Latest readmission study shows progress has stalled
With rates static, some wonder if focus helps quality
After a national report last week showed stagnant progress in hospital readmission rates, some providers questioned if the current national focus on this measurement will actually yield the better quality that policymakers expect.
For the study— After Hospitalization: A Dartmouth Atlas Report on Post-acute Care for Medicare Beneficiaries— researchers examined the records of more than 10.7 million hospital discharges for two periods: July 2003 through June 2004, and July 2008 through June 2009. The findings showed little change in U.S. 30day readmission rates, regardless of the cause of the initial hospitalization. Surgical readmission rates were 12.7% in both 2004 and 2009, while medical readmission rates increased slightly to a rate of 16.1% in 2009, versus 15.9% in 2004. (For more on readmission rates, see p. 32.)
The study comes at a time when providers are readying for 2013, when they face a payment penalty for excessive readmissions (embedded in last year’s Patient Protection and Affordable Care Act) of as much as 1% of their total Medicare billing, according to Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. That number will climb to 2% in 2014 and 3% in 2015.
“Generally, during this time period, this is really a static problem,” Dr. David Goodman, the study’s lead author and co-principal investigator for the Dartmouth Atlas Project, said during a call with reporters last week. “Although there was a variation by region in readmission rates, there is no place that stands out as having low readmission rates.”
Despite the overall slow improvement rate, some hospitals showed notable advances, such as the University of Michigan Hospitals and Health Centers in Ann Arbor, where the rate declined to 17.4% in 2009 from 20% in 2004.
The leader of the 859-bed Michigan hospital acknowledged that readmission rates are one piece of a broader quality spectrum and may not be the be-all-and-end-all that some industry leaders anticipate. “First of all, it’s hard work and we’re probably just scratching the surface, as is everyone else,” said CEO Doug Strong. “It may prove that readmissions is not the golden nugget everyone is after.”
As providers work to improve quality and efficiency simultaneously, Strong said, the concept of readmissions is seen as a “proxy” for both. “Our organization treats very sick patients, many of whom need to be readmitted. It’s not necessarily a medical error,” he said. “That’s why I call it a proxy. Time will tell. The measurement of what is ‘quality’ and what is ‘efficiency’ is an ever-changing game right now.”
Strong cited a strong connection between inpatient and outpatient care as a primary reason for the University of Michigan Hospitals’ better rates, and he highlighted examples of successful programs. One includes having a solid discharge strategy that ensures patients have a clinic appointment scheduled when they leave. If a patient is unable to schedule an
appointment with his or her regular doctor, then the University of Michigan will work to schedule a clinic appointment.
“Having a clinic appointment after discharge appears to be one of the most important elements of success,” Strong said. He also said some of the improvement can be attributed to better “medication reconciliation” for patients who leave the hospital with a variety of medications, as well as a robust health information technology system, which includes chronic-care registries, that has helped clinicians providing ambulatory services. Under a subacute-care program, meanwhile, University of Michigan geriatricians work full time in several unaffiliated nursing homes.
William Van Slyke, vice president of communications and public relations at the Healthcare Association of New York State, echoed Strong’s comments that time will judge if hospital readmission rates will be as important a predictor of quality as some think it will be.
“There is a huge element of experimentation here,” Van Slyke said. “I think in some broad ways it parallels preventive care,” he said, referring to the idea that preventive-care programs can reduce healthcare costs. “There have been studies that say preventive care doesn’t reduce long-term expenditures,” he added. “A lot of this is like a jack-in-the-box. Everyone is working hard to turn that crank, and we’re not sure what’s going to pop out.”
Roughly 273,600 patients landed back in New York hospitals within 30 days after leaving, for a total cost of $3.7 billion, according to a study of 2008 figures published recently by the New York State Health Foundation, a private not-for-profit organization. Complications from infections accounted for 26.5% of the readmissions and 35% of the cost, or $1.3 billion, the study said.
And a strained reimbursement environment just adds to the problem, Van Slyke said, adding that the state of New York has seen hospital inpatient rates cut by billions—including about $15 billion over 10 years as part of the healthcare reform law, and nearly $6 billion in cuts to Medicaid in the last 3½ years. “The infrastructure and resources for post-discharge services is virtually under assault.”
Meanwhile, the AHA’s Foster said the Dartmouth report’s study period came just as the industry began to take a serious interest in hospital readmission rates. The starting point was August 2008, when data on readmissions first appeared on HHS’ Hospital Compare website. “Because these are complex problems, I would not have expected to see much improvement in 2009,” Foster said. “We need the data to catch up with what we’ve been engaged in.”