Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
A decade ago, not much attention was paid to patients who had to be readmitted to hospitals shortly after their discharges. Wasn't that just the normal way of providing care? However, proposals included in the current healthcare reform measures in Congress that call for cutting back on Medicare payments for readmissions tells us that times have changed.
Payments for discharges paid by Medicare could be reduced by up to 3% in the Senate bill or 5% in the House bill. Could these proposed reductions in payments for unplanned readmissions be seen as a carrot or a stick for the healthcare industry? The answers are not simple and require us to look beyond the hospital walls—and at the needs of the patients within our communities once they are discharged.
Nearly 20% of Medicare fee for service patients were readmitted within 30 days of discharge in 2004, according to a study that appeared last spring in the New England Journal of Medicine. The cost of these readmissions to Medicare: $17.4 billion. But the study brought up the point that this was no time for finger-pointing. It is time for cooperation—both inside and outside the hospitals.
The lead author of the study, Stephen Jencks, MD, formerly head of the Centers for Medicare and Medicaid's Office of Clinical Standards & Quality, says that the issue of reducing rehospitalizations initially brought up fears that the policies might be handled in clinically insensitive ways and "create a lot of problems for standard good practices."
This created a challenge for hospitals and providers of how to address readmissions, says Jencks, who is now a preventive medicine specialist in Baltimore. "People need to figure out how to do it right. This doesn't require a huge amount of research, but it does require clinicians sitting down and saying: 'OK, we can do this."
Recent examples have emerged on how to better discharge patients so they don't require readmission within 30 days. For instance, Boston Medical Center has introduced the Re-engineered Discharge that outlines 11 steps to follow before a patient is discharge. The Society of Hospital Medicine has unveiled the "BOOST" (Better Outcomes for Older Adults through Safe Transitions) program that hospitalists could use to improve the discharge transition process, and enhance the flow of information between inpatient and outpatient providers.
Another anxiety is that providers are being asked to see the healthcare business in a different way. "The system is to a very large extent built around the convenience of practitioners and providers,” says Jencks. “The notion that it's simply OK for a patient to go out the door without a [clinical] appointment or follow-up is a challenge to the way things were working."
On another note, reducing payments for avoidable rehospitalizations may not bode well for those hospitals that see many poor patients, says Richard "Buz" Cooper, MD, a professor of medicine and senior fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia. He notes that recent studies have indicated that 25% to 35% of expenditures of this "excess utilization" is related to individuals who are at two times the poverty level or below.
The idea of reducing payments for rehospitalizations is "related to the notion that everybody should have the same readmission rates and that any higher readmission rate are all due to inefficiencies or other aspects of how providers try to fill beds," he says. But this is not necessarily true, he argues.
It's not a matter of whether one has insurance coverage, Cooper says, but understanding how this population may be accessing care multiple times in an untimely and inefficient way—which may contribute to higher costs to hospitals in the long run. With the rates of readmissions initially higher for poorer population groups, hospitals treating them will be penalized even when they try to bring these readmissions down from a high level, Cooper says.
One of the problems is the support and social structures for these patients once they leave. For instance, many do not have family support at home, may not understand directions because of language barriers, or will fail to obtain needed prescriptions. "Even if they do obtain prescriptions, they may take them wrong or miss appointments," he says. As a result, the patients—many with multiple chronic conditions—may be back in the hospital, again, continuing the cycle.
So are reductions in avoidable rehospitalizations a carrot or stick? Maybe instead it's time to see readmissions as a wake-up call and as the beginning of a new dialogue for hospitals—and for the communities they serve—to listen to and address the needs of patients the serve.
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Tucked into the House and Senate healthcare reform bills are provisions that would give the Secretary of Health and Human Services the power to identify "excess hospital readmissions"—and then penalize hospitals that surpass that rate.
Payments for discharges paid by Medicare could be reduced by up to 3% in the Senate bill or 5% in the House bill.
Not all readmissions are avoidable, but for those hospitals where many of those readmissions are "unplanned and potentially the result of missteps in care either during the hospitalization or in the period immediately following the hospitalization," the Commonwealth Fund has put together a guide to help hospitals reduce their occurrence. The guide, released on Tuesday, suggests strategies that hospitals could try at different stages of the care continuum to reduce avoidable readmissions.
