Are 30-Day Readmissions Rates a Reliable Indicator for Poor Healthcare Delivery? (Part 1 of 2)

A look at healthcare delivery quality through hospital readmission rates.

Obamacare (Patient Protection and Affordable Care Act) has provisions that require the Centers for Medicare and Medicaid Services (CMS) to financially penalize hospitals and clinics that have unacceptably high readmission rates for Medicare and Medicaid patients within 30 days. Institutions with high 30-day readmission rates in just a handful of situations will suffer financial penalties for ALL Medicare and Medicaid charges during the following fiscal year – not just the handful that are monitored.  Specifically, the CMS tracks 30-day readmission rates for[1]:

 

  • Heart failure
  • Heart attack
  • Pneumonia
  • Chronic lung problems (emphysema and bronchitis)
  • Elective knee and hip replacements

 

The penalties can be as much as 3% of all the Obamacare charges for the coming fiscal year. In most organizations, this can easily amount to millions of dollars. In larger institutions, this can amount to tens of millions of dollars.

The rationale behind this policy is that high 30-day readmission rates are a reliable sign of poor healthcare delivery. The idea is that if the hospitals had done a good job in the first place, patients wouldn’t need to come back so soon.

Ironically, I would say that this claim is both true and false. There are good reasons to treat 30-day readmission rates as a reliable surrogate for poor healthcare delivery.  But there are equally good reasons to treat this arbitrary metric as completely misleading.  We will explore both sides of this argument. Part 1 of this blog will argue that 30-day readmission rates are a reliable guide to the overall quality of the healthcare provided.  Part 2 of this blog will argue just the opposite: 30-day readmission rates are a bogus measure of the healthcare provided.

 

Medicare Readmissions Cost $17 Billion a Year

The most compelling argument in favor of using the 30-day readmission rates as a metric of quality comes directly from the Centers for Medicare and Medicaid Services (CMS). CMS claims that of the total $26 billion it pays annually for readmissions, $17 billion of that figure is for avoidable readmissions[2]. One in five elderly patients returns within 30 days of discharge. These are staggering numbers and, if true, are a strong indictment of the healthcare industry.

Further, this is the figure only for Medicare and Medicaid readmissions – a minority of all hospital admissions. Since there is no organization charged with tracking the costs of readmissions for those with private health insurance or no insurance at all, we will never know the full extent of avoidable readmissions for all patients.

 

Poor Communications at Discharge Is a Primary Driver of Readmissions

High readmission rates have been tracked to poor communications between hospitals and their discharged patients. Patients are often discharged with little explanation about the medications they are to take or the pain they will experience.  Post discharge pain is particularly severe for patients with hip and knee replacements.[3] Patients who expect the pain, know that it is normal, and know how to manage it are far less liable to return to the hospital than those who suffer pain and believe something has gone wrong.

There are other examples of poor communications that lead to rapid readmissions. Some patients who are admitted for chronic obstructive pulmonary disease have their condition treated and are discharged promptly. But the hospital personnel fail to tell some of those patients to stop smoking! They continue to smoke and return to the hospital promptly. Better communications at discharge about the need to stop smoking would make these readmissions unnecessary.

One patient suffered from type 2 diabetes for 14 years. She showed up at the hospital because her blood sugar was out of control. She got patched up and was back on the street again – but with no idea how to administer her insulin or manage her diet. Wham! She was back in the hospital again. This time the nurses and dietician showed her how to handle her insulin and how to change her diet. This was the first she had heard of these things in 14 years.  Strange but true.

Some research[4] indicates that 30-day readmissions could be reduced by 5% simply by improving communications with the patient prior to and at discharge while following a defined process of care protocol.  This is a cheap solution to an expensive problem.

If the solution is so obvious, why hasn’t it been widely adopted? Well, it really boils down to the way our healthcare system is organized. Each of the participants in the system does his or her job as they were trained to. If the system doesn’t focus on clear, thorough communications at discharge, it won’t happen. But that is changing.  Now that CMS is tracking readmission rates, financial penalties are applied regularly, and research uncovers the underlying reasons, the system is changing. Again, we need to point the finger at the hospital protocols, not the individual practitioners.

 

Poor Follow Up is a Big Problem, Too

Half the Medicare patients do not see their general practitioners or a specialist during the first two weeks after their discharge. We have no numbers for non-Medicare/Medicaid patients, but it is reasonable to assume that the story is somewhat similar.

This lack of follow up leaves patients who suffer problems – real or imagined – little recourse but to return to the hospital where they received their most recent care.  Most of them don’t know what else to do.

“Evidence Based Medicine” May Be Another Culprit

Medical and nursing training focuses on the technical aspects of healthcare. This training focuses on the “evidence-based” aspects of what works and what doesn’t. Since there have been few (perhaps no) studies of the importance of patient/clinician based interactions, patient communication hasn’t attracted the attention it should as an important factor in long-term healthcare.

But even if there have been no studies to validate the importance of those communications, common sense should have done the trick.  In any case, the culture is likely to change. Hospital staff will pay more attention to discharge communications in the future.

