Policy Must Examine the Complexity of Hospital Readmissions

Focusing on hospital readmissions can be a strong impetus for positive change, healthcare system redesign, and improved health status for patients. But it only works if we do it with the proper considerations in mind.
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Healthcare and government officials share the common goal of reducing hospital readmissions to improve medical care and better manage medical resources. But new regulations to back this mission must be supported by real-world experience to prevent unintended consequences to hospitals that serve the neediest communities.

Readmission regulations are meant to encourage hospitals to do more so patients do not come back to the hospital soon after discharge. Hospitals will not be reimbursed by Medicare for readmission within 30 days of discharge for patients with heart attack, heart failure, or pneumonia if the hospital's readmission rate is higher than predicted. This applies regardless of whether the patient returns to the same hospital or another hospital.

There is potential for tremendous benefit to patients and for Medicare. But the reasons for readmissions are complex and the study of how to reduce them is truly a nascent science.

We do know readmissions are costly. Medicare spends about $15 billion a year on readmissions to hospitals, according to the Medicare Payment Advisory Commission, and about $12 billion of those readmissions may be preventable.

A successful nationwide campaign to end unnecessary readmissions would improve outcomes for patients as well as allow those resources to go to training, research, care innovation, expanding coverage and access to care. Not every readmission is preventable, but rates across the country and the experience of many hospitals suggest that hospitals can do better.

In fact, many hospitals are rethinking and redesigning their approach. Led by the work of researchers like Eric Coleman, MD and Mary Naylor, RN, hospitals are providing greater support for the patient during the transition from the acute care hospital to home. Nurses are coaching patients to manage their condition better. Follow-up calls to patients are helping them keep appointments and medication management programs are helping them stay on regimens. Other programs are improving coordination between primary care offices, hospitals and nursing centers.

The new regulations need amendments to prevent unintended harm to hospitals that are following these steps and others to reduce readmissions. It should start with proper risk adjustment of readmissions data.

Risk adjustment is common in hospital outcomes data. A hospital that sees heart patients who have no other co-morbidities, for example, will see different results than a hospital that treats heart patients with multiple, serious complications.

Readmission risk factors can include social isolation, financial barriers to medications and supplies, limited health literacy, limited access to outpatient and primary care providers, as well as common co-morbidities like depression. These are exactly the conditions that are most severe in communities of need. It would be an undesired and unintended consequence of the readmissions rules to cut payments to hospitals whose patients are disadvantaged, creating greater inequity.

If these factors are not incorporated into risk adjustment models, a misleading impression may occur about a hospital's readmissions. Indeed, a hospital may have a higher than average readmission rate, but still be managing readmissions well and to the benefit of patients, when compared with peer institutions caring for similar patient populations.

Regulations also should focus on conditions where evidence suggests readmissions can be reduced. These conditions include congestive heart failure and asthma, where following care guidelines and implementing post discharge care management can prevent relapses.

These reasonable changes will improve the goal of reducing hospital readmissions, allow hospitals to maximize their efforts and resources on readmissions they can control, and provide balanced measures that all hospitals can follow.

Focusing on readmissions can be a strong impetus for positive change, healthcare system redesign, and improved health status for patients. But it only works if we design our intervention and measurement approaches with careful consideration of what patients need, what is fair, and what has been proven through medical studies.

Eliot J. Lazar, MD, MBA, is Senior Vice President, Chief Quality & Patient Safety Officer at NewYork-Presbyterian Hospital. Karen A. Scott, MD, MPH, is Vice President, Quality and Patient Safety for NewYork-Presbyterian Hospital.

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