Addressing potentially avoidable readmissions requires a community approach with input from entities across the continuum of care, the guide noted. Better healthcare outcomes are not only dependent on receiving better care in the hospital, but increasingly, on receiving better care at home, it said.
Hospital leaders could benefit from "positioning" their organizations to succeed in the face of financial penalties and other payment reforms suggested in the legislative proposals to avoid readmissions. This means taking step by step actions, the guide said, to provide a springboard for hospital leaders to "proactively address avoidable readmissions."
Here are the steps the guide suggests for hospital leaders to avoid readmissions:
Examine your hospital's current rate of readmissions. Currently, payers, legislators, and other healthcare stakeholders have been focusing on Medicare readmissions data as evidenced by the reporting of 30 day readmission rates for heart attacks, heart failure, and pneumonia on Hospital Compare at www.hospitalcompare.hhs.gov.
Hospitals could examine readmissions data for trends by looking at: Readmission rates for different conditions; examination of the rates by physician to determine if the patterns of readmissions are appropriate; or reviewing readmission rates at different times.
Assess and prioritize improvement opportunities. The prioritization process should capitalize on "immediate opportunities" for the hospital's improvement. Hospital leaders can consider: Focusing on specific patient populations that may have high readmissions or focusing on an organization's strengths, such as a multilingual staff that can communicate with patients or an electronic medical record that can promote better care coordination inside and outside the hospital.
Develop an action plan of strategies to implement. Hospitals may need to involve key stakeholders in the care delivery process within the organization, such as patients, physicians, pharmacists, social services, nutritionists, physical therapists, and the community. Outside the organization, partnerships should be considered with other healthcare providers and public and private support groups in their communities to aid patients' transitions back into the community.
Monitor a hospital's progress. Monitoring a hospital's progress will inform hospital leaders of "the efficacy of these strategies and perhaps guide them in implementing additional strategies," according to the guide. Monitoring a hospital's progress should focus on readmission rates for different conditions, by practitioners, by readmission rates by readmission source, and readmission rates over different time frames.
Though hospitals have improved efforts to prepare for so-called "surge" demands posed by mass casualty events, the Government Accountability Office (GA0) found the federal government can provide more assistance to make sure every state is on the same page when these emergencies occur.
In a June 2008 report, GAO found that only three states in a sampling of 20 states had developed and adopted guidelines for using "altered standards of care" in case of a medical surge of patients or mass casualty event, such as a flood or terrorist act.
At the time, the Department of Health and Human Services (HHS) had provided broad guidance that established a framework and principles for states to use when developing their guidelines for altered standards of care. However, because of the difficulty in addressing the related medical, ethical, and legal issues, it was a while before many states could develop such guidelines because they lacked resources, such as ventilators, to care for large numbers of people were available.
In a mass casualty event, the guidelines would be "a critical resource for medical providers" who may have to make repeated life-or-death decisions about which patients get or lose access to these emergency resources, GAO said.
Additionally, these guidelines can help address medical providers’ concerns about ethics and liability that may occur when negative outcomes are associated with their decisions, GAO said. In its role of assisting states’ efforts to plan for a medical surge, HHS has not been collecting altered standards of care guidelines that various states and medical experts had developed to make them available to other states.
If a mass casualty event occurs, GAO said, "difficult choices" will have to be made, and "the more fully the issues raised by such choices are discussed prior to making them, the greater the potential for the choices to be ethically sound and generally accepted."
If Congress enacts the Senate healthcare reform bill (HR 3590), the legislation could extend the life of the Medicare Hospital Insurance (HI) trust fund—or Medicare Part A—well beyond fiscal 2017, according to a new review by the Congressional Budget Office (CBO). Fiscal 2017 is the year when officials predict Part A's fund would be exhausted.
Enacting that bill, plus including the manager's amendment, could reduce net outlays for Medicare Part A by $245 billion over the 2010-2019 period relative to that baseline, CBO said, in response to a question from Sen. Jeff Sessions (R-AL). Part of the reason is that enacting the legislation would also increase HI payroll tax receipts by about $113 billion over that period.
