Last week the head of the American Hospital Association sent a letter to Donald Berwick, director of the Center for Medicare and Medicaid Services, stressing how “crucial” it is that the agency consider the racial and ethnic backgrounds of patients when it determines how well hospitals are doing on preventing readmissions within 30 days of discharge.
Why so crucial? The Affordable Care Act includes a hospital readmission reduction program (HRRP) that uses incentives and starting in October 2012, penalties to encourage hospitals to enact better follow-up and other procedures that reduce preventable readmissions among Medicare patients. For Medicare patients aged 65 and older, about 19% percent of all hospital stays were readmissions within 30 days, according to a new statistical brief from the Agency for Healthcare Research and Quality. Some 2.3 million rehospitalizations a year racked up more than $17 billion in annual Medicare costs in 2008, and the Medicare Payment Advisory Commission (MedPac) reported that expenditures for “potentially preventable rehospitalizations” were as high as $12 billion in 2005 alone. It’s a significant—yet avoidable—expense that drives up the ever-rising cost of Medicare.
Under the HRRP, those hospitals that report higher than expected 30-day readmission rates for patients who had been hospitalized with heart attacks, heart failure and pneumonia could see their Medicare reimbursements decreased by up to 1% the first year, up to a maximum of 3% in 2015 with an expanded list of relevant health conditions. Hospitals already submit information about readmissions as part of Medicare’s “pay-for-reporting” program and these rates are then published on CMS’s Hospital Compare site. By adding incentives and penalties to this benchmark, the goal of HRRP is to drive quality of care improvements while saving Medicare $710 million each year.
Rich Umbdenstock, the AHA president and author of the letter, takes the position that the 10% of hospitals serving a larger proportion of black and non-English-speaking patients will be unfairly penalized in this pay-for-quality program. He argues that a recent study in the Journal of the American Medical Association (JAMA), for example, shows “that blacks have a higher likelihood of being readmitted to the hospital than do whites. In addition,” the letter continues, “the JAMA article concluded that hospitals serving a disproportionately large number of minorities have higher readmission rates. Proper accounting for these racial disparities is crucial as the Department of Health and Human Services (HHS) implements the Hospital Readmissions Reduction Program (HRRP)…”
The AHA letter acknowledges that the health agency already uses risk adjustment measures that account for disparities in patient populations served by individual hospitals. These factors include adjustments for severity of the underlying medical condition and whether patients suffer from multiple diseases as well as demographic information like the age and gender of patients.
But, HHS is not considering “patients’ race or life circumstances [the letter specifically mentions limited English proficiency], which can have just as great an impact on health outcomes,” asserts the hospital group. “As it implements the HRRP, HHS [Department of Health and Human Services]should incorporate these additional characteristics into its risk-adjustment methodology both to comply with the law and to avoid penalizing the very providers who are trying to eliminate racial disparities in health care.”
This is where the logic gets a little twisted. The AHA is correct that the authors of the JAMA paper did find racial disparities in hospital readmission rates: Black Medicare patients had 13 percent higher odds of 30-day readmission than white patients (24.8 percent vs. 22.6 percent) and patients discharged from minority-serving hospitals had 23 percent higher odds of readmission than patients from non-minority-serving hospitals (25.5 percent vs. 22.0 percent).
In general, the researchers found that white patients at non-minority serving hospitals had the lowest rate of readmission while black patients at minority-serving hospitals had the highest rate of readmission. But interestingly, white Medicare patients who were treated at minority-serving hospitals still had 23% higher odds than their counterparts at non-minority hospitals of being readmitted. From this and other findings, the JAMA authors concluded that “the association of readmission rates with the site of care was consistently greater than the association with race, suggesting that racial disparities in readmissions are, at least in part, a systems problem—the hospital at which a patient receives care appears to be at least as important as his/her race…”
Clearly, this is a complicated problem whose resolution will need to involve taking into account regional variations and socioeconomic disparities. Preventing hospital readmission is going to require a different approach at a small community hospital in a wealthy suburb, for example, as compared to a large urban medical center with a high proportion of poor, minority Medicare patients. First of all, in the original JAMA study cited by the hospital association—which looked at over 3 million Medicare hospital discharges from 2006 to 2008—only 8.7% involved black patients and only 10% of the hospitals were classified as “minority-serving.” The authors note that care for minorities is concentrated in just a few facilities. As to why these minority-serving hospitals have higher readmission rates—irrespective of who is released from them—the researchers and commentators can only speculate. “[E]ither our measures of financial stress are inadequate or…the higher readmission rates among these hospitals are due to other factors, such as a failure to prioritize quality or inadequate focus on transitions of care and coordination of care,” they write.
