Remit And Readmit

Many hospitals in Michigan and elsewhere struggle to break even, but the path to profitability has gotten a lot tougher since October due to declining Medicare payments for readmitted patients.

From Henry Ford Hospital in Detroit to Beaumont Hospital in Troy to Mercy Hospital in Cadillac, health care organizations across metro Detroit — and throughout the entire state — are trying to decelerate one of their busiest and most expensive revolving doors: the one that admits, discharges, and then readmits the same heart attack, heart failure, and pneumonia patients. When hospitals fail to reduce readmissions, they stand to lose out on millions of dollars in Medicare reimbursements.

The goal of reducing readmissions is urgent, since the reimbursement penalty affects a hospital’s total annual Medicare billings, not just those for patients with heart and pneumonia problems. A new regulation that took effect at the start of Medicare’s 2013 fiscal year, Oct. 1, impacts hospitals whose readmission rates are in the top 25th percentile. The payment penalty, part of the Patient Protection and Affordable Care Act, starts at 1 percent, increases to 2 percent in 2014, and then to 3 percent in 2015 and thereafter.

Given most hospitals have operating margins of 1 percent to 5 percent annually, few can afford to stand pat. Across the nation, one in five Medicare patients discharged from a hospital is readmitted for the same ailment within 30 days. The most common reasons for returning to the hospital are medication-related issues. The added cost to taxpayers is an estimated $17 billion annually.

Industry experts say the current reimbursement cuts are only the beginning. The government can expand on the three diagnoses — heart attack, heart failure, and pneumonia — in fiscal year 2015.

In addition, some predict Washington will apply the readmission-related reimbursement cuts to physicians, nursing homes, home health businesses, and other entities that care for people once they’re discharged from the hospital. That’s the model used in the United Kingdom. “I think that’s a great idea,” says Dr. Bill Bithoney, national business leader for Thomson Reuters Healthcare, an information aggregator with offices in Ann Arbor.

Supporters point out that there is a valid argument for including health care professionals and businesses in the policy going forward. After all, they say, why penalize the hospital if a patient is readmitted due to a slipup at a nursing home or the lack of access to a primary care physician?

Hospital officials admit that unnecessary readmissions are a waste of time and resources. They’ve tried different steps to reduce the problem, but efforts so far have been largely unsuccessful.

In fact, when a group of researchers led by Dr. Luke Hansen at Northwestern University evaluated medical journal articles that described 36 years’ worth of efforts aimed at reducing readmissions, they concluded that no single intervention (follow-up phone calls, seeing a primary care doctor within seven days after discharge, etc.) was successful. Another study of 1,044 patients by the Mayo Clinic rejected the theory that the timing of a post-discharge doctor’s appointment made any difference.

Residential Home Health Care on the Rise // Click Here

Given the decades-long efforts by hospitals to reduce their patients’ length of stay, it may seem evident that shorter stays must be the problem — acting like a boomerang that brings people back for care they should have received in the first place.

But discharge information from 4,000 hospitals indicates that longer lengths of stay led to higher readmission rates, according to an analysis published in 2011 by Thomson Reuters. What really makes a difference to reduce readmissions, Thomson Reuters found, is ensuring high-quality inpatient care by using standardized, evidence-backed treatment.

To that end, Steward Health Care System in Boston, which operates 11 hospitals that collectively serve more than 1 million patients annually, recently launched a command center for Intensive Care Unit patients. The facility, located in a Boston suburb, is staffed with dozens of medical experts who remotely monitor Steward’s ICU patients via a live remote feed of cameras, cardiac-monitor readings, test scans, and lab results.

Staffed with medical experts, the command center offers another set of eyes to observe ICU patients, who collectively account for 4 percent of the nation’s annual health care costs, though only about 1 in 4,000 Americans is in intensive care at any one time.

So far, about 250 hospitals in the United States are using some form of remote monitoring, and the results are promising. While some doctors and nurses have reacted negatively to what they consider “Big Brother” medical treatment, the system has improved overall outcomes and costs.

Additionally, hospitals are facing another financial challenge. In an effort to promote higher quality and more efficient health care for Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) recently implemented a Hospital Value-based Purchasing Program as mandated by the Affordable Care Act.

