Back in October 2012, Medicare began penalizing hospitals for excessive readmission rates, with the penalties rising annually through 2014. In that initial phase, more than 2,000 hospitals were hit with payment penalties.
Nearly one in five Medicare patients is readmitted within 30 days of hospitalization, often for preventable causes, and the nationwide cost of preventable readmissions under Medicare alone has been pegged at $17 billion, according to the Centers for Medicare and Medicaid Services.
Preventable hospital readmissions remain a challenge for the healthcare system, as does the fact that patient characteristics significantly affect readmission risk. A November 2015 report in JAMA Internal Medicine concluded, “Hospitals with high readmission rates may be penalized to a large extent based on the patients they serve.” The study identified more chronic conditions, less education, more depressive symptoms, worse cognition and more difficulties with activities of daily living as among more than a dozen problematic patient characteristics.
So the current system of Medicare penalties, and indeed expectations regarding readmissions more broadly, might well be unfair to a substantial degree. But unless and until that changes, hospitals will remain under pressure to reduce readmissions.
Given that, and for ample other reasons, it makes sense to examine management approaches that can minimize preventable readmissions.
1. Get better, timelier data
“One issue,” says Kip Piper, president of Health Results Group, “is just data and the lack of it.”
The healthcare system needs “a much more robust system of data and analytics,” instead of relying on a billing system or CMS, he contends. “You can’t wait for that. You need that actionable, decision-relevant information day to day.”
2. Identify high-risk patients
Such timely (if not necessarily real-time) information, Piper says, increases the likelihood of identifying patients who are at risk of readmission, based, for example, on the source of admission.
“Certain populations are far more likely to be readmitted,” he says. “We know that certain nonclinical characteristics are highly influential on whether they’re at risk of readmission.”
One warning characteristic is payer status, because, for example, a Medicaid or dual-eligible patient is less likely to speak English well and more likely to have a behavioral health issue.
“It’s not about blaming the patient,” Piper says, but rather about recognizing that some patients have to contend with an abusive living environment, a low level of education, substance use/abuse or even homelessness.
Medical complexity, such as chronic health conditions, behavioral health issues or multiple medications, is an issue with many patients at high risk for readmission, says Anita Morris, director of practice transformation in the Office of Healthcare Innovation and Quality, University of Massachusetts Medical School.
She adds that parallel to medical complexity there is “social complexity.” A high-risk patient might, for example, lack transportation to get home from the hospital or to pick up prescription medications. A lack of transport, Morris notes, could, for example, delay a patient starting on antibiotics for two or three days, compromising a clinical outcome.
A common mistake, says Don Hall, president of DeltaSigma LLC, is to treat people from different cultures the same or to ignore socioeconomic disadvantage. A patient with diabetes might not have something as simple as ready access to orange juice after being discharged.
Finally, Piper points out, factors that had nothing to do with a patient’s admission, such as behavioral or mental health issues, might strongly increase the patient's risk of readmission.