According to estimates by CBO and Joint Committee on Taxation staffers, these changes in outlays and revenues would diminish budget deficits and add to trust fund balances by $358 billion over that 10 year period between 2010-2019. Given those changes to the trust fund's financial flows, CBO estimates that the HI trust fund would have a positive balance of about $170 billion at the end of fiscal 2019.
At the same time, enacting the Senate bill would reduce debt held by the public at the end of 2019 by more than $132 billion through increased revenues and reduced direct spending, plus interest savings from the smaller debt during the 10 year period, according to CBO.
Therefore, enacting the Senate bill would increase debt held by government accounts more than it would decrease debt held by the public—and would thus increase gross federal debt. However, that measure of debt "conveys little information about the federal government's future financial burdens and has little economic meaning," CBO said.
Since early last year, accountable care organizations (ACOs) have caught the attention of policymakers on Capitol Hill as a different way to deliver and pay for healthcare at the local level under current reform legislation.
Under the House bill approved in November (HR 3962), provisions are included that call for incentive payment for pilots encouraging ACOs in both Medicare and Medicaid beginning in 2012. The Senate health reform bill allows for providers organized as ACOs that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program. These shared savings programs also must have "adequate" participation of primary care physicians, and would also start in 2012.
ACOs are one response to concerns over the fragmented nature of healthcare delivery across the United States, according to a new brief from Mathematica. Organized delivery systems that involve multispecialty physician practices linked to other components of healthcare can "provide cohesion, scale, and affiliation, leading to enhanced quality of care and efficiency," notes author Marsha Gold, a senior fellow at Mathematica in Washington, DC.
Both bills are "envisioning something that builds on fee-for-service in these models," Gold says. Massachusetts also is proposing to create incentives for provider integration as part of its state’s health reform efforts, but it is emphasizing more fundamental provider payment reforms—such as global payment, she adds.
Although various types of ACOs have been proposed, they all share two essential features, Gold says:
Designated accountable provider entities. ACOs are collectives that will share responsibility for treating a group of patients. Although some qualifying entities may already exist, many will have to be created. Entities may form voluntarily, with providers taking advantage of existing structures. Under some proposals, "virtual organizations" may be created, with patients identified from claims analysis—showing patient referral relationships among local physicians, hospitals, and other providers.
Performance measurement and new payment approaches. Common ACO proposals will call for part of each provider’s payments to be based on care the ACO as a whole provides to its patients. In most proposals, these payments will supplement existing fee for service payments. Supplemental payments, such as "shared savings," will be provided retrospectively to the extent that an entity meets goals related to quality or cost.
"Small incentives don't necessarily yield results, but I think the intention is to organizationally encourage an infrastructure by which people think of themselves more as sharing responsibility for a set of patients—and then realign the financial incentives so that they address that," she says.
When President Obama steps to the podium for his State of the Union address Wednesday, he will not have a signed healthcare reform bill to hold up. But, despite a turn of events this past week in Massachusetts and signs of discontent in some parts of Congress, he still anticipates that healthcare reform legislation will prevail.
On Friday, at a town hall meeting in Elyria, OH, he put the focus on health insurance practices and affordable care. "Now, since this has been in the news a little bit this week, let me say a little something about healthcare. I had no illusions when I took this on that this was going to be hard," he said.
"Let me tell you why I did it. I knew that insurance premiums had more than doubled in the past decade. I knew that out of pocket expenses had skyrocketed. I knew that millions more people had lost their insurance, and I knew that because of that economic crisis that was only going to get worse," he said.
He added that he "had encountered "a little bit of a buzz saw this week" with the election of Scott Brown to U.S. Senate in Massachusetts—which ends the Democrats’ super majority grip in the Senate. He also encountered dissent in Congress—especially with the House expressing displeasure with the Senate health reform bill.
However, he acknowledged that the "process was so long and so drawn out. This is just what happens in Congress. I mean, it's just an ugly process. You're running headlong into special interests, and armies of lobbyists, and partisan politics that's aimed at exploiting fears instead of getting things done," he said.
White House senior adviser Valerie Jarrett said on Sunday's "Meet the Press" that "nothing changed about the fact that costs are escalating too high." She added that out of pocket expenses for healthcare were growing, and that many people who do have insurance are losing it because of pre existing conditions.
"The deficit is looming out of control in large part because of healthcare and that small businesses are having to choose between laying off people and paying for healthcare," she said.
