As CMS expands its 30-day readmission penalty program, more financial pressure is placed on hospitals and seniors. This program has driven hospitals to increase the use of outpatient observation services. Inpatient stays are paid by Medicare Part A, but outpatient observation is paid by Medicare Part B which covers only 80 percent of the bill. Here is what is happening in some markets. Let’s say a person is admitted to a hospital for heart failure. The length of stay might be 3-4 days and then the patient is discharged. If that same person has a recurrence of heart failure within 30 days of the initial discharge, the hospital will not be paid for that episode. However, if the 2nd episode is handled under outpatient observation status, the hospital is paid, but the patient (who probably didn’t realize he/she was not admitted to the hospital) receives a bill for 20 percent of the charges.
This is an issue, but the larger issue is how the law assigns all the risk to the hospital. Perhaps the thought was that poor inpatient care is the cause for readmissions, but the reality is that many other factors not under the hospital's control can drive readmissions. The patient has some responsibility — the patient needs to be compliant with medications, follow up with his/her primary care physician, and follow all discharge instructions. In some cases, a primary care physician might not be available, or the patient might not be able to travel to pharmacies and doctors offices, thus not getting needed follow-up care.
Another issue is that heart failure is a complex clinical condition, and despite the best level of care, sometimes symptoms recur and patients need to be re-admitted. The 30-day provision doesn’t seem fair to hospitals in the case of heart failure; if the patient is readmitted on day 29, the hospital is not paid, but if the 2nd episode occurs on day 31, the hospital is fully paid. The 30-day rule makes more sense for certain surgeries such as hip and knee replacements. With those surgeries, a readmission within 30 days could be avoided.
Given these issues, I believe the 30-day rule should be modified. Certain medical diagnoses could use a “sliding scale” based on number of days since discharge. I don’t think the rule should be dropped, however. This rule is forcing hospitals to consider continuity of care issues, ensuring that appropriate post-discharge planning and care does occur. It also further encourages ACO and patient centered medical home approaches, which are designed to provide continuity. It discourages fee-for-service approaches, which are typically not structured to provide these services very well. For these reasons, I think the 30-day rule is (and should be) here to stay.
Michael L. Taylor, MD
Chief Medical Officer
The release of the list of Illinois hospitals penalized for avoidable readmission of Medicaid patients in a recent Chicago Sun Times article was interesting reading! While the list was led by two brand name hospitals, Ann and Robert H. Lurie Children’s Hospital of Chicago and Rush University Medical Center, the list also included John H. Stroger, Jr. Hospital of Cook County, University of Illinois, University of Chicago, St. Mary, St. Catherine, and others with long histories of treating the poor and disadvantaged.
Policy wonks argue that the only way to reduce delivery system fragmentation, which is known to cause quality gaps, is by creating penalties that force changes in the structure of the delivery system. Development of metrics that force hospitals to be responsible for care beyond their current control has become much more common. Why? Because it’s the hospital that has the staff and financial resources to make changes in the delivery system across the community. If the penalty is high enough, the hospitals will innovate to avoid the penalties, ultimately transforming the healthcare system.
Transformation requires innovation, trial, and error, and the ability to rapidly correct error. Setting policies that attempt to drive innovation in the delivery system via stiff penalties is innovative itself! This approach might be reasonable if government could act fast enough to adjust for error inherent in the innovation process. However, in a democracy, government is deliberative by definition, and therefore slow to act. It is especially unfortunate that states are piling on to extend avoidable readmission penalties without taking into account socio-economic conditions of patients. Both state and federal government could simply exempt or reduce the impact of the penalties on safety net hospitals now. There are existing socio-economic adjustment methodologies that have been used for over a decade by health systems like Dignity Health. Neither solution is perfect, but fast action is necessary to reduce safety net hospital financial harm that is being exacerbated by the state “pile on.”
There is no doubt that the government is trying to innovate, and I applaud those efforts. Using hospital penalties to drive innovation and delivery system structural change might even work well in some cases. But the risk of government’s inadvertent commission of “avoidable error” is too great, given its slowness to act. It would be better to run a few small pilots first to get the kinks out. Then, when the piling on occurs, it will not hurt those that are already hurting.
To read more about the connection between socio-economic factors and readmissions, download our white paper, Community Need Association with 30-Day Readmissions.
