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CliftonLarsonAllen analyzed the acute care discharge information for the state and the seven county Minneapolis-St. Paul area to determine how acute care and post-acute care had changed from 2010 through 2012. This analysis raised many questions.

Navigating health reform

Health Reform on the Leading Edge: More Questions Than Answers

  • 12/4/2013

Health Reform on the Leading Edge: More Questions Than Answers

Leaders in health care organizations are divided about how much and how fast reform will change the health services field. There is, however, no dispute that significant changes are already in process as payment reforms and organizational redesigns are implemented.

Minnesota’s Minneapolis-St. Paul metropolitan area has long been home to early adopters of health care reform initiatives. It is one of the few communities in the country with multiple accountable care organizations (ACOs). It has three Pioneer ACOs, one Shared Savings ACO and one Medicaid ACO. In the early 90s, Minnesota health care providers moved to integrated health system organizational structures, (a model similar to the ACO), and have persevered through the usual challenges of significant structural change. Most of the health systems continue to have corporate structures that employ physicians as well as hospital, home care, and hospice staffs. With a few exceptions, the structure they embraced two decades ago has endured.

Although, the Minneapolis-St. Paul market has some unique factors that influence the way health services are used, the basic elements are similar to markets all over the country. So although Minnesota’s market may have a head start, what this community has learned is directly applicable to other markets.

We analyzed the acute care discharge information for the state and the seven-county Minneapolis-St. Paul area to determine how acute care and post-acute care has changed from 2010 through 2012. Because many organizations here have the benefit of 20 years of adapting to the ACO structure, assessing short-term change in this community is challenging. The analysis included an assessment of key data compared to the changes we had expected to see with the implementation of ACOs. The research raised many questions, but three areas were particularly interesting because they challenged the assumptions we had made about how health care reform was impacting the community.

Acute care discharges

We assumed acute care discharges would increase slightly, but not as fast as the population growth. The Twin Cities population of those 65 and older grew 10.5 percent over the three years examined. However, despite the strong population increases, both the number of individuals and total acute discharges remained flat. Yet, with all the increased focus on reducing 30-day readmissions, improving care transitions, and implementing care coordination, the number of discharges per individual remained at 1.87 per year and 2.31 for those discharged home. Another unresolved question is the wide variance in the metro area between counties where care model or delivery differences would not be substantially different.

Skilled home care

We also assumed the use of post-acute home health would increase as these sites were used to reduce readmissions or in lieu of hospitalizations. However, discharges to skilled home health services remained flat for individuals in the metro area. In retrospect, our analysis did not take into account the growth in skilled home health care that was not preceded by a hospital stay, so some growth may have been masked because of patients following a new pathway to home health services. This suggests we must be particularly careful when evaluating the changes brought about by reform. The paradigm has shifted so drastically that we must be certain we’re asking the right questions, before we analyze the results.

Short-stay skilled nursing care

We anticipated that transfers to skilled nursing post-acute care would also increase as those facilities were used to reduce readmissions or in lieu of hospitalizations. The discharges to nursing facilities declined about 2.2 percent for individuals in the metro area, particularly for those over 85, which declined 4 percent. Again, the most likely explanation is that we did not take into account the growth in nursing facility care that was not preceded by a hospital stay.

CliftonLarsonAllen will continue to explore the questions raised in this research as we follow the changes occurring in the Minneapolis-St. Paul market. We hope the insights gained in this community may provide a glimpse of how health reform and market changes may play out in other urban areas across the country.

The changes initiated by health reform were necessary — the status quo hadn’t been working for decades. But change, particularly on a large scale, is difficult. Organizations in Minnesota have been exploring and experimenting with new models for many years, and although the transition has been slow, the results have been positive. Minnesota has a strong health care system, and more people have access to it than in other states. However, it is important to acknowledge that leaders were responding to changes in the health care market — a demand for higher quality and better results. Those changes happen to look a lot like health care reform.