The Centers for Medicare and Medicaid Services launched its Readmission Reduction Program in October, and few hospitals made it through unscathed.
The program and the readmissions penalties it metes out were authorized under the Affordable Care Act. In this first year of launch, the reduction program penalized hospitals up to 1 percent of their regular Medicare reimbursements for having high rates of 30-day readmissions (calculated via an "excess readmission ratio") for heart attack, heart failure and pneumonia.
After a few adjustments to the data, CMS announced that 2,217 hospitals will be penalized this year, and 307 will be hit with the 1 percent maximum penalty. All in all, hospitals were assessed a total penalty of about $280 million this year.
While that's a bitter financial pill to swallow, the going will get tougher: the maximum Medicare reimbursement penalties assessed by CMS will rise to 2 percent in federal fiscal year 2014 (which begins in October 2013), and 3 percent in fiscal year 2015. On top of that, the secretary of the Department of Health and Human Services, which oversees CMS, has the discretion to add additional readmission categories to the mix. It's expected that readmission rates for cardiac bypass surgery, cardiac stenting and other vascular procedures will be under the microscope.
To say that readmissions have hospitals' attention is an understatement. But for all that attention, and the subsequent I.T. expenditures and program launches, readmission rates for heart attack, heart failure and pneumonia are barely budging: data published in mid-2012 on the government's Hospital Compare Web site, showed that readmissions for heart attack and heart failure patients declined only 0.1 percent in 2011, and the rate actually went up slightly, by 0.1 percent, for pneumonia readmissions.
Debbie Larkin Carney, vice president of quality at Saint Barnabas, sums up the sentiments of clinical and I.T. leaders who are in the trenches of reducing readmissions: "Readmissions are just so hard to analyze and address because the factors behind them are so diverse-you can slice by socioeconomic factors and clinical factors and other data, but while you see some commonalities there's also a lot of differences."
Saint Barnabas, part of massive, 10-hospital Barnabas Health in New Jersey, has reduced readmissions by 8 percent over the past year, but compared with national averages, it's a mixed bag: for some conditions it's better than the national average, and for some it's slightly worse, Larkin Carney says. And another perplexing issue, she says, is that at Saint Barnabas, 60 percent of the patients readmitted came back for health problems unrelated to their initial diagnosis."
Sometimes lost in all the talk of unacceptably high readmission rates and clinical failures is the fact that hospitals are dealing with chronically ill patient populations that spent most of their times on the razor's edge healthwise.
"Many of the efforts around readmissions are targeted at the chronically ill, and the reason they're called that is because these conditions are chronic-the patients don't really get well," says Wayne Bazzle, the CEO of Dallas-based CareCycle Solutions, a home health telemonitoring company that provides post-acute care for patients referred by hospitals and physicians. "Someone with congestive heart failure, for example, is not going to get well-what you're trying to do is stabilize their conditions so they can get on with their lives and stay out of the hospital. But to do so takes intensive effort."
The 30-day readmission rate is the magic number CareCycle's client hospitals are focused on, Bazzle says, and the company has been able to significantly reduce the readmission rates for its patients under its care: while the national average for 30-day readmission rates for chronically ill patients is around 20 percent, about 7.5 percent of CareCycle patients are being readmitted in that timeframe.
One of the I.T. underpinnings of the company's efforts is monitoring via the HomeMED device, from Honeywell Inc. Patients are given monitoring devices such as blood pressure cuffs and weight scales that are either hardwired to the device or communicate wirelessly with it via Bluetooth connections. CareCycle programs the devices with question bundles for their specific conditions, as well as voice prompts reminding them to take daily readings from the monitoring devices. The information is automatically transmitted to a database maintained by CareCycle, which uses proprietary algorithms-developed in conjunction with the North Texas Science Center-that analyzes the daily input. It then assesses which patients need extra attention and urgent interventions before their conditions warrant readmission.
Bazzle's experience crunching the data yield some insights into the disconnects that send patients back to the hospital in such short order.
At the top of the list is a lack of adherence to medication regimens, Bazzle says. "It's always amazing to me what goes on in the home-patients take medications prescribed to a family member or they simply forget to mention other drugs they have in the medicine cabinet-those issues come up all the time," he says. "But we also often find that many patients get confused because they don't get real clear instructions on their medications. For example, they continue to take a brand-name drug while they're also taking the same thing in generic form because they didn't understand or weren't told they were supposed to stop taking the brand name."
Another medication issue that's an underlying source for many readmissions is over- and under-medicating patients, he says. "You'd be surprised how often a prescription doesn't take into account the patient's weight-it doesn't make clinical sense to give the same amount of a drug to a 120-pound person than to a 250-pound person, but that's what we've found drives a lot of readmissions."
Getting chronically ill and recently discharged patients to take their medication and follow diet and exercise recommendations has always been a seemingly intractable problem with elusive solutions. But at the root of the problem is a simple question: Why don't patients take the advice of their doctors?
