By Joanne Kenen, POLITICO
Want to save Medicare money without making Congress agree to a plan?
Start by keeping patients out of the hospital.
Especially if they really don’t need to be there.
About one in five Medicare patients who are hospitalized end up bouncing right back within 30 days, so reducing unnecessary hospital readmissions has become a bit of a holy grail.
The 2010 health reform law includes new penalties for hospitals that have particularly high rates of repeat Medicare patients — sometimes called “frequent fliers” — for three specific diseases. The law also creates incentives and programs through Medicare for hospitals to improve discharges and the transition from the hospital back to the community — where lots of things can go wrong and do go wrong, setting the stage for that patient to go home and ricochet right back in.
Now a major multicity Medicare quality initiative, highlighted this week in The Journal of the American Medical Association, has reduced readmissions by nearly 6 percent compared with similar communities over two years. The authors estimate that in an average community with 50,000 Medicare patients, spending $1 million on relatively simple steps to curb hospitalizations would save $4 million per year on hospital bills alone. That would add up fast if these programs were to spread nationwide.
And improving care in the community didn’t just slow readmissions. It reduced all Medicare hospitalizations, not just those round trips.
“We didn’t just bend the [cost] curve — we turned it down, enough to be convincing,” study co-author Joanne Lynn, a leading geriatrician now at the Altarum Institute’s Center for Elder Care and Advanced Illness in Washington, told POLITICO.
Lynn noted that most of the study period was before the health care law passed so the communities weren’t responding to any new carrots or sticks in the legislation. Rather, she said, the health professionals and organizations that partnered with the Medicare Quality Improvement Organizations realized, “It feels good to work in a system that works and doesn’t hurt people.”
The JAMA researchers reported, too, that the improvements were quite consistent — in very poor and more affluent communities, in places that are big spenders on health care and those that are more sparing. That the readmission reductions were seen in the poorer communities helps push back against a school of thought that readmissions are an intractable problem, rooted more in poverty than in health care itself.
The solutions that these communities found included linking medical and social services — so that if Aunt Sally went from hospital to home, she’d be connected to various agencies that work with the poor or the elderly so she’d get meals, and a ride when she needs to see the doctor. They also made a point of teaching patients and families to do more self-care; in one pilot city, Tuscaloosa, Ala., faith leaders took that on as a mission, and local churches ran workshops on how people could better manage their own or their relatives’ chronic diseases, said Jane Brock of the Colorado Foundation for Medical Care, a co-author.
The quality team also emphasized better care coordination among doctors and specialists, and having hospitals and nursing homes sit down and talk so they became less adversarial and more collaborative.
The researchers said quality improvement organizations are in place across the country — and these ideas can spread easily, with room for local adaptation and the potential for quick changes and visible savings.
Most research projects published in journals like JAMA lay out an experiment, follow it and measure when it’s done. This project was more fluid, Lynn and Brock said. The building blocks were a set of evidence-based practices and protocols — but the pilot communities monitored and measured the quality and changes as they worked and were able to modify the program in ways that fit their own community in real time. And that didn’t require legislation, waivers or rule changes from Washington.
Alabama, for instance, drew in those churches. Denver, where health care utilization was already low, stressed data sharing. In Harlingen, Texas, a local nursing home physician decided that any patient entering, or re-entering, the home from the hospital should be seen by a doctor within 48 hours — not the current practice of 30 days. He made that the communitywide standard, and Brock said it made a difference when a doctor quickly laid eyes on the patient and personally reviewed the treatment plan.
One mixed blessing of the side effect is reducing all Medicare hospital visits. That’s a good thing for the quality of care and for Medicare’s bottom line — which is so much a part of the national conversation about the debt and entitlements. But it may prove a wrinkle for quality programs and incentives that are based specifically on measuring readmissions rates. A hospital doing everything right — bringing down admissions and readmissions — could still score high on its proportion of readmissions, Lynn noted.
That’s going to be important to hospitals that don’t want to be “dinged” even if they are improving quality. About 2,000 hospitals in October started losing $300 million in fines — and that amount is likely to grow as the readmission penalty program goes into its next phase in the coming years.
In an accompanying editorial in JAMA, Mark Williams of Northwestern’s Feinberg School of Medicine said, “Lack of coordinated-care transitions has affected patients in the United States for half a century but individual patients now see an increasing number of physicians, increasing the possibility of medical error, duplication of services, reduced quality and increased cost.” He praised the approach that “engage[s] all members of a care team, especially front-line clinicians” to address that fragmentation and give patients a better chance of going home from the hospital — and staying there.