Dianne Feeney, associate director of quality initiatives for the Maryland Health Services Cost Review Commission (HSCRC), discusses reasons for potentially preventable readmissions as well as the related costs for these readmissions.

The HSCRC has a list of the top 15 reasons for a potentially preventable readmission (PPR). The first three constitute a big chunk — septicemia, heart failure and chronic obstructive pulmonary disease (COPD). All told, these 15 PPRs represent 42 percent of charges on PPRs for a 30-day readmission time window.

We also have listed the top 15 initial admissions that are followed by one or more PPRs. The top three have changed positions a bit — compared with the reason for the readmission is the initial reason for the admission. Again, the top three are heart failure, COPD and septicemia.

We also looked at the top five PPR reasons for an initial admission of heart failure. We delved down into heart failure because it’s a critical one. The top reasons for readmission in 2007 for 15 and 30 days are heart failure, renal failure, septicemia, respiratory system, ventilator support and pulmonary edema. Those are the heart failure reasons why people come back most frequently.

We then looked at length of stay and charges for initial admissions followed by a PPR. We wanted to make sure we were not seeing a shorter length of stay followed by a readmission — in other words, the patient got out quicker, was too sick and then was readmitted. We’re seeing that with those readmissions, the length of stay is longer in the initial admission for those who are readmitted, not shorter for both 15 and 30 days.

There were 472,380 admissions or candidates for having a subsequent PPR and 31,873 admissions were followed by one or more PPRs. The formula to calculate the PPR rate is as follows: 6.75=31,873/472,380. The admissions that had a readmission go over the candidates for admission. The important thing to recognize is that there are exclusions to patients that are counted in the mix as being candidates. These exclusions are obstetric patients, newborn patients, patients with multiple traumas who are very sick, patients with multiple malignancies and patients with severe immunosuppression, like AIDS. That’s why not every single patient who is admitted is counted in the denominator; we do remove some people that are excluded.

Overall, $430.4 million in the state in 2007 — or almost 200,000 hospital bed days — were related to PPRs in our state. For the 30-day numbers, the impact is $656.9 million in charges out of that $800 billion industry in inpatient care and 303,000 hospital bed days. We’re not talking about small money or small impact.

Diabetes affects approximately 8 percent of people in the United States, and adults with diabetes have heart disease death rates two to four times higher than adults without diabetes, according to the American Diabetes Association. In this week’s issue, you will discover how sugar-sweetened drinks are contributing to this problem, along with the link between diabetes, depression and dementia.

You will also learn about two doctors’ prescriptions that could help improve diabetes care.

Although the 2010 Winter Olympics concluded more than a week ago, several athletes are still making headlines. A figure skater, a skeleton racer and a snowboarder will appear in a series of videos from first lady Michelle Obama’s Let’s Move initiative to solve childhood obesity within a generation.

Also out of Canada this week is a new tool to predict a patient’s probability of readmission to the hospital within 30 days. A featured story in this week’s Healthcare Business Weekly Update describes how an individual’s LACE score (devised from Length of stay, Acuity, Comorbidity and ER utilization) can indicate their risk of readmission or death. That’s a gold medal strategy that healthcare organizations can use to reduce costly avoidable hospitalizations, as is a related Maryland initiative to identify reasons for potentially preventable readmissions. This week’s issue provides more details.

Back on U.S. soil, there’s a lot of work going on in medical homes around the country to improve care coordination and delivery. Take our fourth annual Patient-Centered Medical Home survey and see how your efforts stack up against those of your peers. (More than 50 companies have described their programs so far.) Respond by March 31 and you’ll be e-mailed a summary of the survey results.

This week’s issue highlights how location and race can play a part in disease management and the link between sociodemographics and cancer screenings. Also, a CDC report outlines where hospitalizations for heart disease occur the most among the elderly.

Geography affects funding for disease prevention, too. Find out how federal and state budget cuts are affecting the states’ disease prevention efforts.

In response to first lady Michelle Obama’s efforts to fight childhood obesity in America, this issue of the DM Update is focused on this epidemic. You will learn whether increased rates of obesity and other chronic conditions in children will improve over time and when efforts to prevent obesity among children should in fact begin.

