Can Medicare Feed its Way Out of Some Readmissions?

Feeding some Medicare patients after they are discharged from the hospital could reduce readmissions and save taxpayers millions, a new study has concluded.

According to the new Bipartisan Policy Center report Next Steps in Chronic Care:  Expanding Innovative Medicare Benefits, providing a limited number of free meals to certain Medicare patients could eliminate nearly 10,000 readmissions a year and save more than $57 million.

Participating patients would be those with more than one of a limited number of chronic medical conditions and the meals would be for one week only.  According to the report, more than 575,000 Medicare beneficiaries would be eligible to participate in such a program, with their meals costing $101 million a year, or $176 a person for one week, but the nearly 10,000 Medicare readmissions that would be prevented would reduce Medicare spending more than $158 million a year.

Such a program, if implemented, would be yet another approach to addressing the social determinants of health in many communities.

Such a program would undoubtedly benefit the low-income communities most private safety-net hospitals serve because food insecurity is one of many social determinants of health that challenge the health of the residents of those communities.

Learn more about how such an approach would work and whom it would serve in the Bipartisan Policy Center report Next Steps in Chronic Care:  Expanding Innovative Medicare Benefits.

Medicare Readmissions Down Almost Everywhere

Hospitals in 49 of the 50 states have reduced their Medicare readmissions since the federal health care program introduced its readmissions reduction program in 2010.

Only hospitals in Vermont have failed to cut readmissions.

Nationally, readmissions fell more than five percent in 43 states and more than ten percent in 11 states. Overall, readmissions fell 100,000 in 2015 alone compared to 2010 and have fallen 565,000 since 2010.

cmsAs the program ages more medical conditions are being subjected to the readmissions reduction program’s requirements. In the coming year, the Centers for Medicare & Medicaid Services estimates it will penalize 2500 hospitals $538 million for failing to reduce their readmissions.

Learn more about CMS’s efforts to reduce readmissions among Medicare patients in this entry on the CMS Blog.

Socio-Economic Factors Again Tied to Hospital Readmissions

Another study has linked socio-economic factors to increased hospital readmissions.

This latest study, published in the Journal for Healthcare Quality, found that

… meaningful risk-adjusted readmission rates can be tracked in a dynamic database. The clinical conditions responsible for the index admission were the strongest predictive factor of readmissions, but factors such as age and accompanying comorbid conditions were also important. Socioeconomic factors, such as race, income, and payer status, also showed strong statistical significance in predicting readmissions.

Conclusions: Payment models that are based on stratified comparisons might result in a more equitable payment system while at the same time providing transparency regarding disparities based on these factors. No model, yet available, discriminates potentially modifiable readmissions from those not subject to intervention highlighting the fact that the optimum readmission rate for any given condition is yet to be identified.

iStock_000001497717XSmallThe study found that low-income patients are more likely to require readmission to the hospital than those with higher incomes and hospitals that serve higher proportions of low-income patients are more likely to incur Medicare penalties for readmissions than other hospitals.

NAUH has long made the same argument: that socio-economic considerations make the patients private safety-net hospitals serve far more likely to require readmission to the hospital than is the case with other hospitals. This, NAUH maintains, makes Medicare’s hospital readmissions reduction program unfair to private safety-net hospitals. NAUH most recently expressed this view in a February 2016 letter to the chairman of the House Ways and Means Committee and the chairman of that committee’s Health Subcommittee. See that letter here.

To learn more about the study, how it was conducted, and what it found, find the study “Patient Factors Predictive of Hospital Readmissions Within 30 Days” here, on the web site of the Journal for Healthcare Quality.

Hospitals Not Using Observation Status to Avoid Readmissions Penalties

Hospitals are not moving returning patients to observation status to avoid incurring financial penalties under Medicare’s hospital readmissions reduction program, according to new study published in the New England Journal of Medicine.

new england journalSince that program’s inception, more than 3300 hospitals have reduced the rate at which they readmit Medicare patients within 30 days of their discharge from the hospital. A moderate increase in the classification of Medicare patients in observation status led some critics to suggest that observation status was being used to avoid penalties for readmissions.

