Summary: If hospitals pay more attention to how they discharge patients, and what happens to them after they leave, Medicare could save billions. Under the reform legislation, beginning in 2011 Medicare will refuse to pay for an excessive number of preventable readmissions. Over at the New American Foundation’s “Health Care Dialogue” Joanne Kenen reports on research that shows that we do know how to reduce “bounce-backs.” And hospitals aren’t waiting for 2011, they are already finding creative solutions to the problem.
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In a post titled “Slowing Down that Revolving Readmissions Door" the New America Foundation’s Joanne Kenen writes about avoidable readmissions. “I once interviewed a patient who literally could not remember how often he had been hospitalized within just a few months,” Kenen recalls, referring to a story published in the Washington Post last year.
There, she reported that “one of five Medicare hospital patients returns to the hospital within 30 days–at a cost to Medicare of $12 billion to $15 billion a year—and by 90 days the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks.” Within a year, two out of three are back in the hospital—or dead—says Jencks who consults on this issue for the Institute for Healthcare Improvement (IHI).
This is money that health care reformers could use as we expand care to the uninsured. It’s worth noting that what many call “Medicare cuts” are really “Medicare savings”—billions that could be reclaimed if we rescued patients from that revolving door.
Under reform legislation, hospitals with particularly high rates of avoidable readmissions will have Medicare payments reduced, beginning in 2011. I would guess that some private insurers will follow Medicare’s lead.
Going forward, Medicare will be using financial carrots as well as sticks. When it begins “bundling” payments to hospitals and the doctors who treat the patient before he enters the hospital, while he is there, and after he is discharged, hospitals and doctors will have a greater reason to collaborate, and will share in the savings when smooth transitions lead to fewer re-admissions.
But do we know how to avoid readmission? Kenen reports on a study which provides more medical evidence showing that, indeed, we do know how to reduce high readmission rates among the million or so Medicare patients with heart failure who are hospitalized each year. Drawing on data from more than 30,000 Medicare patients, the study found that hospitals that follow up for a week after discharge bring down the hospitalization rates significantly. The study drew on quality-improvement data that 225 hospitals provide to the American Heart Association.
But too often, poor follow-up, lack of communication between doctors who care for patients in the hospital and their regular physicians; miscommunication between doctors and patient, and poor coordination and medication management during transitions from hospital to home or nursing home cause patients to “bounce back.” Kennen offers a simple example of poor communication: “I’ve spoken to heart failure patients who had been told to follow a low-salt diet but had no idea that meant they had to avoid high sodium processed foods. They thought it was just about the salt shaker on the table.”
UCSF’s Bob Wacther also has looked at Jencks work, and highlights some of the more interesting findings:
• Like so many things in health care, there was striking geographic variation in readmission rates – from a low of 13% in Idaho to 23% in Washington, D.C. [See map below]
• There were also variations by DRG, with the highest readmission rates in patients with heart failure, psychosis, vascular and cardiac surgery, and COPD – pointing the way toward targeted interventions.
• More than half the patients readmitted within 30 days appeared not to have had an outpatient visit between hospital discharge and readmission, perhaps another target for intervention.
• Most (70%) surgical patients who are readmitted come back for a medical diagnosis such as pneumonia or UTI.
• Approximately 30% of readmitted patients come back to a different hospital, so hospitals will underestimate the extent of their readmission problem by looking solely at their own bounce-backs. [Medicare will need to pay attention to its bills. If a patient is admitted to hospital B less than 30 days after being discharged from hospital A, hospital A should pay the penalty.]
Rates of Rehospitalization within 30 Days after Hospital Discharge (Source: JAMA)
Hospitals Are Acting Now
Hospitals are not waiting for Medicare penalties to kick in. In September of 2008, the Society of Hospital Medicine (SHM) announced that it was starting a pilot project in eight hospitals called Project Boost (Better Outcomes for Older Patients Through Safer Transitions) designed to avoid unplanned or preventable readmissions and emergency department visits within 30 days after discharge. In March of 2009, the project was expanded to 24 other sites, and recently, SHM announced that it is working with Blue Cross and Blue Shield of Michigan and the University of Michigan, to launch a new 15-site version of the program.
This pilot, which will begin in the fall, is taking the project one step further. All of the institutions involved are concentrated in one state and united by a single payer. Most importantly, the hospitalists are reaching beyond the hospital walls to include outpatient physicians.
For more on creative solutions that some hospitals are trying—including using nurse practitioners as a “bridge” from hospital to home—see Kenen’s full post.
It’s too bad that it takes financial penalties to get hospitals to take the “revolving door” issue seriously, but it seems like in this business that’s the only thing that works. I am thrilled to find that hospitals will now be penalized for their sloppy discharges, because that’s what it takes to get hospital administrators to invest in staff to help coordinate discharges to prevent readmission. The majority of these readmissions could be prevented by hiring enough experienced nurses to do real discharge planning, especially for elders. Nurses really have the training and skills to think through a discharge plan in a way that doctors generally don’t.