Another one of the President's top political advisors, David Alexrod, disagreed with the idea that healthcare reform is dead in Congress. "No, that's not true at all," Axelrod said.
"I think what he's saying is let's take a look at [the reform bills]. There are so many elements of this—tax breaks for small business, extending the life of Medicare, more assistance for seniors with their prescription drugs, a cap on out of pocket expenses, help for people with pre existing conditions—that are too important to walk away from," Axelrod said. "What he's saying is, 'Let's get back to it.'"
Republicans in Congress, though, may have other idea. Senate Minority Leader Mitch McConnell (R-KY), speaking Sunday on "Meet the Press," said the Senate Democrats "ought to make . . . the decision that [healthcare reform] ought to be over," he said. "The American people are telling us, 'Please stop trying to pass this.'
"What I hope we're going to hear from the president on Wednesday night is an indication that he'd like to go in a different direction. And as I've said all year, if he wants to meet us in the middle of the political spectrum, we'll be there to help him," McConnell said.
The effort to reconcile both the House and Senate bills—once seen as a quick effort in early January—is slower than initially anticipated. While 80% of both bills are the same, "certain things in the Senate bill can't be supported," said House Majority Leader Nancy Pelosi (D-CA) at her weekly briefing on Thursday. "I don't see the votes for it at this time."
Some of those areas of contention include special financial favors given to states in the reform bill, such as Nebraska, plus an additional tax on higher cost insurance policies. "In its present form without changes, I don't think it's possible to pass the Senate bill in the House," she said.
She said the House will not give up passing health reform. "We are not in a big rush," she said. "[We want to go] where we can build consensus."
One provision that most likely will be included in the healthcare reform bill is the insurance exchange—an entity that initially lets individuals and small businesses purchase health insurance at reasonable prices. But getting there may not be so simple since the House and Senate bills remain divided on what type of a exchange—state or federal?
The House bill calls for a national exchange with a provision for state opt-out. The Senate bill, though, specifies state exchanges with provisions for a federal intervention—if the state fails or refuses to create an exchange.
The House and Senate bills actually do have a number of points in common, said Timothy Jost, a professor of law at Washington and Lee University. For instance, they are similar in that the exchanges would be open to individuals in the non-group market and for employees of small businesses, said Jost, at a recent Alliance for Health Reform briefing in Washington.
Both bills will provide premium subsidies that will cover more than half of the uninsured in the non group market, Jost said. "Both give the exchange some discretion over whether or not to offer health plans and thus some bargaining power with insurers."
In addition, both bills generally outlaw risk underwriting by insurers and pre existing condition exclusions, and both have a program for "reallocating risk among insurers"—although the programs in the two plans for risk allocation "are very different," he said.
Differences are that the House bill would put responsibility for creating exchanges on the federal government. However, this national exchange would allow states to opt out and create alternative exchanges—similar to the model now found in Massachusetts. The Senate bill, on the other hand, would place the responsibility for forming exchanges specifically on the states.
These state exchanges, though, would be considered "an unfunded mandate" since no federal money would be available to create them. "[The states] are going to have to pay for them themselves—presumably by taxes that will be imposed on insurers," Jost said. "The [Senate] bill provides only startup funds for the exchanges and expects them to be self supporting once they are underway."
State based exchanges have certain advantages, such as better knowledge of local insurance markets and regulatory environments. "But national markets offer larger risk pools and greater efficiency,” he added. "You don't have to set up 50 exchanges—each with its own program."
Also, a major difference is that the House bill includes a public plan option, which does not appear to be going anywhere in the current congressional debate. The Senate bill, on the other hand, layers one exchange on top of another exchange, "which can lead to some interesting dynamics," Jost said.
Still, the exchanges—no matter which one is selected—can have many variables. "There's more that we don't know than that we do know about how the House and Senate versions' visions would actually play out," said Jon Kingsdale, who heads up Massachusetts' exchange—the Connector Authority.
One "major issue" that the exchanges will need to guard against is adverse selection, Kingsdale said at the briefing. One way to avoid this is to make sure claims based risk adjustment is done "across the entire market segment," he said. "If you're risk adjusting for small group, you can't just do it in the exchange. You have to do it across the entire market."