The study disagrees, concluding that

we found a change in the rate of readmissions coincident with the enactment of the ACA, which suggested that the Hospital Readmissions Reduction Program may have had a broad effect on care, especially for targeted conditions. In the long-term follow-up period, readmission rates continued to fall for targeted and nontargeted conditions, but at a slower rate. We did not see large changes in the trends of observation-service use associated with the passage of the ACA, and hospitals with greater reductions in readmission rates were no more likely to increase their observation-service use than other hospitals.

For a closer look at the study, the methodology employed, and its conclusions, go here to see the New England Journal of Medicine article “Readmissions, Observation, and the Hospital Readmissions Reduction Program.” In addition, the U.S. Department of Health and Human Services features a commentary about the study on its blog. Go here to see that commentary, titled “Reducing Avoidable Hospital Readmissions to Create a Better, Safer Health Care System.”

Feds Issue Guidance on Reducing Medicare Readmissions

cmsThe Centers for Medicare & Medicaid Services has issued a new report advising hospitals how to reduce readmissions among their racially and ethnically diverse Medicare patients.

According to a CMS news release, the guidance

…is designed to assist hospital leaders and stakeholders focused on quality, safety, and care redesign in identifying root causes and solutions for preventing avoidable readmissions among racially and ethnically diverse Medicare beneficiaries.

The guidance also notes that

Racial and ethnic minority populations are more likely than their white counterparts to be readmitted within 30 days of discharge for certain chronic conditions, such as heart failure, heart attack, and pneumonia, among others. Social, cultural, and linguistic barriers contribute to these higher readmission rates.

The document presents an overview of issues affecting readmissions and offers what it calls “high level recommendations” for hospital officials to “move the needle” on those readmissions. Those recommendations:

  • Create a stronger radar.
  • Identify the root causes.
  • Start from the start.
  • Deploy a team.
  • Consider systems and social determinants
  • Focus on culturally competent, communication-sensitive, high-risk scenarios.
  • Foster community partnerships to promote continuity of care.

According to the report,

Some studies have shown that certain patient-level factors, such as race, ethnicity, language proficiency, age, socioeconomic status, place of residence, and disability, among others—when tied to particular costly and complicated medical conditions such as heart failure, pneumonia, and acute myocardial infarction, to name a few—may be predictors of readmission risk and readmissions. In fact, research has demonstrated—and evaluations of the HRRP to date have found—that minority and other vulnerable populations are more likely to be readmitted within 30 days of discharge for chronic conditions, such as congestive heart failure, than their white counterparts. Given the cost and quality implications of these findings, addressing readmissions while caring for an increasingly diverse population has become a significant concern for hospitals and hospital leaders. In sum, there is a need for additional guidance on how hospitals can focus both system-wide redesign as well as targeted and specific efforts at preventing readmissions among minority and vulnerable populations. 

NAUH has long been among the leaders in calling to policy-makers’ attention the special challenges posed by socio-economically disadvantaged patients and the potential unfairness of Medicare payment policies that fail to reflect challenges. Among other activities in support of this view, NAUH endorsed legislation last year to require Medicare to add a risk-adjustment component to its Hospital Readmissions Reduction Program.

To learn more about the new CMS document Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries, go here to read a CMS news release on its report and find the report itself here.

Study Considers How Best to Prevent Readmissions

A five-year study performed by researchers from the Yale School of Public Health has found that while many hospitals have successfully reduced the rate of readmission for their Medicare patients, few specific strategies have emerged as best practices for tackling this challenge.

commonwealth fundIn fact, only one strategy appears to be universally effective: discharging patients with their follow-up appointments already made.

Beyond that, researchers found that hospitals lowered their readmission rates by employing a number of tools and that most successful hospitals employed at least three such tools – although which tools they employed differed and more tools did not produce better results.

Hospitals have been working to lower their readmissions in response to Medicare’s hospital readmissions reduction program, which imposes financial penalties for hospitals that readmit “too many” of their Medicare patients.

The study’s conclusion:

Hospital readmission rates result from the confluence of diverse patient, provider, and organizational factors. Despite a wide range of hospitals and five years of study, we found little evidence that specific strategies conferred improvements across hospitals, aside from booking follow-up appointments before discharge. Rather, adopting at least three strategies, tailoring implementation efforts to local circumstances, and persistence over time seemed to be keys to success.

