The United States healthcare system is in a period of transition from volume-based to value-based payment models. In the last several years, we have seen the rise of alternatives to traditional fee-for-service as part of the Centers for Medicare & Medicaid Services (CMS) strategy to reign in the burgeoning and unsustainable cost-of-care for its beneficiaries. In the outpatient setting, the Medicare Share Savings Program (MSSP)—the largest Medicare ACO model—provides financial incentives for participating organizations to assume financial accountability for achieving quality and cost of care metrics.1 Since its launch in 2012, the MSSP has grown to include 477 ACOs providing care to 10.7 million Medicare beneficiaries.2 In 2013 CMS launched a parallel inpatient program in the form of a voluntary alternative payment program to improve the costs and quality of care for hospitalized beneficiaries. The Bundled Payment for Care Improvement (BPCI)3 aims to foster hospital care redesign and innovation to improve care coordination and reduce expenditures while improving the quality of hospital care. The BPCI combines payments for physicians, hospitals, and other health care provider services into a single “bundled” payment amount calculated based on the expected costs associated with an episode of care. Like the MSSP, participating organizations are incentivized to contain spending below a predefined benchmark while maintaining care quality to realize a financial gain. As CMS continues to investigate and refine alternate payment models, more research into the impact of innovative care models on patient outcomes, quality of care, healthcare utilization, and costs of care are needed.

Geriatric and palliative care consultation models have the potential to impact healthcare utilization. Studies on inpatient geriatric hospital and consultation care models including the Acute Care for Elders (ACE) unit and Mobile Acute Care of the Elderly service have shown a reduction in hospital lengths of stay and readmission rates.4, 5 However, a systematic review and meta-analysis of inpatient geriatric consultation interventions showed no impact on readmission or length of stay.6 Similarly, while inpatient palliative care consultation services may reduce overall costs of hospitalization,7 a length of stay analysis showed palliative care interventions had no impact on the length of stay outside the intensive care unit (ICU).8

In this issue of JAGS, Min and colleagues describe the impact of a non-randomized controlled study of an interprofessional geriatric and palliative care intervention on length of stay, 30-day readmission, and inpatient services utilization at a large, academic medical center.9 The intervention consisted of the attendance of a geriatrician, palliative care physician, and social worker in twice-weekly multidisciplinary discharge rounds, with informal recommendations for identified geriatric or palliative care issues made to the hospitalist team. The investigators found that compared to control teams, patients cared for by the intervention hospitalist group had a 0.36 days shorter length of stay with no change in readmission rates but with a modest increase in overall relative value unit utilization. While the intervention and control teams were pragmatically chosen, the recommendations were not standardized, and quality indicators and patient outcomes were not reported, these findings suggest that interprofessional collaboration for the care of frail, older patients may result in inpatient days savings at the expense of slightly increased utilization.

A challenge facing organizations participating in the BPPI is the higher cost of care for frail, older patients and, for CMS, the risk of avoidance of these vulnerable patient populations by BPCI-participating hospitals. While higher levels of frailty are indeed associated with higher costs of care and worse clinical outcomes (including 90-day readmissions and mortality), BPCI hospitals caring for frail patients have been able to decrease Medicare payments without negative impacts on days at home, risk-adjusted admission rates, or mortality.10 Involvement of geriatricians and palliative care physicians in discharge planning have the potential to help make value-based hospital care for older patients more financially sustainable. Future research is needed to identify specific, standardized, and replicable interventions that will not only reduce the length of stay and other healthcare utilization metrics but also improve quality of care, reduce low-value care and increase patient and caregiver satisfaction of care for older hospitalized patients.

CONFLICT OF INTEREST

The author has no relevant conflict of interest.

AUTHOR CONTRIBUTIONS

Dr. Zaldy Tan is the sole author.

SPONSOR'S ROLE

The sponsors have no role in the conception, design, preparation or approval of the manuscript.