Being mentioned next to the word "worse" in one of the latest Centers for Medicare & Medicaid Services' HospitalCompare data files is the kind of achievement no hospital aspires to.
The list names 292 hospitals whose 30-day readmission rates were the highest in the nation in at least one of three disease categories, acute myocardial infarction, pneumonia and congestive heart failure over three years.
Of the 4,627 hospitals listed , 54 were "worse" in two categories and seven hospitals were "worse" in all three categories. More than one-third of hospitals had too few cases to be scored.
Rates of readmission were recorded as high as 33.8%.
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Although these hospitals aren't necessarily the same ones that will be financially penalized for being in the highest 25% of readmissions starting October 1, 2012 – the three-year spreadsheet uses only two of the three years being evaluated for payment* – it's close enough to give organization leaders a pretty good idea what their chances of getting a reimbursement cut from Medicare look like right now.
The data tables should clue them in as to whether their organizations should be working like crazy to find out why their patients keep coming back, and reverse that trend.
In an Aug. 5 briefing about the HospitalCompare update with CMS administrator Don Berwick, MD, the agency's chief medical officer Patrick Conway, MD, said that was the intent. He said CMS's goal in publishing the data now is so "hospitals will know their readmission rates. ... Some of those hospitals will improve and no longer get the payment adjustment, and [for] hospitals that don't improve and do end up in the lower group, there will be a payment adjustment."
In looking through the data, I noticed it's not necessarily just medium or smaller rural or community hospitals that are getting whacked with bad scores.
Beth Israel Deaconess Medical Center, with 631 beds in Boston, shows up as "worse" in its readmission rates in all three categories. So does Barnes Jewish Hospital, a 1,259-bed facility in St. Louis, MO and Brookhaven Memorial, a 306-bed hospital in Patchogue, NY.
Others on the list include Florida Hospital in Orlando, Franciscan St. James Health of Olympia Fields, IL, Our Lady of the Resurrection in Chicago, and San Juan VA Medical Center in Puerto Rico.
Also surprising is the number of well-known names in the list of 54 hospitals that were "worse" in two out of the three categories. They include Northwestern Memorial in Chicago, University of Massachusetts Memorial Medical Center in Worcester, the Cleveland Clinic, Henry Ford Hospital in Detroit, Johns Hopkins Bayview Medical Center in Baltimore and the University of Maryland Medical Center in Baltimore.
The penalties start at 1% for Medicare DRG discharges on or after Oct. 1, 2012, increase to 2% on or after Oct. 1, 2013 and to 3% on or after Oct. 1, 2014.
Which hospitals have the best, or lowest readmission scores, the ones that appear now to be least likely to get a payment cut? Pennsylvania-based Lancaster General Hospital and University of Pittsburgh Medical Center Hamot and Muncie, IN-based Ball Memorial Hospital all fell into the “better" range in all three disease categories. About 21 other hospitals scored "better" in two disease categories.
Now, with press reports shedding light on this obvious quality problem, hospitals are starting to react in an effort to thwart negative publicity.
For example, in an Aug. 26 letter to employees and physicians, Barnes Jewish President Rich Liekweg responded to a prominent article in the St. Louis Post-Dispatch. He pledged to improve care transitions, and the hospital's public image. He blamed some of the reason for such high readmission scores on "socio-economic factors, such as limited access to primary care, not having a consistent medical home to help manage care, lack of transportation, [poor] literacy, and poverty."
However, Liekweg said in the letter, the hospital will try to do more to reduce avoidable readmissions within six months. It will open a post-discharge clinic for those at high risk for readmission; "to ensure they see a primary care physician within seven days at no cost to the patient," he said. And it will launch a program that will do the same for heart failure patients and is piloting a program to provide a low-cost, seven-day medication "starter pack" for low-income patients.
"Through these efforts, I believe we are on the right track to prevent what could be avoidable readmissions and bring our rates into line with national norms starting later this year, and certainly in 2012," Liekweg wrote.
I wondered if what Liekweg and others are doing will be enough. So I asked Stephen Jencks, MD, who some have dubbed the “father of readmission research" for his thoughts. Jencks, former director of the Quality Improvement Organization in the Office of Clinical Standards and Quality and CMS' chief scientist, is the author of a pivotal paper in the April 2009 New England Journal of Medicine that woke everyone up about the severity of the nation's hospital readmission problem.
He and his colleagues found one in five Medicare beneficiaries who were discharged from a hospital were readmitted within 30 days and 34% were rehospitalized within 90 days. Moreover, his research found some clues about what was going wrong.
For those patients rehospitalized within 30 days, 50% had not visited a physician's office after discharge. And of those surgical patients readmitted within 30 days, slightly more than two in three patients were rehospitalized for a medical condition, as opposed to a planned surgery.
"The cost to Medicare of unplanned rehospitalization in 2004 was $17.4 billion," his paper said. And he has a two-fold message for those hospitals to pay heed:
Jencks explained the disconnect in a conversation between a hospital discharge planner and a downstream provider at a skilled nursing facility that he personally witnessed. When asked by the hospital discharge planner why so many patients were coming back from the nursing facility, the interchange went like this:
SNF Worker: "The truth is, the information we get from the hospital isn't very helpful in taking care of the patient."
Hospital Worker: "Do you have any idea how hard we work to get you the physician's discharge summary so it could come to you right along with the patient?"
SNF Worker: "I appreciate the effort. I really do, and it's useful in some ways, but you have to remember that we are a nursing facility. Physicians don't understand nursing, and no physician I've ever met writes a plausible story about what the nursing needs of the patients are, and what the care plan is."
A lot of the issue, too, has to do with what Jencks calls "resetting how much patients need to know about their disease, their treatment and their care, and how much families need to know, to a higher level of understanding and awareness." Not only does the evidence suggest that when this happens, there are stunning differences between study groups and control groups, the hospitalization decreases extend to 60 and 90 days. "These community-based interventions are quite significant," he said.
Jencks says that hospitals should not sit around. "You're going to have to find approaches to deal with it, and you can't use a formula where it takes you three years to accumulate data just to know what's happening...You need to get cracking on this now."
>>Download the HospitalCompare database <<
* Note: CMS' downloadable data files cover a three-year period between July 1, 2007 and June 30, 2010, while the three-year measurement period the federal agency intends to use for penalty payments starts one year later, from July 1, 2008 to June 30, 2011. The 371-page rule governing the details for how those readmissions will be risk adjusted and penalties finally determined was published in the federal register Aug. 18.