GREENSBORO -- Reducing hospital readmissions -- particularly among the elderly -- requires improving coordination and communication, and engaging patients, according to speakers Friday at a statewide health-care summit.
More than 400 health officials attended the summit, which was sponsored by the N.C. Alliance for Effective Care Transitions.
The alliance is comprised of public and private stakeholders representing hospitals, long-term care, assisted living, home health, hospice, mental health, case management, insurance plans, community care networks and consumer advocacy groups.
The summit was conducted at a time when a spotlight has been placed on readmission rates as it relates to patient care and rising costs.
In North Carolina, about 190,000 Medicare beneficiaries are admitted to the hospital each year. Of those patients, about 16 percent, or 31,000, have at least one readmission within 30 days of being released.
Nationally, close to 2.6 million Medicare beneficiaries -- about one in five -- are readmitted to the hospital within 30 days. These readmissions cost an estimated $26 billion nationally.
In 2008, Medicare reported it paid more on average for treatments for readmitted patients than they did for their initial admission treatment in five categories -- major joint replacement, pneumonia, heart failure, renal failure and chronic obstructive pulmonary disease.
The Affordable Care Act authorizes Medicare to reduce payments to acute-care hospitals with excess readmissions through the federal Hospital Readmissions Reduction program.
"There is no magic bullet" when it comes to reducing readmission rates, said Pam Silberman, president and chief executive of the N.C. Institute of Medicine. "If we knew what to do in every community, we'd already done it.
"We believe we will be able to noticeably rein in health-care costs within five years because of what ACA provides in new opportunities to test new models of care delivery and payment models."
Speakers said that while their presentations were through Medicare and Medicaid filters, reducing readmission rates affects all demographics and ages, particularly as more people lose health insurance because of job layoffs. About 1.5 million North Carolinians, or 19 percent of the nonelderly population, lack health insurance.
"Being uninsured has a profound impact on health and financial well-being," Silberman said. "People who are uninsured are less likely to have a personal doctor, more likely to report delaying care due to costs, and more likely to end up in the hospital for preventable health problems or late stage cancer."
However, the increasing use of hospital services may be contributing more to high readmission rates than the severity of patients' conditions or the care they receive after being discharged, according to a December 2011 study by researchers at the Harvard School of Public Health.
Key elements of the ACA is that hospital are no longer paid for treatment of "hospital-acquired conditions" by Medicare, and hospitals with excessive readmission rates for pneumonia, heart failure and heart attacks will receive lower Medicare payments.
A total of 88 N.C. hospitals will receive lower Medicare payments in 2013, according to an October report by Kaiser Health News,
For example, because of its higher readmission performance, Wake Forest Baptist Medical Center faced reduced Medicare reimbursements of $730,000 to $980,000 for the fiscal year that ended Sept. 30, 2012. It was the largest penalty among the state's urban hospitals. Wake Forest Baptist has been cited in several studies in the past year as performing worse than the U.S. average when it comes to patient readmissions.
Wake Forest Baptist officials say the federal government's performance review doesn't fully take into account how many very sick Medicare patients from 20 counties end up there, often referred from other emergency rooms. Officials with Medicare and the foundations say their ratings and study account for that.
Stuart Altman, a professor of national health policy at Brandeis University, said he gets questions from hospital chief executives and chief financial officers asking "why are we getting penalized when we take care of the patient?"
"I tell them, 'you are big, rich and powerful, and you have the ability to resolve the problem and you will be part of the solution whether you like it or not.' "
Some summit participants said they are concerned about health-care consolidation putting too much power in the hands of the large not-for-profit systems. They said they are concerned about backlash from the hospitals for requesting that patients be readmitted since it now affects their Medicare reimbursement amounts.
"There are appropriate readmissions, such as related to different ailments or an unforeseen health event unrelated to the first admission," Altman said. "Hospitals are not penalized in those situations.
"However, there also are non-appropriate readmissions that can be benchmarked and compared with peers and the community."
Jennifer Cockerham, director of the chronic care program and quality management for Community Care of N.C., said one factor complicating readmissions within 30 days is that in 23 percent of the cases, the patient is not going back to the initial hospital. "That can lead to multiple records and diagnosis and tests that can be prevent with better coordination of electronic medical records," Cockerham said.
Most efforts to reduce readmission rates have focused on improving transitional care -- what happens to patients at discharge and shortly after they're released from the hospital.
For example, Forsyth and Wake Forest Baptist medical centers have formed a partnership aimed at enlisting local nonprofit organizations to help reduce readmission rates by at least 20 percent, hospital officials said.
"We know we have a three-day window to make sure patients have their proper medication, have doctor appointments set up and other appropriate post-hospital care," Cockerham said. "To make the most of that time requires accountability, relationships, coordinated care and communication."
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