Fisher: Readmission Problem Needs a Teaching Hospital Solution

Wednesday's Dartmouth Atlas report targets a failure to reduce hospital readmissions and places 94 academic medical centers in its crosshairs, disproportionately heaping more blame on them than on community hospitals.

Between 2005 and 2009, "Academic medical centers made limited and uneven progress in improving care," the report says. "These findings suggest that even some of the largest and most technologically sophisticated hospitals in the country over the five-year study period face considerable challenges in improving care for the elderly."

But the nation's teaching hospitals did not have higher rates of readmission than community hospitals, and regional variation was just "somewhat higher."

So I asked Elliott Fisher, MD, director of the Dartmouth Institute's Center for Population Health: Why pick on them? Fisher is an architect of the accountable care organization  and other concepts embedded in the Affordable Care Act.

"Academic medicine has held itself up as leaders of both thinking and improvement in healthcare," he said in a telephone interview. "So the question is, if not academic medicine, then who? Where else are we going to do the research that allows us to improve the quality of care and lower its cost?"

It just hasn't happened at anywhere near the level it's needed at the places teaching the next generation of physicians, he says.

"It's fair to say we have not seen an emphasis on care coordination as the focus of academic initiatives as much as in other areas of innovation and clinical treatment. And innovation in care management is one of the things we need desperately," he says. In fact, Dartmouth studies 15 years ago showed academic medical centers with the same readmission problems, so really nothing has changed.

Fisher also criticizes academic and community hospital systems for failing to reduce the number of beds that won't be needed when all these readmissions are avoided. Instead, hospitals are expanding lines of service with greater profit margins, even those procedures with questionable effectiveness. No money will be saved that way, he says. But more on that later.

Joanne Conroy, MD, chief healthcare officer for the Association of American Medical Colleges, acknowledged in a phone interview that the nation's teaching hospitals must do a much better job in discharge planning and managing patients in their homes or care facilities. And they need to do more research in care processes to find better ways to coordinate care and translate that into practice. They're working on it, she says.

But it's a much tougher problem than the Dartmouth folks appreciate, she contends. For many teaching and research hospitals, patients come from miles away for specialized kinds of care and then return home, perhaps to a suburban or rural area, where care is taken over by a community physician. And town/gown conflict rears its head.

The hospital discharge planners might send the doctor a fax with instructions for the patient's follow-up care. "But the doctor says, 'No, I know this family. I'll manage them the way I'll manage them,' and throws the fax in the trash," Conroy says.

In some of these smaller community hospitals and physician practices, she says, "the trigger point for a readmission is lower, or the (care providers in that area) are not involved in the same care pathway that an academic medical center tends to follow."

That's a polite way of saying that communities with hospitals grappling with reduced census may be hungrier for business than academic medical centers, which Conroy says have remained full. And how does a teaching hospital tell a community practitioner or emergency room doctor hundreds of miles away that their patient should not be admitted?

But Fisher says academic medical centers should not be allowed to make that excuse.

"It's implausible that all the variation is explained by hospitals receiving their patients from distant places. I don't think we should let academic medical centers off the hook because their patients might come from a long ways away.

What patients want is that their care is coordinated. So if there needs to be information provided, you give it back to the other hospital and providers to help keep that patient out of the hospital."

Conroy says that the AAMC has gone so far as to purchase a large dataset from Medicare to see in detail which hospitals are readmitting patients discharged from academic medical centers, readmissions that raise the teaching hospital's readmission rate, not the readmitting hospital's.

"We are taking this very seriously," she says. "But first we are getting the data."

It's true that prior to 2009, academic hospitals were expanding or grappling with the cost cutting necessitated by the economy. "But in 2009, we started saying, this is an issue we have to address."

"Best Practices for Better Care," is an example of one campaign that focuses on three initiatives: surgical checklists, central line infections, and readmissions, she says. Creative patient management after discharge is starting to emerge.

For example, in Georgia, congestive heart failure patients waiting for heart transplants were found not have air conditioners, which could exacerbate their co-morbidities. So now they receive $200 window units while they wait for a match.

In other parts of the country, to improve communication between community practitioners and patients who have no land lines, university hospitals are purchasing cell phones.

"These are things that a university center and an endowment have funds for," she says.

Fisher says that if all hospitals put their minds to it, 30% of readmissions at academic medical centers and community hospitals can be avoided, with concomitant savings of a very large chunk of the $26 billion Medicare now spends on readmissions each year.

Fisher and David Goodman, author of Dartmouth's readmissions report, emphasize that the problem of readmissions is also a problem of admissions. Regions of the country with the highest rates have higher rates of both. That indicates that hospitals are being used as the primary sites of care more than they need to be, and that's because until healthcare reform fully kicks in, that's where the money is.

But payment incentives are starting to change with the creation of accountable care organizations and the federal imposition of fines as high as 1% of Medicare reimbursement for hospitals with higher than expected readmissions poised to take effect one year from Saturday. The names of hospitals said to have "worse" rates than the U.S. average are now posted on HospitalCompare.

But, Fisher has a big worry about what might come next. The whole point of reducing readmissions is to improve care and reduce cost, of course. That means that hospitals need to close down beds that are no longer needed.

That's not what seems to be happening.

"We know from anecdotes around the country that hospitals that successfully reduce readmission rates through effective programs are then recruiting orthopedic surgeons," he says, for lines of service that may not be in the patient's best interest. Types of spine surgery for back pain, for example.

"They're being recruited for surgeries that we know from our work on informed patient choice that if the patients get good balanced information for many of these procedures, they would choose not to have them," Fisher says.

"We are going to need to right-size the healthcare system, and that may very well lead to fewer hospital beds." Until we move to accountable care, we're not going to fix this problem.

In sum, Fisher says, "academic medicine has an opportunity to help us solve this problem. But we don't see a lot of evidence of their having done so in the last five years with this data we show. Why not?"