typically involve?
Where are people transitioningfrom and to and who's involved?
MacKenzie Hughes (02:01):
Yeah. Yeah. Your introduction was a nice
overview of kind of what we'retalking about here. And this is
a good place to start. So, youknow, when we're referring to
care transitions, we're reallytalking about this movement that
a patient undergoes when theyare moving between health care
providers or between differentsettings.
(02:22):
And this movement typicallyhappens as a patient's health
care needs change. So in ourpaper, we refer to care
transitions. Kind of what we'rereally talking about is the
transition that a patient wouldmake from the hospital setting
to a community setting. And forfor many people, this would look
like, you know, for example,going home from the hospital.
Rob Lott (02:44):
Okay. And traditionally, these transitions
have been associated with badoutcomes and high costs. Why is
that?
MacKenzie Hughes (02:54):
Yeah. So you yeah. You mentioned a few of
those outcomes in yourintroduction. So, you know, a a
patient's transition from thehospital to home or to some
other community setting canreally kind of put them in a
vulnerable spot in terms oftheir risk for rehospitalization
and these other kind of pooroutcomes. And, you know, as I
(03:16):
mentioned earlier, thesetransitions during these
transitions, a patient mightexperience changes in their
health care settings or changesin the individuals that are
responsible for their care.
So really to successfullycoordinate these transitions and
to avoid those bad outcomes andto avoid the high costs,
information needs to be sharedwith the patient and with the
(03:40):
individuals that are involved inthe patient's care. So this can
look like, you know,communication between the
patient's health care providers.That's really critical here. I
can also, it's important thatpatients and their caregivers
have the information that theyneed to manage, you know, the
patient's health condition andtheir medications as they're
(04:00):
going home.
Rob Lott (04:01):
So the scenario I'm envisioning is someone's in the
hospital, they're typicallybeing cared for, or at least
their care is overseen by ahospitalist, someone who's sort
of managing their in the momentin the hospital care, then
they're sent home and theyusually say, follow-up with your
primary care provider in twodays or something like that. Is
(04:24):
that sort of a typicaltransition and is often, I
imagine there's some losstypically of information when
the basically, the report goesfrom the hospital to the primary
care provider. Is that fair?
MacKenzie Hughes (04:44):
Yes. Yeah. So, you know, maybe the patient has
been seeing one doctor, maybethey're a specialist, and now
their care will be managed bysomeone else. Maybe it's their
primary care provider. And, youknow, what we know with, and we
can dig in a little bit moreabout these, you know, TCM or
transitional care managementcodes is in in many cases, it's
(05:05):
the primary care provider that'sproviding the services.
So yeah, that scenario that youdescribed, I think is a good one
here.
Rob Lott (05:13):
Against this backdrop, let's say policymakers kind of
looked at the situation, theysaid this is a problem area. So
let's have Medicare reimburseclinicians to manage these
transitions. I think thisstarted in 2013. Can you say a
little bit about the theorydriving that policy change
(05:34):
around the reimbursement? Was itsimply a case of policymakers
saying, well, the reason thesetransitions go badly is because
no one has an incentive tomanage them?
Or did we know more about whatwas kind of going on under the
hood at that point?
MacKenzie Hughes (05:50):
Yeah. There were a few things going on
around that time that Medicarehad introduced these
transitional care managementcodes. So kind of looking back
on on what was going on, pre2012, thirty day
rehospitalization rates werepretty high. And vulnerable
(06:11):
patients were kind of revolvingfrom the hospital to the
community and back. And,obviously, that's that's not
ideal.
And so this prompted Medicare tomake a couple of policy changes.
So in the fall of twenty twelve,Medicare introduced the hospital
readmissions reduction program.And that program incentivizes
(06:34):
hospitals to pay attention to,you know, how and where they
were discharging patients. Andthen just a few months later, so
in 2013, Medicare had introducedthe transitional care management
codes and those codes are andthose codes are are meant to
incentivize the practitioners tobetter care for their patients
(06:55):
after discharge. I shouldmention, you know, before these
transitional care managementcodes were introduced, Medicare
did not pay for any non kind offace to face services that the
patients needed during theircare transitions, like
medication reconciliation,scheduling follow-up visits and
(07:17):
referrals, or helping patientsaccess community resources and
support services.
