A Closer Look at Transitional Care, Primary Care Providers, and HIPAA

A Closer Look at Transitional Care, Primary Care Providers, and HIPAA

Despite efforts to make the healthcare system more transparent, significant gaps persist. This is no more evident than in transitional care, the process of moving a patient from the hospital to a sub-acute rehab facility, or skilled nursing facility (SNF), as a permanent patient.

Specifically, poor communication and blurry interpretations of HIPAA rules create significant healthcare inefficiencies.

And from my personal experience being on both the payer and provider side, I can say with some certainty that there’s a lot of room for improvement.

For example, on the payer side, there are clear procedures in place for initial hospital care and transitional care. Once a patient is admitted to the hospital, the payer gets notified and the medical management team reviews clinical documentation for both admission and transition to sub-acute care. If standards are met, transitional care is approved, and an authorization number is assigned. I served on various medical management teams, and there is a considerable amount of transparency because the hospitals and medical systems are incentivized to be transparent, to ensure they get paid.

On the flip side, from my current ACO care coordination perspective, when a patient is transitioned from a hospital to a sub-acute rehab, I’m not notified like when I was working for the payer. The only way I get this information is from the patient themselves, family members, or sometimes a specialist.

So when I do eventually get this information, I call the facility with the expectation of verifying the new care setting, the patient’s progress, and confirming the admission date and discharge plan.

The problem is that some of these facilities won’t give me any patient information, claiming the request is a HIPAA violation and they are under no obligation to share information with the primary care provider (PCP).

This, of course, makes no sense.

When all is said and done, a rehab physician is a specialist just like a cardiologist, endocrinologist or oncologist— and the primary care provider is still the governing body. And in order to reduce costs, a process should be in place for the PCP to monitor and track care at these transitional care facilities.

Unfortunately there is no set care coordination between the two entities, and as a results, inefficiencies occur.

For example, sub-acute rehab was designed for about 7-10 days, and I’ve encountered sub-acute patients in these facilities for between 60-100 days.

It’s for situations like these that I immediately seek a discharge plan from these facilities, which should have been done on Day 1 of the patient’s stay. After 14 days it’s reasonable and customary to ask about progress. Why shouldn’t the PCP have this information? What if the patient has plateaued?

I’ve also encountered situations where patients were kept at these facilities because of socioeconomic reasons, like homelessness. While I truly sympathize, it’s unfair for payers to bear the costs of a non-health issue.

I expect that over the next few year CMS will take a closer look at some of the language in the HIPAA statement to address these transitional care issues. And as value-based care evolves, inefficiencies will come more into focus.