Although the quality of care during an inpatient hospital stay has been the focus of readmissions, a significant reason for readmissions may be because patients have obtained or did not receive appropriate follow-up care and outpatient management after a hospitalization. Reasons for patients’ lack of post discharge care include lack health insurance or a primary care physician, inability to get an appointment with the primary care physician in a reasonable amount of time, not being able to afford medication, and poor diet or not following a diet.
The Medicare program has targeted quality of care issues in hospitals for many years, requiring hospitals to report on quality of care or be penalized by reducing the amount of payment the hospital receives. Under §3025 of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), (see Social Security Act §1886(q)), Medicare will begin imposing financial penalties on acute care hospitals that have excess risk-adjusted rates of readmission for heart attack, heart failure, and pneumonia during fiscal years beginning on or after October 1, 2012. Hospitals most likely to be impacted by the penalties would be those hospitals with the largest share of poor patients, according to Kaiser Health News (KHN) analysis of data CMS collected and reported on the Medicare Hospital Compare Website. KHN concluded that hospitals treating poorer patients were 2.7 times more likely to have high readmission rates.
Although the emphasis has been on payments made by Medicare for readmissions, it should be noted that private insurers pay a greater share of 30 day readmissions (47%) than Medicare does (40%), according to authors Anna Sommers, Ph.D., HSC Senior Researcher, and Peter J. Cunningham, Ph.D., HSC Director of Quantitative Research, in their article, Physician Visits after Hospital Discharge: Implications for Reducing Readmissions, in the December issue of the Research Brief, a publication of the National Institute for Health Care Reform. In addition, Sommers and Cunningham stressed that reforms specific to one payer [i.e. Medicare] that focus only on hospital care may fall short unless attention is given to efforts to coordinate with community providers and encourage patients to access to these providers.
“Understanding what care patients receive after discharge is critical to designing effective policies that support provider efforts to reduce avoidable readmissions,” Sommers and Cunningham stated. The authors identified strategies that could address gaps in care after discharge including bundled payments and patient-centered medical home efforts, which could potentially encourage hospitals and community-based clinicians to work together to lower rates of avoidable readmissions or rehospitalizations for other conditions. In addition, they explained how health information technology could help physicians identify and monitor care for high-risk patients and foster information sharing between hospitals and community-based physicians.
The KHN analysis stated that a key reason for so many readmissions is that one third of adult patient discharged from a hospital do not see a physician within 30 days of discharge. To interrupt this pattern, KHN reported that some hospitals are turning to post-discharge clinics and identifying patients who are more likely to have trouble after discharge because of their medical conditions or because they lack health insurance or a primary care physician.
CMS also has recognized the need for post-discharge care. PPACA §3026 requires the establishment of a Community-Based Care Transitions Program to provide funding to “eligible entities” that furnish improved care transition services to high-risk Medicare beneficiaries. “Eligible entities” means a hospital identified as having a high readmission rate or an appropriate community-based organization that provides care transition services across a continuum of care. The Community Based Care Transitions Program goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measurable savings to the Medicare program
Reducing hospital readmissions will reduce costs, hopefully, as the result of improved quality of care. Improved quality of care should include hospital care as well as post-discharge care. To attain improved quality of care, post-discharge care should be a coordinated effort between hospitals, community providers, and patients.