Dou­ble whammy

So­cio-eco­nomic fac­tors can drive up read­mis­sions at safety net hos­pi­tals, leading to dis­pro­por­tion­ate penal­ties

Modern Healthcare - - COMMUNITY HEALTH - By Sabriya Rice

For the health pol­icy team at Henry Ford Hospi­tal, un­der­stand­ing the eco­nomic and de­mo­graphic makeup of the lo­cal com­mu­nity is es­sen­tial. Many of the pa­tients who visit the 751-bed safety net hospi­tal in Detroit come from neigh­bor­hoods that have spe­cific chal­lenges, which hospi­tal of­fi­cials say could neg­a­tively af­fect pa­tient-care out­comes.

Among the chal­lenges are “low house­hold in­come, re­duced ac­cess to gro­cery stores, re­duced ac­cess to a neigh­bor­hood phar­macy, and greater dis­per­sion of people be­cause you have aban­doned houses and va­cant lots,” said David Nerenz, di­rec­tor of the Cen­ter for Health Pol­icy and Health Ser­vices Re­search at the Henry Ford Health Sys­tem.

The lack of re­li­able trans­porta­tion makes it dif­fi­cult for pa­tients to get to fol­low-up ap­point­ments or to pick up med­i­ca­tions. “So, you have people who are more likely to be re­liant on pub­lic trans­porta­tion, but then they are only able to get by with the fre­quency the buses show up,” he adds.

Ac­cord­ing to U.S. Cen­sus Bureau data, about 38% of the pop­u­la­tion of Detroit had an in­come that fell

be­low the poverty level be­tween 2008 and 2012, more than dou­ble the aver­age for the state as a whole. Nearly 83% of the pop­u­la­tion is black.

These are all as­pects, Nerenz said, that po­ten­tially feed into the prob­lem of pa­tients re­turn­ing to the hospi­tal within 30 days of be­ing dis­charged, an is­sue for which U.S. hos­pi­tals are now pe­nal­ized un­der the CMS’ Hospi­tal Read­mis­sions Re­duc­tion Pro­gram, a part of the Pa­tient Pro­tec­tion and Af­ford­able Care Act.

The CMS cal­cu­lates each hospi­tal’s read­mis­sion per­for­mance over a three-year pe­riod, for con­di­tions such as acute my­ocar­dial in­farc­tion, heart fail­ure and pneu­mo­nia. If a hospi­tal has an ex­cess read­mis­sion ra­tio that is worse than the na­tional aver­age, the hospi­tal is sub­ject to a penalty of up to 2%. The method­ol­ogy takes into ac­count in­di­vid­ual fac­tors, such as the pres­ence of co-mor­bidi­ties that dis­pro­por­tion­ately af­fect cer­tain pa­tient groups. But health pol­icy ad­vo­cates are point­ing to a grow­ing body of re­search that sug­gests the so­cio-eco­nomic con­di­tions of the over­all com­mu­nity, specif­i­cally un­em­ploy­ment, racial com­po­si­tion and the amount of unin­sured people, should also be in­cluded to more fairly ap­ply the penal­ties and re­wards, and pre­vent hos­pi­tals with the high­est need from be­ing un­fairly pe­nal­ized for fac­tors be­yond their con­trol.

“As we link re­wards to penal­ties, it’s all the more im­por­tant to un­der­stand where these prob­lems come from,” Nerenz said. “Per­haps the ef­fec­tive mea­sures are not in the hospi­tal at all, but in some other as­pect of com­mu­nity care.”

Amer­ica’s safety net hos­pi­tals, be­cause they pro­vide care for dis­pro­por­tion­ately higher num­bers of pa­tients in these chal­leng­ing de­mo­graph­ics, may be vul­ner­a­ble to dis­pro­por­tion­ately higher penal­ties un­der the cur­rent method­ol­ogy for pe­nal­iz­ing read­mis­sions.

In re­sponse to these con­cerns, more re­searchers have been delv­ing into whether the so­cio-eco­nomic as­pects of the com­mu­nity re­ally do mat­ter. A new study from the re­search and data firm Tru­ven Health An­a­lyt­ics is among the lat­est to tackle the is­sue, by at­tempt­ing to quan­tify ex­actly how much cer­tain de­mo­graphic fac­tors could im­pact read­mis­sion rates.

