Transitional care management yields benefit but is used rarely, study finds

A study described transitional care management as a promising delivery model innovation, but an editorial cautioned that payments may not be high enough to justify the extra work involved or may be targeted to the wrong place in the health care system.


Transitional care management (TCM), for which Medicare established payment codes in 2013, appears to improve outcomes and costs after discharge from a medical facility but is not frequently used, according to a recent study.

Researchers performed a retrospective cohort analysis of all Medicare fee-for-service claims eligible for TCM services from Jan. 1, 2013, through Dec. 31, 2015, to determine whether receipt of TCM was associated with costs and mortality in the subsequent month. Main outcome measures included total Medicare health care costs and mortality rates 31 to 60 days after discharge from a medical facility. Both outcomes were adjusted for age, sex, risk score, dual eligibility for Medicare and Medicaid, type of discharge, year of discharge, and receipt of home health care. Study results were published on July 30 by JAMA Internal Medicine.

During the study period, 18,756,707 Medicare beneficiaries were eligible for TCM services. Of these, 13,497,066 were discharged from hospitals, 764,062 were discharged from inpatient psychiatric facilities, 89,900 were discharged from long-term care hospitals, 3,671,914 were discharged from skilled nursing facilities, 657,138 were discharged from inpatient rehabilitation facilities, and 76,627 were discharged from an outpatient facility after an observational stay. A total of 43.9% of patients were men, and the mean age was 72.5 years. In 2013, 2014, and 2015, respectively, TCM services were billed after 3.1%, 5.5%, and 7.0% of eligible discharges. Patients who received TCM services after an eligible discharge had lower adjusted total Medicare costs ($3,033 vs. $3,358) and lower mortality rates (1.0% vs. 1.6%) than patients who did not (P<0.001 for both comparisons).

The authors noted that follow-up was short, only a month after TCM services could have been provided, and that the benefits seen in their study could have been affected by differences in patients or clinicians, among other limitations. However, they concluded that TCM appears to be “a promising delivery model innovation that has the potential to improve health outcomes and costs among Medicare beneficiaries discharged to the community from medical facilities.” They called for efforts to reduce the administrative burden involved in billing for TCM services and additional consideration regarding payment amounts.

An accompanying invited commentary highlighted the existing difficulties in providing TCM services and meeting the billing requirements and said that TCM payments may not be high enough to justify the extra work involved or may be targeted to the wrong place in the health care system. “Monetary reimbursement for TCM services is a small ‘carrot’ for outpatient physicians; it provides a relatively small payment for an array of additional services,” the commentary authors wrote. “Hospitals face the larger ‘stick’ of potential readmission penalties under the Hospital Readmission Reduction Program, which can sum to 3% of a hospital's total annual Medicare payments for inpatient admissions.”

The commentary authors said the current study supports the idea that involving outpatient physicians in TCM will help improve outcomes and reduce costs but improvements are needed to the existing system.

“Like any improvement on the standard of care, diffusion of TCM will require workflow changes, investments in health care information technology, and a potential expansion of clinician capacity or staffing,” the commentary authors wrote. “The TCM services policy may need to be refined to more effectively align financial incentives with these goals.”