So what to expect? President Obama told House Democrats earlier this month that he intends to use the Senate bill as the launching pad for the final legislation though Speaker of the House Nancy Pelosi said this week that the Senate bill doesn't have enough support in the House. Additionally, Obama has said he would support the national exchange plan proposed in the House bill.
When looking for ways to pay for quality healthcare, we tend to look at two endpoints. On one end is fee-for-service, which often encourages volume over value and lack of care coordination. On the other end sits full capitation, which could encourage providers to withhold services to maintain profits. So what's in between?
Think episode-based payments.
With this approach, payments would be bundled for all services delivered to a patient for an episode of care for a specific condition for a specific period of time, according to researchers with the Washington-based National Institute for Health Care Reform, which recently released an overview of episode-based payments.
As an example, the care provided to a patient involved in a car accident—from triage in the emergency department through hospitalization, trauma surgery, and rehabilitation—would comprise an episode. Then, in theory, the episode-based payments would provide financial incentives for providers to improve both efficiency and coordination of care.
This concept of episode-based payment is not new, the researchers noted. In the 1990s, Medicare experimented with some form of bundled payment through a demonstration program that combined physician and hospital payments for coronary artery bypass graft (CABG) surgery. The demo produced cost reductions between 12% and 27% among participating hospitals.
Despite the favorable results, Medicare did not expand the bundled payments to other major inpatient episodes until the Acute Care Episode (ACE) demonstration at five hospitals last year. With ACE, the government bundled payments for hospital and physician services for specific episodes of inpatient care for orthopedic and cardiovascular procedures.
So are episode-based payments here to stay? Perhaps, but a number of major issues need to be addressed. Policymakers need to define episodes of care, establish episode based payment rates, identify which providers would receive the episode-based payments, and figure out how they would work with other types of payment reforms.
How payments are designed will depend particularly on providers' willingness and ability to assume “financial risk and accountability for quality performance for episodes of care," the researchers said. Also, it payment structure' will depend on a payers' willingness to delegate risk and accountability.
Also, how a payer will identify those providers responsible for an episode of care will have "important implications for the feasibility and effectiveness of episode based payments," the researchers said.
On one hand, payers could target broader groups of providers with mandatory payment systems—but only if modest financial risk is involved for the provider. Payers also could refine payment structures that place greater financial risk on a group —and then make offers to smaller subgroups of providers who are capable of voluntarily assuming that risk, the researchers suggested.
Probably the simplest approach would involve identifying providers responsible for an episode of care—holding all of those delivering care within an episode jointly responsible for the patient's outcomes. This means payers would continue to pay each provider using fee for service templates but provide bonuses—or repayment of withholds—based on how care was provided for that episode and its quality results.
Attention also would have to be paid on how episode-based payments would interface with new types of care delivery such as accountable care organizations (ACOs). "Although some perceive episode based payment and ACOs as competing payment reforms, pursuing them simultaneously could be viewed as hedging bets on payment reform success," the researchers said.
ACOs and episode based payments could work together, they said. Episodes-based payments could be included in the calculation of total payments per enrollee. This could then be compared to benchmarks to determine rewards or penalties for ACOs.
For the most part, payment reform received a short shrift in the healthcare reform debate. While many questions still surround episode-based payments, they show promise in terms of promoting quality care. Now may be the time to open new horizons on paying for health services.
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A new Gallup Survey of opinion leaders from across the country found that most believe nurses should have greater influence in many healthcare areas—from reducing medical errors to improving efficiency and reducing costs—but that significant barriers continue to block them from fully achieving those goals.
The survey, called "Nursing Leadership from Bedside to Boardroom: Opinion Leaders' Perceptions," was conducted on behalf of the Robert Wood Johnson Foundation and released at a briefing in Washington on Wednesday. It was compiled from interviews of more than 1,500 "opinion leaders" in the fields of insurance, corporate, health services, government and industry thought leaders, and university faculty.
In the survey, conducted between Aug. 18 to Oct. 30, 2009, most of the opinion leaders agreed that nurses are one of the most trusted sources of health information. However, they saw nurses as having less healthcare reform influence than government, insurance, and pharmaceutical executives.
