Medicare Initiative Cuts Hospitalizations

By David Pittman, Washington Correspondent, MedPage Today

Published: January 24, 2013

Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania

Action Points

·         Note that this pre-post study performed in multiple communities across the U.S. showed a reduction in hospitalization rates among Medicare beneficiaries in communities where quality improvement measures to improve transitions of care were implemented.

·         Be aware that although 30-day readmissions were reduced, this appears to be due to a lower number of total admissions rather than an improvement in the readmissions-per-discharge -- a critical metric.

A community-wide quality improvement program led by Medicare's Quality Improvement Organization (QIO) helped reduce all-cause hospitalization and 30-day rehospitalizations, a study showed.

Hospitalization dropped on average by 5.74% and rehospitalization by 5.7% per 1,000 Medicare beneficiaries in 14 communities during a 2-year intervention period, according to the study, published in the Jan. 23 Journal of the American Medical Association.

At the same time, hospitalizations decreased on average by 3.17% and rehospitalizations dropped 2.05% in 50 comparison communities.

"However, the widely used measure of rehospitalizations as a percentage of hospital discharges did not change during the study period," wrote Jane Brock, MD, MSPH, medical director at the QIO, and colleagues.

The study sought to analyze the effectiveness of the QIO, which is run by the Centers for Medicare and Medicaid Services (CMS) and aims to improve transition of care between healthcare providers and social services.

CMS has piloted various ways to improve care transitions, which can reduce costs and rehospitalizations if done well. Many Medicare beneficiaries have serious illnesses and receive care from multiple providers and facilities, increasing the difficulty of smoothly transitioning from one provider to the next.

An intervention was defined broadly as "an activity introduced into clinical care processes that was intended to improve the quality of care transitions." It included evidence-based improvements with hospitals working with other hospitals, nursing homes, home health agencies, and the Area Agency on Aging.

The 14 selected intervention communities developed a baseline of hospitalization and rehospitalization rates from 2006 to 2008, and then implemented the interventions for 2 years beginning in 2009. The study also included 50 comparator communities who didn't implement interventions. The studied communities combined accounted for more than 22,000 beneficiaries, and the comparison communities for more than 90,000.

Rehospitalizations dropped from 15.21 per 1,000 Medicare beneficiaries per quarter at baseline to 14.34 in 2009-2010. That compared with a drop of 15.03 to 14.71 in the 50 comparison communities, Brock, who is also chief medical officer for the Colorado Foundation for Medical Care, and others found.

However, rehospitalization as a percentage of all hospital discharges fell by 0.06% in the study group compared with an increase of 0.15% in the comparison cohort (P=0.14). The authors claimed no significant difference in the pre-post between-group differences.

"One possibility for these findings is that enhancing coordination of care across a community might reduce overall hospitalization rates by preventing unnecessary hospitalizations, but not change rehospitalization rates because presumably only sicker patients are hospitalized, and these patients are at greater risk for rehospitalization," Mark Williams, MD, of the Northwestern University Feinberg School of Medicine in Chicago, wrote in an accompanying editorial. "Nonetheless, the overall decrease in all hospitalizations among a community population of Medicare patients is a noteworthy finding."

Williams noted that the findings will be difficult to replicate because the researchers did not provide concrete examples of interventions. "The researchers do not provide a well-defined intervention that others can adopt, but instead the description of a process," he wrote.

Martin Padgett, president and chief executive of Clark Memorial Hospital in Jeffersonville, Ind., said that working to reduce readmissions is a tough task for hospitals.

"What it is doing for us is forcing us to partner and collaborate and work with other post-acute or pre-acute care delivery systems such as our medical staffs, such as our pharmacies, home health agencies, nursing homes," Padgett said at an American Hospital Association event in Washington Thursday. "It will be a great thing for us, but it is also more difficult than accomplishing objectives just inside of our four walls."

Verde Valley Medical Center in Cottonwood, Ariz., holds a quarterly summit with area nursing homes and home health agencies so they can work to prevent readmissions, according to Harry Alberti, MD, chief medical official at the hospital.

"We have to look at who is taking care of our patients when they are outside of the hospital, so that they can help us and work together to prevent those readmissions," Alberti said at the same event.

Hospitals began losing money last year -- to the tune of $300 million nationally in the first year -- when CMS began instituting penalties for excess readmissions, Williams noted in his editorial. That number could triple by 2014 when new provisions of the Affordable Care Act take effect, he said.

The study should raise awareness among physicians that the increasing fragmentation of patient care has negative consequences, Williams wrote.

"Individual patients now see an increasing number of physicians, increasing the possibility of medical error, duplication of services, reduced quality, and increased cost ... This has likely been driven, at least in part, by the marked expansion in the number of subspecialists, who now outnumber primary care physicians by about 2 to 1."

Brock reported links with the Alliance for Home Health Quality and Innovation, Ramona VNA and Hospice, the Lewin Group, CHRISTUS St. Vincent Regional Medical Center, George Washington University, and the Hebrew Home of Greater Washington. Co-authors reported links with several organizations, including the Wisconsin Hospital Association, LeadingAge Wisconsin, Kauffman & Associates, the Institute for Healthcare Improvement, Texas Medical Foundation, Lilly, Insignia Health, National Quality Forum, Health Insight, and the Centers for Medicare and Medicaid Services.

Primary source: Journal of the American Medical Association
Source reference:
Brock J, et al "Association between quality improvement for care transitions in communities and rehospitalizations among Medicare beneficiaries" JAMA 2013; 309(4): 381-391.

Additional source: Journal of the American Medical Association
Source reference:
Williams, MV "A requirement to reduce readmissions take care of the patient, not just the disease" JAMA 2013; 309(4): 394-396.

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David Pittman is MedPage Today’s Washington Correspondent, following the intersection of policy and healthcare. He covers Congress, FDA, and other health agencies in Washington, as well as major healthcare events. David holds bachelors’ degrees in journalism and chemistry from the University of Georgia and previously worked at the Amarillo Globe-News in Texas, Chemical & Engineering News and most recently FDAnews.