Hospitals
Question Medicare Rules on Readmissions
Published: March 29, 2013 - New York Times
It is no longer enough for hospitals to make patients
healthy enough to leave. Now, as part of the Obama administration’s health
care overhaul, they are spending millions of dollars to keep those patients
from coming back, often acting like personal assistants to help them manage
their post-hospital lives.
While federal statistics show the effort is beginning
to reduce costly and unnecessary readmissions, a growing chorus of critics is
asking whether the government policy, which penalizes hospitals that have high
readmission rates, is unfair. They are also questioning whether hospitals should
be responsible for managing the personal lives of patients once they are
released — or whether they should focus on other ways to improve care.
“It’s consumed a lot of resources,” said Dr. J.
Michael Henderson, who focuses on quality and patient safety for the Cleveland
Clinic, which attributes its relatively high readmission rate to the fact that
it successfully treats a high number of severely ill patients.
Under the new federal regulations, hospitals face
hefty penalties for readmitting patients they have already treated, on the
theory that many readmissions result from poor follow-up care.
It makes for cheaper and better care in the long run,
the thinking goes, to help patients stay healthy than to be forced to readmit
them for another costly hospital stay.
So hospitals call patients within 48 hours of
discharge to find out how they are feeling. They arrange patients’ follow-up
appointments with doctors even before a patient leaves. And they have redoubled
their efforts to make sure patients understand what medicines to take at home.
But hospitals have also taken on responsibilities far
outside the medical realm: they are helping patients arrange transportation for
follow-up doctor visits, get safe housing or even find a hot meal, all in an
effort to keep them healthy.
“There’s a huge opportunity to reduce the cost of
medical care by addressing these other things, the social aspects,” said Dr.
Samuel Skootsky, chief medical officer of the U.C.L.A. Faculty Practice Group
and Medical Group.
Medicare,
which monitors hospitals’ compliance with the new rules, says nearly two-thirds
of hospitals receiving traditional Medicare payments are expected to pay
penalties totaling about $300 million in 2013 because too many of their patients
were readmitted within 30 days of discharge. Last month, the agency reported
that readmissions had dropped to 17.8 percent by late last year from about 19
percent in 2011.
But increasingly, health policy experts and hospital
executives say the penalties, which went into effect in October, unfairly target
hospitals that treat the sickest patients or the patients facing the greatest
socioeconomic challenges. They say a hospital’s readmission rate is not a clear
measure of the quality of care it provides, noting that hospitals with higher
mortality rates may also have fewer returning patients.
“Dead patients can’t be readmitted,” Dr. Henderson
said.
“We’re using a proxy because it’s a convenient proxy —
it’s just not a very accurate proxy,” said Dr. Karen E. Joynt, a health policy
expert and co-author of an article critical of
the penalties in The New England Journal of Medicine this month. Large
academic medical centers and so-called safety-net hospitals are bearing the
brunt of the new policy, and the authors warn that the penalties could make it
even harder for hospitals struggling to care for those patients with the highest
needs. The current policy, the article says, “has the potential to exacerbate
disparities in care and create disincentives to providing care for patients who
are particularly ill or who have complex health needs.”
The penalties, which apply to rates of readmission
after hospitalization for heart attacks, pneumonia
and heart
failure, are now calculated at 1 percent of hospital payments but will
increase to 3 percent by 2015. Medicare also expects to expand the targeted
readmissions to include more kinds of hospitalizations, like those for chronic
lung disease.
Some hospitals say they have little choice but to
incur the penalties, simply because they have other demands. At Boston Medical
Center, which serves a high number of low-income patients, efforts to reduce
readmissions, including making follow-up appointments and writing out a simple
plan of what to do after leaving the hospital, have been successful for Medicaid
patients.
But the medical center chose not to immediately expand
the program to all patients, including the Medicare patients who would count
toward future penalties.
“We make those trade-offs,” said Dr. Stanley Hochberg,
the center’s chief quality officer. Medicare’s focus on readmissions “doesn’t
necessarily align with our social priorities and medical priorities,” he said.
Medicare officials say they have listened to hospitals’ concerns but defend the
policy as heading in the right direction. “It’s a very traumatic event to go
back to the hospital,” said Jonathan Blum, a senior Medicare official. “I’m
personally comfortable with some imprecision to our measures.”
“The ultimate goal is to have these numbers come
down,” he said.
Because so many hospital readmissions are tied to
social or economic factors, hospitals have a hard time predicting which patients
are likely to return, said Dr. Jan Berger, the chief medical officer for
Silverlink Communications, a consulting firm. When Marjorie Crear, 66, left
Ronald Reagan U.C.L.A. Medical Center after a stroke, she struggled to keep
track of her medications and to remember her doctor appointments. Tiffany Phan,
a newly hired care manager, helped with those tasks and has also been trying to
find public housing with a shower instead of a hard-to-navigate bathtub.
Making it even harder for hospitals is the number of
consultants and companies springing up to offer solutions with little hard
evidence about which steps are the most effective. “We don’t really know very
clearly how to prevent more readmissions,” said Austin Frakt, a health economist
at Boston University.
In some cases, such prevention may take a combination
of efforts that differ from hospital to hospital, said Dr. Risa Lavizzo-Mourey,
chief executive of the Robert Wood Johnson Foundation, which has been financing
pilot programs aimed at reducing readmissions. “One of the key factors we keep
emphasizing is that there isn’t a single magic bullet to fix everything,” she
said.
And complicating the issue even further is the
possibility of doing harm. In 2011, for example, the Department of Veterans
Affairs halted a program in which patients with chronic lung disease were
supposed to learn to take better care of themselves when 28 patients in the
program died, in contrast to 10 deaths in the group receiving typical care.
“It was just an incredible thing,” said Dr. Dennis E.
Niewoehner, a researcher from the University of Minnesota who said the findings
were “a warning signal” for others thinking about embarking on similar programs.
The higher death rate may have been purely chance, he said, but the researchers,
who published their
findings last year, do not know.