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Dear Director,
My hospital is spending a lot of time talking about 30-day readmissions and how the ER needs to stop admitting people. Frankly, I don’t understand how a readmission is an ER problem. Aren’t we taught that a patient returning to the ED is like a red flag warning giving us an opportunity to correct something? Wouldn’t this same logic apply to patients who were recently admitted to the hospital? Aren’t admission bounce backs related to the discharge process and home care?
Signed,
Conflicted

Like it or not, the list of metrics by which your ED will be weighed and measured is growing, and even includes benchmarks that are more-or-less out of your control. The 30-day readmission metric is one such number, and it’s going to be one of the key administrative issues for your C-wing this year. Why? CMS will be posting your hospital’s performance in this category publicly at www.hospitalcompare.hhs.gov, and, more importantly to your hospital, money is at stake. Hospitals could lose up to 1% of Medicare dollars in fiscal year 2013, and that number increases to 3% in FY15. It’s estimated that only a quarter of hospitals nationwide won’t lose money while about 65% of hospitals will lose up to 1% and 9% of hospitals will lose the full 1% in 2013. And don’t forget the increase to 3% in 2015.

If you don’t know about this metric yet, you’re only about six months behind the 8 ball since this measure started October 1, 2011. The hospital’s performance will be graded for 12 months and then an adjustment will be made in the hospital’s Medicare base operating DRG payments beginning in FY13 (which starts October 1, 2012).

Ask your CFO what a 1-3% reduction in Medicare payments means and you may actually watch their eyes pop out. Many community hospitals operate on a 3-5% profit margin and for your typical 200 bed hospital with an operating budget of $200 million, losing 1% equates to $450K less in revenue, which is about a 20% reduction in profit. However, this gets worse for the urban hospital with a larger government payer mix and a lower – maybe as low as 1% – profit margin. This could wipe out their whole margin.

We all recognize that profits are important, but how do they impact us on a daily basis? Most hospitals (and all non-profits) reinvest their profits back into the hospital in areas such as capital purchases (new construction and expensive technology, like CTs, MRIs, and EMRs) and growth initiatives such as seeding new physician practices, resulting in more patient referrals to the hospital and ED. Additionally, since about 50% of a hospital operating budget is staffing, that $450K equates to about 5 nursing FTEs. I don’t know about you, but I don’t want to lose even one FTE in the ED.

What’s a 30-day Readmission?
As with any game, you really need to understand the rules and you’ll be judged for your 30-day readmissions. For starters, we’re talking about Medicare patients at least 65 years old who are readmitted (to any facility, not just the one they were discharged from) within 30 days of their date of discharge. While the readmission may be associated with any diagnosis, the initial discharge diagnosis is what really matters for this measure. At this point, CMS is strictly looking at patients who were initially given the discharge diagnosis with a primary ICD-9 code of acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). These diagnoses were selected because CMS estimates that they represent about 30% of all preventable readmissions. It’s likely that the list of diagnoses in this measure will increase over the next few years. To complicate score keeping, there are numerous exclusion criteria including patients brought back to the hospital for a planned cardiac procedure after an AMI, patients readmitted for hospice care, and also patients who get placed in observation status.

For your own comparison, it’s estimated that the average rate of 30-day readmission for Medicare patients are as follows: AMI 19.8%, HF 24.8%, and PN 18.4%.

The hospital then gets penalized if its performance is worse than average with regard to any of the three diagnoses after its actual readmission rates for these conditions are “risk adjusted.” Not surprisingly, the criteria used to risk adjust are very complicated and include patient demographic factors, co-existing medical conditions and other indications of patient frailty.

Hospital Strategies
There is no doubt that at least one, and probably numerous people in your hospital our currently working on a variety of strategies to reduce your 30-day readmission rate. Many hospitals are reengineering their discharge process to insure reliable information exchange and follow up as the patient transitions to outpatient care. Other hospitals are actually filling patient’s prescriptions for the first several weeks to make sure that lack of medications doesn’t cause a bounce back. Most hospitals have established committees to examine trends in both 30-day readmissions and disease management.

Our Role
As emergency physicians we have a unique opportunity to really help the hospital fix a problem that doesn’t start in the ED. Regardless of whether we’re hospital employees or a contracted group, we need to partner with the hospital administration and make sure that our actions are aligned with the hospital’s goals. This starts by understanding how a 30-day readmission is defined and developing a system that can notify the clinicians during the ED evaluation if a patient would be a potential 30-day readmission. This will be best accomplished by working with your IT department and building it into your electronic tracking board (easier said than done, I know). Once patients are identified, there is an opportunity to better utilize our resources (i.e. case managers, hospitalists, PMDs) to determine if a patient could be safely discharged home rather than be admitted if certain resources can be provided, such as home O2, IV meds via home therapy, etc… For patients who still require further care, definitely consider observation status. Finally, make sure that there is at least one ED physician who is actively engaged with the hospital’s 30-day readmission committee.

Conclusion
As emergency physicians, we have successfully navigated numerous core measures and 30-day readmission is but one more challenge for us to face. However, unlike the pneumonia core measures, which really fell directly on the ED attending, this measure puts us as one of several potential lines of defense for the hospital. Understanding the metric, partnering with hospital administration, and considering alternatives before hitting the “easy button” to admit the patient, are part of the keys to success. There will always be patients presenting to the ED who are clearly sick and require readmission, but for most hospitals, if we can identify a handful of patients per month and change our practice slightly to tune them up and not admit them, we will have done our part in reducing our hospital’s readmission rate. Your CFO and CEO will thank you.


Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

Comments   

# ED AttendingDarrell Looney 2012-03-07 11:38
I've said it before and I'm saying it again. ALL of these "new initiatives" will be at most 50% effective because there are no requirements or expectations on the patients to do their part. Patients are held to no standard and do whatever they please. In the case of CHF and COPD diagnoses, most of these patients continue to smoke and maintain poor diets. At this point in their lives they cannot tolerate exercise so this combination results in a slow progressive decline. It is laudable to do all we can, but if we are forced to practice this way, one can only expect success inversely proportional to the level of self destructiveness of the patient themselves.
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# Pit DocMark Foppe DO FAAEM FACOEP 2012-03-08 10:24
Who and what we admit will be scrutinized more and more.
Many of our fellow EM physicians have the philosophy that there is "no reward in sending a patient home". There is the risk of liability and EM physicians to this point were never criticized for admitting a patient, while sending a patient home... At my hospital in litiginous Southeast Florida I am the only physician with an admission rate less than 50% with
Several physcians with admission rates which are above 70%
This article mentions an "out" of observation admissions.
If this is the case then why is CMS having all this discussion about tracking the observation admissions as "unnecessary admissions" and penalizing hospitals that have greater than normal observation admission rates.
In the very near future the way many EM physicians practice will be "encouraged" to change.
For the sake of the hospitals profit EM physicians will be asked to make tougher choices, take on greater liability, all
while keeping the greater good of our patients in our hearts.
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