It was probably just coincidence that this week was chock full of news about dreaded 30-day hospital readmissions.
But then, maybe not when you consider that the three-year performance period which determines which hospitals will see Medicare payment cuts of up to 3% starting in Oct. 1, 2014, ends on June 30. That will be a shock to hospitals grappling with 1% cuts in their Medicare payments this year.
The clock is ticking.
And in just another few weeks, the Centers for Medicare & Medicaid Services rule makers will roll out proposed readmissions policies for FY 2014 and FY 2015, or at least signal their intent.
No one thinks they will be more lenient.
According to the Patient Protection and Affordable Care Act, the number of conditions measured now congestive heart failure, pneumonia and heart attack—must be expanded to include vascular surgery, stenting, chronic obstructive pulmonary disease, and coronary artery bypass surgery, "and to other conditions and procedures as determined appropriate by the Secretary."
Specifically, the thinking may be that now is the time for hospitals to start measuring readmission rates for all conditions, lest hospitals not get into a habit of ignoring discharge planning for patients with conditions not yet targeted with financial consequences.
I'm also sensing a heightened push on the part of discharge planners and physicians to make sure their patients know what's at stake, and to impress upon them their responsibility to pay attention and follow instructions.
For example, because we know patients may forget how they're supposed to take care of themselves after they leave the hospital, some organizations are filming the entire discharge instruction process, and enabling patients to access it when they get home, either through a private portal on the internet or through their own personal iPhone video
Initiatives, such as the "Good to Go" program at Cullman Regional Medical Center in Cullman, AL, are even giving patients mobile devices and developing video portals so patients can review recordings of what they were told about their post-hospital care after their discharge.
So perhaps the rush, or the panic, is in full bore.
In any case, we now have a number of projects that parse readmissions prevention efforts so that programs put the lion's share of resources into areas promising to produce the best reductions.
On Monday, for example, authors of a paper in JAMA Internal Medicine suggested that, since for the subset of patients undergoing colon surgery, (there should be a separate lineup of discharge instructions.. There are 600,000 such procedures performed each year and the readmission rate is 16.6%.
The paper's authors, from Baylor College of Medicine and the Houston VA surveyed an expert panel and developed 12 warning signs planners and physicians should make sure their patients know about.
In time, patients hospitalized for other reasons, whether surgical or medical conditions, might get their own tailored lists.
On Tuesday, the Dartmouth Atlas and the Robert Wood Johnson Foundation rolled out its latest report, "The Revolving Door Syndrome,"showing that in 2010 compared with 2008, hospitals reduced readmission rates by just one-third of a percent. Worse, there is still wide variability throughout the country even within specific types of hospitals such as academic medical centers.
The Dartmouth group sliced the data even further to show high and low rates of readmissions in regions around the country depending on whether the patient was hospitalized for a surgical procedure or for a medical condition, such as congestive heart failure, pneumonia, or heart attack.
During an interview with David Goodman, MD, co-principal investigator for the Dartmouth Atlas Project, I asked if it wasn't a bit unfair to criticize hospitals for not reducing readmissions by 2010.
After all, the health reform law that established such penalties wasn't passed until March of that year, and I suggested that few hospitals would have had a chance to read or understand it until fall or later.
But he replied with an adamant 'No,' saying hospitals have known that their readmission rates were abysmal for a very long time.
"The interest and concern about higher readmission rates really extends back at least 15 years, both in terms of recognizing that they are too high, as well as the development of care models that are effective at reducing them," Goodman said. "This is quite a long-standing problem that's not news to anyone in the healthcare community."
He also said that hospitals must do a better job to help their patients assume responsibility as well. "There are stories that reflect the importance of patients to be engaged in their own care, and their caregivers and families get engaged. This is a big problem. It's about the fragmentation in our healthcare system, the lack of communication. But it also reflects how they generally do with regard to their health not just in 30 days, but in 90 days and 180 days."
Also this week the Journal of the American Medical Association published an argument-dulling paper saying that there is only a weak link between readmissions and mortality performance.
The report, by Yale University School of Medicine algorithm expert Harlan Krumholz, MD, looked at 3 million hospital admissions for Medicare beneficiaries treated for heart attack, pneumonia or heart failure, who were readmitted in 30 days. Krumholz then tried to see if hospitals that did well in readmissions also did well in 30-day mortality, or whether the inverse was true, as some hospitals executives have complained.
There has been concern that hospitals may put resources and effort into preventing readmissions only to see their discharged patients dying, and that hospitals with more liberal readmission practices might be preventing death.
Researchers failed to find any evidence of a relationship for heart attack or pneumonia, and for heart failure, "only a modest and not throughout the entire range of performance" relationship was identified, Krumholz and colleagues wrote.
If anyone thought CMS or its readmissions policy consultants were going to come out and say, 'hey, we didn't carefully think these policies through the first time and we were wrong,' there's a bridge I know that's for sale.
Finally, the Robert Wood Johnson Foundation had a special webinar this week on preventing readmissions. It featured top experts in policy including Jonathan Blum of CMS; Eric Coleman, MD, who designed the Coleman model of care transitions, Mary Naylor of the University of Pennsylvania School of Nursing, and Risa Lavizzo-Mourey, MD, RWJF's President and CEO.
The audience heard numerous stories of interventions as part of RWJF's Care About Your Care campaign.
The urgency around reducing readmissions is real, and the reason is dollars.
For the fiscal year that began Oct. 1, 2012, when the readmission penalty can not exceed 1% of a hospital's base DRG, CMS estimated it expects to ding hospitals about .3% or about $280 million. Starting this Oct. 1, if my math is correct, that amount would double, and by Oct. 1, 2014, when the full 3% penalty kicks in, the penalty might be $840 million.
As the saying goes: A few hundred million here and a few hundred million there—it starts to add up. Now we're talking real money.