It may surprise some hospital leaders that we're now in the final year of the first three-year performance period that will determine which hospitals receive the most severe (3%) readmissions penalties.
Those penalties take effect with discharges in FY 2015, and persist every year after that.
So you'd think that hospital leaders would be setting readmissions prevention as their top priority, realizing that both the dollars and their reputations are at stake.
But to a large extent, that's not happening, says national readmissions expert Amy Boutwell, MD. She's calling out the industry for this lapse.
While many hospitals have launched readmission reduction efforts, she says, many are doing so in "a modest way." Some think the strategies are unproven or hope that the penalties will go away. And many executives don't understand how much money they could lose, she says. Boutwell elaborated in a recent interview with me.
HLM: I was surprised by your view, because we hear hospital officials insisting they are working on readmissions.
AB: If you called all 5,000 hospitals today, I'm sure they'd say they're studying or looking at or worrying about readmissions. But as an expert trying to help hospitals get out of the penalty box and improve their readmission rates, I often start by asking them exactly what they're doing. I find that many of the efforts are modest or at the pilot project level.
A quality leader might say, "We're doing Project X, but it's only with 80 heart failure patients who are being discharged home." That's a great place to start. But now, in 2012, we need to rapidly expand those efforts throughout the entire hospital.
HLM: Your observations that hospital executives and their teams are not yet committed, or fully committed, to readmission efforts was a shocker. How commonplace is this attitude?
AB: Some hospital executives know what the penalties are, but sometimes it doesn't go much broader than a limited circle of the C-suite. The chief financial officer, chief medical officer, and director of quality and safety usually know the magnitude of the penalty in dollars, but beyond that, relatively few secondary managers, unit managers, the chiefs of hospital medicine service, or others outside that small circle are aware of the magnitude for their hospital.
HLM: I must live in a rarified atmosphere. I thought this was a top priority.
AB: I recently spoke to a chief medical officer at a large, 650-bed academic medical center in the northeast that's getting the full 1% penalty this year. And he didn't realize that it was a rolling set of data for three years, and that this year's penalty was for a period from 2008 to 2011. And that's not uncommon.
And I recently spoke to a state conference of directors of case management, the managers of discharge planning in their hospitals, and they were surprised that anyone can go online and find out exactly which hospitals are getting penalized and that you can find out the magnitude of their rate adjustments.
HLM: I would think this would be at the top of the CFO's mind.
AB: So far, the only concern or excitement I'm seeing at the CFO level is when they start to make five-year predictions. If you're just looking at this year, you say, 'Oh, we got a letter saying our hospital is going to be dinged $15,000 or $150,000, or even $200,000 for FY 2013.
Who cares? "It's not until you realize that's going to double next year and go up 50% more again the next year, and the number of conditions may go up after that. And they start to realize, "Wait a second. Now we're dealing with a new business model."
HLM: You mentioned that hospitals are reluctant to spend money on readmissions because it costs money for programs and reduces volume, which gives up revenue. Are hospitals still banking that the fee-for-service revenue model will persist?
AB: Some hospitals have been waiting and hoping that advocacy by the American Hospital Association or other lobbying groups would be effective, as it so often it is in D.C., in watering down the penalties. So there were bets the penalties would be rescinded or that the Affordable Care Act would not be held up by the Supreme Court, and so on.
And that gave hospitals who don't yet embrace that the market is moving to a value-based purchasing future too much time to pause before they need to get serious. Now, that's going to do them a lot of harm for the next three years.
HLM: Or perhaps threats from Gov. Mitt Romney to do away with 'Obamacare?'
AB: That's right. There are strategists and consultants who look at all that and may well advise hospitals that if an administration leadership change occurs, you may not need to worry about any of this.
Also, there's a lot of uncertainty about the efficacy of interventions, and that has slowed hospitals from this work. Unfortunately we in medicine, we love to study things. It's a vice of a virtue. And too often we get stuck in the state of studying.
I've had a lot of conversations with chief medical and chief quality officers who say, "We're not ready to commit to investing in a readmission program because there's no clear evidence of efficacy."
HLM: Do you think that all-cause readmission will become part of the penalty in the near future?
AB: We have some signals this will happen. The first is that in July, 2012, the National Quality Forum endorsed a standard rigorous methodology for measuring all-cause readmissions. And history tells us that when the NQF measure is endorsed, we can expect exploration of policy around this measure.
Also, according to the Affordable Care Act, the secretary at her discretion can expand to other procedures and diagnoses (coronary artery bypass graft, vascular surgery, stenting and chronic obstructive pulmonary disease) by Oct. 1, 2014. So it's just a prediction, but all cause readmission might come into play at that point.
HLM: Hospital officials often say they can't be responsible for what their patients do after discharge, and especially safety net hospitals say that poverty and other social issues affecting their patients should exempt them from blame for higher readmissions.
AB: I say that they should first demonstrate that they are doing four things better: communicating with patients and their caregivers about what illnesses they have; ensuring that patients understand what medications they are and are not supposed to be taking; using translators 100% of the time when you're talking to someone for whom English is not their first language; and making follow-up appointments, writing them down, and explaining to the patient what they should do when they leave the hospital to take care of themselves.
The field is extremely uncommitted to doing those basic things, as anyone who has had a loved one in a hospital knows. We haven't rearranged our commitment to our workflow to be doing these basic things.
But the good news is there are plenty of examples of hospitals that have improved their basic standard of care and reduced readmissions. We should all aspire to make this the new standard.
Amy Boutwell, MD, co-founded the Institute for Healthcare Improvement's STAAR (State Action on Avoidable Rehospitalizations) and serves as a consultant to the Centers for Medicare & Medicaid Services. She is a practicing physician in Massachusetts and recently started her own company, Collaborative Healthcare Strategies.