So, you know, through these TCMcodes, Medicare started to pay
practitioners. And again, Ithink primary care physicians
for their time spent on carecoordination, care transition
activities that go beyond thatoffice visit. And then, you
(07:42):
know, one more thing was goingon around that time. So, you
know, around the time thatMedicare had introduced those
TCM codes, they also startedimplementing alternative payment
models, which I'm, of course,happy to talk about in more
detail. But, you know, thesemodels were also helping to
address better delivery of wholeperson care while reducing
spending.
(08:03):
And so our work and the work ofothers has shown that these
alternative payment models adoptTCM or transitional care
management as a key strategy forcoordinating care during that
post discharge period where, youknow, a patient is transitioning
from the hospital back to thecommunity.
Rob Lott (08:24):
Gotcha. So what I I think you're hinting at is that
the ACOs and other alternativepayment models have sort of
included this transitional caremanagement as sort of like one
strategy of a menu of strategiesthat they're using. And that
it's fair to see thetransitional care management
(08:45):
reimbursement as sort of a pieceof this kind of larger vision
and not just a standalone fixthat someone has said, let's
flip the switch and things willget better.
MacKenzie Hughes (08:59):
Sure. Yeah. We yeah. What we're finding is,
these accountable careorganizations and others are
that are participating in thesealternative payment models are
are more likely to adopt thesecare transition, you know,
management services.
Rob Lott (09:13):
Great. Well, in just a I wanna ask you about the
findings of your study. Butbefore we do, let's go to a
quick break. And we're back. I'mhere with Doctor.
(09:40):
Mackenzie L. Hughes talkingabout her paper on transitional
care management and itsassociation with increased
healthy days at home and lowerspending after hospital
discharge. I kind of spoiled theend here, but I wanted to ask
you about the findings of yourpaper. I just hinted at them
(10:00):
with the title of that paper,but can you tell us a little
more about the outcomes that youstudied and what you found?
MacKenzie Hughes (10:07):
Yes. So our analysis focused on examining
the associations of transitionalcare management and alternative
payment models on four qualityand cost outcomes. So those were
readmissions, mortality, healthydays at home, and then total
Medicare spending, andspecifically during the thirty
(10:28):
one to sixty day period afterthe patient was discharged from
the hospital. And so before Italk about our main findings, I
just quickly wanna mention, youknow, that we had categorized
hospital discharges into kind ofin a couple of different ways.
we had categorized dischargesinto those that received TCM and
(10:51):
those that did not receive TCM.
And again, TCM is thetransitional care management. So
you can kind of think of theseas the treatment and comparison
groups, you know. And then wealso categorized the discharges
into those that were alignedwith alternative payment models
and those that were not alignedwith an alternative payment
model. And so, you know, reallywhat we were trying to get at
(11:17):
here was if you kind of imagineyourself as a patient, you know,
if you received TCM servicesafter leaving the hospital and
you were aligned with analternative payment model, you
know, are your outcomes betterand are your costs lower
compared to someone else whoalso received TCM, but maybe,
you know, after leaving thehospital, but but they were not
(11:37):
aligned with an APM. So I'llshare kind of our our main
findings, which I know are alsoin our title.
But with the healthy days athome outcome, we found that the
association between TCM receiptand healthy days at home was
more pronounced in the patientsthat were aligned with
(11:58):
alternative payment modelscompared to those that were not
aligned with an alternativepayment model. So, you know,
basically, if you focus on onlythe patients that received TCM,
the patients that were alignedwith the alternative payment
model had more healthy days athome compared to those that were
not aligned with an APM. If youlook, you know, at our results,
(12:22):
you know, we are talking about adifference in the a fraction of
a day during that thirty one tosixty day period following
hospital discharge. But I think,as a patient who has been ill or
has had to undergo treatment inthe hospital, having any
additional healthy time at homeand being out of the hospital is
(12:43):
meaningful. So we were excitedto see that result.
And then in terms of costs, theassociation between TCM and
total Medicare spending was alsomore pronounced among the
patients that were aligned withthe alternative payment models.
So again, if you focus only onthe patients that received TCM,
(13:07):
the patients that were alignedwith an alternative payment
model had lower spendingcompared to those that were not
aligned to an alternativepayment model. So those were the
the two main findings, and thosefindings, you know, were
incorporated in the title of ourpaper.
Rob Lott (13:23):
Great. And what do we know about the sociodemographic
factors at play? Were theresegments of the population that
were more likely to see thebenefits of transitional care
management? Or what other sortof variation did you see that
might be illuminating?
