To improve our patients’ health, look beyond reducing readmissions
In this issue of the Cleveland Clinic Journal of Medicine, Drs. Ayache, Boyaji, and Pile share evidence-based strategies for reducing the risk of readmission for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).1 They emphasize standardizing practice by combining effective clinical management with appropriate patient education, communication, and postdischarge follow-up.
Reducing the rate of preventable hospital readmissions (as well as avoiding admissions in the first place) is the right thing to do for the patient. Moreover, broader adoption of the strategies that they outline in their article will be critical to the success of health care organizations in improving patient outcomes and navigating a rapidly evolving landscape of reimbursement and reporting changes associated with the Centers for Medicare and Medicaid Services (CMS) Readmissions Reduction Program. Hospital readmission rates, while imperfect measures of the quality of care, demonstrate opportunities to optimize transitions of care. Success in our efforts to improve the health of our patients will likely be aligned with reductions in preventable admissions and improved attention to care coordination.
HOSPITALS ARE PENALIZED FOR EXCESSIVE READMISSION RATES
With nearly 20% of Medicare beneficiaries being rehospitalized within 30 days of discharge, at a cost of $17 billion annually,2 Congress enacted the Hospital Readmissions Reduction Program3 as part of the Affordable Care Act (ACA) in 2012. The Centers for Medicare and Medicaid Services (CMS) had already been reporting the readmission rates for heart failure, acute myocardial infarction, and pneumonia since 2009 (www.medicare.gov/hospitalcompare). Building on this work, the Affordable Care Act implemented financial penalties against hospitals that had excessive rates of readmissions for these conditions.
The Affordable Care Act put 1% of a hospital’s Medicare base payment at risk for all inpatient diagnoses in 2013—not just the three listed here. The risk is 2% in 2014 and will rise to 3% in 2015. In its first year, more than 2,200 United States hospitals were penalized a total of approximately $280 million because of readmission rates above the national mean. Nearly 10% of hospitals incurred the maximum 1% penalty, and about 30% paid no penalty.
The Secretary of the Department of Health and Human Services has the authority to extend the Readmissions Reduction Program to additional high-volume or high-expenditure conditions, and the department has announced it will expand the program in October 2014 (fiscal year 2015) to include two additional conditions: elective hip or knee replacement and COPD.4 In both cases, CMS began by publicly reporting these rates before including them in the program. Additional readmission measures, including those for stroke and hospital-wide all-cause readmissions, are also publicly reported and receive increased attention but are not yet included in the Readmissions Reduction Program.
UNFAIRLY PENALIZING THOSE THAT SERVE THE POOR
Avoidable causes of readmissions include hospital-acquired infections and complications, inadequate medication reconciliation and management, poor communication and coordination of care among the members of the health care team, and suboptimal care transitions.5 But other important drivers of readmissions are outside of a hospital’s direct control. These include mental illness, lack of social support, and poverty.6
A criticism of the Readmissions Reduction Program is that it disproportionately penalizes hospitals that serve the poorest patients.7 Currently, CMS readmission risk models do not adjust for socioeconomic factors. Further, CMS responds to these concerns by noting that it does not want different outcome standards for poor patients, and that adjusting for these factors may conceal potential health care disparities in disadvantaged populations.
NEW MISSION FOR HOSPITALS: MITIGATE SOCIOECONOMIC BARRIERS
Effective programs to reduce hospital readmissions must address the clinical interventions and patient education needs in the COPD discharge checklist discussed by Ayache et al, but must also attempt to mitigate social disadvantages that drive up readmissions for patients at highest risk.
Are hospitals in a position to do this? Too often, it is assumed that patients have access to medications, transportation to follow-up appointments, and social support. Early identification of patients at highest risk of being affected by lack of these factors and innovative solutions for mitigating these risks are important considerations in our efforts to reduce hospital readmissions.