The Value-based Purchasing Program scores hospitals according to how well they perform on specific measures, based largely on patient surveys about dozens of experiences including pain management, discharge information, staff responsiveness, and cleanliness. The goal is to reward hospitals that provide excellent quality over those institutions that drive revenue via added tests and treatments.

Hospitals that fail to improve could stand to lose hundreds of thousands of dollars in revenue under Medicare’s inpatient system (1 percent decrease annually, climbing to 2 percent by FY 2017). Money that is withheld will be put into a fund, estimated to be $850 million, that hospitals can apply for a portion based on improved performance in patient care.

Michigan’s 150 hospitals have adapted to some of the new programs. For example, in late 2009, McLaren Greater Lansing (then Ingham Regional Medical Center) selected 40 patients for intense coaching, and cut the readmission rate at the 389-bed hospital by 10 percentage points, to 12.5 percent overall.

Michigan Hospitals’ Readmission Rates / Click Here

“A huge part of this reduction is (that) hospitals collaborate and hospitals are talking among themselves,” says Annie Ervin, manager of cost quality programs at Greater Detroit Area Health Council Inc., a nonprofit health care coalition in Detroit. Ervin recently enrolled a dozen regional hospitals in the American College of Cardiology’s “See You in 7” program. Its goal is to get people with heart failure to a follow-up appointment within seven days after they’re discharged.

The council — along with MPRO, Michigan’s federally designated quality improvement organization for Medicare, the Institute for Healthcare Improvement, the Area Agency on Aging 1-B, the Michigan Health & Hospital Association, and the Society of Hospital Medicine — is bringing big ideas to the table.

In addition to “See You in 7,” they’ve enrolled hospitals in programs that focus on the discharge process and the transition from inpatient to follow-up care in a skilled nursing or rehabilitation facility, or in the community. Some hospitals participate in several of the suggested programs.

Discharge planning used to happen at the last minute, but that’s changing; experts now say preparation should start when a patient is admitted. “If you don’t look at discharge from the moment of admission, you’re going to have a problem,” says Thomson Reuters’ Bithoney.

Strategies vary, but include steps such as making sure a patient has all of his or her necessary prescriptions, knows how and when to take them, and that none of the patient’s newly prescribed medicines conflict with other medications. Hospitals also are working to simplify discharge instructions so they’re easier for patients — and their families — to understand.

Better communication is another factor. Some hospitals include follow-up phone calls from a hospital nurse or, as is the case at Henry Ford West Bloomfield Hospital, discharged patients are contacted by an outside company hired to handle post-discharge communications. Another program, the Michigan Transitions of Care Collaborative, schedules follow-up appointments within seven days and reconciles a patient’s medications. This program is unique in the state, given it includes hospitals and doctor organizations in fostering better transitions from a hospital to a home, rehab center, or nursing home.

“Unless the hospital does a good job of  handing over the care of the patient to the next site’s care providers, the patients will be left on their own,” says Dr. Christopher Kim, at the University of Michigan, who’s leading the project.

Nancy Vecchioni, MPRO’s vice president for Medicare operations, is optimistic that collaboration will lead to a solution. “If you think about it, one person, one organization, one health care facility is just a drop,” she says. “When you pull the drops together it becomes an ocean, then a tsunami.”

At first glance, it looked like Boston Medical Center had the problem of readmission whipped. The 508-bed, urban, safety net hospital with ethnically diverse patients reported in a peer-reviewed journal that its Project Re-Engineered Hospital Discharges reduced hospital re-use (hospitalization or emergency department visits) by 30 percent and saved money at the same time. The program included a nurse-coach for patients and follow-up phone calls from a pharmacist after discharge.

But the fine print reveals that hospital researchers cherry-picked patients for the project. They had to have a phone, comprehend English, couldn’t be transferred from another hospital or nursing home, and more. Medicare makes no such allowances in its reimbursement formula.

