Readmissions: No Quick Fix to Costly Hospital Challenge

A pair of research studies reveals high hurdles providers face as they try to reduce readmission rates and avoid reimbursement penalties.

Two recently released studies on costly hospital readmissions of seriously ill, elderly patients draw the same conclusion: Fixing this vexing problem is far from easy.

With hospitals under mounting financial pressure to reduce readmissions in the form of Medicare reimbursement penalties, the search is on to find intervention strategies that work. The studies released this month deliver a sobering message.

Ariel Linden, DPH, is lead author of "a study on interventions to reduce readmissions in chronically ill patients published in the American Journal of Managed Care.

The research, which was conducted at a pair of standalone community hospitals in southern Oregon, found "no statistical difference" between seriously ill patients who participated in a hospital-based transitional care program and those who received "usual care."

"In the macro, I was surprised," Linden says of the study's results. "We threw everything we could at this thing… The truth of the matter is, if the physician doesn't want to be engaged with these really sick patients, nothing is going to happen."

In addition to standard transitional care interventions at the pair of hospitals, Linden says his study added two elements: motivational interviewing of patients to "get them to listen to what their doctors told them to do" and "interactive voice response" consisting of a nurse calling patients every morning to answer a brief questionnaire on their health status. The nurses and patients also reached out to local physicians.

"We sent out letters to the doctors, and we made follow-up phone calls," Linden says. "We did everything we could except beg and plead with doctors."

Local physicians lacked the necessary incentives to work with their community hospitals to help reduce post-hospitalization readmissions for patients suffering with congestive heart failure and chronic obstructive pulmonary disease. "In some cases, the doctors said they had no time for these patients," Linden says. "These doctors had no skin in the game."

The researcher, an adjunct associate professor at the University of Michigan's School of Public Health in Ann Arbor, and president of Linden Consulting Group, says the research revealed a key weakness at the Oregon hospitals. "They do not have a very good collaborative relationship with physicians in the community."

'Not One-Size-Fits-All'
L. Elizabeth Goldman, MD, is the lead author of the another readmissions study published this month in the Annals of Internal Medicine, focused her research on an urban hospital in Northern California and drew similar results and conclusions to Linden's study.

"There have to be reasons for people to feasibly collaborate," she says. "It's developing solutions that actually work for the stakeholders."

In Goldman's study, the post-hospitalization intervention involved the following: "Usual care versus in-hospital, one-on-one, self-management education given by a dedicated language-concordant registered nurse combined with a telephone follow-up after discharge from a nurse practitioner."

Hospitals seeking to reduce readmissions must examine the challenges in minute detail, she says.

"One of the big takeaway points for us is [that] it's really important for any of these interventions to see if it fits locally," Goldman said. "These are not one-size-fits-all products."

In addition to finding ways to boost collaboration between hospitals and community-based physicians, transitional interventions have to be crafted to individual patients, she says. "Some folks may need targeted home visits. Some folks might need the follow-up visit very soon after discharge. Different folks might need different things."

Solving the readmissions problem requires a constellation of caregivers, such as behavioral health clinics, hospice organizations, and nursing homes, Goldman suggests. "It's not just the primary care clinics and hospitals. It really depends on the setting and facilitating communication between these groups."

Stepping Up to the Plate
Linden says the results of the Oregon-based research have shaken his confidence in the advisability of penalizing standalone community hospitals for failure to hit readmissions targets set by the Centers for Medicare & Medicaid Services.

"Everybody is running around saying, 'The transitional care model!'" he said. "At this point, we don't know what works… I have a newfound respect for serious illness and the resources we should throw at this."

Standalone community hospitals could be at a disadvantage compared to integrated health systems, and CMS should consider taking that possibility into account when meting out Medicare reimbursement penalties linked to readmission rates, Linden argues.

"They will ding hospitals if their readmissions are too high," he said of CMS. "Is it fair to ding hospitals when they can't engage their physicians? It takes two to tango."

Linden believes more research is needed to address the fairness issue. "Do big, integrated health systems have better readmissions outcomes? I don't know. The studies haven't been done yet."

CMS: "Readmission Measures Can Signal Potential Issues"
All hospitals need to be held accountable for their readmission performance, says a CMS spokesman in response.

"CMS believes the readmission measures can signal potential issues with a hospital's system for transitioning patients to the outpatient setting, collaborating with communities and providers, and communicating with patients and caregivers regardless of the type of hospital," the spokesman said.

"CMS continually strives to improve the Hospital Readmission Reduction Program as the agency gains further experience with it. We will continue to work with all stakeholders to seek feasible ways to encourage hospitals to reduce hospital readmissions while addressing any unintended consequences, particularly for those hospitals serving dual-eligible and low-income beneficiaries."

Goldman believes the healthcare industry is in the beginning stages of trying to come to grips with the readmission challenge. "If we think we can make a dent in healthcare in general, we can make a dent here, too," she says. "Now it's getting the attention it deserves because there are financial incentives involved."

The University of California-San Francisco researcher said CMS officials deserve credit for taking action: "They have brought the attention to where it needs to be."