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Background <p>Medicare began reimbursing Transitional Care Management (TCM) services in 2013 to cover the transitional care gap for Medicare beneficiaries after hospital discharge and reduce their readmission risk. While a minority of practices bill TCM services for their Medicare patients, practices that do bill for TCM are likely to participate in the Medicare Shared Savings Program (MSSP). However, little is known about the impacts associated with TCM among high-cost, high-need patient populations, especially in the context of the MSSP.</p> Objective <p>To examine the association between billing TCM codes and changes in the likelihood of hospital-based care among dual-eligible beneficiaries, and whether MSSP participation among practices enhances patient-level effects.</p> Design <p>This retrospective cross-sectional cohort study used Medicare fee-for-service claims, MSSP provider files, and the Medicare Data on Provider Practice and Specialty files (2013–2017).</p> Participants <p>Dual-eligible beneficiaries with 60-day post-discharge episodes (3,766,804) that are potentially eligible for TCM.</p> Main Measures <p>Key explanatory variables are billed TCM codes within 30 days of discharge and practice MSSP participation status. Outcomes are the likelihood of an emergency visit or observation stay within 60 days after discharge, a 30-day readmission, and a 31–60-day readmission.</p> Key Results <p>Billing TCM codes is associated with significant reductions in the likelihood of an ED visit or a 30-day readmission, with relative reductions of 9.0% for ED visits (95% confidence interval [CI] − 10.0%, − 7.9%) and 13.0% for 30-day readmission (95% CI − 15.3%, − 10.6%), regardless of a practice’s MSSP participation status.</p> Conclusions <p>With TCM codes billed for less than 10% of dual-eligible beneficiaries’ discharges, policy makers and providers should work together to identify more discharges eligible for TCM services and increase patient access to TCM services.</p>

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Association of Transitional Care Management Billing With Hospital-Based Outcomes Among Dual-Eligible Medicare/Medicaid Beneficiaries

  • 期刊论文

  • 发表日期：

    2025年11月11日

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  • Jill K. Akiyama,
  • Sally C. Stearns,
  • Justin G. Trogdon,
  • Brad Wright,
  • Erin E. Kent,
  • John A. Batsis

摘要

Background

Medicare began reimbursing Transitional Care Management (TCM) services in 2013 to cover the transitional care gap for Medicare beneficiaries after hospital discharge and reduce their readmission risk. While a minority of practices bill TCM services for their Medicare patients, practices that do bill for TCM are likely to participate in the Medicare Shared Savings Program (MSSP). However, little is known about the impacts associated with TCM among high-cost, high-need patient populations, especially in the context of the MSSP.

Objective

To examine the association between billing TCM codes and changes in the likelihood of hospital-based care among dual-eligible beneficiaries, and whether MSSP participation among practices enhances patient-level effects.

Design

This retrospective cross-sectional cohort study used Medicare fee-for-service claims, MSSP provider files, and the Medicare Data on Provider Practice and Specialty files (2013–2017).

Participants

Dual-eligible beneficiaries with 60-day post-discharge episodes (3,766,804) that are potentially eligible for TCM.

Main Measures

Key explanatory variables are billed TCM codes within 30 days of discharge and practice MSSP participation status. Outcomes are the likelihood of an emergency visit or observation stay within 60 days after discharge, a 30-day readmission, and a 31–60-day readmission.

Key Results

Billing TCM codes is associated with significant reductions in the likelihood of an ED visit or a 30-day readmission, with relative reductions of 9.0% for ED visits (95% confidence interval [CI] − 10.0%, − 7.9%) and 13.0% for 30-day readmission (95% CI − 15.3%, − 10.6%), regardless of a practice’s MSSP participation status.

Conclusions

With TCM codes billed for less than 10% of dual-eligible beneficiaries’ discharges, policy makers and providers should work together to identify more discharges eligible for TCM services and increase patient access to TCM services.