Also provided in this issue is information about the Partnership for a Healthier America, a new initiative with a goal of solving childhood obesity within a generation.

Findings published in an April 2009 issue of the New England Journal of Medicine formalized what healthcare organizations have observed for a long time: that Medicare readmissions are frequent and costly. Given this data, it’s not surprising that more than 40 percent of respondents to the Healthcare Intelligence Network Reducing Hospital Readmissions survey are focusing much of the work to reduce readmissions on their Medicare population. However, organizations who have successfully reduced avoidable hospitalizations among the elderly say it’s not unusual for these pilot efforts to trickle down to all patients with high-risk factors, especially when the pilot programs get positive results.

“Because we saw the potency of this intervention, we expanded this across our entire book of business in 2009,” notes Mary Cooley, R.N., B.S.N., M.S., C.C.M., manager of case and disease management at Priority Health. During a recent HIN webinar, Cooley reported on Priority’s robust results on hospital readmission rate reductions for its MedicareAdvantage^SM product line. On the heels of that success, Priority Health rolled out the program across its entire book of business — and is reporting success across all populations. “We focused first and foremost on our heart failure members, knowing that the literature tells us that many of those admissions are avoidable. We started in January 2009 promoting care transitions for anybody leaving the hospital with a primary diagnosis of heart failure, and shortly expanded that in March 2009 to all members on our heart failure registry who are inpatient for any reason.”

Readmission of patients with heart failure represents one of the most expensive and often preventable adverse outcomes. CMS research has shown that hospital readmissions are reducing the quality of healthcare while increasing hospital costs. CMS’s Hospital Compare data show that for patients admitted to a hospital for heart attack treatment, 19.9 percent of them will return to the hospital within 30 days, 24.5 percent of patients admitted for heart failure will return to the hospital within 30 days, and 18.2 percent of patients admitted for pneumonia will return to the hospital within 30 days.

According to the American Heart Association, an estimated 5.7 million Americans are living with heart failure, and 670,000 new cases are diagnosed each year. The condition is the number one cause for hospitalization among the elderly; one fifth of all hospitalizations have a primary or secondary diagnosis of heart failure.

Heart failure was overwhelmingly the number one condition at which respondents’ efforts to reduce hospital readmissions are directed, as reported by 77.6 percent of survey-takers. Nearly the same number of programs — 71.4 percent — are working to reduce readmissions among patients with COPD, closely followed by work in the area of CVD (67.3 percent). At the same time, nearly half of respondents are working to prevent avoidable hospitalizations among those patients with stroke (46.9 percent), pneumonia (44.9 percent) and heart attack (42.9 percent).

Faced with nearly irreconcilable differences after a seven-hour healthcare summit last Thursday, there’s renewed talk of Democrats employing a little-used parliamentary tool known as budget reconciliation to pass their version of healthcare reform. Budget reconciliation allows legislation tied to the budgeting process to be passed with a simple majority rather than a 60-vote majority needed to block filibusters.

While the debate simmers, a new analysis by the Kaiser Family Foundation indicates that state Medicaid rolls are bursting with new enrollees. The analysis, a featured story in this week’s Healthcare Business Weekly Update, found that nearly 3.3 million more people were enrolled in state Medicaid programs in June 2009 compared to the previous June. Every state experienced an increase in Medicaid enrollment, and in 32 states enrollment grew at least twice as fast as the year before. The swelled Medicaid ranks come at a time when 29 states are considering mid-year cuts to Medicaid budgets, and federal monies from the American Recovery and Reinvestment Act of 2009 will shortly expire.

Dr. Barbara Walters, D.O., M.B.A., senior medical director at Dartmouth-Hitchcock Medical Center, details how participation in CMS’s physician group practice demo contributed to the construction of Dartmouth’s medical home and reimbursement model.

Although it wasn’t our original intention, participation in the CMS physician group practice (PGP) demo retrospectively allowed us to build the medical home, although we didn’t know at the time that we were doing that. Building the clinical model first was a key to the measure of our success in being able to contract with both commercial plans and Medicaid in our area. This project also became the model for reimbursement and for our contracting.

