Hospital Readmissions With Value-Based Penalties Vary by Provider

March 13, 2018 - Hospital readmission rates for conditions that carry value-based penalties under the Hospital Readmissions Reduction Program (HRRP) varied by admitting physician attending type, with geriatricians having the lowest 30-day readmissions rates for penalty diagnoses, a new study showed.

The study of a Massachusetts-based Pioneer accountable care organization (ACO) published in the American Journal of Accountable Care also found that a patient’s social context, including a lack of social support and difficulty speaking in English, also contributed to hospital readmission rates.

“Taken together, these data suggest that efforts to reduce 30-day readmissions should include comprehensive care teams that focus on the needs of elderly patients with chronic illness and provide continuity in the care team during and following hospitalizations,” the authors wrote. “Furthermore, we show that more attention should be paid to the context of patients’ lives as discharge plans are developed, which may enable identification of those at highest risk of readmission and the provision of enhanced services to meet their needs and mitigate this risk.”

Almost one in five patients experience a hospital readmission within 30 days of discharge, costing about $17 billion per year, an analysis of Medicare claims data showed.

With avoidable hospital readmissions accounting for a significant portion of Medicare’s budget, hospitals now face penalties for hospital readmission rates above an average rate.

READ MORE: 3 Strategies to Reduce Hospital Readmission Rates, Costs

Hospitals in the Hospital Readmissions Reduction Program must ensure their readmission rates for several diagnoses are below average. The value-based penalties apply to readmissions for patients treated for myocardial infarction, congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD), total knee replacement, and total hip replacement.

With Medicare revenue on the line, hospitals are trying to identify the causes of hospital readmissions and implementing strategies to reduce their rates, especially for diagnoses that could result in value-based penalties.

The retrospective study of patient-level data from 2013 to 2015 uncovered that focusing on admitting physician attending type could help hospitals drive down hospital readmission rates.

Of the 17,099 hospital readmissions recorded during the study’s period, 2,226 readmissions occurred within 30 days of an index admission.  As a result, the Pioneer ACO had an overall readmission rate of 13 percent.

The majority of patients experiencing a hospital readmission within 30 days were admitted by hospitalists. These providers admitted almost three-quarters of the patients facing a readmission. Other physician attending types demonstrated the following rates:

READ MORE: Why Focusing on Hospital Readmission Causes Is Essential

• 13.4 percent of the patients readmitted by a primary care provider

• 6.6 percent readmitted by a geriatrician

•  4.1 percent readmitted by a cardiologist

• 1.3 percent readmitted by an intensivist

While cardiologists and intensivists readmitted the least number of patients overall, they topped the list of admitting physicians for readmissions for the three original diagnoses that carried a potential value-based penalty under the HRRP. The study showed the following readmission rates for CHR, COPD, and pneumonia by physician attending type:

READ MORE: Preparing the Healthcare Revenue Cycle for Value-Based Care

• 18.5 percent readmitted by a cardiologist

• 17.4 percent readmitted by an intensivist

• 16.7 percent readmitted by a primary care provider

• 13.7 percent readmitted by a hospitalist

Geriatricians readmitted the least number of patients with penalty diagnoses, reporting a hospital readmission rate of 11 percent.

In addition, geriatricians also lowered their hospital readmission rates during the study’s period unlike the other provider types analyzed.

Hospital readmissions generally increased from 11.5 percent in 2013 to 13.65 percent in 2015 and 13.66 percent in 2015.

However, the readmission rate for geriatricians did not follow this overall trend. The rate dropped from 16.7 percent in 2013 to 13.7 in 2014 and to 12.7 percent in 2015.

In contrast, the hospital readmission rate for hospitalists rose from 10.8 percent in 2013 to 13.7 percent by 2015.

Researchers attributed decreasing geriatrician readmission rates to the care model used by the provider type. Geriatricians in the Pioneer ACO provide continuity of care across the inpatient and outpatient settings, which can prevent hospital readmissions.

In addition, the geriatrics care model contains a robust infrastructure, according to the researchers. The care model includes the use of post-discharge home visits, enhanced palliative care, and care goals under the supervision of a multidisciplinary team of providers who know the patient.

The geriatrics team in this particular Pioneer ACO also prioritized discharge process and transition of care optimization. The organization hired a nurse practitioner to support the care of chronically ill patients and implemented post-discharge home visits for the most complex patients.

To reduce hospital readmission rates, researchers advised other healthcare organizations to implement a similar care model by other attending types for high-risk patients.

Healthcare organizations working to drive down their readmission rates should also focus identifying social risk factors. Interviews with 58 patients with value-based penalty diagnoses revealed that patients who were readmitted demonstrated the following:

• Almost three times more likely to report that they were not able to complete one or more activities of daily living without assistance (32.1 percent of readmitted patients versus 11.1 percent of non-readmitted patients)

• More than twice as likely to lack an outpatient primary care provider (10.7 percent versus 1 percent)

• Over twice as likely to say they cannot recall having their discharge instructions reviewed with them prior to discharge (14.3 percent versus 0 percent)

• About 1.6 times more likely to report a lack of social support during their inpatient stay (17.9 percent versus 10.7 percent)

• More likely to say they did not know who to call with questions or concerns following discharge (10.7 percent versus 0 percent)

• Three times more likely to report they did not manage their own medications at home (35.7 percent versus 10.7 percent)

• Over twice as likely to have a first language other than English (17.9 percent versus 7.1 percent)

The findings showed that social risk factors lead to increased hospital readmissions and potential value-based penalties for hospitals.

“These findings suggest the need for rigorous identification of individual risk factors for readmission and for tailoring of discharge planning to mitigate the likelihood of readmission for those found to be at high risk,” researchers concluded.