MacKenzie Hughes (13:44):
Yeah. Our findings did show that certain
groups of people were lesslikely to receive transitional
care management. So for example,black and African American
beneficiaries and those who aredually eligible for Medicare and
Medicaid were less likely toreceive transitional care
(14:05):
management. And then we alsofound the beneficiaries who are
female and white were morelikely to receive transitional
care management. And thesefindings are consistent with
prior research and with theliterature showing
sociodemographic differences inaccess to health care.
And this is a area of futurework, I think. You know, we need
(14:28):
to better understand the impactof this uneven delivery of TCM
services and how it might impacthealth disparities.
Rob Lott (14:36):
Your data ends in 2020, which as we know is sort
of the early phases of COVID.And do you have a sense of
whether or not the pandemic'simpact is manifest in this data
and maybe how the results mighthave changed if your data
extended another additional twoor three years?
MacKenzie Hughes (14:58):
Yeah, this is a good question. I'm glad you're
bringing this up. And it's animportant point to clarify for
our paper. So eligible hospitaldischarges that were included in
our analysis were taken from2018 and 2019 data. And like I
mentioned before, our studyoutcomes were measured between
(15:18):
thirty one and sixty daysfollowing hospital discharge.
And I'm saying all this becausethe latest possible follow-up
data included in the analysiswould have been from 03/01/2020,
which is still, you know, priorto when the COVID nineteen
pandemic began in The US. Youknow? So we cut it close, but
(15:40):
all of the outcome data includedin the analysis were from before
the pandemic. But, you know,regarding your the part of your
question about how our resultsmay have been different had our
data overlapped with thepandemic. You know, of course,
the pandemic introduced allkinds of challenges on the
(16:01):
health care system, and it'shard to know how our results
would have been different.
But what I will say is TCM isreally focused on follow-up care
and contacting patients andtheir care caregivers after they
leave the hospital. And thesefollow ups can actually be made
using telehealth, like atelephone call or email. So
(16:22):
there's flexibility in how theTCM follow-up contacts are made
with patients. And then on topof that, we also know that
alternative payment models havebeen kind of at the forefront of
adopting telehealth supported byMedicare waivers. So kind of
considering these details, I'mgoing to guess that our results
may not have been all thatdifferent had we done this same
(16:43):
analysis using data from acouple years into the pandemic.
But, you know, this is sort ofmy best guess. I think there's
you know, this is a good area offuture work kind of looking at
how results might be different.We're using data from, you know,
2020 to 2022, for example.
Rob Lott (17:01):
Okay. Let's assume you have maybe a few members of
congress on your emaildistribution list, and, one of
them is really interested in,their aging constituents. The
rising costs associated with theaging US population, their care,
(17:21):
the fact that our system seemsto be consistently failing them.
They read this paper and theycome back to you with something
along the lines of, well, youknow, what do we do now? So
based on the findings of yourpaper, where would you recommend
that a policymaker, whether atthe federal level or the state
(17:43):
level, go forward in terms ofpotential policy changes
inspired by your findings?
MacKenzie Hughes (17:51):
Yeah. So our results indicated that beyond
the overall benefits, TCM may bea useful strategy within
alternative payment models tohelp reduce spending while
maintaining or improvingquality. So there may be
complementary effects betweenTCM and these alternative
payment models or, you know,these two policies may be
(18:12):
reinforcing. That's really whatour results can say. Our study
did not focus specifically onidentifying areas for, you know,
practice and policyrecommendations within TCM or
APMs.
But, you know, given ourresults, I'll say a few ideas.
So practice leaders shouldconsider both strategies, TCM
(18:34):
and alternative payment modelstogether in care redesign
initiatives. policymakers couldconsider harmonizing across TCM
and alternative payment modelpolicy as Medicare continues to
work towards its goal oftreating all Medicare
beneficiaries through theseaccountable care relationships.
(18:58):
And then you know, our findingsshowed that TCM services may not
have been used or or deliveredfor many beneficiaries who may
have benefited from them. So,again, our findings can't speak
to this directly, but given thepromising results associated
with these transitional caremanagement codes, I think there
(19:20):
are efforts that could be madeto increase uptake of the
services.
So for example, policymakerscould consider making
adjustments to TCM. The currentcodes only allow one health care
professional, either a physicianor a qualified nonphysician
practitioner to bill for TCMservices for each beneficiary.
