Cue the shark music. Because just when you thought you were getting a handle on reducing readmissions for your Medicare population, the Agency for Healthcare Research and Quality (AHRQ) has another task for you: Look at your Medicaid readmissions, because you may find that those patients are bouncing back in at least the same quantity as your older patients. And if you aren’t being penalized for those readmissions now, there may be a time coming when you will, says the lead author of a new toolkit commissioned by the agency to help get you through the project.
Released in August, the Hospital Guide to Reducing Medicaid Readmissions, available at http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html, was created to help organizations "unpack the differences" between the Medicaid and Medicare populations, says lead author Amy Boutwell, MD, MPP, a practicing physician, Harvard Medical School instructor, and consultant who guides organizations through the morass of health reform. She says even the best organizations who want to make sure they look at readmissions in a way that pays no attention to payer but focuses on keeping patients from bouncing back are still using guidebooks, evidence, articles, and information that was created specifically for Medicare patients. That just won’t work for many, if not most, members of the Medicaid population. "They are looking for patients with congestive heart failure, or pneumonia, the diseases of frailty," Boutwell says, "We still need to know those high-risk conditions, but they may not be the high-risk conditions for your Medicaid patients. In fact, very few organizations are aware of what their Medicaid population’s readmissions risks are."
In an ideal world, we wouldn’t stratify based on payer, and maybe in a few years, that’s where healthcare will arrive, she continues. "We would screen for readmission risk for every patient," she says, noting that a few facilities are already diving headlong into this effort. "But my experience working with thousands of hospitals is that unless there is an incentive to do so — or a disincentive in the case of a penalty — then they won’t do it."
Medicare stopped paying for unplanned readmissions. Some third-party payers are following suit. And now, Medicaid is jumping on board. Just two months ago, Illinois announced more than $16 million in penalties against hospitals for unplanned Medicaid readmissions, and Boutwell says there are "a handful" of other states considering similar options. New York state has created a waiver program designed to reduce Medicaid readmissions. Focus is increasingly on this vulnerable population.
"This kind of effort has, up to now, been defined by financial incentive and forcing people to put extra focus there because of that," Boutwell says. "And it’s shameful that it takes that."
Some people think that because Medicaid patients are treated at a financial loss makes changing behavior low on the priority list. "We’re losing money on them; how can they penalize us when they don’t pay us enough?" is the thought process. "What’s a percentage of a negative number?" But Boutwell says that’s like saying your boat is sinking, so why not punch another hole in the bottom? Every time a patient who is a drain on resources comes into the hospital, he or she is costing money. If they come in once and you make them well and they don’t come back, it’s a win. If you don’t make them well enough and they bounce back, you lose money twice. Added to that in the future may be a cash penalty that will speak louder than anything up until now has, she says.
The toolkit Boutwell and her peers wrote doesn’t include pregnant women or pediatrics because the dynamics are different for those patients and there is just too little literature to figure it out. Besides, you want pregnant women to come back in for delivery. And sick children? They don’t act like other sick patients.
The book includes worksheets to figure out your case mix and the number of readmissions for each payer — something Boutwell says she doubts many people know. She says it might be very surprising just how many of the unplanned readmissions come from Medicaid patients. Medicaid patients between 45 and 64 have a 24% readmission rate; Medicaid heart failure patients have a 30% readmission rate, compared to Medicare patients, who have a 25% readmission rate.
The emphasis is on young Medicaid patients — "a third of older adults are dual eligible patients, so the existing Medicare readmissions reduction efforts will apply to them," she says. "But what are the issues for these younger patients? It tends to be the health and social issues that lead to the very diseases we see in older patients. We don’t see the heart failure, but we see substance abuse, stomach problems, bleeding ulcers, and pancreatitis. We don’t need the dementia and functional status screening tools we use for older patients, and if we use them on this group, we are missing the highest-risk Medicaid patients, most of whom are more likely to bounce back than an older Medicare patient."
Boutwell acknowledges that this will take added work, but she says the toolkit was designed to complement what you are already doing. "We made this so that it is easy to integrate with what you are already doing in the spectrum of readmission reduction efforts. We are simply making the argument that you should expand them to include Medicaid and providing tools that may make it a little easier."
The tools even include estimated time involved at the top of each, so you can more easily budget for each step. Some take a couple of hours. Others are simply there to help providers remember that there is another population out there. For example, a readmission risk factor list is included and can be posted in workrooms, discussed at meetings or seminar sessions, or even handed out as laminated cheat-cards to key staff.
With healthcare reform, you will likely see a large influx of Medicaid patients through your doors. They will be unfamiliar with the healthcare system. They will have infections, sickle cell disease, HIV — things that your previous experience with readmissions reduction programs didn’t deal with, says Boutwell. They will have lower literacy levels and perhaps difficulty with the English language. All this and more will make them a potential drain on resources. More importantly, it will make them harder to heal.
"Nurses in hospitals are running around looking for the older patient with heart failure to try to make sure they do everything so that patient doesn’t come back," Boutwell says. "That violates every principle of quality improvement. We should be doing something for patients across the board to make sure none of them come back unexpectedly."
For more information on this topic, contact Amy Boutwell, MD, MPP, Co-Founder, Collaborative Healthcare Strategies, Boston, MA. Email: [email protected]
