|By the Innovations Exchange Team|
A major contributor to health care costs is the high number of hospital readmissions, especially for people with chronic diseases. One study showed that nearly 20 percent of Medicare patients discharged from hospitals were readmitted within 30 days for an exacerbation of the diagnosed condition. Nearly one-half of the readmitted patients had no postdischarge contact with health care professionals. Chronic disease management can reduce hospital readmissions and lower health care costs.
Innovations Exchange: What is the main concern that policymakers have about hospitalizations?
Jack Meyer, PhD: First, many hospitalizations are avoidable if chronic illnesses such as diabetes, asthma, and hypertension are properly managed. Second, the cost of the hospital stay is frequently inflated by excessive or duplicate testing; poor coordination among various specialties or specialists; hospital-acquired infections; long waiting periods for laboratory and diagnostic results; and the high cost of medical devices, drugs, and other services. Third, too many people are readmitted to the hospital for complications that are avoidable.
The Affordable Care Act includes provisions designed to reduce hospital readmissions. Since October 2012, hospitals that receive Medicare payments can lose up to 1 percentage point in payment if they do not meet targets for reducing readmissions that occur within 30 days for acute myocardial infarction, heart failure, or pneumonia. Medicare’s Innovation Center is pilot testing accountable care organizations’ participation in its Shared Savings Program to examine the impact of new payment arrangements such as bundled payments on decreasing Medicare costs.
Which patient populations drive up health care costs?
More than 125 million people experience at least 1 chronic illness, whereas 75 million of them have 2 or more. Chronic medical conditions such as heart failure, chronic obstructive pulmonary disease, diabetes, hypertension, asthma, and depression account for more than 75 percent of total health care spending. A typical patient with multiple chronic medical conditions cycles in and out of the hospital and the emergency department; sees multiple specialists; and may take as many as 12 to 14 medications, some of which may be duplicative or unnecessary. The problem is that the delivery of care is fragmented, and the old-fashioned fee-for-service payment system encourages and perpetuates the delivery of care in “silos.”
How can chronic diseases be managed effectively to reduce readmissions?
The key is to identify high users of health care services, design individualized care management plans, and monitor each patient’s progress and compliance with treatment. Intensive multidisciplinary predischarge and postdischarge planning and counseling are effective interventions. An example of a successful postdischarge intervention involves home visits or weekly telephone calls by a trained clinician, who asks the patient questions such as "Are you taking your medications?" and "Have you experienced any side effects such as weight gain?". In patients with congestive heart failure, sudden weight gain can indicate fluid buildup and that the patient needs to be seen immediately.
Patients also need to be educated about their treatment plan, self management, and how to detect warning signs of problems. For example, people with diabetes need to get periodic hemoglobin A1c tests to measure their glucose control and learn how to manage their glucose levels through diet, exercise, and medications, and people with asthma need to learn how to use inhalers and prescribed corticosteroids.
Health care providers can work with patients to monitor some of these conditions from their homes through the use of electronic devices that transmit patient data, such as body weight or blood glucose levels, directly to the physicians’ offices.
Electronic medical records, e-prescribing, and computer-assisted physician order entry of medications can all reduce medical errors and improve patient safety.
What other components of chronic disease management need to be addressed?
A multidisciplinary care team is essential to provide a comprehensive range of services, including social services, education, predischarge and postdischarge planning and monitoring, and early access to physicians to prevent exacerbations. Communication and care coordination among the team members and other health care providers is essential, as is communication with patients and family members in a culturally and linguistically appropriate manner. Health care providers also should ensure that patients have a consistent source of primary care—whether a physician, medical home, or community health center—and help to arrange such care, if needed.
What health care models reward physicians for keeping patients out of the hospital?
There is a lot of interest in accountable care organizations, in which providers agree to share cost savings and risks. Patient-centered medical homes and Medicare’s Shared Savings Program also incentivize health care providers to deliver comprehensive care and avoid unnecessary emergency department visits and hospitalizations of patients with chronic diseases. Reforming fee-for-service payment models is critical so that providers are rewarded for improved patient outcomes and lower total spending instead of the volume of treatment and tests that they order.
The Affordable Care Act established a prevention and public health trust fund of $15 billion. It also requires restaurants with at least 20 locations and vending machines to publish the calories of their food and beverage items. The law also waives any fees for preventive services such as annual examinations, screening tests, and smoking-cessation services.
About Jack Meyer, PhD
Dr. Meyer is a Managing Principal with Health Management Associates, an independent research and consulting firm in Washington, DC. He is also a professor in the Schools of Public Policy and Public Health at the University of Maryland. As a health economist, he specializes in developing and evaluating policies to cover the uninsured and to improve health care access, quality of care, and patient safety.
Disclosure Statement: Jack Meyer, PhD, reported that Health Management Associates received consultation fees or honoraria relevant to the work described in this article.