Senior Vice President, Performance Improvement and 100 Top Hospitals
As healthcare practitioners and administrators, we are keenly aware of the complexities associated with preventing readmissions. Common questions that come to mind when tackling the readmissions dilemma include: What patient care and education interventions can we implement? Do we have a solid transition of care program? What is the cost impact to my organization, from direct costs to loss in reimbursement? Most importantly, how can we embed sustainable programs to avoid readmissions?
Take for example the impact of medication management related issues as a factor for readmissions. In an evaluation conducted by Feignbaum, et al. at Kaiser Permanente, researchers studied factors contributing to readmissions within 18 hospitals (1). Medication management issues impacted 28 percent of preventable readmissions and were identified as one of the top five areas for to prioritize for organizational intervention programs. Upon interviewing 189 patients and caregivers, researchers found that 32 percent of patients indicated they would have liked to have received more communication regarding their medications, and of these, 73 percent of caregivers indicated that lack of information was one of the components that lead to a readmission (1). This data, coupled with a recently published article by Mixon, et al. focusing on post-discharge medication errors, highlights a significant area of opportunity to prevent medication management related issues. The study indicates that medication errors ranging from omissions, commissions, and misunderstanding in indication, dose, and frequency were found in 50 percent of patients after hospital discharge (2). The groups most impacted were those with low health literacy and numeracy scores (2). These statistics are sobering and should make us want to re-evaluate our current approach towards medication-related patient education in order to improve our practices to reduce the risk for patient harm and eliminate avoidable readmissions.
When creating a strategic approach to reduce medication management related readmissions and errors, organizations should consider the following areas of improvement:
These interventions are not only meaningful for the clinical outcome improvement results they can provide, but they are also aligned with safety, regulatory standards, and compliance standards that lead to higher reimbursement payments. These incented standards range from reduction in readmissions related to medication management events, to attestation for Meaningful Use Stage II criteria for integrated patient education and improving patient satisfaction scores as evaluated by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
- Integrate medication handouts into Electronic Health Records (EHR) to optimize clinician work flow and enhance the patient discharge process
- Provide patient education handouts that adhere to health literacy standards to improve patient comprehension and retention of medication management related topics with tools designed for those with greatest risk of non-compliance (low health literacy and numeracy)
- Embed a “Teach-back Process” to validate patient and/or caregiver comprehension of the medication management related information provided
- Provide low-literacy aids to augment learning with tools such as pill-boxes, text messages, and/or daily medication schedules
Pharmacists, physicians and nurses, it’s time to ask yourself how your organization is approaching medication-related patient education. Has your organization mobilized the medication-related experts who impact care decisions at the point of care? Do you have the opportunity to improve your work flow to make time for caregivers to exercise best practices in education on discharge? Do you know how many patients you are discharging with medication errors? These questions can help you on the journey to reduce your medication management related risk and improve your organizational approach.
Arti Bhavsar, Pharm.D.
A new report on potential uses of big data for controlling cost in the hospital setting has just been published. The report, from Brigham and Women’s Hospital in Boston, appeared in the July 2014 edition of Health Affairs. Six areas of potential benefit were discussed:
As the authors point out, these are six key areas for intervention to lower healthcare costs in the hospital setting, and using more diverse data sources to analyze these opportunities will be useful.
- High-cost patients
- Preventable readmissions
- Triage upon hospital admission
- Decompensation of clinical condition while in the hospital
- Adverse events, particularly renal failure, infections, and adverse drug reactions
- Treatment optimization for those with chronic disease involving multiple organs
As I reflect on this report, it strikes me that this type of report would have probably not been published several years ago. Healthcare reform, particularly changes in the payment methodology, is driving this type of research. I understand the need to minimize the healthcare spend and agree these are six key areas for research. But, in my opinion, the more important clinical issue is the improvement in the quality of care and probable saving of lives from better care. This is the real issue and opportunity.
