Resources and readmissions: a challenging policy for hospitals

Monday was the start date for an Affordable Care Act provision aimed at reducing high rates of hospital readmission among Medicare patients. This year, hospitals determined to have excess readmissions for patients with acute myocardial infarctions, heart failure, and pneumonia can lose up to one percent of their Medicare reimbursements for the year -- and in future years, the list of applicable conditions will get longer and the percentage of payments at risk will rise to three percent. But to what extent are readmissions under hospitals' control?

First, a bit of background: Readmissions are inpatient hospital admissions that occur within 30 days of a patient having been discharged from a previous inpatient admission. In 2010, the readmission rate for Medicare beneficiaries was 19%, and those readmissions cost Medicare $17.5 billion in inpatient spending alone (figures are from this presentation, via Sarah Kliff). A recent Health Affairs brief reports that three-fourth of Medicare readmissions are preventable, and their cost adds up to $12 billion annually.

Factors behind readmissions
As for what could prevent these readmissions, improved care transitions are a major focus. To continue healing after a hospital discharge, patients need to follow what's often a long list of medical instructions, including taking medications, caring for wounds, receiving follow-up care from a provider outside the hospital, and getting help if their condition takes a turn for the worse. The process can break down at several points. Patients and those caring for them can misunderstand, disregard, have difficulty following instructions. They may be unable to get the necessary follow-up appointments. The doctors who see them post-discharge might not have received the relevant medical records.

Over the past few years, my grandfather has been admitted to the hospital multiple times. My mom and her siblings have spent many weeks helping him manage his complex pill regimen, sort through paperwork, and make follow-up doctor visits. They've noticed when his condition has started to deteriorate, and have made the appropriate calls or appointments or trips to the emergency department. They've driven him to various providers, compiled extensive notes on his care, and spent hours on the phone with insurers. It hasn't been easy (it still isn't), but there are many ways it could've been worse. My grandfather has various forms of insurance, and enough money to cover expenses the insurers don't. My mom and her siblings have enough FMLA leave and financial resources to take time off work and travel to Texas for repeated caregiving visits. I can only imagine how much harder all of this would be if my grandfather didn't have insurance, money, and family members with the time, money, and job security for caregiving.*

Having seen how many resource it takes to keep my grandfather from cycling endlessly in and out of the hospital, I'm not surprised that a Kaiser Health News analysis found "places that have the highest proportion of poor patients are nearly three times as likely to have high heart readmission rates." One big concern about financially penalizing hospitals for high readmission rates is that it will disproportionately hurt the hospitals with the neediest patients, when they're the ones who most need Medicare money.

The Centers for Medicare and Medicaid Services (CMS) Hospital Readmissions Reduction Program rule does address the issue of underlying local factors in readmission rates. CMS will use a National Quality Forum-endorsed risk adjustment methodology to calculate hospitals' excess readmission ratios for the selected conditions (acute myocardial enfarctions, heart failure, and pneumonia). The risk adjustment will involve "clinically relevant [factors] including patient demographic characteristics, comorbidities, and patient frailty." Some hospitals with high-risk patient populations have achieved low readmission rates, and CMS thinks it should be possible for other hospitals with similar populations to follow those examples. But I'm sure some hospital administrators are worried about where they'll find the money to invest in readmissions reduction efforts.

Another concern, described by Jordan Rau at the NPR Shots blog, is that one analysis has found high readmission rates for heart failure patients was associated with lower mortality. Rau notes that mortality rates will be incorporated into a value-based purchasing formula that Medicare will start using next year to reward high-performing hospitals, so the high-readmission, low-mortality hospitals might be compensated through that mechanism. Overall, though, this situation shows that it's challenging to develop metrics that effectively measure quality of care (including adjusting for local factors), and there's always the potential for unintended consequences like taking money away from hospitals that are actually doing a good job saving lives.

