Are Your Medicare Patients Missing Post-Surgical Appointments?

February 19, 2020 Anne Davis

The RAND Corporation recently released a study, which found that a minority of Medicare patients are attending postoperative appointments. Yet, Medicare is paying for those visits implicitly through bundled payments. The researchers found that between 2017 and 2019:

  • Only 4% of patients who had minor surgical procedures attended a postoperative visit with their doctor.
  • Just 39% of patients who had a major surgical procedure attended a postoperative visit with their surgeon.

Not only is Medicare paying for care that hasn’t been provided (RAND estimates that undelivered postoperative care in 2018 cost the Centers for Medicare and Medicaid Services $2.6 billion), these skipped visits may result in avoidable hospital readmissions since complications aren’t caught early.

Can Expanding the Scope of Population Health Management Help?

Historically, population health management has focused on primary care medicine, with an emphasis on closing gaps in care and scheduling preventive care appointments. To reduce healthcare costs and derive the greatest value from Medicare expenditures, however, we must expand population health management and the “whole person” philosophy of care to the realm of specialty care, ancillary services and behavioral health.

What might this approach of population health management look like in terms of post-acute care management? Here are four examples:

  1. End-to-end management of surgical cases. Some health plans manage surgical cases from prior authorization all the way through discharge planning. For instance, if a high percentage of members needs hip or knee replacements, plans may develop member engagement and outreach programs to ensure that individuals get the care they need, beginning with shared decision making & coaching and culminating in a discharge plan and follow-up.
  2. Focusing on the sickest members. When high-risk members need surgery, the health plan may initiate pre-surgery calls, share information about what to expect post-discharge, assist with post-discharge care plans and emphasize the importance of following up with both surgeons and primary care physicians.
  3. Partnerships and/or referrals to certain “preferred” specialty groups. Health plans may recommend that members have procedures done by “preferred” specialty groups with high rates of follow-up appointments and/or low rates of hospital readmissions following acute care or surgeries.
  4. Better communication and information sharing between primary care doctors and specialists. Primary care physicians are held responsible for health plan members’ care, even when care occurs outside the primary care setting. Data sharing and analytics across provider groups offers visibility into what is happening with members across the entire “care neighborhood,” from the PCP to specialists, health plan care managers, and more.

For these types of tactics to work, health plans must integrate data from many different sources and gain insights on member risks, then share discoveries and highlights with care team members at the point of care. HMS offers a suite of population health management solutions that offer clinical intelligence on your membership. This enables providers and health plans to identify hidden and rising risk, and avoid preventable, high-cost events across the healthcare continuum – including minor and major surgical procedures.

Data sharing, seamless care management and analytics are the foundation of a robust population health management infrastructure that extends beyond primary care to the entire healthcare neighborhood.

Are you interested in learning more about how to expand your healthcare organization’s scope of population health? Visit our website to discover how HMS’ Population Health Management solution can enable you to help healthy happen.  

About the Author

Anne Davis

Anne Davis is the Director of Quality Programs & Medicare Strategy at HMS where she focuses on the company's Population Health Management product portfolio. Anne has spent the last 20 years focusing on healthcare quality, care and evaluation. Prior to joining HMS, Anne was responsible for care management, utilization review, and population management at a five-star Medicare Advantage plan and integrated delivery system. Since 2015, Anne has worked as a consultant, focused on HEDIS and Stars, quality programming, and reporting & evaluation. When she isn’t working, you’ll find Anne at the beach with her family, teaching yoga classes and hiking in her beautiful home state of Maine.

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