What Can Be Done About Hospital Readmissions? – Is Home Care Part of the Solution

posted by Joel Wittman

A comprehensive analysis of Medicare claims data demonstrates that Medicare payments more than double when the beneficiary’s care contains at least one hospital visit.  A report by the Alliance for Home Health Quality and Innovation examined the effects of hospital admissions and readmissions on Medicare expenditures.

Hospital readmissions play a key role in the amount Medicare spends per patient per episode.  The research aims to more fully explain how hospital readmissions affect the Medicare episode payment and to provide guidance on the Medicare home health benefit.  The data will provide information on to lawmakers as they look to revamp the Medicare fee-for-service payment system and eliminate unnecessary spending on avoidable hospitalizations.

In post-acute care episodes, patients whose episodes contained at least one readmission cost Medicare twice as much – roughly $33,000 compared to $15,000.  When the number of chronic conditions per patient increases, so does the average number of readmissions, suggesting that a more complex patient is more likely to be readmitted.  Services such as home health may be able to reduce the number of unplanned readmissions for some clinically appropriate patients by caring for them in home health and improving coordination and continuity of care.

There are interesting trends when an episode contains an admission.  With regard to chronic conditions, the severity of the primary chronic condition, rather than the number of conditions, plays a more significant role in the impact on Medicare payment for the episode.  For example, an episode with a primary chronic condition of diabetes and a prior admission generates a Medicare episode payment nearly three times that of a diabetes episode without a prior admission.  This suggest that better management of low-severity chronic conditions (as well as high-severity conditions), which can be provided by home health care, may limit prior admissions for pre-acute episodes or even prevent some hospital admissions and subsequent post-acute care.  As the severity of a chronic condition increases, so does the proportion of episodes in non post-acute care episodes.  However, when patient with low-severity chronic conditions require a hospital admission, the payment per episode nearly quadruples since the cost of caring for these patients is relatively low without the readmission.

The data suggest that better management of chronic disease through home health intervention could enable more patients to remain out of the hospital following an initial admission.  With clinically appropriate and effective care, patients have the potential to avoid some unnecessary admissions altogether, ultimately saving Medicare and taxpayers a significant amount.  Home health care combines the right mix of care management, prevention training, and close observation to significantly reduce hospital admissions.

A program conducted in upstate New York generated some positive results.  See below:

A group of hospitals in upstate New York have been able to cut inpatient readmissions by 25 percent as the result of a home visit program, reported the Rochester Democrat and Chronicle.

The collaboration between Rochester General Hospital and three other area facilities not only cut readmissions over 30 days but also cut down readmissions over a 60-day period, the article noted.

Reduction of readmissions is critical particularly for hospitals as the Centers for Medicare & Medicaid Services intends to cut payments for excess numbers of patients readmitted within 30 days of discharge for congestive heart failure, heart attacks and pneumonia. According to research, up to 75 percent of hospital readmissions may be avoidable, Consumer Reports magazine noted.  Specific cost savings from the initiative were not immediately disclosed but could be as much as $100 saved for every dollar invested. “The cost of the intervention is measured in hundreds of dollars,” said Martin Lustick, corporate medical director for Excellus BlueCross Blue Shield. “The cost of a readmission is upward of $10,000.”

The program, known as Care Transitions Intervention, was conducted in coordination with the hospitals, local home health agencies, Excellus and the Monroe Plan for Medical Care, a Medicaid managed care program, according to the article. State and federal grants will allow the initiative to expand.

Joel Wittman is an Adjunct Associate Professor at the Wagner School of Public Service of New York University.  He is the proprietor of both Health Care Mergers and Acquisitions and The Wittman Group, two organizations that provide management advisory services to companies in the post-acute health care industry. He can be reached at joel.wittman@verizon.net.

The Power and Shortcomings of Healthcare Interventions

Posted by Katie Magoon

I was living in rural Kenya the first time I really began to think critically about the power and shortcomings of healthcare interventions.  I stumbled upon this totally accidentally as I was studying the economic empowerment of females in the “informal sector” of Kenya’s rural economy.   Specifically, I was exploring the ways in which women create and distribute their wealth, and the how these decisions impact the communities in which they live.  As I looked more intimately into the lives of these women, I realized that one could not truly understand the role of a female in an economy without understanding a variety of aspects related to her health.

