Providers have been aware of problems with patient readmissions, but what was once a back-burner priority has suddenly grown into a looming dilemma, thanks to the move by Medicare to start penalizing hospitals that consistently show high rates of readmissions. And information technology plays a huge role in efforts to reduce readmissions, but providers are struggling to determine where I.T. will have the biggest impact in the process of extending the care continuum in a hybrid paper/electronic environment.
In federal fiscal year 2013, which begins in October, the Centers for Medicare and Medicaid Services will penalize hospital with high readmission rates-readmits within 30 days of initial discharge-the equivalent of 1 percent of their total Medicare billings, with the penalty rising to 2 percent in fiscal year 2014 and 3 percent in 2015. The program will focus on readmission rates for three common conditions-congestive heart failure, pneumonia and acute myocardial infarction (heart attacks). CMS was authorized to roll out the penalties through the hospital readmission reduction program tucked into the massive Affordable Care Act. It also has shined a light on readmission rates by publishing hospitals' 30-day readmission data for heart failure, pneumonia and heart attacks on its Hospital Compare site at www.hospitalcompare.hhs.gov.
The Dartmouth Atlas Project, which for 20 years has used Medicare data to document variations in how medical resources care consumed in the United States, found that overall, 16.1 percent of hospital patients were readmitted within 30 days of initial discharge. That rate, despite the billions of dollars poured into clinical systems over the years, has actually increased slightly in recent years-the readmission rate in 2004 was 15.9 percent, according to the project's research.
CMS estimates that costs associated with preventable readmissions exceed $17 billion annually. Another study by the Agency for Healthcare Research and Quality estimates that for Medicare patients aged 65 and older, about 19 percent of all hospital stays were readmissions within 30 days.
The decision to penalize high readmission rates comes on top of a 2008 move by CMS to stop reimbursing hospitals for readmissions for 10 hospital-associated conditions, including falls and trauma, vascular catheter-associated infection, stage 3 and 4 pressure ulcers and air embolisms.
The threat of losing a percentage of Medicare billings sent a shiver through numerous hospital board rooms, says Thomas Yackel, M.D., the chief health information officer at Oregon Health and Science University, a Portland-based academic medical center which encompasses two hospitals and a number of physician practices. OHSU had more than 800,000 total patient visits last year, including nearly 31,000 inpatient admissions and 31,000 emergency department visits.
"This is the basic truth-the hospital, in our case and at many other academic facilities and health systems, pays for everything," Yackel says. "It's the revenue-generator that allows the medical school to survive and pays for all the other programs. So when executives see a potential payment adjustment, even if it's a small one, it gets their attention. Executives act on these things."
But understanding the reasons for readmissions is an emerging science, Yackel adds. Some conclusions can be drawn fairly easily-disease states such as CHF leave patients frail and physically vulnerable, making them likely candidates for readmissions-but a host of underlying social and medical complexities still need to be interpreted. "That's the first thing that strikes you when you look at readmission data-you just don't know what causes many of them," he says. "There's no great predictive formula that says if you do these five things, readmissions will drop dramatically. But hospitals are starting to do things that make great common sense, and that's a start."
Some consensus has emerged: a disconnect between patients and multiple caregivers-lack of communication about post-discharge appointments, medications and execution of care plans-causes many readmissions, as does the lack of intensive medication reconciliation, which results in patients not understanding how and when to take prescribed medications and stop taking others in their bathroom medicine cabinets.
Scratching the surface
Many hospitals are using those two areas as starting points for their efforts to reduce readmissions as they gear up for more intensive programs to understand their underlying causes.
While that's a good place to start, the industry is really just scratching the surface when it comes to understanding the problem, says Michael Hollenbeck, vice president of health care at Predixion Software, a San Juan Capistrano, Calif.-based vendor of predictive analytics.
"At this point the industry has to do broad swatch interventions they can do across the board, but we've learned that at each institution, cultural issues and local practices have a significant effect on readmissions," he says.
Case in point: Predixion analyzed readmissions for a New York health system and found that patients who were on psychotropic drug therapies were "pretty much guaranteed to be readmitted to the hospital," Hollenbeck says. But at another client site in Texas, psychotropics were such a non-factor in readmissions that Predixion initially thought it had crunched the data wrong.
"Think of readmissions right now in terms of credit scoring, and think what a mess commercial lending would be if those lenders didn't have FICA scores to base decisions on," Hollenbeck says. "The health care has no standardized data that can guide caregivers to their highest probability candidates of readmissions, so they have to look at ways to universally lower those readmissions."
While shortcomings in patient hand-offs and other process-related care issues are a widespread industry weakness, the fundamental reason for high readmission rates are the disease states themselves, says Steven Shapiro, M.D., chief medical and scientific officer at University of Pittsburgh Medical Center, a massive integrated delivery system that encompasses more than 20 hospitals and 400 other care facilities, along with a health plan covering 1.6 million lives.
Long, complicated lives
"We've advanced to a point where we can keep people alive much longer, but the result is that the elderly patients we treat are living with multiple chronic conditions," Shapiro says. "The same issues we're seeing with our elderly population is what CMS sees when it looks at the data. There are certainly opportunities to better educate the patient and keep them on care plans, but some readmissions are unavoidable." To illustrate his point, Shapiro points to UPMC's readmission rates for chronic obstructive pulmonary disease. While readmissions for other disease states such as congestive heart failure have dropped significantly with more intensive care plans, the health system hasn't been able to bring down COPD readmission rates, which hover around 15 percent. "A large subset of patients with severe COPD gets readmitted frequently, and we haven't been as successful with disease modifying therapies as we have with other conditions. Right now the industry doesn't have the answers to COPD, which is now the third-leading cause of death in the United States."