Readmissions (1): what are the best policies to reduce them?

To create this readmissions post, I have chosen three publications, the first of which provides a critical review of how the American public insurers address the issue, the second publication gives the point of view, also critical, of two hospital doctors, whilst the third is a review promoted by "The Commonwealth Fund" on the policies of US hospitals that are having the lowest rates of readmissions nationwide.

First publication

According to this article, CMS (the public body that manages the Medicare and Medicaid contracts in the US) estimates the average for the 30-day readmissions rates for patients who have been hospitalized for myocardial infarction, pneumonia and heart failure. If a hospital’s rates go above the average, CMS penalizes it with a reduction in the fees of all income in the following year, in proportion to the deviation of readmissions of the three monitored conditions. It’s estimated that in 2013, in a particular centre, the punishment can reach up to 3% of the turnover. Ah! And there will be no prize for hospitals with rates lower than the average.

With this new contracting model, American hospitals have to deal with two kinds of disincentives: the direct costs of readmissions reducing programs and the falling economical income resulting from the corresponding drop in patient admissions.

On the other hand, the article says that the private HSPC Geisinger has created a bundle fee for surgical procedures. This pack (or bundle) includes the initial admission and all associated services and readmissions for a period of 90 days. In essence, Geisinger, with this action, has launched the concept of a month health guarantee for surgical interventions. In light of the Geisinger experience, then, the authors propose that CMS makes a rate increase in exchange for assuming the risk of hospital readmissions.


Second publication

According to two doctors who signed the article, only a small part of the 30-day readmissions are preventable. Apparently a recent review says that 27%, (ranging from 5 to 79%, van Walraven 2011) and also claim that many of the causes of readmissions are due to circumstances of the patients themselves or their community environment, all of them far from the hospital’s reach. The authors argue that it’s unclear whether readmissions are a reflection of the poor quality of care centres because high rates of readmissions can be the result of low mortality, or even be due to the easy accessibility to the hospital.

"As clinicians, we recognize that both the plans of high protection and the care coordination are often ineffective. Sometimes we notice the occurrence of readmissions because we have not been able to foresee the challenges that the patient has to face once he’s back home, or we have not taken into accounting the patient’ difficulties to connect with their primary care team. For this reason, we the clinicians should redouble our efforts to ensure the issues that are within our reach, such as medication reconciliation at the time of registration or the management to ensure post-discharge visits to the family doctor or community nurse (...) The clinicians are more motivated to prevent readmissions in the first 3 days, or even the first 7 days, after discharge because we believe this is more in our power. We believe that CMS may require guarantees from hospitals for this period, and even penalize them for it".

"The new policy of reducing 30-day readmissions clearly tells hospitals they have to put the focus on achievements that are not within their reach. This will have a negative impact because hospitals will forget to strengthen internal quality improvements and clinical safety which are a big part of their responsibility".

Third publication 

This "The Commonwealth Fund" report draws lessons from the four US hospitals that, in a benchmarking, have the lowest rates of readmissions:

• They invest in quality: if the quality of care and clinical safety improves, they say, the readmission rates are reduced.
• They extensively utilize information technology and patients stratification software as a basic tool for integrated management.
• On admission, they pre-emptively identify patients at risk and they ensure good internal multidisciplinary teamwork.
• They educate patients and their families in managing symptoms and conditions and ensure that there is an understanding of each of the important issues.
• They maintain a hot line with the patient after discharge: telephone, tele-monitoring or other practices.
• They align efforts between the hospital, the primary care and other community services to ensure the care continuum.

Discussion

Hospital readmissions are a phenomenon of different causalities that go from the manifestation of a medical error (such as a suture dehiscence); from a treatment failure (an unfortunate dose) to the lack of coordination between the hospital and primary care units when patients are managed with complex chronic care needs. In my opinion, "bundle” payment models at the risk of hospitals are suitable in the first cases, however they don’t seem to be a good instrument for the latter.

I think doctors who signed the second article are right, with the small exception that this view is too hospitalist, which is greatly limiting in its reasoning. In fact, they admit that there are home–brewed readmissions, once the patient is back, and they say that it's a shame that they’re not more effective there.

But I think the solution is given by "The Commonwealth Fund" report. Observe the policies followed by centres with low levels of readmissions, and you’ll see that what must be fostered is the integrated management between levels, beyond the simple coordination which, although praiseworthy, is clearly insufficient for patients with complex chronic health needs.

Bibliographys

van Walraven C, Bennett C, Jennings A et al. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ, April 19, 2011;183(7):391-402.



Jordi Varela

Editor