Follow-Up Programs Help Prevent Hospital Readmission, But Hospitals Have Financial Incentive Not to Implement Them

Too Many Hospital ReadmissionsTwo new studies published today in the Archives of Internal Medicine give hope that readmission to hospitals within 30 days after discharge can be reduced significantly by programs that include coaching of the patient at the time of discharge, and follow-up by nurses within the 30 days after discharge.

This is highly significant, because, as noted by both of these studies, currently in the U.S., 20 to 25 percent of patients 65 years or older are readmitted to the hospital within 30 days after discharge. This costs Medicare Billions of Dollars per year, on top of the added suffering for seniors, who, with better health care follow-up, might avoid these relapses and readmissions to the hospital.

“In the United States, 30-day all-cause readmission rates for patients 65 years or older generally range from 20 percent to 25 percent, depending on clinical condition and geographic region, indicating much room for improvement,” wrote the authors of one of the new studies. However, “Interventions addressing patient- and systems-level factors show promise for reducing hospital readmissions,” they concluded.

One of the studies, however, also highlights the fact that in America’s current health care system, such interventions are not fully covered by Medicare or insurance, thereby costing the hospitals more to implement them, than they can be reimbursed. On the other hand, hospital readmissions are reimbursed and revenue-producing for hospitals, thereby creating economic incentives for hospitals not to implement the follow-up programs that could reduce hospital readmissions.

The two new studies appear in the July 25 issue of Archives of Internal Medicine, one of the journals of the American Medical Association.

Background

According to a 2009 study published in the New England Journal of Medicine, about 20 percent of hospitalized Medicare patients were then readmitted to the hospital within 30 days, which cost Medicare an aggregate $17 billion a year at that time.

That study found that in half of these cases, patients don’t see a doctor between hospital stays, suggesting a discouraging lack of follow-up.  Often they are readmitted because they have developed an infection, which may have occurred in the hospital because the medical staff didn’t follow infection-control procedures. According to a report in U.S. News & World Report, a study of heart failure patients published in June, 2010 revealed that while hospital stays shortened between 1993 and 2006, the readmission rate jumped by 3 percentage points.

The Patient Protection and Affordable Care Act contains provisions aimed at reducing hospital readmissions. This includes incentives as well as, starting in 2012, penalties. Beginning in 2012, the new law will reduce reimbursement rates for hospitals with high readmission rates, and Medicare will be directed to recover payments made for unnecessary readmissions within 30 days of discharge after a stay for three conditions: heart attack, pneumonia, and heart failure.

The CMS Hospital Compare website contains information on the readmission rates of different hospitals.

The New Studies

The two new studies reported in the July 25 issue of Archives of Internal Medicine, a journal of the American Medical Association, evaluated hospital programs designed to help transition care for older patients upon discharge from the hospital. Both studies found reduced rates of hospital readmissions among patients included in the programs.

Rhode Island Study

Methodology. In the first study, Rachel Voss, M.P.H., of Quality Partners of Providence, Rhode Island, and colleagues reviewed the results of a Care Transitions Intervention trial, implemented in a real-world setting by six Rhode Island hospitals in 2009 and 2010.

The intervention included a coaching of the patient while in the hospital, as well as a home visit and two follow-up telephone calls with the patient. The objectives of the interventions were “to empower individuals to manage their health and communicate effectively with their providers,” according to the study authors. The coaches gave participants booklets in which to record their personal health records, their main health problems, their medications, and questions for their health care providers. The coaches also provided information to help the patients understand the signs and symptoms of worsening of their conditions before emergency issues occur.

The researchers recruited 1,888 patients at the six Rhode Island acute care hospitals for participation in the program. Patients were separated into three groups: intervention group, internal control group (patients who were approached but declined the intervention or did not complete the home visit) and external control group (patients who were not approached but eligible for participation based on study criteria).

Of the 1,888 patients approached for the study, 1,042 (55.2 percent) agreed to participate and of those, 257 (24.7 percent; 13.6 percent of the eligible participation group) completed the full intervention with home visit.

Findings. The rate of hospital readmissions within 30 days after discharge was significantly lower for patients who participated in the intervention than for those who were never approached for participation in the intervention: 12.8% of the former group were readmitted to the hospital within thirty days, while 20% of the later group were readmitted within 30 days. Patients in the internal control group (those who were approached but declined the intervention or did not complete the home visit) had a similar readmission rate (18.6%) as those in the external control group.