On the other hand, when Sinai-Grace Hospital in Detroit handpicked patients for a pilot study, it chose patients from the opposite end of the scale: those whose circumstances you might expect to lead to failure. It chose about 100 heart failure patients, so-called “frequent flyers,” who appeared regularly in the emergency center or a hospital bed. Surprisingly, the hospital reduced the readmission and emergency center visit rate for this group by 35 percent, says Dr. Mohamed Siddique, chief of internal medicine at the 404-bed hospital and chairman of the Michigan Pioneer Accountable Care Organization.

Under the Affordable Care Act, accountable care organizations, or ACOs, are groups of health care providers that share in Medicare savings derived from better care. To drive progress, Sinai-Grace set up a multidisciplinary heart failure clinic, which patients visit weekly to see a doctor, pharmacist, dietitian, and social worker. They also receive education regarding their disease and medications, and they know they can call for instructions or advice at any time.

Siddique adds that the hospital’s participation in the Michigan State Action on Avoidable Rehospitalizations program produced similar results for 1,000 patients with multiple medical problems. As part of the effort, patients and staff received special attention from the Institute for Healthcare Improvement, which scrutinized the hospital’s data and processes, and coached staff in adopting better practices.

“If we could do it with difficult patients, we knew we could do it with less difficult patients,” Siddique maintains.

Sinai-Grace, with a Medicare population of up to 50 percent — along with one of the highest readmission rates in the state, according to the most recently available data compiled by CMS — has room to improve. Because the data is from 2007-2010, Siddique was hopeful that the hospital’s recent efforts would result in new figures that would save Sinai-Grace from Medicare payment penalties, but its readmission rate actually increased to 31.4 percent from 30.2 percent the year before.

Under the new federal guidelines, Sinai-Grace will have to pay $647,000 in penalties. Other metro Detroit hospitals ordered to pay the highest penalties, a 1 percent reduction in each Medicare bill submitted, include: Beaumont Hospital in Troy, $1.2 million; Henry Ford Hospital in Detroit, $1.1 million; St. John Hospital and Medical Center, $1 million; St. Mary Mercy Hospital in Livonia, $698,000; Port Huron Hospital, $404,000; and Garden City Hospital, $220,000. Nearly 50 other Michigan hospitals will pay smaller fines through a provision in the Affordable Care Act.

Given Michigan hospitals’ relatively low operating margins (which averaged 2.8 percent in 2010, the latest year available from the Michigan Health & Hospital Association), a 1-percent penalty makes a significant dent in operating revenue.

While Sinai-Grace’s efforts didn’t help decrease its readmission rate, Siddique says all patients admitted at the hospital now get help understanding their medications. In addition, the hospital’s new chronic disease registry, created using electronic medical records, alerts specialty teams to admitted patients with heart failure, chronic obstructive pulmonary disease, diabetes, and kidney failure. That’s their cue to check that the patient’s medical care for a specific condition is up-to-date.

Living for the City

While hospitals constantly strive to improve their discharge procedures, they say some factors are out of their control.

In Detroit, for example, many people with low incomes have high rates of diabetes, high blood pressure, kidney failure, heart failure, mental disorders, and untreated addiction(s). What’s more, many have limited access to a primary care doctor due to cost or transportation issues, or both. Finding healthy food in the city is challenging, too, and when there are healthier options available, they’re often cost-prohibitive.

The Affordable Care Act offers some hope for better access to doctors through a regulation that makes $11 billion available in 2013 and 2014 to equalize Medicare and Medicaid reimbursements. In Michigan, Medicaid reimbursement is 59 percent that of Medicare for the same service.

“It’s going to be easier for (patients) to find a primary care provider, and they’ll have better outcomes,” says Dr. Jeffrey J. Cain, president of the American Academy of Family Physicians, a medical specialty society headquartered in Leawood, Kan. that represents more than 105,000 family physicians and medical students.

In the meantime, Detroit has Michigan’s largest population of people eligible for Medicare and Medicaid due to disability, and Detroiters who qualify for Medicare have the highest hospital readmission rate in the state, MPRO’s Vecchioni says.

Cultural issues also play a part. For example, the African-American and Arab-American communities largely reject palliative care with no objective to cure, such as a hospice. “It is family that cares for each other, as opposed to a stranger,” in such communities, says Rose Khalifa, a certified cultural competence expert and trainer, and member of the National Arab American Medical Association.

