The issue of unnecessary hospital readmissions is now front and center in the national conversation about the quality of health care. Thanks to Medicare’s readmissions reduction program, hospitals are working hard to bring their readmission rates down, and that’s good news — good news being drowned out by a chorus of complaints.
Avoidable readmissions are a strong indicator of a fragmented health care system that too often leaves discharged patients confused about how to care for themselves at home, and unable to follow instructions and get the necessary follow-up care. Readmissions are also a costly price to pay for a system that doesn’t have resources to spare; Medicare alone reports spending $17.8 billion a year on patients whose return trips to the hospital could have been avoided.
Unfortunately, too much of the conversation of late has turned to whether the penalties for excessive readmissions treat hospitals fairly, whether hospitals should be held accountable for issues patients face after discharge, and whether the readmission rate is even a valid measure of quality. The debate grew particularly loud this week, as the readmissions penalties increased from 1 percent to a maximum of 2 percent, as scheduled to occur in the Affordable Care Act.
All are worth discussing, but what’s getting lost is the fact that thanks to the new incentives, patients are getting better care, and as a result, fewer of them are revolving back through the hospital door. This is as it should be; going to the hospital should be a last resort. Hospitals are a costly and at times even dangerous venue for care. While the news about the increased penalties drew lots of attention, the fact is the average hospital was fined less in the second year of the program than in the first, and that overall the national total will be $53 million less despite the 2 percent maximum penalty. This means hospitals are making progress.
As the major player in health care in most communities, hospitals are best equipped to organize systems of care where they didn’t exist before, and invest in care transition programs that reach beyond the hospital walls into the community. And many are rising to the occasion.
Evidence of improvement. The Centers for Medicare & Medicaid Services reported in February that the 30-day, all-cause readmission rate is estimated to have dropped to 17.8 percent in the fourth quarter of 2012 after averaging 19 percent for the past five years. Further, MedPac’s June 2013 Report to the Congress indicates that, at a national level, all-cause readmissions for the three reported conditions had a larger decrease in readmissions over the three-year measurement period than for all conditions, suggesting a strong connection between public reporting and implementation of the Hospital Readmissions Reduction Program. The results tell a compelling story that underlies the adage that, “what gets measured gets attention.” It is clear that linking financial incentives to publicly reported, standardized quality metrics has driven, and will continue to drive, significant improvement in patient outcomes and reduce unnecessary costs to the system.
This improvement translates into 70,000 fewer readmissions in 2012—meaning real people did not have to experience the trauma of landing back in the hospital. While this trend appears promising, it also bears further probing. We must make sure that public reporting and financial incentives are driving better care, not the unintended consequence of people not being admitted to begin with or not getting the quality, timely care they need.
Innovators. A tide of innovation to improve care transitions out of hospitals is now sweeping through the hospital sector, largely motivated by Medicare’s performance measurement. For example, innovators recently spotlighted by the Robert Wood Johnson Foundation’s Care About Your Care initiative include Cullman Regional Medical Center in Cullman, Ala., which is using iPod Touches to record discharge instructions for patients at high risk for readmission and then making the recording available online and by calling a toll-free number.
Other pacesetters include Mercy Health in Cincinnati, which employs nurses specifically in charge of care transitions to meet with patients from the time they are admitted through their discharge. After discharge, the nurses make home visits, ensuring medications and discharge instructions are being followed and patients are attending follow-up appointments with primary care physicians. And Central Maine Medical Center in Lewiston, Maine, partners with a local home care/hospice service to confirm heart failure patients receive a home visit within the first three days of discharge from the hospital and uses transtelephonic devices to transmit patient data and detect abnormalities or other risk signs for readmission.
The danger of low expectations for the safety net. One of the biggest complaints leveled at the Medicare penalty is that it is indifferent to the socio-economic circumstances of a hospital’s patient population. The logic for adjusting for such differences is that patients in these hospitals and communities are less likely to have access to the resources they need to keep them from returning to the hospital. But our thinking is that we must guard against adjustments that lead to acceptance of substandard care for low-income patients. It is critical that we focus both attention and support on our safety net hospitals and populations.
Moreover, it is worth noting that many hospitals serving these populations are also finding ways to reduce readmissions. Examples include New York Methodist Hospital—a CMS Community-Based Care Transitions Program (CCTP) site—which has received numerous recognitions for its excellent work in care transitions; and Temple University Health System, also a CCTP site, which is training and deploying community health workers to assist high-risk Medicaid patients with care transitions in an effort to reduce unplanned readmissions.
We acknowledge that managing readmissions is a complex task, but thanks to the Medicare program, hospitals are taking an important leadership role that was previously unfilled.