Readmission penalties hit hospitals, but it's not that simple
witf.org, | 05.09.14
It’s hard to find someone who is anxious to return to the hospital, especially after a heart attack, heart failure, or a bout of pneumonia. As part of the federal Affordable Care Act, hospitals face penalties for higher than normal readmission rates. Health care professionals are pleased the issue is getting tackled, but also question whether it’s a good measure of the quality of care.
"I think that's one of our biggest problems. These patients are high risk, no matter what we do, no matter what program we institute for them, they’re coming back anyway," says Tiffany Tidona, at Memorial Hospital in York.
Photo by Penn State Hershey
All the hospitals sound like they’re working to reduce readmissions.
"We’re not just having 1 or 2 people that's just the physician or nurse or otherwise in the rooms while we're talking about these issues. We are bringing in patients, nurses, physical therapists, care coordinators," says Jennifer Goldstein.
Or Memorial Hospital in York:
"We ask them questions. We ask them very specific questions about medications. We ask them about their discharge instructions, if they understood what their discharge instructions were. If they understand what medications they’re on," says Tiffany Tidona.
And there’s Wellspan, with hospitals in Gettysburg, York, and Ephrata:
"Staff very carefully assess what will happen to the patient once their discharged, and they work together as a team, taking essentially a timeout before a patient is allowed to leave to ask the question of 'Is it safe for this patient to leave?'", says Charlie Chodroff.
But the data varies widely.
Medicare looks at how many heart attack, heart failure, and pneumonia patients return to a hospital within 30 days, runs the number through a formula, and determines if a penalty is appropriate. The penalty then impacts the next year’s reimbursements.
So what’s different? Charlie Chodroff, talking about Wellspan’s jump, says hospitals don’t operate in a vacuum.
"It's the hospital and it's community and I think these are community questions as much as they are hospital questions."
That’s a bit of a shift for hospitals that are used to sending patients out the door as healthy as they can be. Now, Wellspan Gettysburg makes sure patients have a follow up visit with their primary care doctor within five to seven days, two nurse practitioners are designated to visit high risk patients at home, and they even coordinate transportation when required.
Karen Joynt is a professor at the Harvard School of Public Health. She wrote an article on the issue in the New England Journal of Medicine.
"These are people, they’re not widgets, they’re not hamburgers, they're not bicycles, they’re not things we can measure and compare to each other. They're people."
Coming up with an explanation for the difference between Wellspan’s rate and Memorial’s or the Hershey Medical Center’s can be like guessing where fruit in the grocery store came from – there’s just so many options.
"It could be the size of the hospital. We’re smaller than Wellspan," says Tiffany Tidona, at Memorial.
"Our clientele is largely elderly. We have patients who prefer to come to us because of the care we give to them."
Photo by Memorial Hospital York
The truth is there just isn’t any good research on the topic. Household income, public transportation, family history, exercise habits and so much more could affect readmissions rates.
And thus, the problem.
"If we’re comparing a hospital that maybe is located in a wealthy suburb and has a lot of patients who have very good access to outpatient care, who can afford their medications, and we compare that hospital's performance to a hospital that’s caring for patients who may have trouble with even securing safe housing, not to mention being able to take their medications and having access to primary care, which is really lacking in a lot of disadvantaged communities," says Joynt.
"I think comparing those two hospitals to each other can get a little tricky."
Joynt also questions the 30 day readmissions time frame. She would rather see something closer to five to seven days, when community effects aren’t as prominent. But she says it has started a good conversation.
"And the leadership, in many ways, has said 'This is tough. These penalties are hard, we're trying to figure out how to deal with it.' And when you talk to the front line staff, say the director of nursing, or the head of care coordination, they would say 'We knew all this. We knew this was a big problem. And now finally someone is recognizing we need to think about health and health care differently.'"
In Memphis, Tennessee, hospitals have started pairing church parishioners with patients going home. In Boston, one health system gives out, for free, 30 days of low-salt meals to heart patients.
"It should prompt the question of, 'So what are you doing to prevent me from coming back into the hospital?' I think that's a very fair question. What do I need to do to [avoid] coming back into the hospital? That’s how I think the questioning should go. If you don’t get a good trustworthy response to that answer, then I would suggest yeah, you probably do want to look elsewhere."
Charlie Chodroff says Wellspan isn’t getting that creative yet, but is thinking about it. Staff from Hershey Med and Memorial echoed his thoughts. Whether any of the ideas actually make it on to the hospital floor, whether the rate is a good, fair measure, one thing is clear: the threat of a financial hit have focused all of them on reducing readmissions.