The authors concluded that, “the Care Transitions Intervention appears to be effective in this real-world implementation. This finding underscores the opportunity to improve health outcomes beginning at the time of discharge in open health care settings.”

Baylor Study

Methodology. In the second study, Brett D. Stauffer, M.D., M.H.S., of the Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, evaluated an advanced practice nurse-led transitional care program for patients 65 years and older with heart failure who were discharged from Baylor Medical Center Garland (BMCG) from August 2009 through April 2010. The program included a pre-discharge meeting with an advanced practice nurse and at least eight post-discharge house calls per patient.

The study analyzed readmission data collected to determine the relationships between participation in the transitional care program and the all-cause readmission rate within 30 days of discharge, the length of stay in the hospital, and the direct cost for BMCG within the 60 days from admission, compared to the similar direct cost within 60 days from admission incurred by other hospitals within the Baylor Health Care System that did not participate in the program.

During the period of the study, 140 Medicare patients with heart failure were eligible for participation in the transitional care program, and of these, 56 (40 percent) enrolled in the study.

Findings. The adjusted 30-day readmission rate was 48 percent lower at BMCG after the intervention than before. The program had little effect on the length of hospital stay. However, while the total 60-day direct costs for BMCG were lower per patient who participated in the transitional care program than those incurred by other hospitals in the Baylor system for patients not participating in the program, nevertheless, the hospital lost money by implementing the program because Medicare and Insurance providers did not reimburse for the intervention at adequate rates to cover costs.

The authors wrote:

“Total direct costs for patients receiving the intervention were less than those receiving usual care. However, costs associated with the intervention were not recovered through reductions in index admission direct inpatient costs—the intervention did not save money from the hospital perspective. Additionally, under the current reimbursement system, the hospital lost revenue by preventing readmissions and had a reduction in the contribution margin for an episode of care.”

The authors specifically addressed the changes to be implemented under the Affordable Care Act. They concluded that, even with the financial penalties for certain hospital readmissions that the Act will impose on hospitals starting in 2012, still the costs of implementing interventions like the Baylor program will exceed revenues for the hospitals at currently published reimbursement rates.

They concluded, “Preliminary results suggest that transitional care programs reduce 30-day readmission rates for patients with heart failure.” “This underscores the potential of the intervention to be effective in a real-world setting, but payment reform may be required for the intervention to be financially sustainable by hospitals.”

Implications of the Studies

In an Editorial relating to the two new studies and also published in the July 25 issue of Archives of Internal Medicine, Mitchell H. Katz, M.D., of the Los Angeles County Department of Health Services, observed that, “Decreasing hospital readmissions offers the hope of improving care while simultaneously reducing health care costs.” “It is therefore comforting to read in this issue of the Archives about two successful real-world translations of interventions shown to be effective in reducing hospitalizations in RCTs.”

However, Dr. Katz also noted that, “Although it is pleasing to see the results of the prior interventions extended, other aspects of these real-world trials are sobering.” He concluded by addressing the serious problem created by financial incentives in our medical reimbursement system that discourage hospitals from implementing such programs, which he termed “a widespread problem in American medicine.”

Dr. Katz wrote:

The cost-analysis by Stauffer et al points to a widespread problem in American medicine. Reimbursements are generally linked to episodes of care: visits, hospitalizations, treatments, and procedures. Reimbursements are rarely provided for preventing negative outcomes. As long as this is the case, the American system will produce more visits, hospitalizations, treatments, and procedures. Meaningful health care reform requires meaningful finance reform. We need to pay for quality not quantity, for preventing illness not just treating it. Global payments with quality incentives are needed to improve America’s health care system and reduce its cost.”

More Information

The full study reports are available in the July 25, 2011 issue of the Archives of Internal Medicine at:

The Care Transitions Intervention; Translating From Efficacy to Effectiveness by Rachel Voss, MPH, and colleagues; and

Effectiveness and Cost of a Transitional Care Program for Heart Failure, by Brett D. Stauffer, MD, MHS, and colleagues.

The Editorial is found in the same issue of the Archives of Internal Medicine at:

Interventions to Decrease Hospital Readmission Rates: Who Saves? Who Pays?, by Mitchell H. Katz, M.D.

See also HelpingYouCare™‘s resource pages on VoicesForCare™ > Health Care Reform, including:

Please add your thoughts and comments below.

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Copyright © 2011 Care-Help LLC, publisher of HelpingYouCare™.

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