ORLANDO — “Hospital readmissions” has become the latest bad-practice buzzword out of Washington, and the American College of Cardiology is scrambling to put a lid on unnecessary readmissions.
The ACC is alarmed because the worst readmissions offender in medicine is heart failure, linked to about one-third of all 30-day, U.S. hospital readmissions, according to data collected by the Centers for Medicare and Medicaid Services. The next biggest cause of readmissions is acute renal failure, which kicks in a relatively miniscule 4% of the total.
A 2008 report by the Medicare Payment Advisory Commission, a Congressional advisory group, estimated that eliminating unneeded hospital readmissions for heart failure could potentially save $900 million annually based on Medicare's 2005 numbers. (See chart.)
The stick that the CMS seems poised to wield against readmissions is bundling of reimbursement for Medicare beneficiaries. This would mean a hospital receives a fixed amount for all care for a hospitalized heart failure patient during the next 30 days, including subsequent readmissions. This clear focus on reducing hospital readmissions, with heart failure and a handful of other cardiologic disorders as prime targets, prodded the ACC to respond with a new program aimed at paring back readmissions through better attention to the hospital-to-home handoff of patients once they are discharged. During a press briefing at the annual meeting of the ACC, Dr. Jack Lewin, the college's CEO, announced the H2H program (www.acc.org/h2h/Enrollment/Default.aspx
The program seeks to encourage better communication between the attending cardiologists and hospitalists who oversee heart failure care while patients are hospitalized, and the community cardiologists, primary care physicians, and nurses who take primary responsibility for heart failure patients once they are discharged. An immediate goal of the H2H program is to cut unnecessary readmissions for heart failure patients by 20% over the next 3 years, Dr. Lewin said. The ACC will seek involvement of the professional societies of hospitalists and nurses and other groups with stakes in this issue.
The expected campaign against readmissions that the Obama administration, Congress, and the CMS are expected to launch “is a big deal. This is here to stay. This is where people will look, thinking that [readmissions] are low-hanging fruit, even though you and I know it's not exactly low-hanging fruit,” Dr. Harlan M. Krumholz said in a talk on the readmissions issue at the meeting.
“We need to think about patients, and be sure there are not unintended consequences that cause patients to suffer,” said Dr. Krumholz, professor of medicine, epidemiology, and public health at Yale University in New Haven, Conn. “I'm personally trying to steer [the CMS effort] away from penalizing people.
“I'm not against bundling; bundling may be okay,” he said. “But we need to go through a period where people can see their performance, understand it, and have a chance to improve. Let's see if we can improve and pull in the hospitals that don't perform as well. Give us time as a community to show leadership and show what can be done before penalizing people based on measures that we know aren't perfect. I don't want us to leap too fast. It may be that the hospitals with the highest readmission rates are also the ones with the most tenuous financial status. They may be hospitals that work with difficult populations.”
Dr. Krumholz also conceded that until now “hospitals did not have any incentive to improve the transition of care, and so no one worked on it.” He recommended that the CMS give hospitals and health care providers incentives to do a better job in getting discharged patients hooked into outpatient, disease-management programs. The ACC's H2H program will “provide advocacy to the Hill, figure out what key strategies we should all adopt, and how we can share best practices together. My hope is that over the next 2 years [the ACC membership] will show leadership and show that we can identify the issues and move forward on them.
People think readmissions are low-hanging fruit, even though its not exactly low-hanging fruit. DR. KRUMHOLZ
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