This article first appeared in the St. Louis Beacon, Aug. 30, 2011 - When the Commonwealth Fund searched for hospitals that were doing good work in reducing avoidable and costly readmissions, it turned to St. John's Regional Health Center in Springfield for a case study. The choice was a good one. An analysis of three years of data from the Centers for Medicare and Medicaid Services (CMS) shows that St. John's is the best among Missouri hospitals in lowering readmission rates for heart attack, heart failure and pneumonia patients.
The CMS data also show that three other Missouri hospitals have done better than average work in lowering the readmission rates for one or more of the three health conditions during the past three years. The hospitals are Audrain Medical Center in Mexico, Cox Medical Center in Springfield, and North Kansas City Hospital.
The low readmissions at St. John's are in sharp contrast to some other Missouri hospitals, particularly Barnes-Jewish Hospital in St. Louis. Although it has a national reputation for good specialty care and cutting-edge medical research, BJH ranked worst among Missouri hospitals in the numbers of patients needing to be readmitted within 30 days after being treated for heart attacks, heart failure and pneumonia, according to CMS data. Kaiser Health News reports that BJH is one of only seven hospitals across the nation with higher than average readmission rates in all three categories. Another surprise on that list of seven is Beth Israel Deaconess Medical Center in Boston.
According to the CMS data, the national average rate for readmissions within 30 days of discharge for heart attacks was 19.8 percent. The rate at BJH was 22.4 percent, according to the Beacon's analysis. For heart failure, the national readmission rate was 24.8 percent. It was 28.4 percent at BJH. For pneumonia, the national rate was 18.4 percent, compared to 22.9 percent at BJH.
At St. John's in Springfield, the readmission rate data for pneumonia was 16.3 percent. For heart failure patients, the rate was 20.5 percent, and 15.8 percent for heart attack patients. So how did St. John's outpace all other hospitals in Missouri? For one thing, it seems to be more proactive. The Commonwealth Fund case study says the hospital did not set out deliberately to reduce readmissions. Rather, the report says, the hospital focused on standards for delivering optimal care, and lower readmission rates grew out of that approach.
The hospital staff members follow "evidence-based practices, educate patients about their conditions during their stay and after discharge, provide coordinated care, and manage chronic diseases by working with providers in the hospital and community," the Commonwealth report says.
Cora Scott, spokesperson for the six Mercy hospitals in the Springfield region, says the system tries to improve overall wellness so that patients are less likely to be readmitted. Its procedures require care managers to follow-up with patients within 24 to 48 hours to make sure they understand discharge instructions, make sure they have appointments with primary care doctors and "address other barriers that may interfere with a patient's treatment plan."
Barriers might include lack of money to buy medications. Scott says pharmaceutical companies"have programs to provide free medications if you fill out the very complicated paperwork. We assist patients with that to help them with their medications."
Scott concedes that the makeup of patients at St. John's is probably different from some of the patients who walk through the door at BJH. Like most other urban health centers across the country, Barnes-Jewish Hospital treats a large minority population and cares for many patients who don't speak English.
"I kind of understand what they are saying," Scott says about the socio-economic impact on patient care in many urban areas. She adds that Springfield "is not a hugely diverse population." But she says Mercy has learned that patient care management "can improve outcomes, lower their readmissions and save money."
BJH is not alone among area hospitals readmission rates that exceed national averages. Other area hospitals with higher than average rates for one or more of the three conditions over the past three years include: Christian Hospital Northeast, St. Anthony's Medical Center, St. John's Mercy Medical Center, St. Luke's Hospital, SSM DePaul Health Center, SSM St. Mary's Health Center, and Cochran VA Hospital.
This year marks the first time CMS has added VA hospitals to its database. Although Cochran scored higher than average in readmissions among heart failure patients, its readmissions were no higher than national averages for pneumonia and heart attack patients.
Avoidable readmissions add billions of dollars annually to health care costs. A new federal policy, effective in the fall of 2012, will reduce Medicare reimbursement rates by 1 percent to hospitals with higher than average readmission rates. That would be bad news for BJH and the other Missouri hospitals with poor performance.
Experts who think the threat of reduced reimbursements will make a difference include Dr. Ashish K. Jha, an associate professor at Harvard School of Public Health and a staff physician at the VA hospital in Boston. In an email to the Beacon, he said the reimbursement penalties "will motivate some hospitals like Barnes-Jewish to improve -- but others will struggle and probably fail to improve."
Nevertheless, he says, "it is surprising" when first-rate hospitals like BJH have higher than expected re-admission numbers. He says the CMS data suggest that "some hospitals have not paid adequate attention to transitions in care and could probably do more in this area."
BJH has argued that the ratings should give more weight to the socio-economic status of a hospital's patient population. Dr. Don Berwick, the CMS administrator, said in a statement that the government's "inpatient measures are risk-adjusted, taking health conditions into account to 'level the playing field' among hospitals and to help ensure accuracy in performance reporting."
Even so, others say not enough consideration is given to the makeup of patients served by hospitals. Mary Becker, senior vice president of the Missouri Hospital Association, says the solution to high readmissions may require a broad community effort. She says socio-economic factors can have a "significant effect on a patient's ability to comply with hospital discharge instructions. These factors are a challenge (for hospitals) and will have to be addressed in conjunction with other community partners."
She says some patients might lack transportation to reach a doctor's office or to fill a prescription, and that factors, such as smoking and obesity, "can complicate a patient's recovery from hospitalization."
She adds that MHA has no objections to the rankings but thinks some medical experts might object to them due to a disagreement over how best to measure quality. That's one issue raised by Dr. Jha, the Harvard associate professor. He says that there probably were fairer methods of rating hospitals other than readmission data. "Both mortality and patient experience measures are excellent measures of quality, and I would use those first."
Becker says financial penalties could be an incentive for hospitals to improve.
"At a time when hospital financial margins are razor thin, any threat to hospital reimbursements is motivation to address the cause," she says.
Funding for the Beacon's health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization that aims to improve the health of the people in the communities it serves.