Earlier this month, Kaiser Health News reported, based on a study of Medicare data, that 2,610 U.S. hospitals, or fully three-quarters of those subject to the hospital readmissions reduction program under the terms of the Affordable Care Act (ACA) are being penalized this year for having too many patients return within a month for additional treatments.
In an effort to lower avoidable readmissions, many patient care organizations have been implementing post-discharge planning programs, ranging from telehealth initiatives to follow-up care plans to patient engagement strategies. However, according to Eugene Litvak, Ph.D., president and CEO of the Institute for Healthcare Optimization (IHO) and Harvard University Professor, post-discharge planning is only half the battle.
At IHO—an independent research, education and service organization focused on bringing the science and practice of operations management to healthcare delivery—the goal is to develop new theory to simultaneously reduce cost and improve quality of care, contradicting the notion that improving quality and cost of healthcare has to involve trade-offs. Dr. Litvak recently spoke with HCI Associate Editor Rajiv Leventhal about what else hospitals could be doing to lower readmissions, and the most significant elements that came out of the Kaiser Health News report. Below are excerpts of that interview.
What was your initial reaction to the readmissions numbers that Kaiser Health News reported?
I wasn’t surprised in the least, just like I’m not surprised when it’s hot in the summer and cold in the winter. You can’t predict the numbers, but it’s not difficult to predict the trend. Most hospitals concentrate on the patient’s exit from the hospital, and properly, so long as the patient gets all of the necessary information when leaving. Hospitals try to do their best to make sure of this, though they’re not always successful. I think it is the right thing to do when done correctly; by no means am I critical of it. What I disagree with is that hospitals are missing the elephant in the room.
What is the elephant in the room?
The way patients are admitted to the hospital. If you look at bed occupancy at most hospitals, you will find significant changes from peaks to valleys on a daily basis. During the peak in inpatient demand, your resources are stretched thin. And during a valley, you have a [situation] where resources are being wasted. It’s not like you can put it in the freezer for the next day when you have a peak; if you have a valley today, those resources are gone. During peak days, you will hear that the hospital is overcrowded and doesn’t have beds, but needs more patients. Messages are being sent left and right to discharge. You hear, “Sleep faster, someone else needs your blanket.” You cannot sleep faster. Even if you free up beds, patients are being discharged prematurely, and then the chances that the patient is readmitted increase.
And this isn’t just theory. Research at Johns Hopkins Hospital revealed that unplanned readmissions to the neurosciences ICU and readmissions risk increased dramatically for patients discharged as a result of increased admissions to the ICU. This study shows that expediting discharges is not the right way to manage peaks in admissions; unnecessary peaks in scheduled admissions need to be addressed directly. Further research has shown that excessive patient demand for nurses during peaks in hospital census has a significant impact on readmissions, and hospitals with higher nurse staffing had 25 percent lower odds of being penalized compared to otherwise similar hospitals with lower staffing.
Eugene Litvak, Ph.D.
So what can hospitals do to better manage this problem?
One possible solution is to provide more nurses for these peaks. However, no one can afford to do that. And the waste will be huge, because every time there is no peak, there will be waste. So that solution, while it sounds great, is not feasible.
The second solution, and this is at core of what we’re doing, is to ask the question, “Why do we have these peaks and valleys in first place?” Well, patients break legs and come to the hospital, and we don’t have the power to change that. The main contributor to availability in bed occupancy is not patients coming into the ER, but patients being admitted electively. I know that sounds counter intuitive, but elective admissions get scheduled based on doctors’ preferences. For example, if I’m a surgeon and I want to operate today, I will, because it’s my decision. If you and I are heavy-volume surgeons, and we have our block time, or the operating room is available to us on the same day, you have a huge patient volume come into the hospital. Given that those patients are privately insured, they will always get beds.
So you want to get rid of those artificial peaks and valleys. If you’re a physician and you want to admit a medical patient, you are being praised/criticized for the quality of care that you provide. How long would you keep the patient there? The answer is as long as possible, and that leads to artificial peaks. When a patient is almost ready for discharge, he doesn’t require as much attention as in the first day or two; new patients are more lucrative. But it’s critical to remember that “almost ready” doesn’t mean “ready,” and too often they’re being sent out when they’re not ready. Here you have a patient that’s recovered, but not fully, and then another patient who is coming in the entrance. They compete for the bed—who should get it? The problem is there is a solution where both patients get the bed, but that solution requires a cultural change. So the best way is a combination of managing patient flow and following up post-discharge. You can’t forget post-discharge—that would be stupid. But currently, we’re only doing one of these things.
Are hospitals aware of these peaks and valleys and motivated to do something about it?
There is definitely a great proportion of hospitals aware of this and not doing anything when they should be. It looks easy to change your schedule, but that means it becomes patient-focused rather than provider-focused, and the provider doesn’t like that. I talked to one cardiac surgeon, and he asked me, “How come you can tell me when to operate on my patient? No one is in a position to tell me since I know their health status best.” And that makes sense because he does know best. So we looked at some data [on his scheduled operations], and then I asked him, “What kind of cardiac disease are you subjected to that manifests itself every Tuesday? Every Tuesday, you have a peak!” He stopped talking to me, but obviously no disease manifests itself on Tuesdays.
Big data and analytics will continue to be a critical component in hospital leaders’ response, right?
That’s the right thing to do, but you cannot discharge patients prematurely, as they will come back. The more premature discharges you have, the more likely you have an increased number of readmissions. That’s simple, right? Hospitals will say they don’t discharge patients prematurely, and bed occupancy doesn’t matter. And let’s even assume that they’re right. Those peaks still overcrowd the hospitals, and nurses who care for four patients now care for eight. And how does that affect the quality of care? What it comes down to is that high patient per nurse staffing ratio is the cause of readmissions.
So do you think that these readmissions penalties will spur more action from hospitals?
It depends. I still speed on the highway when there’s no policeman. If my penalty for speeding was $1, I would speed 100 percent of the time. If it was more, I would be careful. If it became $1,000, I would never speed. Are the penalties enough? We will see, but it might not be significant enough for hospitals to change their culture. That’s not my position to determine that, though. But changing culture could be easier than tolerating the financial pressure. I truly believe that.