Nonacute Care: The New Frontier

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What happens outside the hospital is increasingly important to success, so healthcare leaders need to influence or control care across the continuum.

If you’re running a hospital, one irony in the transformation toward value in healthcare is that your future success will be determined by care decisions that take place largely outside your four walls. If you’re running a health system with a variety of care sites and business entities other than acute care, the hospital’s importance is critical, but its place at the top of the healthcare economic chain is in jeopardy.

Certainly, the hospital is the most expensive site of care, so hospital care is still critically important in a business sense, no matter the payment model. But if it’s true that demonstrating value in healthcare will ensure long-term success—a notion that is frustratingly still debatable—nonacute care is where the action is.

For the purposes of developing and executing strategy, one has to assume that healthcare eventually will conform to the laws of economics—that is, that higher costs will discourage consumption at some level. That means delivering value is a worthy goal in itself despite the short-term financial pain it will cause—never mind the moral imperative to efficiently spend limited healthcare dollars.

So no longer can hospitals exist in an ivory tower of fee-for-service. Unquestionably, outcomes are becoming a bigger part of the reimbursement calculus, which means hospitals and health systems need a strategy to ensure their long-term relevance. They can do that as the main cog in the value chain, shepherding the healthcare experience, a preferable position; but physicians, health plans, and others are also vying for that role. Even if hospitals or health systems can engineer such a leadership role, acute care is high cost and to be discouraged when possible.

Dental Care and Medicare Beneficiaries: Access Gaps, Cost Burdens, and Policy Options


In 2012, more than half of Medicare beneficiaries reported they went without a dental visit in the past 12 months, with lower-income beneficiaries much less likely than higher-income ones to have received dental care. Overall, only 12 percent of beneficiaries reported having any kind of dental insurance. To expand access to care and reduce out-of-pocket exposure for older adults, the authors propose two policy options for adding dental benefits to Medicare’s benefit package.

The Issue

Despite evidence of a strong connection between oral health and physical health, Medicare explicitly excludes dental care from covered benefits. This leaves beneficiaries at risk for tooth decay and disease and exposed to high out-of-pocket costs. Moreover, the lack of regular preventive dental exams means missed opportunities for detecting the onset of certain diseases, including some cancers. A new Commonwealth Fund–supported study in Health Affairs looks at older adults’ access to dental care and their out-of-pocket expenses for dental services. The authors also suggest two policies for expanding dental care for seniors, along with cost estimates.

Key Findings on Use of Dental Services and Out-of-Pocket Spending

  • In 2012, less than half of all Medicare beneficiaries had any dental visits in the past 12 months.

    “Until dental care is appropriately considered to be part of one’s medical care, and financially covered as such, poor oral health will continue to be the ‘silent epidemic’ that impedes improving the quality of life for older adults.”

  • Use of services was sharply related to income. Only 26 percent of beneficiaries with incomes below 100 percent of the federal poverty level had a dental visit, compared with 73 percent of beneficiaries with incomes at or above 400 percent of poverty.
  • Only 12 percent of beneficiaries (6.6 million out of 56.1 million people) reported having at least some dental insurance to help pay bills. In contrast, around 80 percent of Americans under age 65 who were covered by employer-based health insurance had dental benefits.
  • Medicare beneficiaries reported spending an average of $427 on dental care in the past 12 months, of which $329 was spent out of pocket. About 7 percent of beneficiaries spent more than $1,500 in that period.

Four areas of unnecessary senior healthcare

The number of seniors in the United States is projected to nearly double over the next 34 years—from 43 million in 2012 to nearly 84 million by 2050. During that time period, the number of seniors 85 and older is expected to jump from nearly 6 million to 19 million.

“Our Parents, Ourselves: Health Care for an Aging Population,” a report issued by the Dartmouth Atlas Project, a program of The Dartmouth Institute for Health Policy and Clinical Practice, also reveals that the number of seniors in Medicare private health plans such as Medicare Advantage increased from 6.4 million beneficiaries in 1999 to nearly 12 million in 2011—and that number continues to rise.

Because seniors are likely to experience frequent, complex interactions across many providers in the healthcare system, often there’s no single healthcare provider coordinating all of their care, according to the report, which was released in early 2016.

In addition, the American Geriatrics Society’s Choosing Wisely guidelines, which were released in 2013 and updated in 2015, provide geriatrics-specific recommendations to the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. The campaign advances a national dialogue on avoiding wasteful or unnecessary medical tests, treatments, and procedures.

Here are four areas of elderly care—highlighted in the report and guidelines—that healthcare systems and health plans should be aware of to ensure that elderly patients aren’t receiving unnecessary care.