I hope this catches on and that Medicare keeps coming up with the right carrots and sticks to bring some sanity back to our system.
Thanks Sharon-
I agree. I’m afraid that a great many (not all) hospital admnistrators respond mainly to financial incentives and disincentives.
(I don’t think that’s true of doctors and nurses who see medicine as a profession, but for many CEO’s it’s a business, like any other.)
Hospitalists can be enormously helpful in making sure that, beginning the day the patient is admitted, information is gathered that will be needed for discharge. What meds was the patient taking when she came in? What meds is she supposed to take when she gets home?
The patient, a caregiver, and the doctor she will be seeing after she leave the hospital all need to have someone emphasize the changes– in writing.
Mt. Sinai, here in New York, is using Nurse Practioners to follow up with the patient at home as she’s settling back in to make sure everything is okay, everyone knows what they need to know, that she has a follow-up appt. with a doctor . .
I think that hosptialists, nurses who care for the patient and nurse practioners have a real opportunity to collaborate in this area.
Pilot projects have shown improvement. It’s doable. It’s not terribly expensive (not at all expensive compared to the savings.)
And it protects patients from all of the risks and needless suffering associated with “bouncing back.”
At the same time, we need to recognize that fewer readmissions will cut into hospital revenues; insofar as they are succesful in reducing readmissions, they should share in the savings.
(Medicare also should make sure that hospitals are not refusing to readmit patients who need to be readmitted in order to “improve” their record.
Typically, these patients will show up at another hospital, which is why Medicare will need to cross-check records–and
survey patients, caregivers and outside physicians about any problems they experience getting patients readmitted.
The recurrent theme with insurers is being penny wise/pound foolish. It all comes back to what insurers will and will not pay for. What they do not pay for is any of these communications that need to take place between health care providers. Why is medicine the only profession where reimbursement is an open ended obligation full of non compensable expectations and activities? I can see a patient that requires multiple calls to consultants and discussions with family, but can only charge for the time spent in face to face contact with the patient. Is it any wonder that physicians will not acknowledge the value of these activities if society and their surrogate, insurers, put no monetary value to these communications?
The result is that the hospitalist does not talk to the physician caring for the patient outside the hospital, and often does not communicate upon discharge either. I am shocked if I get a call from a hospitalist at any point in a patients hospital admission. I can count on one hand the number of times this has occurred in five years of hospitalists populating the hospital where I attend.
While it is good medicine to perform these communications, in the crush of patients that the hospitalist must see in a given day, and the PCPs harried schedule that is not conducive to chatting with the hospitalist, this interaction rarly occurs. It is a shame, but since payors fail to recognize the importance of these discussions, we get what we pay for. Take a look at what Medicare pays for the time intensive activity of discharging a patient from the hospital and you will get an even better idea of why things are the way they are. It is no wonder that primary care docs have given up following their patients into the hospital, which affords the best coordination of care; instead we want efficiency at the cost of quality. But every time you need to do these handoffs between practitioners, mistakes get made.
Some of this may be the habits that we form in practice. I find it interesting that the emergency room always calls at the beginning of a hospitalization to discuss the case and transfer care (they need an admitting doc to accept the patient), but this is almost never done at the other end of a hospital admission. Got to wonder why one is an ingrained expectation, but the other is not.
Maybe we need to relook at this idea of hospital medicine. While studies seem to suggest a cost savings by using hospitalists, maybe we need to examine the overall picture including hospital readmissions. If having another set of hands having to evaluate the patient and then passing them back to the PCP generates confusion for all, then maybe this new system of hsopital medicine isn’t the brightest idea after all. It may be costing health care system more than it is saving!
I am glad to see that you are addressing the topic of Medicare “savings” promised by the new legislation. One wonders how it can be done without impacting patient care esp in for-profit hospitals.
Transparency and outcomes data will be essential.
And Maggie adds the caveat: “Medicare also should make sure that hospitals are not refusing to readmit patients who need to be readmitted in order to ‘improve’ their record.
Typically, these patients will show up at another hospital, which is why Medicare will need to cross-check records.”
Let’s hope that a Medicare patient who needs re-admission will not be put in the position of today’s uninsured–forced to shop around for a provider who will treat them.
, . . Still hangin’ in there for single payer!
Keith
As a hospitalist active in public policy, I cant agree with you more, and it sounds like your system is not working.
For effective transitions to take place, communication is key. I dont think hospital medicine is broke, appears the program you are working with needs a tune up.
