WBUR

State Will Stop Paying For Some Hospital Re-Admissions

Kim Visconti, a special discharge nurse, talks to patient Edgardo LaSanta as he prepares to be discharged. (Martha Bebinger/WBUR)

BOSTON — Medicaid is one of the fastest growing parts of the state budget. To tackle rising health care costs, Gov. Deval Patrick’s administration plans to stop paying hospitals with high rates of re-admissions when low-income patients return within 30 days.

It could be a man who leaves the hospital with new prescriptions and takes the wrong pill four times a day.  Or a woman with depression who skips a critical follow-up appointment after surgery. Perhaps it’s a child who goes back to the same activities and has another severe asthma attack. These are all reasons patients return to the hospital shortly after release. They might all be prevented with better instruction inside the hospital, a better hand-off to our doctor outside or more active patient follow-up.

“We are paying for the wrong things,” said Dr. Judy Ann Bigby, state secretary for Health and Human Services. Bigby said it’s not just that the state doesn’t want to pay. Repeat hospitalizations carry risk, “either a hospital-acquired infection or some other type of outcome that demonstrates that the quality of care is not as good as it could be, and it’s costly to the system,” Bigby said.

Hospital re-admissions may be prevented with better instruction inside the hospital, a better hand-off to our doctor outside or more active patient follow-up.

Bigby’s office is sending hospitals their re-admission scores. Later this year, the state plans to stop paying hospitals where the re-admission rate is higher than the statewide average.

“We want hospitals and other providers to do a better job of coordinating care for people throughout the system,” Bigby said. “We recognize that this is not just a hospital problem.”

But the burden will be on hospitals and that’s where administrators object. They question the way the state is defining and counting preventable re-admissions and point out that hospitals are working on this issue without state intervention. Medicare and a few private insurance plans are also ending payments for some re-admissions. But Karen Nelson, senior vice president for clinical affairs at the Massachusetts Hospital Association, questions who is really responsible for this problem.

“Re-admissions are a community issue,” Nelson said. “Some of the factors that lead to a re-admission are not something the hospital has control of.” For example, Nelson said, the hospital can’t decide whether “the patient can access their physician to prevent them from going to the emergency department of the hospital.”

Ending some payments for re-admissions is expected to save $8 million in the next fiscal year — a drop in the pool of Medicaid dollars. But Bigby said she hopes the change will compel hospitals to make connections with doctors and other partners in the community so that there’s a network of providers paying attention to each patient. Such networks will be part of the state’s move towards global payments, where doctors and hospitals will be financially responsible for any kind of care that a patient needs. Focusing on re-admissions offers a glimpse of how challenging learning to work as a network of caregivers may be.

“Nurses and doctors on the floor are more worried about the sick patient coming to the floor than about the relatively healthy patient who is ready to go home,” said Dr. Brian Jack, at Boston Medical Center. Jack refers to a study that found most hospitals spend just six to eight minutes, on average, preparing patients to leave the hospital.

Jack designed a program that starts discharge planning well before the patient leaves.

Here’s Kim Visconti, a special discharge nurse, talking to Edgardo LaSanta about a test he just finished taking:

“Depending on what that test shows, they may send you home later today or they may decide to keep you overnight,” Visconti said. “Did they tell you what the plan is as of yet?”

It isn’t clear when LaSanta, who has Hepatitis C, will leave. He’s still a bit yellow. But while he waits for the latest test results, Visconti is putting together a list of the medications LaSanta will take, making the follow-up appointments he’ll need, and going over a few new health problems.

“I got a murmur in my heart, they found today,” LaSanta tells Visconti.

“So that was something that was new for you as well?” Visconti asked. “Do they think that you’re going to need follow-up with a cardiologist?”

Before he does leave, Visconti will hand LaSanta a booklet with a color-coded daily schedule for his medications and an appointment calendar. She’ll quiz him to see if he understands what the prescriptions are for and when to take them.

Jack said this program cut re-admissions at Boston Medical Center by 30 percent and saves $412 for each patient who does not return within 30 days.

“There are not too many things that improve the quality of care and save money, and this is one of them,” Jack said.

Reducing re-admissions has not been in a hospital’s best interests under the current way we pay for medical care, because hospitals are paid to fill beds. That’s supposed to change as the state moves to paying hospitals a lump sum instead of payments based on how many patients hospitals admit. In the meantime, Boston Medical Center is testing a video version of the discharge nurse.

“It looks like you are going to be leaving the hospital soon, so I brought some information for you,” an automated voice said as a black woman in an animated video turns the pages of a booklet.

This is Louise, who takes patients through their detailed discharge plan. Jack said twice as many patients say they prefer Louise to a real nurse. To hear more about why, meet Louise and add your thoughts, go to our CommonHealth blog.

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  • Lizferry

    Dr. Bigby has come a long way since she was Tom Menino’s physician, a man who will never lack for healthcare I assume.

    This seems like putting the burden on the wrong people; if you are poor, there are many reasons you can’t/won’t follow up; lack of money, lack of time (it’s very time consuming being poor), lack of understanding.

    On the other hand, many patients are discharged too early. My partner had a hip replacement with minor complications (catheter in, catheter out, etc.) and was to be released three days after surgery. If he had been sent home and readmitted (if I hadn’t won the struggle to keep him in an extra day), that would have counted too.

    A simplistic solution to a complicated problem.