Other studies have provided more insight into the disparities. The AHA letter seems to suggest that a “patient’s behavior” once he or she is released from the hospital—unhealthy lifestyle choices, poor social support or mental illness, for example—is a significant factor. The hospitals, they say, will be unfairly penalized for the dire circumstances many of their patients find themselves in. I think this is missing the point of the readmission reduction program: the goal is precisely to address just these issues at the system level. Rather than calling for race and ethnicity to be part of the equation in determining readmission target rates, perhaps the AHA should be calling for assurances that HHS will help minority-serving hospitals devise specific programs that will ameliorate the readmission disparity. One finding: patients who contract infections while in hospital are more likely to be readmitted. Therefore, making sure minority-serving facilities implement simple safety programs (hand-washing, checklists, etc.) to reduce hospital-acquired infections after surgery or at the site of central lines could be an affordable way to reduce readmission rates.
The fact is, we actually know quite a bit about how to reduce a hospital’s readmission rate, whatever the racial/ethnic mix of its patients. A critical mass of studies has found that the most important factor in preventing hospital readmissions is improving follow-up care after discharge. This includes devising a comprehensive discharge plan that facilitates communication between doctors who treated a patient in the hospital and those who will see him as an out-patient as well as a link to community services to help monitor those who are particularly vulnerable to ending up back in the hospital. Disease management programs can also be effective in reducing rehospitalization. The chart below offers some key strategies.
The focus on “seamless care” is not currently the norm at most hospitals. A 2009 study in the New England Journal of Medicine of Medicare beneficiaries who were rehospitalized within 30 days of discharge, found that more than half had not visited a physician’s office between the time of discharge and being readmitted. This fact “is of great concern and suggests a considerable opportunity for improvement,” write the NEJM authors. “Hospitals and physicians may need to collaborate to improve the promptness and reliability of follow-up care.”
A letter from Mahesh Krishnamurthy, a geriatrician and clinical assistant professor at Drexel University that was published in the Annals of Internal Medicine last year, gives even more details of the lack of continuity of care: “Approximately 41% of patients discharged from hospital have a test result pending. In two-thirds of these cases the MDs involved were unaware of the results. Of these pending tests, 9.4% required potential urgent action.” Krishnamurthy continues, “One fourth of all discharged patients require additional work up. 33% of these follow up outpatient tests are not completed.”
The health reform law has specific provisions to help hospitals reduce their chance of being penalized. First of all, the ACA sets aside $500 million for a readmissions-reduction Medicare pilot program that started earlier this year. Secondly, the emphasis on increasing the number of primary caregivers—whether they be doctors or nurse practitioners—will be another key to reducing hospital readmissions. Increased funding for community health centers, another provision included in the ACA will also encourage better access to conveniently-located primary care.
In a recent study, Brian Jack, associate professor at Boston University School of Medicine found that adding one family physician per 1,000 residents at the county level, or 100 per 100,000, could reduce hospital readmission costs by $579 million per year, or 83 percent of the ACA target.
The Boston researchers combined figures from the Hospital Compare database with a set of data that measures physicians per population at the county level. “Using these data, we found that 30-day readmission rates for (pneumonia, heart attack and heart failure) decrease as the number of family physicians increases,” writes Jack. “Conversely, increased numbers of physicians in all other major specialties, including general internal medicine, is associated with increased risk of readmission,” he added.
Another important change is the new emphasis on accountable care organizations—groups of providers that include hospitals, primary care doctors, specialists as well as nurses and other caregivers—that will be paid a set fee to follow a patient through all aspects of an illness. Theoretically, fragile patients leaving the hospital will receive follow-up telephone calls and other communications to remind them of tests and doctor visits and to monitor their care for problems before they become serious enough to require hospital readmission. It will be in the accountable care organizations financial interest to keep patients out of hospitals, not bouncing back and forth accruing charges.
It’s become increasingly clear that hospitals will not have to reinvent the wheel when they begin undertaking readmission reduction strategies. Groups like the Society of Hospital Medicine and their Project Boost (Better Outcomes for Older Adults Through Safe Transistions) and the Institute for Healthcare Improvement’s STAAR program (State Action on Avoidable Hospital Readmissions, an initiative funded by the Commonwealth Fund) have already helped dozens of hospitals serving a wide range of patients and geographic locales use grants to reduce Medicare readmission rates.
In the end, the health reform law is introducing many provisions that will fundamentally change the profit motive for providers; linking monetary reward more closely to quality over sheer utilization. When CMS rewards hospitals for reducing readmissions and penalizes them for excess rehospitalizations they are removing deep-seated incentives providers have had in the past to fill empty beds.
Throwing up our hands in resignation and giving minority-serving hospitals a break on having to meet quality standards is ultimately a disservice to those patients who seek care from these facilities. In fact, hospitals that struggle with high Medicare readmission rates are precisely the ones that need incentives to provide better care coordination and will benefit the most from improved follow-up as well as new community health centers and accountable care organizations. It is important that CMS, as well as private groups like IHI and Commonwealth continue to help fund efforts to institute proven strategies in reducing readmissions at the lowest performing hospitals. Only then can we begin making progress on eliminating preventable disparities in health care.