Stay Out! Hospitals Try To Prevent Patient Readmissions

Sep 15, 2017

Darnell Wilson lives off Gorman Street near N.C. State University. He is less active than he used to be – a result of health problems that include congestive heart failure and gout.

He tries to lightly exercise each day and eat vegetables. "I normally sit right here every day. This is my sittin' spot," he said.

He sat on the side porch of his Raleigh apartment unit talking about the days when he was a professional wrestler, during a time before Hulkamania or John Cena.

"I was the guy that set up the ring. Then put on my trunks, wrestled for about 10 or 15 minutes, until the place got big for the big stars to come in," Wilson said. "I might have made $100 here, $100 there."

These days he's less of a showman. Unfortunately, some of his health problems have put him in the hospital more often than he'd like. He has been back to the hospital nearly half a dozen times just this year.

"It's uncomfortable man, I can tell you that much," he said. "There is no joy in going in and out of the hospital. I'd like my health to be to the point that I could spend a whole year out the hospital."

It's no joy being in the hospital. Especially when you've got no family to visit you. No friends, you know? I remember times when I was homeless and I had to go in the hospital. Leaving the hospital and you ain't got nowhere to live. I've been there. I know what homeless is. - Darnell Wilson

Hospitals now pay closer attention to patients like Wilson. If a patient is readmitted to a hospital shortly after being discharged, that first hospital gets dinged with a penalty. These penalties were one of the many provisions from the Affordable Care Act. Even as Congress works on a possible "repeal and replace" of the law – and President Trump bashes Obamacare any chance he gets – many of the law’s provisions continue in full force.

What's more, hospital executives say these provisions have improved health care. By penalizing hospitals if a patient returns shortly after discharge, it has incentivized those hospitals to make sure patients are healthy when they leave in the first place. One of the biggest criticisms of hospitals has long been that they work on sick people, but do little to keep people healthy. This is the fee-for-service model in which hospitals were paid fees for providing services. The more services they provided, the more fees they charged.

Dr. West Paul, the WakeMed Health and Hospitals vice president of Quality and Patient Safety, standing in his office.
Credit Jason deBruyn / WUNC

But with penalties for readmissions – and other types of Obamacare incentives – these health systems now look to better integrate care, says Dr. West Paul, the WakeMed Health and Hospitals vice president of Quality and Patient Safety.

"It has forced us to recognize that we need to change the way we provide health care," he said. "We have to be good stewards of our resources."

That includes thinking about patients after they leave the hospital.

"And that's a big change for us," said Paul. "Out of the hospital is a big change for most hospital systems. It's the right thing to do, and it makes everyone's lives easier."

How Triangle Hospitals Fared

Readmission penalties are set to enter their sixth year and Triangle area hospitals have done well, meaning they face smaller penalties. The WakeMed Raleigh campus had its penalty reduced to zero percent this year.

The penalties apply to Medicare reimbursements – a significant chunk of any health system's revenue – and the federal government docks payments by as much as 3 percent. Eight hospitals in North Carolina face a penalty of 2 percent or higher, while 63 were hit with a penalty of smaller than 1 percent, according to data released by the Centers for Medicare and Medicaid Services, and analyzed by Kaiser Health News.

While penalties of this size might sound small, consider that Medicare spends $600 billion annually. In total, hospitals across the nation will lose out on an estimated $564 million in the coming fiscal year, which begins Oct. 1.

Even with the zero percent penalty at the Raleigh campus, WakeMed estimates it will see Medicare reimbursements cut by $38,000 because of the 0.6 percent penalty at the Cary hospital.

2018 Readmission penalties by Triangle hospital. The WakeMed Raleigh campus saw its penalty reduced to zero percent.
Credit Centers for Medicare and Medicaid Services / Jason deBruyn

Academic medical centers like UNC Health Care or Duke Health, will see complex cases from patients who travel long distances.

"Some of those local, especially rural, communities may not have the capabilities or sometimes the experience with sicker, more complicated patients," said Dr. Thomas Owens, Duke University Health System chief medical officer. "And in those settings if the patient presents to the local emergency room – which is the right thing to do if you are sick and concerned about your care – there's a very high likelihood that you will get readmitted to the hospital. Higher than if you were closer to one of our care facilities."

Hospital executives complain about the formulas used to calculate the penalties. Better hospitals tend to see more complex patients which have a higher likelihood of requiring a readmission. There was also a quirk in which hospitals with higher mortality rates were seeing smaller penalties: if patients died, they couldn't be counted as readmitted – clearly not the intention behind the readmission penalties. But the Centers for Medicare and Medicaid Services (CMS) have largely worked out these intricacies and adjust hospital scores based on their risk profile. Executives say the risk-adjustment formula isn't perfect, but that it helps.

Below is an interactive chart that shows Medicare readmission penalties by Triangle hospital through the years. Click on one hospital to highlight, or hover over data points to see more information. A list of the 2018 penalty for all North Carolina hospitals is further in the story.

Changing Health Care Landscape

The desire to keep patients healthy and out of the hospital has changed health care in meaningful ways. Groups like Community Care of North Carolina, a statewide nonprofit, work closely with patients and meet their most basic needs, which can often provide the most benefit.

"We found that a lot of why our patient populations were being readmitted was based on social determinates," said Ben MacDonald, a registered nurse care manager for Community Care of Wake and Johnston Counties. "Not being able to get their prescriptions, they either couldn't afford them or couldn't get to the pharmacy to pick them up. Didn't have the education, didn't have the access to the right kinds of food."

Brandon Utley, an advanced practice paramedic with Wake County Emergency Medical Services, left, and Ben MacDonald, a registered nurse care manager for Community Care of Wake and Johnston Counties
Credit Jason deBruyn / WUNC

MacDonald works with clients – including Wilson – to fill prescriptions or coordinate transportation to primary care. Even something as simple as helping patients know what signs to look for to manage their own health.

"What we found is that the 24 to 48 hours after discharge is probably their most vulnerable time," he said. "The risk factors for readmission are not having the right medications, not understanding what the red flags of their condition look like. And what to do if those red flags happen. So is there an intervention that can be done that doesn't require going to the hospital?"

Emergency medicine has changed as well, according to Brandon Utley, an advanced practice paramedic with Wake County Emergency Medical Services.

"EMS is rapidly moving from emergency medical services to medical services with an occasional emergency. We are the easiest access to health care," Utley said. "You call one number; everybody knows it. It's easy to call the number and it's free for us to show up and treat you. Why would you do anything else? So we've had to adapt to that, and learn how best to manage people, rather than the old adage of: 'You call and we haul.'"

The interactive chart below shows the 2018 readmission penalty for every North Carolina Hospital. Hover over any of the lines to see more detail about that hospital.

Hospitals have done a better job of following up with patients as well, and running all the numbers to identify patients with a higher risk of requiring a readmission.

"Even things like if you are discharged on a Friday or a Saturday you are more likely to be readmitted because you can't reach your physician over the weekend if you have a problem," said Paul. "So we designate these patients early, they are called afterwards after discharge within two or three days to see how they're doing, make sure they have follow up. We have programs to make sure we have medications available for those who can't afford them, so they will never be readmitted because they can't afford or can't get their medication."

It's no panacea, but even hospital executives generally agree that these readmission penalties have helped to move health care in the right direction.