Reducing hospital readmissions from the emergency department

All of the focus that CMS is putting on hospital readmissions via the Readmissions Reduction Program, and the financial penalties that readmissions can generate, is causing hospital administrators to look to the emergency department and emergency physicians to intervene and resolve the issues that interrupt recovery for post-hospitalization patients.

In today’s world of budget-constrained financing of government health care programs and narrow hospital margins, the question of how best to mitigate the need for readmission is as uncertain as it is important. Some recent studies cast a bit of light on the question, and bloggers like Jordan Rao in the Incidental Economist have taken note. In this post, Rao notes that “readmissions are down … to what extent can that be explained by an increase in ED visits that don’t result in an admission?”

Reducing hospital readmissions from the emergency department

In the same blog, Austin Frakt questions whether the trend is really a reflection of better care or of gaming the measure, or both. Certainly, aggressive ED intervention or observation care can fend-off the need for inpatient readmission; but I can tell you from the experience of a family member who bounced from hospital to ED to SNF to ED to SNF to ED until definitive surgical care was finally provided, that preventing readmissions in this way does not necessarily imply better care.

A recent study of 15,519 inpatient discharges from a large safety net hospital published in the Annals of Emergency Medicine concluded that, “Excluding a return to the ED misses more than 50% of all returns to the acute level of care after discharge.”

What happens if Medicare decides, as seems inevitable, to count and ding hospitals for ED visits within 30 or 60 days of hospital discharge (presumably for issues related to or precipitated by the inpatient stay)?  Will this new accounting measure suddenly cause hospital administrators to shift the role of readmission-blocker from the ED to other services, and likewise reallocate resources like care coordinators and social services staff that may have been moved into the ED to assist in this role? It seems like the regulatory tail may be wagging the health care best-practice dog; and the evidence base for the economic value of these incentive/penalty based regulatory initiatives is very lean.

In fact, the cost-effectiveness of all sorts of care management tools that are being employed to curtail readmissions is still uncertain. There is even a question as to the effectiveness of community health worker intervention on health outcomes and resource utilization, as related in a 2013 report by the New England Comparative Effectiveness Public Advisory Council on Community Health Workers in New England and shown in the following graphic.

Reducing hospital readmissions from the emergency department

Given that the rate of readmissions seems to be significantly dependent on the socio-economic status of the patient, is it fair to disproportionately penalize safety-net hospitals for circumstances that may be beyond the control of these hospitals, even when they invest in community care resources and close post-discharge follow-up? I suspect that the most cost-effective approaches to preventing readmissions are those that are executed during the hospitalization, and are tailored to the specifics of the patient’s health care and social services needs, and to the nature of care provided.

I would argue that trying to prevent readmissions post hoc may or may not lead to better inpatient care and post-operative outcomes, even though it seems intuitive that such a reduction should save health care expenditures (given the costs of hospital care).

However, if by enhancing recognition of the role of EDs and emergency physicians and staff in circumventing readmissions, the Readmission Reduction Program has encouraged hospitals to add discharge planning, social services, and care coordination staff and resources into the emergency department, I am all for it. These resources have, for far too long, been limited or absent from most EDs, to the detriment of many of the patients treated there.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

Comments are moderated before they are published. Please read the comment policy.

  • Dr. Drake Ramoray

    “Given that the rate of readmissions seems to be significantly dependent on the socio-economic status of the patient, is it fair to disproportionately penalize safety-net hospitals for circumstances that may be beyond the control of these hospitals.”

    Pay for performance hurts doctors and patients alike in underserved areas. The study has been done, the government knows it, they don’t care. The best thing you can do as a physician in a pay for performance system is move to a more affluent area.

    http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-skewed-panel-finds.html?_r=3

    • Trish Browning

      Appreciate the article linked…thank you.
      So, the answer is from the White House via the proxy of CMS?
      “Nope, can’t admit that the poor and uneducated need more care and have worse outcomes. There is no naked emperor here from what we see, with our heads in the sand….nothing at all.”

      • Dr. Drake Ramoray

        I don’t think it as much head in the sand but more that the real reason for the changing healthcare system to an ACO/PCMH model is to reduce healthcare costs largely through decreasing pay to physicians and as such mitigating factors as your patient demographics that should increase pay or change the pay scale our counterproductive to that aim. It has never had anything to do with improving care but that had to be part of the salesmanship.

        Patients have largely passed on the cost of their unhealthy lifestyles (yes I know healthy people get sick too) and their demand for every latest test to be paid for by insurance companies. The insurance companies are tired of holding the bag largely placed upon them by the government. The government has to find a way to reduce Medicare costs. So those two in concert with the hospitals (the hospitals were never allies with doctors but more tolerated the necessity of each other) have formed an unholy triumvirate to leave the docs holding the bag and financial burden of caring for patients. By the very nature of being an employee of a company means the CEO is making money off of you, but even more so now when monies can be withheld due to poor survey scores or when patients have less than optimal outcomes.

        Physicians have the worst lobbyists and as such have been screwed by the more focused and powered interests. The rest of the talk is merely window dressing.

        • Trish Browning

          Sadly true. For what it is worth, this RN appreciates the corner you have been backed into….and I am terrified that I will not find another kick-@$$ PCP like mine when he retires from the stress of this BS. If he goes concierge first, I am going with him!

Most Popular