When Medicare “Cuts” are Medicare “Savings”

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.

Comments

[Beth Wellington]

Posted your piece at NewsTrust:
http://newstrust.net/stories/1725767/