These factors and others that are beyond a hospital’s control impose an unfair disadvantage on urban hospitals, both in Michigan and in other states — and urban hospitals generally have higher readmission rates than rural facilities.

In Detroit, these urban facilities include Henry Ford Hospital, St. John Providence, and the Detroit Medical Center hospitals. The organizations are lauded for keeping even the sickest people with complex problems alive, but they may suffer reimbursement penalties because many of their patients are chronically or acutely ill, and view hospitals as the only place to get medical care for everything. The result is ironic.

“We have the seventh-lowest hospital mortality in the country,” says Dr. William Conway, chief quality officer for Henry Ford Health System, “but we have the seventh-highest statewide readmission rate.”

The 802-bed Detroit hospital was penalized the 1 percent reduction in each Medicare bill submitted that amounted to $1.1 million.

While Henry Ford has been working on reducing unnecessary readmissions for five years by participating in collaborative programs, paying extra attention to high-risk patients, home-monitoring patients’ vital signs, and hiring 40 nurses this year alone to manage patient cases, little has worked.

“What I think is unfair is to not look at socioeconomic factors (among patients),” Conway says. “Some of this is beyond the ability of individual health systems to solve.”

A Harvard School of Public Health study of elderly Medicare recipients concluded that African-American patients were more likely to be readmitted after hospitalization for heart attacks, heart failure, or pneumonia — a gap that was related to both race and to the site where they received care. Henry Ford’s annual inpatient population ranges from 42 percent to 50 percent African-American.

“Our findings suggest that minority-serving hospitals might be disproportionately affected by such penalties,” the authors wrote in a study for the Journal of the American Medical Association in 2011.

Despite its suburban location, Beaumont Hospital in Troy was hit with the high readmission penalty. It, too, is very good at keeping very sick people alive, says Dr. Samuel Flanders, Beaumont Health System’s executive vice president for quality, safety, and clinical effectiveness. The 406-bed hospital in Troy lost $1.2 million because of the penalty. Medicare accounts for 60 percent of payments to the hospital, and people with heart failure make up 5 percent of its Medicare population.

The hospital can barely budge the readmission rate for its heart failure patients, despite getting 90 percent of them to make a follow-up appointment with their doctor, Flanders says. The Troy hospital set up a heart failure program, enlisted cardiac rehab specialists to help patients with the condition after discharge, and reached out to nursing homes and home care staff in an effort to better coordinate patient care. Its staff even conducted readmission interviews, which elicited no clear problem that could be addressed.

“By and large it was just very old, very sick people,” Flanders says of the readmission interview results. “It’s hard to apply blame to the hospital just for this.”

While Henry Ford Hospital in Detroit has one of the highest readmission rates in the state, its affiliate, Henry Ford West Bloomfield Hospital, has one of the lowest. The suburban, 191-bed center attributes its enviable ranking to patient and caregiver education; multidisciplinary care that fosters greater communication among staff in its clinics, emergency department, and inpatient units; and follow-up phone calls to discharged patients. It also operates an in-house incubator to develop new ideas and, in a pilot program, pays for 30 days of phone health monitoring for discharged heart failure patients.

The three-year-old hospital also offers highly nutritious food, wellness services such as a spa, and private rooms — meaning germs are less likely to spread from patient to patient.

One of the most important initiatives is getting eligible patients into a hospice, says Dr. Nabil Khoury, an emergency medicine physician and adviser for new ideas to reduce readmissions at Henry Ford West Bloomfield. “Many patients with multiple readmissions are dying,” he says. “They need to be identified and gotten into hospice.”

Khoury says the hospital increased its hospice participation rate by 88 percent during the last year by adding hospice nurses on multidisciplinary rounds and better educating staff members, among other initiatives. It now enrolls about 40 percent of eligible people into a hospice.

Justin DeWitte, president of Residential Hospice in Madison Heights, says doctors and patients often see end-of-life services as a failure. “I think the biggest misperception is that (patients think), ‘I’m giving up from trying to get better’ as opposed to, ‘I’m making a choice to enjoy my time,’ ” he says. “I think even some of the doctors, to some extent, believe ‘I’m failing them if I turn them over to a hospice.’ ” db