 

Race and Ethnic Background Are Major Factors in Readmissions

Race and ethnic background are important factors in determining readmissions. Blacks and Hispanics have higher rates of avoidable readmissions than whites.[5] There is a multitude of reasons for this:

  • Less likely to see a primary care provider or specialist
  • Less likely to have a primary care provider they visit regularly
  • Limited proficiency in English leads to poor follow up (less likely to take the medicines prescribed, less likely to understand the discharge instructions, etc.)
  • Poorer health literacy and, as a result, less likely to take personal responsibility for their health
  • Cultural beliefs and customs
  • Less likely to have adequate food, transportation, and social support to follow medical regimens
  • More likely to suffer anxiety, depression, and poor mental health
  • More likely to suffer from a host of medical problems that lead to readmission

Collectively, this means that it is costlier and more time consuming to deal with these patients. When hospital readmission rates were not measured, there was no financial incentive for hospitals to make special efforts to deal with these demographic groups. But now that these statistics are measured and reported publicly and there are financial penalties, we are likely to see hospitals take the steps necessary to minimize readmissions with this demographic.

This does not suggest that hospital administrators were negligent in the past. Rather, it suggests that they were responding to public evaluation and financial metrics that made sense at that time. Once we change the system, we change behaviors.

 

What Gets Measured, Gets Done

This is an old management bromide that applies directly to hospital readmissions. Until the CMS started focusing on hospital readmissions, the issue simply escaped notice. Since it was never an issue, it was never addressed. It was only when healthcare administrators found that their institutions were evaluated and financially penalized with this metric that they focused on it.  That is normal.

Measuring 30-day readmissions and penalizing the worst performing 25% brought a focus to healthcare quality that has been missing for the last three millennia.

The fee-for-service payment model that has been used in this country since day one has never brought light to bear on the quality of healthcare. We have always automatically assumed that all clinicians showed superb judgment and did all that can be done. This uncritical attitude never held anyone in the healthcare field accountable for actual results.

Now, here’s the important point: By pointing a spotlight on high readmission rates and putting penalties in place to penalize poor performers, the federal government believes it can change behaviors.  The rise of Accountable Care Organizations to address this issue is unlikely to have occurred without this sort of impetus. Further, there is evidence (The Revolving Door) that this new-found attention is, in fact, changing some behaviors at the community level. In other words, by measuring readmission rates, hospitals find that they can improve their performance on this metric.

 

Readmissions Are Determined by Where Patients Live

If patient demographics and healthcare delivery systems were homogeneous across the country, we would expect to find the same rate of readmissions uniformly everywhere.  That is not the case. Rather, we see a lot of “lumpiness.” In other words, the rates or readmissions to hospitals are determined to a surprising degree by where patients live.

The map below shows the intensity of readmission rates within hospital referral regions.

Although it would be convenient to tie these widely ranging readmission rates solely to quality of medical care, that would be a mistake.  There are other forces at play:

  • Patient health status
  • Discharge planning
  • Care coordination with primary care physicians and other community based resources
  • Quality and availability of ambulatory care services

Further, some places treat their hospitals as a routine site of care. In other words, it is normal for those in some areas to go to the hospital rather than doctors’ offices or community clinics.

hospital-readmissions
Percent of patients readmitted within 30 days following medical discharge among hospital referral regions (2009)

 

Here is something else I find interesting. If you look at the readmission rates for any one of the five factors I listed immediately after the first paragraph above, you’ll find that the readmission rates for the other four factors are nearly the same for hospitals in the same geographic region.   This correlation suggests that there is some dynamic at play that is independent of the illnesses and chronic conditions in the region.

In other words, the patient is not at the hub of the healthcare system.

 

So, What Does It All Mean?

It requires some judgment to stand back, look at this disparate information, and draw conclusions.  In fact, different people are likely to draw different conclusions.

Nevertheless, I think it’s reasonable to say that 30-day readmission rates can be used, at a minimum, as a rough measure of quality of care. The rise of Accountable Care Organizations (which we will discuss later) and the fact that hospitals have been able to shift their position significantly on the readmissions scale suggests that improvements are possible if we develop the right metrics, measure all hospitals by the same yardstick, and provide rewards accordingly.

 

Read Part 2 Here

 

[1] A Guide to Medicare’s Readmissions Penalties and Data, https://khn.org/news/a-guide-to-medicare-readmissions-penalties-and-data/

[2] The Revolving Door: A Report on U.S. Hospital Readmissions, https://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404178

 

[3] Reducing Readmission Rates with Superior Pain Management, by Bobbie Gerhart, owner, BGerhart & Associates, LLC; former president, Miami Valley Hospital, Dayton, Ohio

 

[4] What Has the Biggest Impact on Hospital Readmission Rates, by Claire Senot and Aravind Chandrasekaran

 

[5] Guide to Preventing Readmissions among Racially and Ethnically Diverse Medicare Beneficiaries, Prepared by: The Disparities Solutions Center, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA

https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/OMH_Readmissions_Guide.pdf