The US health system focuses an enormous amount of money and attention on post-acute care—the medical treatment patients receive after they have been discharged from a hospital. But it would more cost effective, and far better for patients, to refocus on what you might call pre-acute care: What the US can do to prevent those hospitalizations in the first place.
Don’t like nursing homes? Worried about the ongoing nursing shortage? One solution: Reduce the medical crises that lead to hospitalizations and the inevitable need for follow-up skilled nursing care in facilities or at home.
Saving Billions
In 2021, Medicare spent $57 billion, or 8 percent of its total budget, on post-discharge care such as physical and occupational therapy and nursing. In 2017, it paid hospitals another $34 billion for 3.5 million avoidable admissions, according to the federal Agency for Healthcare Research and Quality. That equaled about 13 percent of all non-obstetric stays.
About half of post-acute care costs , or about $27 billion, went to skilled nursing facilities. Nearly one-third went for home health care and the rest to long-term care hospitals and inpatient rehabilitation facilities.
Some avoidable admissions among older adults are directly caused by long-standing chronic conditions such as heart disease. Others result from acute events such as infections, falls, or dehydration that often happen to older adults with poorly-managed chronic conditions. Those with multiple admissions may account for as many as one-third of hospitalizations.
A study in the United Kingdom found a growing number of patients are admitted to hospitals directly from nursing facilities. In the US, causes include preventable infections or poor communication among nursing home staff, physicians, and families that lead to residents being sent to the hospital for relatively minor changes in health status. And they often return as more costly skilled nursing patients.
Preventing Hospitalizations
But many hospital admissions can be avoided with good preventive care.
Take congestive heart failure, the most common cause of preventable hospital admissions. Weight gain is a sign that the condition may be worsening, a situation that can be addressed simply by adjusting medications. But if patients are not weighed regularly, their decline can be missed until it leads to hospitalizations followed by rehab.
For those with very severe illness, home-based palliative or hospice care can avoid the risks of hospital stays and ineffective post-acute care.
These days, patients may spend days waiting in hospital emergency departments before a bed becomes available. These waits can be extremely debilitating, leading to, yes, more post-acute care after patients are released from the hospital.
In 2021, the Organisation for Economic Cooperation and Development (OECD) looked at hospitalization rates in 35 member countries for three common chronic conditions that can be managed relatively easily—asthma, chronic obstructive pulmonary disease (COPD), and congestive heart failure.
In the pre-Covid-19 year of 2019, the US rated close to average for asthma, but was much worse than average for COPD, and among the worst in the developed world for heart disease—where admissions were almost double the OECD average.
How can the US fix this?
More accessible primary care. There is overwhelming evidence that preventive care can reduce hospitalizations. Yet primary care often is inaccessible in rural and low-income communities. And the US faces a growing shortage of geriatricians, who specialize in the care of older adults.
Better patient communication. Hospital admissions happen because physicians often do a poor job explaining diseases to their patients and advising them on how to manage their conditions. The result: Patients miss doctor visits or fail to properly manage medications. And they land in the hospital.
Better coordinating care. Organizing care among doctors and between health systems and providers of personal care is a critical way to keep people home and healthy. And the ability to coordinate care and provide necessary follow-up is supposed to be a major benefit of Medicare Advantage managed care plans that now insure more than half of Medicare beneficiaries. One new study finds the plans do a good job managing medications. But for other services and health outcomes, the evidence is mixed.
Social Determinants of Health. There is growing evidence that, for example, proper housing and nutrition can keep people healthier. And that, in turn, can reduce hospital stays and the need for post-acute care. Imagine how much housing and nutrition support the government could provide for what it spends on avoidable medical care.
For years, experts have proposed lowering payment rates to post-acute providers or expanding financial incentives that encourage better post-hospitalization care coordination. These reforms may help to lower costs. But it would be much better for both the Medicare budget and for beneficiaries themselves to take proactive steps to avoid hospitalizations in the first place.