Find the Yale study “National Campaigns to Reduce Readmissions: What Have We Learned?” here, on the web site of the Commonwealth Fund, which underwrote the research.

Residents of Disadvantaged Neighborhoods More Likely to Require Readmission

Medicare beneficiaries living in the most disadvantaged neighborhoods are more likely than others to require readmission to the hospital for problems associated with congestive heart failure, pneumonia, or myocardial infarction.

annals of internal medicineThis is one of the findings in a new Annals of Internal Medicine study titled “Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization:  A Retrospective Cohort Study.”

The study, based on data from 2004 through 2009, compared Medicare readmission rates in different geographic areas using what is called a validated area deprivation index that measures relative social determinants of health to identify the most disadvantaged areas.  Researchers concluded that

The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate of 21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI.

These findings confirm the argument that the National Association of Urban Hospitals has been making ever since Medicare’s hospital readmissions reduction program was introduced:  that the low-income Medicare patients many private safety-net hospitals serve are fundamentally more difficult to treat than the typical hospital patient and that the readmissions reduction program needs to be risk-adjusted to account for this difference.

The Annals of Internal Medicine study is just the latest academic research that confirms NAUH’s contention about Medicare’s readmissions reduction program.

Find the study here, on the web site of the Annals of Internal Medicine.

Study Suggests Key to Avoiding Medicare Readmissions

Researchers from the Columbia Business School believe they have identified the key to reducing Medicare readmissions.

Keep patients in the hospital for one more day.

The Columbia study “Should Hospitals Keep Their Patients Longer?  The Role of Inpatient and Outpatient Care in Reducing Readmissions” was based on an analysis of hospital records for 6.6 million patients between 2008 and 2011.

iStock_000001497717XSmallThe study compared the value of one additional day of hospitalization to that of better post-discharge management of patient care.  It found virtually no difference between the two types of additional interventions for heart failure patients but a significant difference when it came to pneumonia and heart attack patients, suggesting that the extra day in the hospital reduced readmissions within 30 days and saved the lives five to six times as many heart attack and pneumonia patients.

The findings could be useful for hospitals attempting to avoid penalties assessed by the federal government under Medicare’s hospital readmissions reduction program, which was mandated by the Affordable Care Act.

Find a summary of the study in this Fierce Healthcare report and see the study itself here.

Community Factors Influence Readmissions, Study Says

A new study reports that a variety of factors, including several linked to socio-economic status, account for 58 percent of the variation in the rate of Medicare hospital readmissions at the county level.

iStock_000001497717XSmallAmong those factors are low employment, living alone, inability to afford care, the supply of primary care providers and specialists, access to post-discharge nursing home care, and more.

The study found that

The evidence shows that after accounting for patient-risk factors (done by the risk- standardization of the publicly reported rates) and community socioeconomic factors (such as income and employment levels), as well as accounting for hospital characteristics and location, a substantial amount of the variation in readmission rates is explained by local health-system characteristics related to primary care access and the quality of nursing homes. These findings have significant implications on how health care leaders, payers, and policy makers should conceptualize the level of accountability for excess readmissions. The current readmission reduction program that aims to penalize hospitals whose readmissions are above a certain threshold may not be appropriate (Centers 2012). Instead, other payment methods such as those being tested in the Community-based Care Transitions Program (Community 2012), where community-based organizations receive a bundle payment to cover the costs of services required in the postacute care transition period, might be more effective.

It also concluded that

… hospital readmission rates might be more effectively reduced if community-based readmission reduction strategies are added to ongoing, hospital-focused improvement efforts.

This has long been the contention of the National Association of Urban Hospitals:  that social determinants of health make the kinds of low-income Medicare patients private safety-net hospitals serve more difficult to treat, contribute to higher readmission rates than the typical hospital, and need to be reflected in appropriate risk adjustment for Medicare’s hospital readmissions reduction program.

The study, from Health Research Services, is titled “Community Factors and Hospital Readmission Rates” and can be found here.