Beyond the potential for poor patient outcomes and wasted money, healthcare experts say excessive readmissions have the potential to undermine the reputations of hospitalists just as they are moving to center stage in national quality-improvement (QI) efforts.
“I see, basically every day, patients that come back to the hospital because the discharge process is broken,” says Eric Howell, MD, SFHM, director of the hospitalist division at Johns Hopkins Bayview Medical Center in Baltimore. Dr. Howell says communication difficulties between the hospital and a nursing home have plagued one “revolving door” case involving a patient with a stomach ulcer that requires surgical resection. Hospital surgeons have repeatedly arranged to see her as an outpatient and schedule the surgery, but before the surgery can take place, the patient vomits up blood and is rehospitalized.
Another contributing factor, Dr. Howell argues, is the lack of incentives for both hospitals and hospitalists to work hard at preventing the next readmission. Although Dr. Jencks’ study suggests readmissions might not always be profitable, Dr. Howell and others say the sizeable contribution of rehospitalizations to overall admission numbers and the single-digit profit margins of most hospitals offer little motivation to change the status quo. “I think there are good people who want to fix it,” says Dr. Howell, an SHM board member and Project BOOST mentor. But changing the reimbursement system so that hospitalists can better focus on reducing readmissions, he adds, “will really go a long way.”
A New Landscape
Change is in the air. As part of the federal Affordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) is expanding a pilot project on bundling payments to doctors and hospitals around episodes of care. Starting Jan. 1, 2013, the bundling pilot will define “episodes” as all medical services administered three days before a hospital admission until 30 days after discharge. A rehospitalization within that timeframe would net reduced reimbursements.
CMS also has begun accepting applications for what’s known as the Community-Based Care Transitions Program, with $500 million over five years authorized by the healthcare reform act to fund collaborative, readmission-reducing efforts between hospitals and community-based organizations. Linda Magno, CMS director of the Medicare Demonstrations Program Group (www.cms.gov/CMSLeadership/19_Office_ORDI.asp), says program participants will form a learning network so the agency can quickly deliver information about who’s doing well and what approaches are working better than others. The participating organizations, she says, can then help teach best practices to other hospitals around the country.
CMS has adopted public reporting requirements as another tactic. The “Hospital Compare” website (www.hospitalcompare.hhs.gov/) set up by CMS, for example, uses discharge data to publish rehospitalization rates for heart failure, acute myocardial infarction, and pneumonia. More published rates will be added soon. More importantly, Medicare will begin penalizing poorly performing institutions in October 2012 by withholding a percentage of their payments, starting at 1% and rising to 3% within three years, as part of the value-based purchasing initiative.