Us­ing CMS data, which in­cluded more than 2,225 hos­pi­tals that had been pe­nal­ized as of Oc­to­ber 2013, re­searchers eval­u­ated seven fac­tors on the com­mu­nity need in­dex, such as poverty among the el­derly, the num­ber of people with­out a high school ed­u­ca­tion, un­em­ploy­ment rates and lan­guage bar­ri­ers. The re­port found race and un­em­ploy­ment were par­tic­u­larly strong pre­dic­tors of higher read­mis­sion rates. About 18% of a com­mu­nity’s read­mis­sions could be at­trib­uted to un­em­ploy­ment, the anal­y­sis found. So, if about a fifth of the people in a com­mu­nity are un­em­ployed, for ex­am­ple, a hospi­tal could po­ten­tially at­tribute about 3.6% of their read­mis­sions to people not hav­ing jobs, ex­plained David Fos­ter, lead sci­en­tist for Tru­ven’s Cen­ter for Health­care An­a­lyt­ics.

The study also found about 6% of read­mis­sions could be at­trib­uted to poverty among the el­derly. In terms of race, the chances of a black pa­tient be­ing read­mit­ted were al­most 15% higher than they were for a white per­son who was other­wise sim­i­lar.

“This is a dis­par­ity is­sue that has been go­ing on for a long, long time in Amer­i­can medicine, and it’s not sur­pris­ing to see it again here,” said Fos­ter, who said the bur­den of “stub­born so­ci­etal is­sues” can’t be solved by a hospi­tal alone.

Each year Tru­ven re­leases its 100 Top Hos­pi­tals list, which rec­og­nizes high­per­form­ing fa­cil­i­ties based on 14 per­for­mance mea­sures, in­clud­ing re­duc­ing mor­tal­ity and in­pa­tient com­pli­ca­tions; im­prov­ing pa­tient safety; re­duc­ing aver­age pa­tient stay and ex­penses; prof­itabil­ity; pa­tient sat­is­fac­tion; ad­her­ence to clin­i­cal stan­dards of care; and post-dis­charge mor­tal­ity and read­mis­sion rates for acute my­ocar­dial in­farc­tion (heart at­tack), heart fail­ure and pneu­mo­nia. When Tru­ven com­pared the top per­form­ers for 2014 on read­mis­sion penal­ties in a sub­anal­y­sis of the re­cent study, while they found no sig­nif­i­cant dif­fer­ences in the mea­sure among toprated fa­cil­i­ties, those in ar­eas that had high com­mu­nity-need in­dex rat­ings still fared poorly on read­mis­sions.

“If you’re talk­ing about in­tractable so­ci­etal prob­lems like that, there are no easy so­lu­tions. Hos­pi­tals should not be get­ting pe­nal­ized un­fairly. That’s just wrong.” David Fos­ter, lead sci­en­tist for Tru­ven Health’s Cen­ter for Health­care An­a­lyt­ics

“If you’re talk­ing about in­tractable so­ci­etal prob­lems like that, there are no easy so­lu­tions,” Fos­ter said. “Hos­pi­tals should not be get­ting pe­nal­ized un­fairly. That’s just wrong.”

Amer­ica’s Es­sen­tial Hos­pi­tals, a 220mem­ber na­tional as­so­ci­a­tion that ad­vo­cates for the na­tion’s safety net hos­pi­tals and health sys­tems, pro­vides on its web­site links to more than 15 stud­ies look­ing at spe­cific so­cio-eco­nomic data re­lated to health out­comes, such as sur­gi­cal mor­tal­ity, cancer sur­vival and blind­ness.

Among the stud­ies is one pub­lished in May in the jour­nal Health Af­fairs, which looked specif­i­cally at the ef­fect of com­mu­nity so­cio-eco­nomic sta­tus on read­mis­sion rates at Henry Ford.