Preventing readmissions
The new rule is one of several provisions in the Affordable Care Act intended to start altering our healthcare systems' incentives to encourage high-quality care. If hospitals fear losing money due to high readmission rates, they have a financial justification to invest in things that can reduce readmissions. And it turns out that researchers are developing promising approaches to bringing down readmission rates.

The day after the Medicare rule went into effect, the MacArthur Foundation announced its list of 2012 MacArthur fellows. One of them is Eric Coleman, MD, MPH, a geriatrician and professor at the University of Colorado School of Medicine who has developed a Care Transitions Intervention. Wonkblog's Sarah Kliff describes Coleman's work:

The model Coleman thought up works like this: After a care transition, the patient receives an hour-long visit from a Transition Coach. The goal of that meeting is to figure out how well the patients are doing at managing their own care – and equip them with the tools they might need to improve.

“Instead of coming in and bringing this long list of discharge medicines, transition coaches would say something like, ‘I’d like to know what medicines you’re taking and how you take them,” Coleman explains. “And they’re saying there is no one right answer, that the patient might be sharing medications or going to Canada or Mexico to buy them.”

There are then three follow-up phone calls, all aimed at “skill transfer:” ensuring that the individuals have the skills they need to know when to call a doctor or how to manage follow-up appointments

The model is, admittedly, a pretty simple one. “It’s one home visit and three phone calls,” as Coleman puts it. But that small intervention has proved incredibly successful in reducing health spending by preventing costly complications down the line. When Medicare piloted Coleman’s model in 14 cities, it saved $100 million.

The Health Affairs brief on Improving Care Transitions describes Coleman's work and another model by Mary Naylor and her University of Pennsylvania colleagues:

Another rigorously tested transitional care model, developed by Mary Naylor and her colleagues at the University of Pennsylvania, involves a longer period of intervention targeted at a high-risk, high-cost subset of elderly patients, such as those hospitalized for heart failure. In six academic and community hospitals in Philadelphia, this approach reduced readmissions by 36 percent and costs by 39 percent per patient (nearly $5,000) during the 12 months following hospitalization. Under the Naylor model, an advanced practice nurse not only coaches patients and their caregivers to better manage their care but also coordinates a follow-up care plan with patients' physicians and provides regular home visits with seven-day-a-week telephone availability.

The targeting of Naylor's intervention may be a key to its cost-effectiveness. As I've noted before, disease-management programs aimed at reducing costly hospital admissions have not delivered impressive cost savings, and the Congressional Budget Office advises that one key to making such programs cost-effective is to target them them at the highest-risk enrollees.

Martha Bebinger, a WBUR reporter and a Health Journalism Fellow, has been following 66-year-old Sue Beder, who has had multiple sclerosis since the age of 18 and is "one of America's most expensive patients." In a recent story, Bebinger reports that Beder is now enrolled with Senior Whole Health, which is trying to find more cost-effective ways to care for patients like Beder (a "global payment" arrangement). Bebinger describes a discharge planning meeting -- involving Beder and several different members of her care team -- that occurs as Beder prepares to return home after two months of cycling between hospitals and nursing homes. This sounds like exactly the kind of meeting that research suggests is important for improving care transitions, but it's obvious that Beder needs more than just clear medication instructions and some follow-up doctor appointments. And after she returns home, Beder keeps falling. Bebinger concludes, "Beder is a sign that controlling costs without sacrificing care for the country’s most expensive patients can be really hard."

Several Affordable Care Act provisions, including the Hospital Readmissions Reduction Program, give providers incentives to achieve healthier outcomes and leave the processes for achieving those outcomes up to the providers. The hope is that today's experimentation will lead to higher-quality care and slower cost growth, and that fewer patients will spend miserable months in and out of hospitals.


* For an excellent illustration of how a patient's background and resources can affect recovery from a heart attack, read Janny Scott's "Life at the Top in America Isn't Just Better, It's Longer" (or, in my mind, "a tale of three heart attacks") from the New York Times' 2005 Class Matters series.


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