The CMS demonstration consists of 10 multi-specialty groups around the United States. It is only a fee-for-service (FFS) demonstration project in a Medicare environment. The patients are assigned to each of the group practices retrospectively, based on the preponderance of outpatient care that is delivered in that group practice. For example, if a patient has at least 51 percent of outpatient visits in our site, that patient is assigned to us and we are assigned the responsibility for the total cost of that patient’s care. Then, the total cost of the care that we spend or coordinate on the patient’s behalf is compared to the total cost of care to all other Medicare individuals in the area who don’t receive the preponderance of care from us. If we provide the care more cheaply — if the rate of rise of the total cost of care is less than the rate of rise of our comparison group — we are eligible for a bonus, which is 80 percent of the difference between the two groups. That is important because we used that basis when we began talking to the commercial health plans about negotiating a medical home pilot. The bonuses allocated for cost savings first, then for quality. You can get approximately 50 or 60 percent for cost savings and the rest are for very specific pay-for-performance (PFP) design quality metrics.

We had success. We are currently in year five of this initiative. We just received the draft report on year three. In year one we did achieve savings, but we didn’t meet the threshold for a bonus payment, which is 2 percent. We did achieve all of the quality metrics in year one, so we increased quality compared to benchmark. Year two we achieved savings, passed the threshold and achieved 98 percent of the quality metrics, so we received a $6.8 million bonus payout. Part of that payout was for quality. An internal analysis shows that we have also achieved savings in year three and the payment is currently being calculated. Because we participated in this program, we did receive CMS Physician Quality Reporting Initiative (PQRI) payments without having to do additional reporting every year.

Here are some highlights from the medical home build that we achieved by participating in this project. We learned and developed a better way of ICD-9 coding. For a successful medical home, Medicare and we believe that the population that you take care of does need to be risk-adjusted. As the only academic medical center in the area and some of the only subspecialists, we do have some adverse risk selection. We also transformed the role of the nurse into health coaches, previsit planners, care coordinators and outreach workers. We developed registries of our patients, beginning with a disease-focused registry. Then, it became very clear that it needed to become patient-focused. Most of our Medicare diabetics also had some other comorbidity, and rather than having 20 disease registries, we needed to have a patient-focused registry. We developed best practice care processes for chronic diseases and for prevention, and we spread them to all 48 care sites. We began doing post-discharge phone calls for our patients because many of our patients are taken care of in the communities in which they live, not necessarily by ourselves. The transfer and the handoff, as part of the care coordination, became a very important part of the medical home build — so much so that when we began looking for a partner in the commercial world so we could test this model of better, more coordinated care, we already had the clinical infrastructure built.

Good or bad, the Jersey Shore has been getting a lot of press lately, thanks to a hugely popular reality show filmed about 10 miles south of our office. A new report issued last week offers a reality check on the health of residents at the Jersey shore and nationwide. The County Health Rankings, a collaboration of The Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute, ranks the overall health of every county in all 50 states after examining its health behaviors, clinical care, social and economic factors and the physical environment.

Interactive maps allow you to drill down to each county, which is ranked within the state on how healthy people are and how long they live. The maps provide an eye-opening look at key factors that affect health, such as smoking, obesity, binge drinking, access to primary care providers, rates of high school graduation, rates of violent crime, air pollution levels, liquor store density, unemployment rates and number of children living in poverty.

Our home base of Monmouth County fares pretty well, receiving an overall rating of 6 out of 21 New Jersey counties. However, there’s room for improvement: we have the highest saturation of binge drinkers in the state (a risk factor for at least 10 adverse health conditions), offer only average access to primary care and could boost the numbers of Medicare enrollees receiving diabetic screenings.

According to the National Multiple Sclerosis (MS) Society, approximately 400,000 Americans and 2.5 million worldwide have MS. Every week, another 200 people are diagnosed. In this week’s issue, discover the link between drinking milk while pregnant and a baby’s risk of MS, as well as new research on blood flow in MS patients.

You will also learn about the benefits of a disease therapy management program for MS patients.