CMS and its health policy experts continue to struggle with
hospital readmissions because they really don’t know what is causing them. Even though they may not understand the root
cause of what could be called the “readmission crisis”, CMS has moved quickly
to set up new reimbursement schemes to lessen hospital readmissions. Hospitals are currently penalized up to 1% of
their Medicare reimbursement for its readmission rates for several disease
states (heart failure, heart attack, and pneumonia), with the penalties going
up each year and additional disease states being added to the mix over
time. Physicians who are employed by or
contract with hospitals to provide medical services can expect to see their
reimbursement tied to readmissions eventually, too.
Coinciding with new reimbursement penalties for readmissions
has been a marked reduction in readmissions nationwide, with CMS publishing
last month a study indicating a reduction in 2012 of 70,000 readmissions, representing
a decline to an 18.4% readmission rate for Medicare beneficiaries from 19% in
each of the previous five years (click here to
read the study). While CMS celebrated
this reduction, even they admit they don’t know why it happened, with the study
concluding: “The reasons behind the apparent reduction are not yet clear and
merit further investigation.”
One hypothesis for the reduction in readmissions making news
today is that hospitals have figured out that to avoid readmissions they need
to treat patients on “observational status” or provide treatment in the ER
instead of admitting the patients. This
currently anecdotal phenomenon of purposely avoiding readmissions was reported
on in Modern Healthcare (click here
to read the story). The approach of
treating patients in outpatient observational settings or the ER has
significant policy implications, ranging from the problem of requiring patients
to pay more out-of-pocket since the outpatient treatment would trigger Medicare
Part B instead of Part A (in fact, there is a lawsuit
on this very issue in Connecticut), to whether “observational status” is the
best treatment for many patients who arguably should be immediately admitted.
This quandary is explored in an article in
this month’s Health Affairs, which concludes that much of a hospital’s
improvement or failure in readmissions is attributable not to quality
performance but rather regression to the mean.
In other words, any movement in readmissions (up or down) in a hospital
that is either doing really well or really poorly is likely to be influenced by
“how high or low [the hospital] was to start” (p. 1087, June Health Affairs)
rather than changes in the care it is providing. Just how much influence statistical noise
like regression to the mean should have on readmission policy is still a
question that needs to be answered.
These are important policy discussions to have, particularly
since current research has not been able to determine much connection between
the level of quality of care that is being provided at a hospital and its
readmission rates. Ironically, the
Health Affairs article suggested that, if anything, hospitals with higher
quality (at least in terms of mortality) have higher readmissions because they
keep more patients alive. More living
patients means more readmissions as compared to a hospital with higher mortality
rates, whose patients are dying instead of being readmitted (p. 1087, June
Health Affairs). This same study also
found that there was little or no correlation between readmissions and other
hospital quality indicators like volume, process-measure performance, and
teaching status.
The bottom line is this…no one seems to really know why
readmissions are happening and why they aren’t.
At the same time, everyone tends to agree that readmissions need to be
reduced. Of course, no one wants
Medicare recipients to be on a revolving door in and out of the hospital every
two weeks. And again, this new
reimbursement penalty will soon be trickling down to the physicians who work in
hospitals, whether employed or independent.
A Solution
This is where physicians need to step in. If anyone knows, physicians know why each of
their patients on an individual basis are readmitted to the hospital. Why?
It’s obvious. Physicians actually
know their patients and what led to the readmission. It could be a issue with care coordination,
it could be patient non-compliance with medication, it could be just the nature
of the disease and its effect on the patient … it could be any number of
things. But these are things that
researchers looking at numbers but not on the front lines of care will be hard
pressed to find. So what should
physicians do? To start, we need to
start talking with each other about how to get the individualized information
that physicians all have and funnel that broad base of information into a
collective source of actionable data that could be used to set policy. Rather than shooting in the dark to set
reimbursement policy that will likely have unintended consequences, let’s as
the physician community assert ourselves and tell the policymakers why
readmissions are really happening. And
during that conversation, let’s shift the reimbursement policy discussion to
ideas that fairly pay physicians and avoid the guessing game that has
influenced so much of today’s reimbursement.
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