Unlocking the Key to Readmissions Reduction Success—Looking at Clinical Transformation, and the “ACO Effect”

April 25, 2017
A recent study lends further credence to already-accumulating anecdotal evidence regarding the value of ACO, bundled-payment, and even MU-driven, work, to support the processes that can unlock success in reducing readmissions

A recent study published in JAMA Internal Medicine lends strong credence to something that might seem logical to begin with, but for which it’s good to have evidence: patient care organizations participating in one or more of the following—the meaningful use program, a federal accountable care organization (ACO) program, or the Bundled Payment for Care Initiative—are considerably more likely to be making good progress on reducing avoidable readmissions, as well—and to be moving forward productively on the essential work of clinical transformation.

The article, “Association Between Hospitals’ Engagement in Value-Based Reforms and Readmission Reduction in the Hospital Readmission Reduction Program,” written by Andrew M. Ryan, Ph.D., Sam Krinsky, and Julia Adler-Milstein, Ph.D., asked directly, “Is hospital participation in voluntary value-based reforms associated with greater improvement under Medicare’s Hospital Readmission Reduction Program?” And its answer is equally direct. “In this longitudinal study of 2,837 U.S. hospitals between 2008 and 2015,” Ryan, Krinsky, and Adler-Milstein write, “we found that participation in one or more Medicare value-based reforms—including the Meaningful Use of Electronic Health Records program, the Accountable Care Organization programs, and the Bundled Payment for Care Initiative—was associated with greater reductions in 30-day risk-standardized readmission rates under the Hospital Readmission Reduction Program.”

As the April 11 report by Associate Editor Heather Landi noted, here’s what the researchers did: “retrospective, longitudinal study using publicly available national data from Hospital Compare on hospital readmissions for 2,837 hospitals from 2008 to 2015. We assessed hospital participation in three voluntary value-based reforms: Meaningful Use of Electronic Health Records; the Bundled Payment for Care Initiative episode-based payment program (BPCI); and Medicare’s Pioneer and Shared Savings accountable care organization (ACO) programs. We used an interrupted time series design to test whether hospitals’ time-varying participation in these value-based reforms was associated with greater improvement in Medicare’s HRRP.”

And what they found was very interesting. And there are a lot of numbers here, so I’m going to quote directly from the article. Here’s what the authors found: “Among hospitals that did not participate in any voluntary reforms, the association between the HRRP and 30-day readmission was −0.76 percentage points for AMI [acute myocardial infarction, or heart attack] (95% CI, −0.93 to −0.60), −1.30 percentage points for heart failure (95% CI, −1.47 to −1.13), and −0.82 percentage points for pneumonia (95% CI, −0.97 to −0.67). Participation in the meaningful use program alone was associated with an additional change in 30-day readmissions of −0.78 percentage points for AMI (95% CI, −0.89 to −0.67), −0.97 percentage points for heart failure (95% CI, −1.08 to −0.86), and −0.56 percentage points for pneumonia (95% CI, −0.65 to −0.47). Participation in ACO programs alone was associated with an additional change in 30-day readmissions of −0.94 percentage points for AMI (95% CI, −1.29 to −0.59), −0.83 percentage points for heart failure (95% CI, −1.26 to −0.41), and −0.59 percentage points for pneumonia (95% CI, −1.00 to −0.18). Participation in multiple reforms led to greater improvement: participation in all 3 programs was associated with an additional change in 30-day readmissions of −1.27 percentage points for AMI (95% CI, −1.58 to −0.97), −1.64 percentage points for heart failure (95% CI, −2.02 to −1.26), and −1.05 percentage points for pneumonia (95% CI, −1.32 to −0.78).”

That’s a lot of numbers to wade through, but the bottom line is clear: when it comes to caring for patients with heart attacks, heart failure, or pneumonia, there is a statistically significant and documented improvement in avoidable readmissions reduction, based on meaningful use alone, and which is magnified if a hospital participates either in the MSSP or Pioneer ACO programs, or in the voluntary bundled-payments initiative (BPCI).

Now, should any of this be surprising? No, it should not. But here’s the thing: we need more and more documentation, like this study, to help to push the entire agenda forward. Which agenda? The “new healthcare” agenda—the need to make U.S. healthcare delivery higher in patient outcomes quality, more efficient, more cost-effective, with workflow that makes clinicians’ lives easier so that they can improve the patient care quality and cost-effectiveness of the system. On so many levels, it’s turning out to be very, very hard work. But here’s the good news: as the leaders of the more pioneering patient care organizations are showing their peers in other patient care organizations, how to leverage data, analytics, and processes, in order to rework their core patient care delivery processes. And those participating in the ACO programs and the bundled-payment initiative clearly have extra motivation to ramp up their efforts to do so.

Indeed, all sorts of partnerships, collaboratives, and alliances are moving forward. As Heather Landi reported in February, “The North Carolina Hospital Association (NCHA), based in Cary, N.C., announced a partnership with Forecast Health, a Durham-based data analytics company, to provide hospitals in the state with predictive data about their readmissions rates and whether they are at risk of penalties by the Center for Medicare and Medicaid Services (CMS).”

The key, as many understand, is how to combine the leveraging of data and analytics with process change. In the interview I published last week with Arta Bakshandeh, D.O., the senior medical officer, and Kerry Matsumoto, the CIO, of Alignment Healthcare, the Orange, California-based population health company, those gentlemen told me in detail about the kinds of very layered work they’re doing with complex, evolving populations. It really is require a combination of optimized data usage and population health risk assessment, care management, and clinical decision support-based supports, in order to significantly and sustainably reduce inpatient readmissions for plan members and patients with chronic diseases.

And, in that context, as I’ve been saying for years now, the mandatory avoidable readmissions reduction program that was put in place as a provision of the Affordable Care Act, is turning out to be a revolutionary vehicle for change in healthcare. There are a number of reasons for that, including the fact that the way in which the program is structured, by definition, brings the clinical, administrative, and finance people in hospitals and health systems into the dialogue, and into the process. Indeed, that mandate immediately brought CFOs together with CIOs, CMOs, CNOs, COOs, and CEOs, and everyone else in hospital-based organizations—in order to meet the program’s requirements, and avoid the pay-cut penalties (which are growing every year) under the Medicare program. And, not surprisingly, private health insurers are moving forward to emulate Medicare’s mandate in this area, as in so many areas.

So these results from this study should be seen as helpful, and hopeful. Let’s hope that many more researchers examine these issues, because their studies and published articles are moving the industry forward, and helping to support and encourage the clinical transformation work that needs to be done to transform the “old” healthcare into the “new” healthcare—one step at a time.

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