(19:42):
And the codes don't reallyincentivize, like, a co
ownership of patients acrossmultiple providers, and they
don't account for the number ofteam members that could be
involved in delivering theservices. So I think, you know,
policymakers could consideropportunities to expand the
codes to increase adoption byallowing groups of clinicians to
receive reimbursement, topromote, you know, team based
(20:03):
care or expanding the codes tomore so that more nonphysicians
could provide and and receivepayment for for TCM. And then
one other kind of adjustment Ithink maybe policymakers could
consider is figuring out how toreduce some of the
administrative burden that isassociated with TCM delivery.
(20:24):
So there's some evidence showingthat, you know, it can be a
burden to billings. I thinkespecially billing for TCM codes
has been play has placed a lotof administrative burden on on
staff. So, you know, those arejust a few ideas that, you know,
we have in terms of, you know,what do we do now, what's next
(20:46):
for this work? But again, know,our paper was really focused on
understanding how the twopolicies might be working
together.
Rob Lott (20:53):
Great. A great road map for potential policy changes
going forward. That's a goodspot to stop. Thanks so much for
joining us here today. Reallyappreciate it.
MacKenzie Hughes (21:02):
Thanks so much for having me.
Rob Lott (21:05):
Absolutely. To our listeners, thanks for tuning in.
If you enjoyed this episode,leave a review, recommend it to
a friend, and smash thatsubscribe button. We'll talk to
you next week. Thanks forlistening.
If you enjoyed today's episode,I hope you'll tell a friend
about a health policy.
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. For hospitalizedpatients, generally speaking,
it's great news to hear you'rebeing discharged and going home
at last. But years of evidencehave shown that this
transitional period isparticularly fraught. Countless
(00:27):
factors from incompleteinstructions, lack of continuity
in care, and delayed follow-upcan lead to serious setbacks and
even harm like falls,infections, or medication
errors.
These in turn can lead somepatients right back in the
hospital again. Is it possibleto reduce the risks associated
(00:50):
with such transitions? That'sthe subject of today's Health
Odyssey. I'm here with Doctor.Mackenzie L.
Hughes, a psychologist andsenior research scientist at
NORC at the University ofChicago. Together with co
authors, Doctor. Hughesconducted a study whose findings
are published in the June issueof Health Affairs. Its title is
(01:14):
also its main finding.Transitional care management
associated with more healthydays at home, lower spending
after hospital discharge.
And I'm really excited to hearmore about the paper, so let's
just dig in. Doctor. MackenzieL. Hughes, welcome to The Health
Odyssey.
MacKenzie Hughes (01:34):
Thank you. Thanks for having me.
Rob Lott (01:36):
So let's start with some background. What do we mean
when we talk about transitionalcare? I alluded to a little bit
of that in the introduction. DidI do a good job of describing
most people's experience oftransitional care? What does
that typically involve?
Where are people transitioningfrom and to and who's involved?
MacKenzie Hughes (02:01):
Yeah. Yeah. Your introduction was a nice
overview of kind of what we'retalking about here. And this is
a good place to start. So, youknow, when we're referring to
care transitions, we're reallytalking about this movement that
a patient undergoes when theyare moving between health care
providers or between differentsettings.
(02:22):
And this movement typicallyhappens as a patient's health
care needs change. So in ourpaper, we refer to care
transitions. Kind of what we'rereally talking about is the
transition that a patient wouldmake from the hospital setting
to a community setting. And forfor many people, this would look
like, you know, for example,going home from the hospital.
Rob Lott (02:44):
Okay. And traditionally, these transitions
have been associated with badoutcomes and high costs. Why is
that?
MacKenzie Hughes (02:54):
Yeah. So you yeah. You mentioned a few of
those outcomes in yourintroduction. So, you know, a a
patient's transition from thehospital to home or to some
other community setting canreally kind of put them in a
vulnerable spot in terms oftheir risk for rehospitalization
and these other kind of pooroutcomes. And, you know, as I
(03:16):
mentioned earlier, thesetransitions during these
transitions, a patient mightexperience changes in their
health care settings or changesin the individuals that are
responsible for their care.
So really to successfullycoordinate these transitions and
to avoid those bad outcomes andto avoid the high costs,
information needs to be sharedwith the patient and with the
(03:40):
individuals that are involved inthe patient's care. So this can
look like, you know,communication between the
patient's health care providers.That's really critical here. I
can also, it's important thatpatients and their caregivers
have the information that theyneed to manage, you know, the
patient's health condition andtheir medications as they're
(04:00):
going home.