The study found pa­tients liv­ing in high-poverty neigh­bor­hoods of the city were 24% more likely to be read­mit­ted to the hospi­tal. Be­ing male and un­mar­ried was also as­so­ci­ated with higher read­mis­sion rates, but the study did not ad­dress why these two fac­tors were as­so­ci­ated.

Ad­vo­cates from Amer­ica’s Es­sen­tial Hos­pi­tals say the Tru­ven and Health Af­fairs analy­ses are con­sis­tent with re­search they have been mon­i­tor­ing over the past few years.

“We don’t be­lieve there is fair­ness in the mea­sure­ment sys­tem right now.” Beth Feld­push, se­nior vice pres­i­dent of pol­icy and ad­vo­cacy at Amer­ica’s Es­sen­tial Hos­pi­tals

“The sci­en­tific lit­er­a­ture is there,” said Beth Feld­push, se­nior vice pres­i­dent of pol­icy and ad­vo­cacy at Amer­ica’s Es­sen­tial Hos­pi­tals. More of the vul­ner­a­ble hos­pi­tals are be­ing pe­nal­ized when you look at the broad cross­sec­tion of U.S. hos­pi­tals, she said, and fac­tors out­side of the hos­pi­tals’ con­trol should be taken into ac­count.

“We don’t be­lieve there is fair­ness in the mea­sure­ment sys­tem right now,” Feld­push said.

The CMS said it is com­mit­ted to en­sur­ing that hos­pi­tals serv­ing dis­ad­van­taged pop­u­la­tions are not un­fairly pe­nal­ized, but it has found that safety net hos­pi­tals can and do per­form well on read­mis­sions mea­sures. As­so­ci­a­tion be­tween cer­tain so­cio-de­mo­graphic fac­tors and health out­comes can be due, in part, to dif­fer­ences in the qual­ity of the health­care re­ceived, the CMS said. “Ad­just­ment for these fac­tors could con­found the re­sults,” the agency said in a state­ment.

Though it ac­knowl­edges the com­plex­i­ties of the is­sue, the CMS con­tends that hos­pi­tals can in­flu­ence some of the so­cio-eco­nomic fac­tors in their com­mu­ni­ties. “The scope of ac­tiv­i­ties that fall within a hospi­tal’s

con­trol is wider than it may seem, giv­ing hos­pi­tals a range of op­por­tu­nity to in­flu­ence read­mis­sion rates in their com­mu­nity.”

In 2011, there were ap­prox­i­mately 3.3 mil­lion adult, 30-day, all-cause hospi­tal read­mis­sions in the U.S., and they were as­so­ci­ated with about $41.3 bil­lion in hospi­tal costs, ac­cord­ing to re­cent data from the Agency for Health­care Re­search and Qual­ity. Medi­care pa­tients had the largest share of to­tal read­mis­sions (55.9%), and Med­i­caid had the sec­ond-largest (20.6%).

But progress is be­ing made in driv­ing down the rates, ac­cord­ing to an HHS re­port re­leased in May, which found the rate for Medi­care ben­e­fi­cia­ries con­tin­ued a down­ward trend, drop­ping to 17.5% through the end of 2013.

De­spite the progress, even hos­pi­tals that have seen sig­nif­i­cant im­prove­ments in their read­mis­sion rates re­main con­cerned about the so­ciode­mo­graphic im­pact. “When you pe­nal­ize people, they will make an at­tempt (to make im­prove­ments) … but that at­tempt can go only so far,” said Dr. Paryus Pa­tel, chief med­i­cal of­fi­cer at Cen­tinela Hospi­tal Med­i­cal Cen­ter in In­gle­wood, Calif., which was rec­og­nized in March as one of Tru­ven’s 100 Top Hos­pi­tals in the large com­mu­nity hos­pi­tals cat­e­gory.

Like Henry Ford in Detroit, Cen­tinela, a 369-bed fa­cil­ity of the Prime Health­care Sys­tem, faces spe­cific lo­cal chal­lenges. The hospi­tal is in a com­mu­nity where one-fifth of the pop­u­la­tion (20.1%) fell be­low the federal poverty line be­tween 2008 and 2012. Some large por­tions of the pop­u­la­tion are black or His­panic, and pa­tients of­ten present with var­i­ous co-mor­bidi­ties, Pa­tel said.

