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Special report: The revolving door

By David Gulliver and Carol Gentry
6/3/2009 © Health News Florida

A year ago, Florida became the first state in the country to disclose the rate of patient readmissions, hospital by hospital. 

Holly Benson, secretary of the Agency for Health Care Administration, said its data-sharing partnership with the Florida Hospital Association would  "help hospitals, providers and especially patients improve the discharge process and the delivery of health care."

But so far it hasn’t worked out that way. A Health News Florida analysis of data at www.FloridaHealthFinder.gov, a state-run website offering information on quality of health care in hospitals, nursing homes and other facilities, shows the revolving-door problem may have actually accelerated after it was identified.

The rate of patients being readmitted to the hospital within two weeks of discharge rose in 13 out of 14 categories for which data comparisons were available. Stroke and heart attack patients’ rate of readmissions rose almost 2 percentage points, to nearly 13 percent -- about one patient in eight. Four other categories, including pneumonia and heart failure, rose about half a point or more. 

The increase isn't reflected on the state's Web site because the 2007 data were taken down when 2008's were posted. Luckily, a Health News Florida reporter had held on to the readmission rates for 14 of the most common conditions and procedures from the prior year, and was able to make the comparison.

An AHCA spokeswoman said the agency had not analyzed the data and referred questions to FHA, where President Bruce Reuben confirmed the trend. "I'd certainly rather see the numbers go down," he said.

Readmission -- an unintended return to the hospital for a problem stemming from an earlier visit -- is a serious problem in healthcare. Sometimes it can’t be avoided, but it can be a sign that a patient wasn’t healthy enough to leave in the first place or was harboring an infection. Often they indicate that patients don’t understand how to take care of themselves, or don’t have access to follow-up care from their doctors. They also may not have family or friends to help them recover.

Readmission rates may be rising in part because of a more comprehensive effort to measure the problem, Rueben said. But the rise also may be for real: Florida’s population is particularly susceptible to readmissions, he said. The state’s high proportion of non-English speakers and elderly people living alone may have more trouble following discharge instructions and taking the right doses of medications, he said.

Last fall -- well after the cutoff for the website data -- the hospital association launched an effort to study why readmissions happen and how to reduce them. Some 100 Florida hospitals are participating. Two keys: Identifying at-risk patients and heading off conflicts between hospital-ordered medications and the patients’ regular medications.

Judy Milne, director of quality improvement and patient safety at the 806-bed Sarasota Memorial Hospital system, said better coordination with home health and primary care physicians is crucial. “Readmissions to the hospital are not necessarily a hospital issue, in that the hospital does not control the entire continuum of care,” she said.

But hospitals will take the brunt of reform efforts. Readmissions mean extra revenue for hospitals, and politicians and researchers have zeroed in on that as a major waste of health care spending. A recent study in the New England Journal of Medicine reported that readmissions of Medicare patients cost taxpayers $17 billion in 2004.

That study used 30 days as the look-back period for a second admission. Florida uses only a 15-day window, which captures fewer readmissions. Hospitals say that’s fairer, given the state’s large population of old and frail residents.

Reuben predicts that Congress will pass legislation tying hospital payments to readmissions and other quality measures no later than July 2010, and perhaps as soon as January.  Last summer, the National Quality Forum, whose recommendations can drive Medicare payment policy, endorsed four hospital quality measures based on readmission rates. And the Medicare Payment Advisory Commission also recommended that hospitals with high readmission rates receive lower per-case payments.

Normally, any changes would have to go through CMS's lengthy rule-making process. But Rueben said he expects government action on readmissions to happen soon, given the Obama administration’s drive to overhaul health care.

“That has to be paid for," he said, "and one way is to stop paying for the stuff we know we don’t need.”

--Questions may be addressed via e-mail to David Gulliver and Carol Gentry.