Transitional Care Services from Hospital to Home Underutilized, Can Save Money and Readmissions Interview with:

Andrew B. Bindman, MD Professor of Medicine PRL- Institute for Health Policy Studies University of California San Francisco

Dr. Bindman

Andrew B. Bindman, MD

Professor of Medicine
PRL- Institute for Health Policy Studies
University of California San Francisco What is the background for this study?  

The purpose of this study was to evaluate the use and impact of a payment code for transitional care management services which was implemented by Medicare in.

The transition of patients from hospitals or skilled nursing facilities back to the community often involves a change in a patient’s health care provider and introduces risks in communication which can contribute to lapses in health care quality and safety. Transitional care management services include contacting the patient within 2 business days after discharge and seeing the patient in the office within 7-14 days. Medicare implemented payment for transitional care management services with the hope that this would increase the delivery of these services believing that they could reduce readmissions, reduce costs and improve health outcomes. What are the main findings? 

Response: We studied the first 3 years (2013-2015) in which this payment code was available to be billed by physicians. We found that as compared to similar patients who were discharged from a hospital or skilled nursing facility who did not receive transitional care management services, those who did had lower total health care costs and a lower odds of dying in the subsequent month.

The average total health care costs were about 10% lower (decreasing from about $3300 to about $3000 for the month) among those who received transitional care management services after a discharge.

The odds of death among those who did not receive the services was 60% higher.

We did some additional analyses and demonstrated that the benefit of transitional care management services is not only from the office visit within 7-14 days but there was an added benefit from contacting the patient within 2 business days of the discharge. Both of these elements are required before a practitioner can bill for transitional care management services. Outreach to patients in that first 48 hours after a discharge is an important time to ensure that they are managing safely at home and that they understand instructions including what medications and what doses they are supposed to be taking. What should readers take away from your report?

Response: This study demonstrates that there are significant benefits, lower total health care costs, lower rates of readmission and reduced risk of death when patients are provided with health care services to manage their transition from a hospital or nursing home back to home. Despite the apparent benefits, transitional care management services are underutilized. In the first 3 years in which Medicare made payment for transitional care management services available to physicians, the rate at which these services were utilized among eligible discharges increased from 3% in 2013 to only 7% in 2015.

Most of the billing for the service is concentrated among a small number of physicians. Patients and their families should ask physicians who are discharging them from the hospital or nursing home to facilitate their receiving these services from their regular physician as a way to reduce costs, risk of hospital readmission, and risk of death. What recommendations do you have for future research as a result of this work? 

Response: We need to better understand the barriers that are keeping transitional care management services from being more broadly used in the care of patients who are being discharged from a hospital or nursing home back to the community. We hope that publication of our study will increase practitioners’ awareness of the benefits of transitional care management services for eligible patients, but there are likely other barriers as well that need to be overcome. For example, we need to understand whether the payment for transitional care management services to incentivize primary care physicians to invest in the establishment of systems and personnel who furnish the services.

We also need to establish ways which ensure that primary care physicians are receiving information in a timely way about when their patients are being discharged back to the community so that they can engage in the outreach within 2 business days to ensure that patients are managing safely at home.


Bindman AB, Cox DF. Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries. JAMA Intern Med. Published online July 30, 2018. doi:10.1001/jamainternmed.2018.2572

Aug 1, 2018 @ 11:43 am


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