Dur­ing federal fis­cal 2013, the first year that the CMS’ 30-day read­mis-

sions penal­ties were im­ple­mented, the hospi­tal saw a 1% penalty. But the fa­cil­ity saw sig­nif­i­cant im­prove­ment the sec­ond year (drop­ping to a penalty of 0.59%), which they at­tribute, in part, to the im­ple­men­ta­tion of a post-dis­charge phone call pro­gram to re­mind pa­tients about fol­low-up ap­point­ments. An­other fac­tor was an af­fil­i­a­tion with a lo­cal phar­macy that of­fers de­liv­ery ser­vices six days a week within a 15-mile ra­dius to help pa­tients with­out re­li­able trans­porta­tion. De­spite the suc­cess, Pa­tel said, get­ting to the ideal—suf­fer­ing no penalty—is not likely to hap­pen.

“We’ve made a small dent, but we’re not ca­pa­ble of chang­ing the whole pic­ture.”

Dr. Paryus Pa­tel, chief med­i­cal of­fi­cer for Cen­tinela Hospi­tal Med­i­cal Cen­ter

“There is no way a hospi­tal can con­trol all the vari­ables,” he said. “We’ve made a small dent, but we’re not ca­pa­ble of chang­ing the whole pic­ture.”

That sen­ti­ment was echoed by Henry Ford’s Nerenz, who said his hospi­tal has ini­ti­ated part­ner­ships with com­mu­nity health­care work­ers who have spe­cial train­ing to help lo­cal pa­tients with high lev­els of need, and lan­guage pro­grams to help those for whom English is not a first lan­guage to im­prove med­i­ca­tion ad­her­ence. The hospi­tal re­ceived a 1% penalty in fis­cal 2013, and im­proved to an 0.80% penalty for the cur­rent year.

“That is money taken away,” Nerenz said, not­ing that a penalty can equate to hun­dreds of thou­sands of dol­lars.

And the real irony, said Fos­ter of Tru­ven, is that it adds an additional chal­lenge to hos­pi­tals that are al­ready strapped.

“Now they have less abil­ity to deal with the prob­lem than they did be­fore,” he said.

Henry Ford Hospi­tal in Detroit has es­tab­lished part­ner­ships with com­mu­nity-based not-for-profit groups to help res­i­dents over­come some of the so­cio-eco­nomic chal­lenges.

Tru­ven Health 100 Top Hos­pi­tals: Na­tional Bench­marks for Suc­cess, 2014 (1 of 3)

Source:Tru­venHealthA­n­a­lyt­ics

*Four­teen hos­pi­tals are Ever­est Award win­ners this year, rep­re­sent­ing hos­pi­tals that have achieved the high­est cur­rent per­for­mance and the fastest long-term im­prove­ment in the past five years. The 100 Top Na­tional Study has been pub­lished for 21 con­sec­u­tive years.

Tru­ven Health 100 Top Hos­pi­tals: Na­tional Bench­marks for Suc­cess, 2014 (2 of 3)

Source:Tru­venHealthA­n­a­lyt­ics

*Four­teen hos­pi­tals are Ever­est Award win­ners this year, rep­re­sent­ing hos­pi­tals that have achieved the high­est cur­rent per­for­mance and the fastest long-term im­prove­ment in the past five years. The 100 Top Na­tional Study has been pub­lished for 21 con­sec­u­tive years.

So­cio-eco­nomic fac­tors in­flu­enc­ing read­mis­sions

At­trib­ut­able risk for ad­justed, 30-day, un­planned read­mis­sions (per­cent­age of in­creased risk)

Tru­ven Health 100 Top Hos­pi­tals: Na­tional Bench­marks for Suc­cess, 2014 (3 of 3)

Source:Tru­venHealthA­n­a­lyt­ics

*Four­teen hos­pi­tals are Ever­est Award win­ners this year, rep­re­sent­ing hos­pi­tals that have achieved the high­est cur­rent per­for­mance and the fastest long-term im­prove­ment in the past five years. The 100 Top Na­tional Study has been pub­lished for 21 con­sec­u­tive years.

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