UNDERUTILIZATION OF TRANSITIONAL CARE MANAGEMENT SERVICE AMONG MEDICARE BENEFICIARIES AT HIGH RISK OF READMISSION

Abstract The CMS introduced transitional care management (TCM) service in 2013 to improve care transitions from hospital to home and reduce readmission. TCM uptake has been slowly increasing over time; however, it remains uncertain whether TCM is delivered to patients at the highest risk of readmission. We used a 5% random sample of 2015-2019 Medicare fee-for-service claims. TCM service was identified using CPT codes and demographic information, census region, diagnosis codes, and frailty were measured. Of 1,556,347 eligible discharges (mean [standard deviation] age, 78.3 [7.8] years, 56.7% female, 84.2% White), TCM was delivered in 169,536 (10.9%) discharges and 30-day readmission occurred in 123,796 (8.0%) discharges. The 30-day readmission risk was higher among beneficiaries who were < 75 years (8.1%) vs ≥75 years (7.9%), male (8.7%) vs female (7.4%), Black (9.3%) or Hispanic (8.7%) vs White (7.8%) and Asian or Pacific Islander (8.0%), with dementia diagnosis (8.2%) vs without (7.9%), or with greater frailty (robust to severe frailty: 6.1% to 14.1%). TCM use was not necessarily higher among those with high-risk characteristics. Notably, TCM was more likely to be delivered to beneficiaries who were ≥75 years (12.3%) vs < 75 years (8.8%), White (11.3%) and Asian or Pacific Islander (10.8%) vs Black (9.0%) and Hispanic (8.4%), without dementia (11.0%) vs with (10.6%), and pre-frail or mildly frail (11.4%) vs moderately or severely frail (10.0-10.5%). Our study found that TCM is not delivered effectively to Medicare beneficiaries at high risk of readmission, including racial and ethnic minority groups, and those with moderate-to-severe frailty.