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Editor's Note
June 2015

The Role of Post–Acute Care in Variation in the Medicare Program

JAMA Intern Med. 2015;175(6):1058. doi:10.1001/jamainternmed.2015.0679

Variation is frequently cited as evidence of unnecessary or wasteful health care, because we would expect a patient’s medical condition, not geography or health care professional, to dictate who receives a particular procedure or service. Understanding how much variation is owing to regions vs providers within regions can help in devising strategies to reduce variation.

A 2013 Institute of Medicine report5 found that differences in individual provider and hospital practices explained variation more than did regional patterns. Hussey, a member of that Institute of Medicine committee, and colleagues1 analyze in depth some of the Medicare data on variation in their article. They find that conditions that more frequently involved post–acute care explained much of the variation by region. Post–acute care refers to a wide range of services, which include skilled nursing facilities, inpatient rehabilitation facilities, home health aides, outpatient physical and occupational therapy, and long-term care facilities. For example, joint replacement of a lower extremity had more than 4 times as much regional variation as conditions that do not generally involve post–acute care, such as gastrointestinal bleeding. The association of post–acute care with the variation seen by Hussey et al is consistent with a 2011 report2 from the Medicare Payment Advisory Commission that found that use of post–acute care services explained the largest portion of Medicare variation at the metropolitan statistical-area level.

Medicare spends more than $59 billion on post–acute care, which has more than doubled since 2001. Discharges to post–acute care facilities have increased nearly 50% during the past 15 years.3 Post–acute care is a major contributor to the costs of a hospitalization episode, because 42% of Medicare beneficiaries are discharged from hospitals to post–acute care.4 The Medicare Payment Advisory Commission’s recommendations to Congress, which promote site-neutral payments for post–acute care, may help reduce variation and increase high-value care for Medicare beneficiaries.

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Article Information

Conflict of Interest Disclosures: Dr Redberg reports being a Medicare Payment Advisory Commissioner.

References
1.
Hussey  PS, Huckfeldt  P, Hirshman  S, Mehrotra  A.  Hospital and regional variation in Medicare payment for inpatient episodes of care [published online April 13, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.0674.
2.
Report to the Congress: regional variation in Medicare service use. Medicare Payment Advisory Commission website. http://www.medpac.gov/documents/reports/Jan11_RegionalVariation_report.pdf. Accessed March 4, 2015.
3.
Burke  RE, Juarez-Colunga  E, Levy  C, Prochazka  AV, Coleman  EA, Ginde  AA.  Rise of post-acute care facilities as a discharge destination of US hospitalizations. JAMA Intern Med. 2015;175(2):295-296.PubMedArticle
4.
Carter  C, Christman  E, Kelley  D. Post-acute care: trends in Medicare’s payments across sectors and ways to rationalize payments. In: Medicare Payment Advisory Committee Meeting Brief. Washington, DC: MedPAC; January 2015.
5.
Variation in health care spending: target decision making, not geography. Institute of Medicine website. http://www.iom.edu/Reports/2013/Variation-in-Health-Care-Spending-Target-Decision-Making-Not-Geography.aspx. Accessed March 1, 2015.
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