  • Jihallberg

    I recently had an outpatient surgical procedure at a large and well-known Boston area medical. In a series of pre-op appointments, I was given a 3-page set of instructions covering the pre-op and post-op care and medications. I took them home and read every word. On the day of surgery, I was given another set of post-op instructions to take home and when I read them, after the surgery, I realized they contradicted some of the earlier instructions for post-op care and medications. I returned to the Dr. (who was the surgeon) 24 hours later for a follow-up visit and, before the Dr. saw me, I was given a third (and shorter) list of instructions for post-op. These contradicted both previous instructions in some points of care and medication and referenced medications that had not been prescribed. All 3 sets of instructions were pre-printed, standard instructions for this important but relatively simple procedure. I spoke to the Dr. about the conflicting instructions and was told that someone was re-writing the instructions (and had been re-writing them for more than a month). My impulse was to throw away all the instructions and function on my own informed intuition. However, I have no medical or pharmaceutical training and no previous experience with this kind of surgery and the medications I’m prescribed cost me $131 in co-payment. This same scenario is what leads to re-admittance. As I was never an in-patient, perhaps if I mess up my post-op home-care and need to be admitted to the hospital I won’t become a RE-admitted statistic…
    Tomorrow I return to the Dr. for my second post-op check-up. I’m going to recommend they contract me to copy-edit all the pre-printed patient instructions, identify the discrepancies and have medical staff correct them. I’d even do it as a volunteer. But I must say, I’m questioning the quality of care I receive from this organzation.

  • Loucohen

    This quote is fascinating: “Later this year, the state plans to stop paying hospitals where the re-admission rate is higher than the statewide average.”

    Since about half the hospitals will ALWAYS be above the average, and about half will always be BELOW the average, this means that payments will be stopped to half the hospitals no matter what the average is or how it evolves. No matter how good a hospital might get, if it’s on the wrong side of the average, too bad. I wonder what statistician thought up this rule…

    • Chettyvk

      This is an excellent observation! I have been working on this problem of incentives for some time now. It is a starting point and surely must be improved.
      V.K.Chetty

      • Brian R

        The description is simplified from how it works.

        My understanding from how this works in other states is that hospitals with significantly higher re-admission rates than the benchmarks achieved by the best performers have a slight decrease in their overall rates of payment – a few percent. The reduction is enough to get the hospital to care about transitions and follow-up care, but not so much of a reduction as to cause them to not have the resources to provide adequate care.

        I hope that’s how MA will implement this.

    • Chettyvk

      I just want to add that this is not a bad idea for “Lake Wobegon” where “all the women are strong, all the men are good looking, and all the children are above average,” …
      As I mentioned earlier, I have worked out better incentive payments.
      V.K.Chetty

  • crodman

    Probably making the hospital and the patient’s physician equally responsible for re-admit costs would do a better job of keeping physicians in touch with their patients and the medical practice having reliable coverage response on off-hours.
    Discharge planning with the patient’s well-being in mind needs more time & attention prior to the day of discharge as well as on that day. It’s not helpful to provide most pts 3 or 4 minutes of explanation just before they are ready to leave; this is just confusing & overwhelming. Written instructions that are verbally reviewed with the patient & the family caregiver are necessary. Each patient should receive follow-up calls at home by a discharge nurse, a few hours after they return home, and the next day, to be sure the pt understands and is able to follow their instructions. The patient needs a phone number to reach a nurse if he/she is confused about anything related to meds, activity, diet, etc. Making the discharge success ful is not just about reducing readmission costs. It is also about taking good care of the patient. Is JACHO needed here?

  • jack sprat.

    I now starts, the race to the bottom. Welcome to the banana republic of the US.

  • MACDOC18

    Of course the hospitals should be penalized if Jack spends his money on cigarettes instead of his Plavix! This makes perfect sense to the budget idiots that are taking over the healthh system. It must be the hospitals fault if Jane.s GP who works on cap for the local HMO can’t give her an appt to adjust the chf meds for 8 weeks after discharge. Just keep banging away at the hospitals and blaming them for all the ills of our medical madness. Why not subtract money from the hmos for poor follwup care? Why not reach back to Janes high school that never taught her to read an instruction book? . Keep cutting the drg rate to hospitals so that each nurse has so many patients that she only has 4 minutes to give discharge planning.
    I am not saying that hospitals cant do better, but at least apportion the failure in a rational ways instead of just kicking the dog every time.
    ML CARR MD

  • http://www.patientcarelink.org Pat Noga

    Readmissions are a concern for the entire healthcare community, and Massachusetts hospitals and their partners are leading the charge to reduce preventable readmissions through a voluntary initiative. Over the past year, 22 Massachusetts hospitals have reached out to various community providers to assemble cross-continuum teams in an effort called the STAAR initiative: STate Action on Avoidable Re-hospitalizations. This initiative is led by the Institute for Healthcare Improvement with funding from the Commonwealth Fund. Through STAAR, these teams are working on smoother patient transitions out of the hospital, improved teaching for patients and families, safer communication handovers, and ensured / scheduled post-hospital follow up to prevent readmissions. The solutions are multi-factorial and involve providers and other services and technologies across the continuum of care. Some tools and processes can be standardized, while others need to be customized to the care environment and the patient. Last week at a Massachusetts STAAR learning session, the 22 existing cross-continuum teams shared their best practices and strategies for reducing readmissions, and 27 new teams joined the STAAR initiative. Hospitals and other care providers are clearly committed to continue the system redesign this statewide effort is leading.

    MA STAAR State Leaders -
    • Pat Noga, Massachusetts Hospital Association
    • Paula Griswold, Massachusetts Coalition for the Prevention of Medical Errors
    • Dr. Bruce Auerbach, Massachusetts Medical Society

    • Macdoc18

      The staar initiaive sounds good . May not be appropriate for all places and most certainly costs money. (Saves money?). How about medicare bonusing hospitals with the lowest readmission rates and let them decide the bets local solution to accomplish this? I am all for “Bonus for performance” rather than “Pay for performance… kick you butt if you don’t” MLC

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