Medicare Working to Prevent Beneficiary Readmissions

NATIONAL HARBOR, MD. — Medicare wants to save money and improve quality of care by reducing the number of patients readmitted to the hospital within 30 days after their initial stay, Dr. Michael Rapp said.

Readmission is a problem within Medicare, said Dr. Rapp, director of the Quality Measurement and Health Assessment Group at the Centers for Medicare and Medicaid Services (CMS). In a recent study, nearly 20% of Medicare fee-for-service patients discharged from the hospital were readmitted within 30 days; 34% were readmitted within 90 days (N. Engl. J. Med. 2009;360:1418–28). The authors estimated the cost to Medicare of those unplanned readmissions at $17.4 billion.

There is “quite a bit of variability” in the 30-day readmission rate, depending on the patient's diagnosis, Dr. Rapp said at the World Health Care Congress Leadership Summit on Hospital Readmissions. For example, 25% of heart failure patients were readmitted within 30 days, compared with 20% of acute myocardial infarction patients and 18% of pneumonia patients.

Part of the problem stems from continuity of care issues, he continued. One study looked at 366 patients discharged from the hospital with a follow-up primary care appointment scheduled within 2 months. The researchers found that 42% of those patients had a medication continuity error, 12% had a work-up error, and 8% had a test follow-up error (J. Gen. Intern. Med. 2003;18:646–51). Subjects with work-up errors were six times more likely to be readmitted than were other subjects, Dr. Rapp noted.

Unplanned rehospitalizations often signal a failure of transition from the hospital to another source of care. Because any hospital admission is a source of revenue for a hospital, reducing the readmission rate means lost revenue for the facility; therefore, other incentives for reducing readmissions need to be worked out, he said.

“One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates,” Dr. Rapp said. “We published them for the first time on the Hospital Compare Web site last July. It got quite a bit of interest.”

Another way the CMS is trying to reduce readmissions is through the Care Transitions Intervention, a way of “coaching” patients during and after discharge. Under a pilot program, the CMS is paying 14 of Medicare's quality improvement organizations to implement this program in some locations. One QIO implementing the program with 130 patients achieved a 7.7% decrease in hospital readmissions, Dr. Rapp said. And 96% of patients said they had a good understanding of how to manage their health after the program was finished, compared with 63% at the start of the program.

Of the 14 communities involved in the pilot program, 9 have seen at least a 2% reduction in readmissions after instituting the program, he added.

Dr. Rapp said the CMS had learned several things from the project:

▸ Community meetings are a catalytic point in the process.

▸ Community recruitment and engagement can take longer than anticipated.

▸ Increased time and resources are required to engage outpatient physicians and specialists.

▸ Patients should be assigned a coach before discharge.

To improve the discharge procedure and reduce hospital readmissions, Dr. Rapp suggested several measures, including creating a collaborative forum that includes patients and families, exchanging quality data routinely, identifying the sickest patients and reviewing the way they get care, and implementing personal health records.

Disclosures: Dr. Rapp reported having no relevant conflicts.

'One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates.'

Source DR. RAPP

NATIONAL HARBOR, MD. — Medicare wants to save money and improve quality of care by reducing the number of patients readmitted to the hospital within 30 days after their initial stay, Dr. Michael Rapp said.

Readmission is a problem within Medicare, said Dr. Rapp, director of the Quality Measurement and Health Assessment Group at the Centers for Medicare and Medicaid Services (CMS). In a recent study, nearly 20% of Medicare fee-for-service patients discharged from the hospital were readmitted within 30 days; 34% were readmitted within 90 days (N. Engl. J. Med. 2009;360:1418–28). The authors estimated the cost to Medicare of those unplanned readmissions at $17.4 billion.

There is “quite a bit of variability” in the 30-day readmission rate, depending on the patient's diagnosis, Dr. Rapp said at the World Health Care Congress Leadership Summit on Hospital Readmissions. For example, 25% of heart failure patients were readmitted within 30 days, compared with 20% of acute myocardial infarction patients and 18% of pneumonia patients.

Part of the problem stems from continuity of care issues, he continued. One study looked at 366 patients discharged from the hospital with a follow-up primary care appointment scheduled within 2 months. The researchers found that 42% of those patients had a medication continuity error, 12% had a work-up error, and 8% had a test follow-up error (J. Gen. Intern. Med. 2003;18:646–51). Subjects with work-up errors were six times more likely to be readmitted than were other subjects, Dr. Rapp noted.