The reasons might shock even a grizzled veterans, says Scott Rusk, M.D., chief medical officer at Mercy Hospital in Portland, Maine. Rusk has been the physician champion of a pilot project in the cardiac department that uses analytics tools to understand the personal circumstances and personality traits that might put patients at risk for readmission.
Patients are asked dozens of questions, the answers to which are run though an analytics engine developed by the Patient Performance Institute and embedded in the cardiology group's electronic health record.
The analysis found the biggest barrier to medication and treatment compliance was fundamental-the patients didn't believe what their physicians were saying.
"I was absolutely floored by this-a significant percentage of our patients simply didn't believe what we were saying is true," Rusk explains. "They thought we were deceiving them when we said they needed to avoid salty foods, or take certain medications-it's almost like they think there was a conspiracy among cardiologists to keep them away from things they want to eat."
The Patient Performance Enhancement Test, as it's called, scores patients in 10 different domains such as emotional control, respect for authority, optimism levels and financial situation. Rusk, like his peers trying to unravel root causes of readmissions, knows there's something going on behind the scenes that's causing patients to behave badly, but has had problems putting a finger on it or understanding how to address those issues. "I don't know any cardiology groups that have psychiatrists or psychologists associated with their group, so we've had to rely on intuition and our own attempts to understand these psycho-social dynamics.
"Let's face it, the medical model is to let the patient lie to the physician. If obese patients gain three pounds in a month and you ask them if they followed the dietary plan, they're likely to tell you they did, even though you know and they know it's a lie. This data helps us get the underlying reasons why they didn't follow the treatment and felt compelled to lie, and that helps us address those issues. It gets you to the real roadblocks."
Saint Barnabas also struggles with medication adherence and recalcitrant patients, Larkin Carney says. But like Mercy, Saint Barnabas is working new angles in its readmissions efforts, in this case re-thinking how the hospital prepare patients for discharge. "We've focused a lot on optimizing our discharge processes and focusing on a specific diagnosis when they leave the hospital. But we're starting to think, did we do the best for that patient in terms of their overall health? Did we optimize them to go home and be able to take care of themselves?"
The reason those questions are so important, she says, is that most readmitted patients are there for reasons other than complications with their initial diagnosis.
A patient was readmitted for a bout of pneumonia, which was not their initial admission diagnosis. Did Saint Barnabas ensure they exercised their lungs during their inpatient stay? Did they get them up and walking enough? Or a patient is readmitted because their wounds are not healing. Did they have the right nutrition when they were in the hospital? Did they get enough protein in their diet to ensure their wounds would heal normally?
"Since looking harder at readmissions, we're putting protocols in place to ensure we are treating the patient in full before we discharge, and not focusing on just one diagnosis," Larkin Carney says. "That's something we can control in the hospital setting."
Barnabas Health is also ramping up its I.T. efforts around readmissions It's currently working with The Advisory Board Company, a health care consulting firm, to develop predictive modeling software for readmissions.
The health system is piloting other programs. In one, an electronic alert is fired off to care teams when a recently discharged patient shows up at one of the health system's EDs. That alert triggers a phone call between the ED staff and the patient's primary care physician, care manager, a pharmacist or other clinician involved in their care. Another pilot calls for an advanced nurse practitioner to oversee the tracking of cardiac patients, one of the more difficult groups to keep out of the hospital.
"What we're doing around readmissions are efforts that try to eliminate the fragmentation of care," Larkin Carney says. "That's really the heart of the issue-patients are getting bits and pieces of care from different providers, and all those pieces don't come together to make a whole."
In the study "Diagnoses and Timing of 30-Day Readmissions After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia," published in January in the The Journal of the American Medical Association, researchers analyzed Medicare fee-for-service claims data for 30-day readmissions after hospitalization for heart failure, acute myocardial infarction and pneumonia. Here are a few findings, based on analyzed data from 2007 to 2009:
* The average age of readmissions was 80.3 years for patients originally hospitalized for heart failure, 79.8 years for patients originally hospitalized for acute myocardial infarction and 80 years for patients originally hospitalized for pneumonia.
* The majority of all readmissions occurred within 15 days of hospitalization: 61 percent of heart failure readmissions, 67.6 percent of acute myocardial infarction readmissions and 62.6 percent of pneumonia readmissions.
* Among all readmissions, approximately one-third occurred from day 16 through day 30 post-hospitalization.
* The median time period between hospitalization and readmission was 12 days for heart failure, 10 days for acute myocardial infarction and 12 days for pneumonia.
* For readmissions after a heart failure hospitalization, 87.5 percent were readmitted once, 9.7 percent were readmitted twice and 2.8 percent were readmitted three or more times.
* For readmissions after an acute myocardial infarction hospitalization, 97.4 percent were readmitted once, 2.4 percent were readmitted twice and 0.2 percent were readmitted three or more times.
* For readmissions after a pneumonia hospitalization, 95.1 percent were readmitted once, 4.3 percent were readmitted twice and 0.6 percent were readmitted three or more times.