Rob Lott (04:01):
So the scenario I'm envisioning is someone's in the
hospital, they're typicallybeing cared for, or at least
their care is overseen by ahospitalist, someone who's sort
of managing their in the momentin the hospital care, then
they're sent home and theyusually say, follow-up with your
primary care provider in twodays or something like that. Is
(04:24):
that sort of a typicaltransition and is often, I
imagine there's some losstypically of information when
the basically, the report goesfrom the hospital to the primary
care provider. Is that fair?
MacKenzie Hughes (04:44):
Yes. Yeah. So, you know, maybe the patient has
been seeing one doctor, maybethey're a specialist, and now
their care will be managed bysomeone else. Maybe it's their
primary care provider. And, youknow, what we know with, and we
can dig in a little bit moreabout these, you know, TCM or
transitional care managementcodes is in in many cases, it's
(05:05):
the primary care provider that'sproviding the services.
So yeah, that scenario that youdescribed, I think is a good one
here.
Rob Lott (05:13):
Against this backdrop, let's say policymakers kind of
looked at the situation, theysaid this is a problem area. So
let's have Medicare reimburseclinicians to manage these
transitions. I think thisstarted in 2013. Can you say a
little bit about the theorydriving that policy change
(05:34):
around the reimbursement? Was itsimply a case of policymakers
saying, well, the reason thesetransitions go badly is because
no one has an incentive tomanage them?
Or did we know more about whatwas kind of going on under the
hood at that point?
MacKenzie Hughes (05:50):
Yeah. There were a few things going on
around that time that Medicarehad introduced these
transitional care managementcodes. So kind of looking back
on on what was going on, pre2012, thirty day
rehospitalization rates werepretty high. And vulnerable
(06:11):
patients were kind of revolvingfrom the hospital to the
community and back. And,obviously, that's that's not
ideal.
And so this prompted Medicare tomake a couple of policy changes.
So in the fall of twenty twelve,Medicare introduced the hospital
readmissions reduction program.And that program incentivizes
(06:34):
hospitals to pay attention to,you know, how and where they
were discharging patients. Andthen just a few months later, so
in 2013, Medicare had introducedthe transitional care management
codes and those codes are andthose codes are are meant to
incentivize the practitioners tobetter care for their patients
(06:55):
after discharge. I shouldmention, you know, before these
transitional care managementcodes were introduced, Medicare
did not pay for any non kind offace to face services that the
patients needed during theircare transitions, like
medication reconciliation,scheduling follow-up visits and
(07:17):
referrals, or helping patientsaccess community resources and
support services.
So, you know, through these TCMcodes, Medicare started to pay
practitioners. And again, Ithink primary care physicians
for their time spent on carecoordination, care transition
activities that go beyond thatoffice visit. And then, you
(07:42):
know, one more thing was goingon around that time. So, you
know, around the time thatMedicare had introduced those
TCM codes, they also startedimplementing alternative payment
models, which I'm, of course,happy to talk about in more
detail. But, you know, thesemodels were also helping to
address better delivery of wholeperson care while reducing
spending.
(08:03):
And so our work and the work ofothers has shown that these
alternative payment models adoptTCM or transitional care
management as a key strategy forcoordinating care during that
post discharge period where, youknow, a patient is transitioning
from the hospital back to thecommunity.
Rob Lott (08:24):
Gotcha. So what I I think you're hinting at is that
the ACOs and other alternativepayment models have sort of
included this transitional caremanagement as sort of like one
strategy of a menu of strategiesthat they're using. And that
it's fair to see thetransitional care management
(08:45):
reimbursement as sort of a pieceof this kind of larger vision
and not just a standalone fixthat someone has said, let's
flip the switch and things willget better.
MacKenzie Hughes (08:59):
Sure. Yeah. We yeah. What we're finding is,
these accountable careorganizations and others are
that are participating in thesealternative payment models are
are more likely to adopt thesecare transition, you know,
management services.
Rob Lott (09:13):
Great. Well, in just a I wanna ask you about the
findings of your study. Butbefore we do, let's go to a
quick break. And we're back. I'mhere with Doctor.