All six of these areas are a result of missed opportunities to improve care. These areas are inter-related: high-cost patients are often a result of those who are readmitted multiple times for the same condition, suffer complications, are inappropriately triaged, and have missed diagnoses or have adverse events. Some of these problems can be prevented medically, but some of these issues have broader root causes. Take readmissions – many cases are due to socioeconomic factors such as inability to pay for medications, poor access to outpatient healthcare, or inability to pay for home care. Doctors and hospitals have historically not been paid to consider and manage these non-medical factors that lead to increased medical cost. While no physician wants complications to develop in their patients, hospitals and physicians have never before been penalized if this happened, so there has not been a focus on preventing these complications. New payment incentives are driving these changes and new approaches to care are developing. The promise of higher pay for better value in healthcare of populations, not for providing more services to individuals, is leading to new solutions in these six areas. “Big data,” meaning information about socioeconomic factors, living situations and other new data sources, and then using these data in predictive algorithms, will improve our ability to care for populations, not just treat individuals.
At Truven Health Analytics, we use data to understand high-cost medical care. As we work with the payers of healthcare, especially large employers, part of our study is high-cost patients. I consistently find these cases to be complex, often involving advanced cancer cases or complicated heart failure cases. Closer oversight of these patients, team-based care, and better methods to predict and manage complications is warranted in many of these cases. Accountable Care Organizations (ACOs), with a patient-centered focus and a population health strategy, are promising new approaches to improving care. The tragedy of many of these cases however, is the missed opportunity to prevent these cases from ever occurring. If screening guidelines were followed more universally, advanced colon cancer would almost never happen. Heart failure is usually due to multiple heart attacks that could be prevented by paying closer attention to decreasing risk factors. Not all high-cost cases can be prevented, but many could be avoided.
Why, as a nation, are we not doing a better job in managing the health of our population? The most obvious answer is because we aren’t focusing on and prioritizing disease prevention among our population. Up to 70% of healthcare costs are due to preventable disease, but our healthcare system hasn’t been paid to focus on this issue. But change is apparent. The healthcare industry is undergoing more rapid change at this time than I’ve ever seen in my 30+ years of being a doctor. The new clear message is this: the way to manage costs is to improve the quality of care for entire populations, including new ways to prevent disease. Technology in the form of implementing integrated electronic health records, using more diverse data streams, re-designing healthcare delivery, and better predictive analytics are all tools to improve the quality of healthcare in the U.S. This is the right path to reduce costs.
Michael L. Taylor, MD, FACP
Chief Medical Office
A lot of attention has been given to hospital readmissions in recent years, and the establishment of a readmission outcome measure by the Centers for Medicare & Medicaid Services (CMS) in value based purchasing has incentivized hospitals to work diligently on the problem. The recent article in Kaiser Health News about Beth Israel Deaconess highlights the challenges and obstacles we must overcame to reduce readmissions. The reasons to address this issue go beyond the cost of it. One reason alone should be to improve the overall quality by preventing the re-exposure of a patient to the hospital environment where they can be subject to hospital-acquired infections and other safety concerns, such as falls.
For some of the top readmission diagnosis like Heart Failure and Pneumonia, the biggest obstacles to reducing readmissions have been not what goes on in the hospital, but what occurs when the patient is discharged. It really involves more about the psychosocial aspect of healthcare than the science of the disease and treating it. When the patient is discharged after a heart failure exacerbation, the medical component is typically stabilized. The failures often occur in the process, communication, and overall care coordination.
These are some of the questions that must be asked in order to reduce the risk of readmission.
- Was the follow-up outpatient procedure scheduled before discharge?
- Is a family member or caregiver aware of the follow-up appointment?
- Can the family member or caregiver drive the patient to the follow-up appointment?
- Did the patient receive the proper diet instructions before discharge?
- Do they have the resources at home to help comply with the dietary guidelines?
- Can the patient afford the prescribed medications, and does the patient understand the instructions for taking their medications?
- If the patient needs outpatient intravenous antibiotics, were home health services arranged?
Hospital systems and hospitals that have been successful in reducing readmissions have ensured a coordinated team of visiting nurses, social workers, pharmacist, and case workers all work together to coordinate the process, education, follow-up visits, and overall answers to questions that may come up to family and patients. The future of our healthcare system will be tied to coordinating care using an overall population health analytics system that not only tracts information across inpatient and outpatient settings, but also enables all care providers to communicate more effectively, tying in real time surveillance, monitoring, and alerts. Therefore no matter where the patient is along the continuum (inpatient, outpatient, emergency department, or home) and whoever is interacting with the patient, information is constantly brought together and communicated to improve the health of the patient and reduce risk of readmission for high risk patients and chronic disease.
Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader