A Solution To Reduce Medicare Spending Per Beneficiary For Hospital Systems, ACO’s, Healthcare Plans and Skilled Nursing Facilities

The Community Integration Model

The Community Integration Model


As hospitals continue to make great strides lowering their Readmission rates, they may be taking their “eye off the ball” and getting blind-sighted by the newest CMS penalty, namely the Medicare Spending Per Beneficiary Measure (MSPB).


MSPB is Medicare’s formula to measure financial efficiency and to curb unnecessary over-utilization.  With this new efficiency domain, Medicare is set to compare an individual’s hospital Medicare spending against a risk-adjusted national average during a Medicare-Spending-Episode.


A Medicare-Spending-Episode is the time period that begins 3 days prior to hospitalization, continues during the hospital stay and ends 30 days after discharge.  All Medicare Part A and Part B costs are calculated throughout the spending episode.


If your hospital spends approximately what CMS feels you should have spent, your MSPB Measure score will be 1.00.  If you spent less, your score would be below 1.00 and if you spent more, your score would be above 1.00.  The lower your hospital’s MSPB Measure, the more financially efficient you are in Medicare’s eyes.


One of the ways to lower your hospital’s MSPB Measure is to evaluate your post-acute spending.  The largest post-acute cost in the Care Continuum is the SNF.


The Community Integration Model was written to help hospitals evaluate their post-acute Medicare spending and ask the question, “Is there a less restrictive non-Medicare environment that can care for the needs of this patient?”  Hospitals that win the MSPB challenge will rule out the high cost SNF in favor of sending the patient home with more cost-effective Home Health Services, or will seek Non-Medicare payer sources like Assisted Living for patients first who have the financial means to pay for them.


More importantly, patients deserve to have knowledge of all post-acute care options and be given “informed choice” before physicians write the “automatic order” to SNF just because a patient is “eligible”.  The Supreme Court ruled that patients have the right to be placed in the least restrictive environment that can adequately care for them.   A Wisconsin study reported the 50% of hospital to SNF admissions were “medically unnecessary”. This drives Medicare spending up significantly while also introduces patients with multiple chronic conditions to potential SNF related infections and unplanned readmissions.


The Community Integration Model uses a patent-pending sophisticated software platform that “clinically matches” a patient’s diagnosis and care needs to specific individual Assisted Living or Memory Care communities.  In addition, it accounts for the medical oversight of a Medicare Home Health Agency for patients that do not necessarily require an in-patient Skilled Nursing Facility stay regardless of “eligibility”.  Only a small percentage of Medicare patients choosing a non-Medicare Post-Acute care option is needed to significantly enhance a hospital’s MSPB Measure.  The goal is for hospitals to give patients and their families the choice to help direct their post-discharge setting.  


There are four primary reasons a patient and their family would choose to pay for assisted living versus a Medicaid paid nursing home, they are –


 Wanting to recover in an non-institutional, more home-like environment

 Improving their quality of life during and after recovery

 Reducing the risk of SNF-induced infections

 Reducing the risk of Transfer Trauma


This process enhances the continued provision of quality care during the post-acute recovery process and as a result also positively impacts hospital readmission rates by eliminating common reasons for avoidable readmissions.  


The model’s procedure includes familiarizing hospital discharge personnel and physicians to their individual state laws regarding assisted living admission criteria.  


If a patient is eligible for assisted living under the guidelines and eligible for the SNF benefit, the discharge planner would give the patient and the family an “informed decision” brochure that describes the pro’s and con’s of both SNF and Assisted Living settings.


If a family chooses to look at both environments, our software and services will direct the family to several options that have been diagnostically “matched” to their care needs.


The family drives the care decision with the medical team, the hospital reduces their MSPB Measures and the patient receives a higher quality of life.