Despite Hospital/Physician Integration, Readmissions Remain High

As physicians and hospitals consider participating in healthcare initiatives, many are asking: Is all the time, effort and money (not to mention the stress) really going to positively influence patient well-being?

So far, most pilot programs and measures put forth by the federal government say yes, participating in these programs (such as ACOs, bundled payments, meaningful use) will improve quality of care and reduce healthcare spending.

But recent statistics from the Veterans Health Administration, which bills itself as the “nation’s largest integrated healthcare system,” and which is at the forefront of several initiatives similar to those under the Affordable Care Act, reveal less optimistic findings, at least regarding readmission rates.

A key element of measuring quality improvements and healthcare spending is readmissions rates. Higher quality of care, naturally, should lead to lower readmissions and therefore, lower spending. This is where, despite its impressive programs, the VA system shows little progress.

In an analysis of readmission statistics based on Medicare's Hospital Compare data, Kaiser Health News found that only one VA hospital (out of 107) had significantly lower readmissions rates for Medicare patients than the average American hospital. The data included readmissions within 30 days between July 2007 and June 2010.

The readmission rate for heart attack patients at the VA system was 20.6 percent (it was 19.9 percent for non-VA hospitals), heart failure was 25.2 percent (24.8 percent for non-VA hospitals), and pneumonia was 19.2 percent (18.4 percent for non-VA hospitals).

"It makes you wonder how much hospitals can really control readmissions if a place like the VA cannot have dramatically lower rates," Dr. Ashish Jha, a Harvard School of Public Health professor who also practices medicine at the VA Boston Healthcare System told KHN.

Why are findings that fall right in line with average readmission rates distressing? The VA system has been very progressive when it comes to “effective discharge” planning in accordance with federal policies and suggestions, Jha told KHN.

"This is what the federal policymakers are trying to push the country towards. They're trying to create the kind of accountability the VA already has.”

For instance, according to several VA hospital websites, prior to discharge, patients typically undergo a conversation with their healthcare team regarding their anticipated discharge date, who the patient’s primary-care doctor will be upon leaving, how to handle medications and other medical supplies, and what follow-up and outpatient appointments will be needed. If applicable, social workers and dietitian counselors are also available to meet with patients.

The VA also uses EHRs extensively, another initiative promoted by health reform designed to help physicians and hospitals, partly to better track patient care across various systems and therefore reduce readmission rates.

And, since VA doctors are usually salaried, according to KHN, they lack the incentives (such as productivity bonuses based on RVUs), that sometimes reward hospitals and physicians for procedures and admissions rather than quality of care.

Still, while the VA’s readmission statistics are not stellar, it does shine in other areas, suggesting that certain health reform initiatives are working. For instance, for many quality indicators, the VA is higher performing than private providers.

What’s the secret? It could be the numerous programs focused on integration and quality.

Here’s just a few of them, according to its FY 2010 Performance and Accountability Report. The VA system implemented a patient-centered medical home model at all its primary-care sites, it piloted about 60 projects focused on improving access to non-institutional long-term care patients, it focused on improving communications between primary-care physicians and specialists, it expanded home telehealth-based services to treat patients with chronic conditions, and it transformed operations to ensure that 99 percent of patients have access to care within 30 days. The VA also invested in employee training to provide staff with continuous quality improvement skills and techniques.

So why is it the VA system’s readmission rates don’t match up to its high performance in other areas?

Kenneth Kizer, who led the VA's health system when Bill Clinton was president, told KHN perhaps the system needs to be even more integrated. About half of its patients have insurance that pays for doctors, hospitals, and rehabilitation facilities outside the VA, he said.

So if the VA - which is at the forefront of several physician/hospital integration programs - needs to be more integrated in order to improve its readmission rates, what does that mean for your practice and other organizations that might be trying to emulate its initiatives?