(09:40):
Mackenzie L. Hughes talkingabout her paper on transitional
care management and itsassociation with increased
healthy days at home and lowerspending after hospital
discharge. I kind of spoiled theend here, but I wanted to ask
you about the findings of yourpaper. I just hinted at them
(10:00):
with the title of that paper,but can you tell us a little
more about the outcomes that youstudied and what you found?
MacKenzie Hughes (10:07):
Yes. So our analysis focused on examining
the associations of transitionalcare management and alternative
payment models on four qualityand cost outcomes. So those were
readmissions, mortality, healthydays at home, and then total
Medicare spending, andspecifically during the thirty
(10:28):
one to sixty day period afterthe patient was discharged from
the hospital. And so before Italk about our main findings, I
just quickly wanna mention, youknow, that we had categorized
hospital discharges into kind ofin a couple of different ways.
we had categorized dischargesinto those that received TCM and
(10:51):
those that did not receive TCM.
And again, TCM is thetransitional care management. So
you can kind of think of theseas the treatment and comparison
groups, you know. And then wealso categorized the discharges
into those that were alignedwith alternative payment models
and those that were not alignedwith an alternative payment
model. And so, you know, reallywhat we were trying to get at
(11:17):
here was if you kind of imagineyourself as a patient, you know,
if you received TCM servicesafter leaving the hospital and
you were aligned with analternative payment model, you
know, are your outcomes betterand are your costs lower
compared to someone else whoalso received TCM, but maybe,
you know, after leaving thehospital, but but they were not
(11:37):
aligned with an APM. So I'llshare kind of our our main
findings, which I know are alsoin our title.
But with the healthy days athome outcome, we found that the
association between TCM receiptand healthy days at home was
more pronounced in the patientsthat were aligned with
(11:58):
alternative payment modelscompared to those that were not
aligned with an alternativepayment model. So, you know,
basically, if you focus on onlythe patients that received TCM,
the patients that were alignedwith the alternative payment
model had more healthy days athome compared to those that were
not aligned with an APM. If youlook, you know, at our results,
(12:22):
you know, we are talking about adifference in the a fraction of
a day during that thirty one tosixty day period following
hospital discharge. But I think,as a patient who has been ill or
has had to undergo treatment inthe hospital, having any
additional healthy time at homeand being out of the hospital is
(12:43):
meaningful. So we were excitedto see that result.
And then in terms of costs, theassociation between TCM and
total Medicare spending was alsomore pronounced among the
patients that were aligned withthe alternative payment models.
So again, if you focus only onthe patients that received TCM,
(13:07):
the patients that were alignedwith an alternative payment
model had lower spendingcompared to those that were not
aligned to an alternativepayment model. So those were the
the two main findings, and thosefindings, you know, were
incorporated in the title of ourpaper.
Rob Lott (13:23):
Great. And what do we know about the sociodemographic
factors at play? Were theresegments of the population that
were more likely to see thebenefits of transitional care
management? Or what other sortof variation did you see that
might be illuminating?
MacKenzie Hughes (13:44):
Yeah. Our findings did show that certain
groups of people were lesslikely to receive transitional
care management. So for example,black and African American
beneficiaries and those who aredually eligible for Medicare and
Medicaid were less likely toreceive transitional care
(14:05):
management. And then we alsofound the beneficiaries who are
female and white were morelikely to receive transitional
care management. And thesefindings are consistent with
prior research and with theliterature showing
sociodemographic differences inaccess to health care.
And this is a area of futurework, I think. You know, we need
(14:28):
to better understand the impactof this uneven delivery of TCM
services and how it might impacthealth disparities.
Rob Lott (14:36):
Your data ends in 2020, which as we know is sort
of the early phases of COVID.And do you have a sense of
whether or not the pandemic'simpact is manifest in this data
and maybe how the results mighthave changed if your data
extended another additional twoor three years?
MacKenzie Hughes (14:58):
Yeah, this is a good question. I'm glad you're
bringing this up. And it's animportant point to clarify for
our paper. So eligible hospitaldischarges that were included in
our analysis were taken from2018 and 2019 data. And like I
mentioned before, our studyoutcomes were measured between
(15:18):
thirty one and sixty daysfollowing hospital discharge.
And I'm saying all this becausethe latest possible follow-up
data included in the analysiswould have been from 03/01/2020,
which is still, you know, priorto when the COVID nineteen
pandemic began in The US. Youknow? So we cut it close, but
(15:40):
all of the outcome data includedin the analysis were from before
the pandemic. But, you know,regarding your the part of your
question about how our resultsmay have been different had our
data overlapped with thepandemic. You know, of course,
the pandemic introduced allkinds of challenges on the
(16:01):
health care system, and it'shard to know how our results
would have been different.
