Many providers at risk of penalties

LEBANON, NH – As score-keeping begins for new Medicare penalties for hospitals with excessive numbers of patients returning shortly after they're discharged, a new Dartmouth Atlas Project report shows little progress over a five-year period in reducing these hospital readmissions and improving care coordination for Medicare patients.

In fact, the statistics show that readmissions for some conditions are on the rise.

“Readmission rates for some conditions have increased nationally and for many regions and hospitals, including some of America's most elite academic medical centers,” the report notes.

For 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians.

The most recent report, released at the end of September, shows that roughly one in six Medicare patients wind up back in the hospital within a month after being discharged for a medical condition.

In an examination of the records of 10.7 million hospital discharges for Medicare patients, researchers found striking variation in 30-day readmission rates across regions and academic medical centers.

Researchers also found that more than half of Medicare patients discharged do not see a primary care clinician within two weeks of leaving the hospital, and that facilities and regions with general patterns of high use of hospitals for medical conditions were frequently the same places with high readmission rates, an indication that some communities are more likely than others to rely on the hospital as a site of care across the board.

"The report highlights widespread and systematic failures in coordinating care for patients after they leave the hospital," said David C. Goodman, MD, lead author and co-principal investigator for the Dartmouth Atlas Project, and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. "Irrespective of the cause, unnecessary hospital readmissions lead to more tests and treatments, more time away from home and family, and higher healthcare costs."

The readmission rate to a hospital is increasingly seen as a marker of a local healthcare system's ability to coordinate care for patients across care settings, and readmissions are often a sign of inadequate discharge planning and the lack of effective community-based care, according to Goodman.

The Centers for Medicare & Medicaid Services (CMS) has estimated the cost of avoidable readmissions at more than $17 billion a year. In hopes of decreasing these costs, Medicare plans to reduce payments for readmissions, exposing hospitals to considerable financial risks. In fiscal year 2013, hospitals face a penalty equal to 1 percent of their total Medicare billings if an excessive number of patients are readmitted. The penalty rises to 2 percent in 2014 and 3 percent in 2015.

"The need to develop more efficient systems of care that include discharge planning and care coordination is clear," said Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project and director of the Center for Population Health at the Dartmouth Institute for Health Care Policy and Clinical Practice. "The report shows the opportunity for improvement, and the importance of aligning efforts to reduce readmissions with other policy and payment initiatives."

"It's very important that patients and healthcare providers communicate clearly so that all questions are answered and everyone understands what will happen when the patient leaves the hospital," said Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, a longtime funder of the Dartmouth Atlas Project. "Everyone – patients, doctors, nurses, caregivers – has a role to play in ensuring quality care and avoiding another hospital stay. They need to work together to create a plan for how care will proceed when the patient returns home. This should include a clear understanding of the patient's medical problems, a schedule for follow-up appointments, a list of medications and instructions for taking them."

Key findings

• Nationally, there was relatively little change in 30-day readmission rates from 2004 to 2009, regardless of the cause of the initial hospitalization. Readmission rates following surgery were 12.7 percent in both 2004 and 2009, while readmission rates for medical conditions rose slightly from 15.9 percent in 2004 to 16.1 percent in 2009.

• Similarly, most regions across the country did not experience significant reductions in readmissions from 2004 to 2009. Readmissions decreased after medical discharges in 11 regions, with Bismarck, N.D. experiencing the largest decrease, from 16.3 percent in 2004 to 14 percent in 2009. There was an increase in readmissions in 27 regions, the highest in Aurora, Ill., which increased from 14.3 percent in 2004 to 18 percent in 2009.

• Readmission rates after surgeries varied as well, with 28 regions experiencing a decrease, most notably in Elyria, Ohio, which decreased from 19 percent in 2004 to 15.2 percent in 2009. White Plains, N.Y. was among the 18 regions with increases in readmission rates following surgical discharges, with an increase from 13 percent in 2004 to 17.4 percent in 2009.

• Only seven academic medical centers had significant changes in 30-day readmission rates following medical discharge from 2004 to 2009. Northwestern Memorial Hospital in Chicago, showed the most decrease, from 19.9 percent in 2004 to 16.7 percent in 2009, while the University of Connecticut Health Center in Farmington, Conn. increased from 13.1 percent to 17.9 percent.

• Among patients discharged after surgery, 11 academic medical centers experienced significant changes in 30-day readmission rates between 2004 and 2009. The University of Missouri Hospital and Clinic in Columbia, Mo. decreased from 19.7 percent of patients in 2004 to 14.5 percent in 2009,hile Montefiore Medical Center in the Bronx, N.Y. increased from 15.6 percent to 19.4 percent.