I anticipate that with the advent of bundling, PQRI and quality measurement, incentives will be on the table to examine and make transparent efforts that HM programs put forth to facilitate communication. Without thinking this through and going at it willy nilly, again, you are 100% correct–there will be transition breakdowns..
Also, to add to Maggie’s narrative, we are still learning about high risk variables that may indicate patients at higher risk of readmission. While CHF is a red flag, we still have a lot to learn about SES factors and things beyond the control of the “system.” For example, inadequate resources at home to administer Rx, transportation to the docs office, health literacy (even after adequate pre-discharge self mgt teaching). This is not easy stuff, and we are in the first stages of working out the kinks.
BOOST is a best evidence tool kit at this point, and assembles a good deal of what we know at this time, but we still need a lot more data.
Just to give you an example of a recent study–more home vists by RNs post d/c led to greater readmissions (look, and ye shall find). Does that mean that this was a bad d/c OR with greater eyes and sensitivity we are avoiding bigger problems. We need to learn more.
I would also ad that the discharge process was broken long before the hospitalist era–even when subspecialists, proceduralists, etc., were working with a PCP in the context of a closed system. Readmits are a longstanding problem.
Brad
I’ve taken notice of the hospitalist/PCP communication (or lack of) Keith mentions. Being a caretaker for my mother, I’ve oberserved over several hospital visits, the lack of communication between the hospitalist that tended to her and her PCP. I thought it was perhaps because her PCP was employed by the larger of the two county hospitals and I had my mother admitted to the other (smaller) hospital. There is no love lost between these hospitals. As a result, I am forever caught in between.
And on the subject of revolving door readmissions, her latest trip to the ER (last week) was met with the fact that she was admitted to the hospital (for a week) just last month. The ER doctor seem to make up some scenario to keep from admitting her again. She’d be better off with oral anti-biotics (which the hospital doesn’t give) rather than intravenous anti-biotics (which the hospital does give). What it did was to delay her treatment and recovery.
It seems that there is always the underlying assumption when talking about readmits, aka Frequent flyers, that they NEED to be readmitted. My many years as a case manager in NJ tells me it ain’t so. What I see every day is a discrete group of physicians whose principle place of practice is in the hospital where they maintain a steady census by admitting those willing to be admitted and or keeping them there as long possible. Hospital administrators certainly aren’t thrilled with that but are totally dependent on the PCPs to keep bodies in the beds. Hospitals and PCPs need to be separated as a place of practice and integrated at the transition point from one to the other. CMS should be shaking their carrots and sticks at these physicians as well as the hospitals.
Keith–
As I’m sure you know, hospitalists are on salary.
So they are paid for their time whatever they are doing–calling an outside PCP like you, or seeing a patient in the hospital.
That said, I understand that hospitalists may be under some pressure from the hospital administration at some hospitals to spend more time seeing patients and ordering tests and procedures that will reap revenue for the hospital.
At the same time, the Hospitalist society seems very focused on lowering rates of unncessary readmissions and they are encouraing consulting with the patient’s outside doctor. (See what I wrote about their most recent pilot.)
But under reform, I think that hospitals putting pressureing on hospitalits and ER doc t boost profits for the hospitals are going to be facing financial disincentives –and investigation– from Medicare.
Meanwhile, under reform, hospitalists are going to get more support (and bonsuses) for creating more collaborative care (as hospitals and doctors both inside and outside the hospital who treated the patient receive “bundled payments” that provide bonsues for better, more efficient outcomes. )
Brad–
Good to hear from you.
As you say, “BOOST is a best evidence tool kit at this point, and assembles a good deal of what we know at this time, but we still need a lot more data.”
Joanne Kenen (who wrote the post that inspired my post) makes it very clear that we are far from solving the problem of unnecessary readmissions.
The news is that we are beginning to make measurable progress– and health care professionals who are on the ground are working on the problem.
But it’s complicated. You point to “a recent study–more home vists by RNs post d/c led to greater readmissions (look, and ye shall find). ” You ask “Does that mean that this was a bad d/c OR with greater eyes and sensitivity we are avoiding bigger problems. We need to learn more.”
I agree. Though for now, I would go with those RN visits. Even when they don’t prevent readmissions, they can give us much more info about what is actually happening out there after people go home. This, in turn, would lead to figuring out how to prevent he unnecessary bounce-backs.
Finally, you note that “the discharge process was broken long before the hospitalist era.”
Yes– The advent of hospitalists certainly didn’t cause this. And i’m hopeful that hospitalists will help solve the problem.
Harriette–
Thank you for emphasizing two points:
“Transparency and outcomes data will be essential. And Maggie adds the caveat: “Medicare also should make sure that hospitals are not refusing to readmit patients who need to be readmitted in order to ‘improve’ their record.”
Agreed. And, as you say, that will mean more transparency and looking at oucomes data.