Unplanned rehospitalizations often signal a failure of transition from the hospital to another source of care. Because any hospital admission is a source of revenue for a hospital, reducing the readmission rate means lost revenue for the facility; therefore, other incentives for reducing readmissions need to be worked out, he said.

“One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates,” Dr. Rapp said. “We published them for the first time on the Hospital Compare Web site last July. It got quite a bit of interest.”

Another way the CMS is trying to reduce readmissions is through the Care Transitions Intervention, a way of “coaching” patients during and after discharge. Under a pilot program, the CMS is paying 14 of Medicare's quality improvement organizations to implement this program in some locations. One QIO implementing the program with 130 patients achieved a 7.7% decrease in hospital readmissions, Dr. Rapp said. And 96% of patients said they had a good understanding of how to manage their health after the program was finished, compared with 63% at the start of the program.

Of the 14 communities involved in the pilot program, 9 have seen at least a 2% reduction in readmissions after instituting the program, he added.

Dr. Rapp said the CMS had learned several things from the project:

▸ Community meetings are a catalytic point in the process.

▸ Community recruitment and engagement can take longer than anticipated.

▸ Increased time and resources are required to engage outpatient physicians and specialists.

▸ Patients should be assigned a coach before discharge.

To improve the discharge procedure and reduce hospital readmissions, Dr. Rapp suggested several measures, including creating a collaborative forum that includes patients and families, exchanging quality data routinely, identifying the sickest patients and reviewing the way they get care, and implementing personal health records.

Disclosures: Dr. Rapp reported having no relevant conflicts.

'One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates.'

Source DR. RAPP

NATIONAL HARBOR, MD. — Medicare wants to save money and improve quality of care by reducing the number of patients readmitted to the hospital within 30 days after their initial stay, Dr. Michael Rapp said.

Readmission is a problem within Medicare, said Dr. Rapp, director of the Quality Measurement and Health Assessment Group at the Centers for Medicare and Medicaid Services (CMS). In a recent study, nearly 20% of Medicare fee-for-service patients discharged from the hospital were readmitted within 30 days; 34% were readmitted within 90 days (N. Engl. J. Med. 2009;360:1418–28). The authors estimated the cost to Medicare of those unplanned readmissions at $17.4 billion.

There is “quite a bit of variability” in the 30-day readmission rate, depending on the patient's diagnosis, Dr. Rapp said at the World Health Care Congress Leadership Summit on Hospital Readmissions. For example, 25% of heart failure patients were readmitted within 30 days, compared with 20% of acute myocardial infarction patients and 18% of pneumonia patients.

Part of the problem stems from continuity of care issues, he continued. One study looked at 366 patients discharged from the hospital with a follow-up primary care appointment scheduled within 2 months. The researchers found that 42% of those patients had a medication continuity error, 12% had a work-up error, and 8% had a test follow-up error (J. Gen. Intern. Med. 2003;18:646–51). Subjects with work-up errors were six times more likely to be readmitted than were other subjects, Dr. Rapp noted.

Unplanned rehospitalizations often signal a failure of transition from the hospital to another source of care. Because any hospital admission is a source of revenue for a hospital, reducing the readmission rate means lost revenue for the facility; therefore, other incentives for reducing readmissions need to be worked out, he said.

“One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates,” Dr. Rapp said. “We published them for the first time on the Hospital Compare Web site last July. It got quite a bit of interest.”

Another way the CMS is trying to reduce readmissions is through the Care Transitions Intervention, a way of “coaching” patients during and after discharge. Under a pilot program, the CMS is paying 14 of Medicare's quality improvement organizations to implement this program in some locations. One QIO implementing the program with 130 patients achieved a 7.7% decrease in hospital readmissions, Dr. Rapp said. And 96% of patients said they had a good understanding of how to manage their health after the program was finished, compared with 63% at the start of the program.

Of the 14 communities involved in the pilot program, 9 have seen at least a 2% reduction in readmissions after instituting the program, he added.

Dr. Rapp said the CMS had learned several things from the project:

▸ Community meetings are a catalytic point in the process.

▸ Community recruitment and engagement can take longer than anticipated.

▸ Increased time and resources are required to engage outpatient physicians and specialists.

▸ Patients should be assigned a coach before discharge.

To improve the discharge procedure and reduce hospital readmissions, Dr. Rapp suggested several measures, including creating a collaborative forum that includes patients and families, exchanging quality data routinely, identifying the sickest patients and reviewing the way they get care, and implementing personal health records.

Disclosures: Dr. Rapp reported having no relevant conflicts.

'One of the ways we've sought to [get hospitals engaged] is by publishing readmission rates.'

Source DR. RAPP