In talking with many women, it became clear that some of their economic concerns were in large part related to the number of children their husbands/communities expected them to have.  Some women secretly obtained birth control in order to shelter their families from the economic hardships that they would face with having more and more children.  In some cases, their husbands would begin to suspect this and abuse them or use it as an excuse to have extra-marital affairs with other women (often bringing home sexually transmitted infections or HIV).  In many settings, women bear the brunt of raising families.  As a result their individual health is extraordinarily important to the health of an individual female’s family as well as community.  Issues such as lack of access to birth control, “back-alley” abortions, the dangers of childbirth, lack of empowerment for sexual decision-making and boundary setting, and even post partum depression can have a tremendous impact on the economic health of a community.  Such issues were so pervasive in the lives of the women with whom I spoke that it quickly became clear that these women could not achieve economic security without accessible and effective healthcare that is responsive to their specific needs.

Many believe that these are problems that do not apply to women in the United States.  I have found this belief to be grossly inaccurate.  In my work as a nurse practitioner, I encounter young women every single day who are forced to have sex, pressured to leave school and have children, and struggle with depression and other mental health problems that can make employment and/or caring for children very difficult.  Often these women put faith in their “boyfriend” who quickly moves on when their belly starts to grow or times get tough.  A young woman may be left to support a family with very limited resources.  Further, she has already stopped school to have and begin to raise the child, leaving her even more vulnerable to economic hardship.  This has obvious implications for her family and community.

Health interventions can address a small portion of this problem by offering family planning to women.  Women that do not want or are not ready to have more children can use birth control.  If need be, they can do this without the knowledge of their partner.  However, a woman is more likely to be successful with the use of her birth control if her partner is supportive.  In my mind, this simultaneously points to a success and shortcoming of the health system.  In this example, birth control is simply addressing a symptom of a larger problem in society—gender inequality.  Birth control could be considered a single disparity-decreasing intervention that can help women, and in turn their communities.  However, in a world that often does not value women as it values men, I cannot help but to ask: Is birth control enough?  Internationally and domestically, when will women finally be empowered to make their own decisions about what happens to their bodies, and offered support for those decisions?

Katie Magoon is a North Canton, Ohio native who currently works as a nurse practitioner at an adolescent community center in Manhattan.  She is an HPAM student, specializing in policy.


Who I Am and What I Hope to Achieve

Posted by Jacob Victory

While inaugural game-day outings, presidential swear-ins, or grand openings of the local laundromat tend to have a lot of noise, glamour and “a 15 percent discount on your first five pounds of laundry,” my premier blog post comes with a large dose of humility, a little about who I am and what I hope to achieve with this blog.

 About Me: As a kid, I was the one who batted a home-run but couldn’t catch the ball (the mitt was too tight remains my excuse). As an artist, I paint my portraits to zoom-in on what I think is going on behind the mask of someone’s face. As a person, I believe in merit and in understanding that the ego doesn’t matter. As a professional, I seek to make an impact in serving those who are vulnerable—in other words, those who are rich, poor or like spicy foods, anyone who needs health care, healthy or otherwise, is always in a vulnerable spot. Why am I sharing my thoughts? Well, I want to give you my angle and I remember what is was like to be a student or what it was like early in my career and I’d like to share my thoughts because I’ve learned a thing or two from my experiences that others could benefit from. I also want to open up a discussion so we all can learn more, too.

My Blogging Roadmap: My blog will primarily focus on two areas. First, I write as an NYU-Wagner alum whose goal is to encourage current students and fellow alums to focus on what is relevant, what I consider smart things to do and not do, and how to work with others to chip away at making an impact. I’d like to address the need for mentorship, for reflection, and for relationship building. Also, I think students and alums always need strategies for job hunting or an understanding of how to network and find who may seem to be an elusive mentor.

Second, as a quiet observer of, but an active participant in, the theatrics of health care delivery, outcomes and, these days, reform, I wish to offer the practical viewpoint of what matters, what gets in the way, and what, in my self-exalted viewpoint, we should focus on. I’ll zero in on the need to maintain the viewpoint that “patient care is the only reason we are here” and what is needed to support this view; the need for collaboration between clinicians and “those business folks;” how performance improvement and succession planning must be priorities; as well as what I think the federal, state and local levels need to tackle in order to help health care organizations, clinicians, and administrators make this health care reform work..

Perhaps most importantly, I’m looking for a dialogue with you. If I can stretch your thinking (or make you chuckle), I’ll consider this blog successful. I’m flattered to write and excited to share.

Jacob Victory, an NYU-Wagner alum, is the Vice President of Performance Management Projects at the Visiting Nurse Service of New York. Jacob spends his days getting excited about initiatives that aim to reform and restructure health care.  He’s held strategic planning, clinical operations and performance improvement roles at academic medical centers, in home health care and at medical schools. Jacob also exercises the right side of his brain. Besides drawing flow charts and crunching numbers all day, he makes a mean pot of stew and does abstract paintings, often interpreting faces he finds intriguing.