But what I will say is TCM isreally focused on follow-up care
and contacting patients andtheir care caregivers after they
leave the hospital. And thesefollow ups can actually be made
using telehealth, like atelephone call or email. So
(16:22):
there's flexibility in how theTCM follow-up contacts are made
with patients. And then on topof that, we also know that
alternative payment models havebeen kind of at the forefront of
adopting telehealth supported byMedicare waivers. So kind of
considering these details, I'mgoing to guess that our results
may not have been all thatdifferent had we done this same
(16:43):
analysis using data from acouple years into the pandemic.
But, you know, this is sort ofmy best guess. I think there's
you know, this is a good area offuture work kind of looking at
how results might be different.We're using data from, you know,
2020 to 2022, for example.
Rob Lott (17:01):
Okay. Let's assume you have maybe a few members of
congress on your emaildistribution list, and, one of
them is really interested in,their aging constituents. The
rising costs associated with theaging US population, their care,
(17:21):
the fact that our system seemsto be consistently failing them.
They read this paper and theycome back to you with something
along the lines of, well, youknow, what do we do now? So
based on the findings of yourpaper, where would you recommend
that a policymaker, whether atthe federal level or the state
(17:43):
level, go forward in terms ofpotential policy changes
inspired by your findings?
MacKenzie Hughes (17:51):
Yeah. So our results indicated that beyond
the overall benefits, TCM may bea useful strategy within
alternative payment models tohelp reduce spending while
maintaining or improvingquality. So there may be
complementary effects betweenTCM and these alternative
payment models or, you know,these two policies may be
(18:12):
reinforcing. That's really whatour results can say. Our study
did not focus specifically onidentifying areas for, you know,
practice and policyrecommendations within TCM or
APMs.
But, you know, given ourresults, I'll say a few ideas.
So practice leaders shouldconsider both strategies, TCM
(18:34):
and alternative payment modelstogether in care redesign
initiatives. policymakers couldconsider harmonizing across TCM
and alternative payment modelpolicy as Medicare continues to
work towards its goal oftreating all Medicare
beneficiaries through theseaccountable care relationships.
(18:58):
And then you know, our findingsshowed that TCM services may not
have been used or or deliveredfor many beneficiaries who may
have benefited from them. So,again, our findings can't speak
to this directly, but given thepromising results associated
with these transitional caremanagement codes, I think there
(19:20):
are efforts that could be madeto increase uptake of the
services.
So for example, policymakerscould consider making
adjustments to TCM. The currentcodes only allow one health care
professional, either a physicianor a qualified nonphysician
practitioner to bill for TCMservices for each beneficiary.
(19:42):
And the codes don't reallyincentivize, like, a co
ownership of patients acrossmultiple providers, and they
don't account for the number ofteam members that could be
involved in delivering theservices. So I think, you know,
policymakers could consideropportunities to expand the
codes to increase adoption byallowing groups of clinicians to
receive reimbursement, topromote, you know, team based
(20:03):
care or expanding the codes tomore so that more nonphysicians
could provide and and receivepayment for for TCM. And then
one other kind of adjustment Ithink maybe policymakers could
consider is figuring out how toreduce some of the
administrative burden that isassociated with TCM delivery.
(20:24):
So there's some evidence showingthat, you know, it can be a
burden to billings. I thinkespecially billing for TCM codes
has been play has placed a lotof administrative burden on on
staff. So, you know, those arejust a few ideas that, you know,
we have in terms of, you know,what do we do now, what's next
(20:46):
for this work? But again, know,our paper was really focused on
understanding how the twopolicies might be working
together.
Rob Lott (20:53):
Great. A great road map for potential policy changes
going forward. That's a goodspot to stop. Thanks so much for
joining us here today. Reallyappreciate it.
MacKenzie Hughes (21:02):
Thanks so much for having me.
Rob Lott (21:05):
Absolutely. To our listeners, thanks for tuning in.
If you enjoyed this episode,leave a review, recommend it to
a friend, and smash thatsubscribe button. We'll talk to
you next week. Thanks forlistening.
If you enjoyed today's episode,I hope you'll tell a friend
about a health policy.
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