Opinion | A Solution to Long-Term Care’s Problems?

I’ve often written about the importance of operationalizing value-based care (VBC) throughout the healthcare industry, but never in the context of long-term care (LTC). The time has come. Across the U.S., LTC and post-acute care (PAC) facilities are grappling with a plethora of challenges that threaten their financial stability and, all too often, compromise their ability to provide high-quality care. Adjusting payment policies and improving the coordination of care at these facilities is imperative for elevating quality and lowering costs.

One recent article made a compelling case for VBC in LTC and the vital role providers play in leading the way. The authors noted that, compared with previous generations, persons enter LTC and PAC at older ages with more advanced, medically complex conditions and a wider range of necessary therapies (e.g., cognitive rehabilitation, cardiac rehabilitation, specialized wound care). That said, the LTC environment now requires a highly skilled, adaptable team of clinicians to manage the care of residents.

VBC holds great promise for resolving many of the issues that plague LTC and PAC facilities. However, existing VBC models (e.g., accountable care organizations [ACOs]) are generally tailored to community-based primary care and do not address the unique challenges LTC and PAC providers face. For this reason, less than 10% of skilled nursing facilities nationwide currently participate in ACOs (most of these in the ACO Realizing Equity, Access, and Community Health [ACO REACH] model) – and nearly 70% of ACOs have no skilled nursing facility participation.

CMS’s stated goal is for all Medicare beneficiaries to be in an accountable care relationship by 2030. To achieve this, the agency must adopt VBC models that align with LTC and PAC providers (e.g., appropriately determine ACO accountability for patients, set financial benchmarks, and determine which quality measures must be reported).

In 2023, the American Health Care Association/National Center for Assisted Living and National Association of Accountable Care Organizations convened a roundtable of LTC representatives, ACO leaders, and patient advocacy organizations to formulate a series of recommendations to CMS for improving the existing value-based arrangements and developing future model concepts. The recommendations included:

Alignment for Medicare beneficiaries residing in LTC and PAC facilities: Permit beneficiary attribution at the facility level. Under CMS’s current methodology, patients are attributed to individual ACO clinician visits. This method is incompatible with the LTC and PAC facility-based approach wherein patient care is delivered by teams of clinicians.

Financial methodology: CMS should account for patients’ conditions in ways that are better aligned with the LTC and PAC needs — e.g., using risk scores collected during the current year to account for patients’ health status rather than applying risk scores collected the previous year. This risk adjustment model (currently being tested in ACO REACH) would avoid the inevitable lags in accurately identifying patients whose health is poor or worsening.

Quality measurement: The unique LTC and PAC patient population requires a distinct set of quality metrics that are clinically pertinent and meaningful to their well-being. For example, CMS should use measures that encourage hospitals and clinicians to establish superior care transitions and discharge planning, including advanced care planning.

How does this translate in “real world” situations? A number of LTC and PAC providers have already achieved higher quality at lower costs using a VBC approach, and I was very impressed by what I learned from them at a conference I attended last spring. Led by senior living executives, the presentations and discussions highlighted the advantages of adopting a VBC strategy in these settings, and emphasized the need for innovation in senior housing as the population ages and healthcare costs continue to rise. I was curious about how VBC works in these often-disorganized care settings.

This led me to follow-up with one of the presenters, a seasoned family practice specialist who has been drawn to the LTC patient population throughout his career. His experience as a medical director in a LTC facility convinced him that the traditional fee-for-service (FFS) model is too restrictive for these patients. He observed that it forces clinicians to focus on treating a large volume of patients with billable services rather than on improving the quality of care and patient outcomes.

A passionate proponent of VBC, Ashir Wahab, MD, now works with Curana Health — an organization that aligns with his preferred approach to care in that it facilitates transitions to VBC in skilled nursing facilities and senior living communities via an on-site healthcare model and customizable VBC solutions (e.g., ACOs and Medicare Advantage Special Needs Plans). Since many of the patients he cares for in LTC buildings have end-stage disease (e.g., dialysis patients), the goal is to improve their quality of care and health outcomes. “FFS required me to see a certain number of patients per day while VBC allows me to provide all the care needed by every patient I see,” he said.

Wahab’s personal mission statement is to “provide my patients with clear, consistent, and compassionate care.” To him, this means eliminating unnecessary and often burdensome treatment (e.g., polypharmacy and non-essential tests), making regular visits that are scheduled at convenient times for patients and staff, providing 24/7 access for patients and staff if questions arise, taking time to listen to patients’ personal stories, and addressing patients’ complaints (usually about food and medication). I couldn’t agree more!

My main takeaway here? VBC models that are better aligned with the unique characteristics of LTC and PAC environments offer a ready-made approach to addressing some of healthcare’s thorniest problems. CMS should act now to make it happen.

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