Earlier this month, CMS released data on the Hospital Readmissions Reduction Program (HRRP), and the news is sobering. A total of 2,573 hospitals face reimbursement cuts in fiscal year 2018, nearly as many as last year.
Under HRRP, Medicare docks hospitals up to 3% of normal reimbursement if they have higher-than-expected 30-day readmissions for six conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, hip/knee replacement and coronary artery bypass graft surgery. Next year’s penalties are based on readmissions that occurred between June 2013 and June 2016.
In the five years since the HRRP began, it has shown clear results. According to a CMS report last year, 565,000 readmissions were avoided since 2010, some a result of the penalty program and others the result of readmission reduction efforts hospitals were independently making. More than half of all U.S. hospitals were docked in 2015, with a total of $528 million withheld.
But there are questions as to how far hospitals can go in lowering readmissions, and how the penalties are assessed. Starting next year, for example, CMS will base penalties on a hospital’s performance relative to other hospitals with similar volumes of dual-eligible patients. This should provide some relief for safety net hospitals by taking into account socioeconomic differences in their base populations.
But while that may help to level the playing field, it doesn't ensure hospitals will make more progress in reducing readmissions in the future. An analysis by Yale researchers found no drop in overall readmissions from 2012 to 2015, despite slight improvements for the targeted medical conditions, according to Kaiser Health News.
A New England Journal of Medicine study also showed the pace of declines slowing, with the biggest drop just after the Affordable Care Act passed in 2010. “Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term,” the NEJM researchers said.
No right rate of admissions
“We know that the right rate of readmissions for patients is not necessarily zero,” says Akin Demehin, director of policy at the American Hospital Association. “There will always be that subset of patients who, for clinical reasons, need to come back to the hospital because that is the safest and highest quality care for them. On the other hand, we look at the trends and the data and it does raise questions about how the measurement is done and whether there are some opportunities to identify additional strategies to reduce readmissions.”
When you look at readmissions as a percentage of hospital discharges, which is what the HHRP measures do, the drop has been significant, but shows signs of potentially leveling off, Demehin tells Healthcare Dive. But if you look at reduction from a population perspective and measure it at, say, a per 1,000 rate, the results look better.
We know that the right rate of readmissions for patients is not necessarily zero. There will always be that subset of patients who, for clinical reasons, need to come back to the hospital because that is the safest and highest quality care for them.
Director of policy at the American Hospital Association
And successful readmission reduction efforts reduce admissions, so the denominator of overall discharges gets smaller. Any drop in readmissions may not result in a drop in penalties, Demehin adds.
Two other factors may help to mask the gains hospitals are seeing. The way the penalty formula is written, the readmission penalties are inversely proportional to the readmission rate. In other words, as the national readmission rate goes down, the penalty can stay the same or increase a bit. In addition, CMS has steadily grown the number of conditions it measures in the program, leading to more opportunity to experience a penalty, since hospitals must show a reduction in readmissions across all measured conditions.
Tackling the readmissions problem
When it comes to lowering readmissions, most hospitals agree post-discharge planning is key. Transitions of care involve everything from providing solid discharge instructions that spell out for patients what they can expect when they leave the hospital (what symptoms to watch for and what to do if they encounter issues) to building connections with resources in the community.
“A lot of readmissions performance is driven less by what happens in the hospital and more by what’s available in the community to help patients recover once they’ve left the hospital — the availability of pharmacies, of primary care, rehab services,” explains Demehin. “Making connections to those resources for patients is really important and part of what the care coordination and discharge planning effort in hospitals is really all about.”
Rebecca Tyrrell, senior consultant for research at the Advisory Board Company, says more hospitals are implementing dedicated teams to manage transitions. The models vary depending a hospital’s resources and patient population, but the most common rely on nurse or social work case managers to follow the patient for those 30 days post-discharge. They will visit the patient in the home, attend primary care appointments, check that they have their medications, engage in teach back and more.
One of the more innovative models combines a telephonic nurse care manager with a mobile unit that includes a social worker and community health worker to assist patients at high risk of readmission because of housing instability, lack of transportation or other social vulnerabilities.
The other piece of readmissions reduction is focusing on processes of care within the hospital. Improvement efforts aimed at infection prevention and ensuring processes are as safe as possible all tie back to the likelihood of patients being readmitted.
“Readmissions does create a very effective lens for us to recognize that a hospitalization is part of the continuum of care and after discharge there’s a lot of vulnerability that’s based on patients being able to successfully or less than successfully follow through on post-discharge instructions, plans, medical care and follow-up,” says Daniel Brotman, director of Johns Hopkins’ hospitalist program and member of the Miller-Coulson Academy of Clinical Excellence. “On top of that, there’s the debility that can result from a hospitalization that can predispose frail patients to getting all sorts of other post-hospital problems.”
Impact on outcomes
For a readmissions reduction approach to be truly effective, it needs a robust risk-stratification process and a risk-assessment process at the individual patient level, says Tyrrell. With limited resources, hospitals need to narrow in on those cases where readmission is predictable and preventable rather than try and tackle their all-cause readmission rate. And they need to understand all the issues that could prevent a particular patient from adhering to their clinical care plan.
“I believe the estimate is about 68% of Medicare avoidable readmissions are related to medication issues,” Tyrrell tells Healthcare Dive. “It’s not a one-size-fits-all approach. It requires you to dive deep and understand the risk factors for the individual patients.”
It’s also not a given that reducing readmissions will improve overall outcomes, though hospitals agree it’s a worthy goal. “There are certainly instances where readmissions do not track with other quality of care metrics,” notes Brotman. For instance, there is not a positive association between low readmission rates and low mortality rates. Yet hospitals that have good mortality rates don’t tend to increase them when they reduce readmissions.
It’s not a one-size-fits-all approach. It requires you to dive deep and understand the risk factors for the individual patients.
Senior consultant for research at the Advisory Board Company
Reducing readmissions is often about figuring out how much can be done outside the hospital without compromising the patient’s care. Hospitals should be working hard to avoid preventable readmissions, but working to keep a patient with advanced heart failure out of the hospital is like putting Band-Aids on a problem that will keep progressing, Brotman says. “That is a long run for a short slide.”
Explore new strategies
While managing transitions of care is key, there are other steps hospitals can take to improve readmission rates. One is to look at the data they have and identify specific subpopulations that are most vulnerable to readmission. An example is the AHA’s 123forEquity campaign, which encourages hospitals to take quality measures, including readmission measures, and stratify them by a variety of factors to identify gaps or differences in care.
“That kind of proactive look at the available data could be very beneficial for ongoing readmission reduction efforts,” says Demehin, who would like to see more research on readmission reduction strategies.
Getting on board the value-based care wagon may also help. According to a recent study, hospitals that participate in voluntary value-based programs have fewer readmissions than those that rely on financial incentives alone to reduce high rates.
And there is some evidence that better palliative care can reduce readmissions by helping patients understand that they are likely to require repeated hospitalizations based due to a medical problem that can’t be fixed.
A growing number of hospitals are also narrowing their post-acute care networks to improve coordination and communication protocols for patients who won’t be returning home immediately after hospitalization. Building very high-quality, collaborative relationships with just a subset of skilled nursing facilities in an area can provide better control on what happens to patients after they’re discharged, Tyrrell says.
Still, it’s unrealistic to expect that patients who leave the hospital will never return in that 30-day window. When studies have looked at what percent of readmissions are preventable, it’s often far less than 50%, says Brotman.
“Even if you do everything right, it is likely that you can only prevent a fraction of the readmissions that you’re seeing at your institution,” he adds. "Any further reduction in readmissions is going to be a result of rationing care.”