A majority said they felt that nurses should have more influence on health policy, planning, and management, said Risa Lavizzo Mourey, MD, president and CEO of the Robert Wood Johnson Foundation. "[But] what this confirms is that they are underutilized in leadership roles."
Among the survey findings are:
Opinion leaders said that nurses' primary areas of influence were reducing medical errors (51%), improving quality of care (50%), and coordinating patient care in the healthcare system (40%).
A majority of opinion leaders said they would like to see nurses have more influence in a large number of areas, including reducing medical errors and improving patient safety (90%); improving quality of care (89%); promoting wellness and expanding preventive care (86%); improving healthcare efficiency and reducing costs (84%); coordinating care through the healthcare system (83%); helping the healthcare system adapt to an aging population (83%); and increasing access to healthcare (74%).
Three-quarters of opinion leaders said government officials will have a great deal of influence in healthcare reform in the next five to 10 years, compared to 56% for insurance executives, 46% for pharmaceutical executives, 46% for healthcare executives, 37% for doctors, 20% for patients, and 14% for nurses.
The top barriers to nurses' increased influence and leadership are not being perceived as important decision makers (69%) or revenue generators (68%) compared with doctors; nurses' focus on primary rather than preventive care (62%); and nursing not having a single unified voice in speaking on national issues (56%).
To move forward, nurses need to pull together "the stories, the knowledge, the experiences" that they encounter every day, said Reed Tuckson, MD, executive vice president and chief of medical affairs at UnitedHealth Group, who spoke at the briefing.
"It seems incredible that in a time when our challenges are the worst that they have ever been and that they are getting more complex—that we were somehow not making use of all our assets," he said. If nurses fail to get "fully engaged at every level of the delivery system—from policy formulation to operations—we all will suffer," said Reed, who added that his mother was a visiting nurse in Washington.
Nurses must find new ways to contribute to the solutions—especially in areas such as healthcare reform, said Mary Naylor, PhD, FAAN, professor at the University of Pennsylvania School of Nursing and director of the New Courtland Center for Transitions and Health.
"We must continue to document how we as nurses are making a difference. We must substantially increase our efforts to move our evidence into practice and policy to influence all of the decisions," Naylor said.
More than 60 groups representing individuals with chronic conditions, orphan diseases, and other medical conditions—including the National Organization for Rare Disorders, the Hemophilia Federation of America, and the National Multiple Sclerosis Society—wrote in a letter to Congress that the Senate healthcare reform bill does not really eliminate annual and lifetime insurance caps. The groups are supporting adoption of the House bill instead because the legislation would eliminate caps.
A provision under Title I of the Senate bill actually does call for eliminating annual and lifetime caps from insurers' policies. However, further down in the bill is a separate section that grandfathers in existing plans—preserving the right to maintain existing coverage, according to the patient groups.
This means that insurers would not be required to eliminate provisions, such as annual and lifetime caps, under current policies, says Diane Dorman, vice president of public policy for the National Organization for Rare Disorders in Washington, DC. "People are missing that because it's in different sections of the title [of the bill]. That's a really big problem at this point."
Currently, many private insurance plans include annual or lifetime caps. Typical lifetime caps are in the range of $1 million or $2 million—a figure that can be reached quickly by people with rare or chronic diseases, Dorman says.
The groups are requesting that the bill include the House language on lifetime limits, which eventually would delete lifetime limits in all private insurance plans beginning in 2010. This language is preferable to the Senate language, the groups say, where individuals—who might not have immediate access to the insurance exchanges in their states proposed under reform legislation—could face lifetime caps for several years or even indefinitely.
For annual limits, the groups called for the inclusion of the House language, which would eliminate annual caps on new plans in 2013 and in existing plans in 2018, with one modification—incorporating the Senate provision that before 2013 restricts annual limits in plans to a "restricted annual limit" as determined by the Secretary of Health and Human Services. These interim restrictions to the House annual limits provision would provide individuals with high medical costs with immediate relief from inadequate annual limits.
"This is a critical issue for people with rare diseases. Their care can be very expensive—to prolong life, to improve their quality of life," says Dorman. "We were really concerned that a lot of times, these patients reach their caps very quickly, and then they had to find [another] job, or to find other insurance. So it can be a really difficult situation—on top of the difficult situation to live with on a daily basis."
