Some very sick patients do need to go back to the hospital for intensive monitoring or potent intravenous medications. But health care experts believe many readmissions can be avoided if patients receive good follow-up care to catch problems early. Dr. Amy Boutwell, who practices at Newton-Wellesley Hospital, believes an over-supply of hospital beds in the state has made readmitting patients an easier choice for physicians. “Readmissions in Massachusetts have always been high and relatively speaking they have remained high,’’ said Boutwell, who is president of Collaborative Healthcare Strategies, a Lexington-based consulting company. “If you have the supply, you use it and practice patterns develop. You say to the patient ‘Let me bring you in and we’ll check you out.’ We need to teach ourselves not to do that.’’ Patricia Noga, vice president of clinical affairs for the Massachusetts Health & Hospital Association, said she does not know why the state’s readmission rate is among the highest. “It’s just a really complex issue,’’ she said. “But we know hospitals are working on it.’’ She said it’s become clear that hospitals must focus their efforts on improving discharge instructions and follow-up care for patients more broadly, not just when it comes to elderly Medicare recipients with certain conditions. As part of the Affordable Care Act, Medicare penalizes hospitals with high readmission rates for patients with heart failure, pneumonia, chronic obstructive pulmonary disease, or who have had a heart attack, hip or knee replacement, or cardiac bypass surgery. More than three-quarters of Massachusetts hospitals were penalized in the fiscal year that ended Sept. 30, losing an average of 0.7 percent of their total Medicare payments. A state analysis of readmissions among all patients, not just those on Medicare, found that rates in Massachusetts barely budged between 2012 and 2014. That could be because providers are focusing too many prevention resources on the wrong patients, or need to use different strategies. For example, patients with mental illness or substance abuse problems, on top of their underlying medical conditions, are at much higher than average risk of returning to the hospital and account for 60 percent of all readmissions in Massachusetts, according to an August report from the Center for Health Information and Analysis. Almost 30 percent of patients with heart failure who also suffer from mental illness or addiction were readmitted to the hospital, compared to 19 percent of heart failure patients without behavioral health conditions. The center publishes readmission rates for individual hospitals on its website at chiamass.gov. Dr. Alastair Bell, chief operating officer for Boston Medical Center, agreed that the focus on Medicare patients with one of the pinpointed conditions has been too narrow. “There are large groups of other patients who may not be getting the same types of programs,’’ such as help scheduling follow-up appointments and check-in calls and visits, he said. Boutwell said she interviews all her patients who are readmitted to learn what went wrong. Returning to the hospital “often increases the anxiety and uncertainty and concern about one’s health status,’’ she said. Patients ask “was my care not good in the first place?’’ One 47-year-old patient with psychiatric and medical conditions had more than 100 emergency room visits and 10 hospital stays in the previous year. Interviewed for a readmission report earlier this year published by the Massachusetts Health & Hospital Association, the patient said she became anxious when staff at her group home left for the night at 9 pm. So she called 911. The hospital association pointed out that even though the woman had a primary care doctor, psychiatrist, and therapist, that hadn’t been enough to prevent her readmissions. Another 41-year-old woman with HIV and pneumonia received antibiotics and antiretroviral therapy in the hospital, but was readmitted eight days later with a cough, the report described. When asked what could have been done to avoid her coming back, the woman, who did not have a primary care doctor, said “it would have been helpful if you had scheduled a follow-up appointment for me.’’ The patient stories show that providers “really have to talk to them’’ if they are going to develop effective strategies to cut readmissions, Noga said. At Boston Medical Center, Bell said the hospital has developed a formula to determine which patients are at highest risk for readmissions -- and require the most intensive intervention. These patients tend to have chronic medical conditions like congestive heart failure but may also be mentally ill, addicted to drugs or alcohol, or even homeless. They often are assigned a care manager to work with them while they are in the hospital and after they are discharged to make sure they are getting to follow-up appointments, taking their medications correctly, and, if necessary, enrolling in treatment programs. Liz Kowalczyk can be reached at kowalczyk@globe.com.
Massachusetts has one of the highest readmission rates in the US, with 17.9% of approximately 198,000 patients being readmitted within 30 days of their first visit, according to the Centers of Medicare and Medicaid Services. The US’ high medical costs are partly due to the preventable readmission of patients within a month of discharge, accounting for around $17bn of Medicare spending per year. Medicare penalizes hospitals with elevated readmission rates for certain heart, lung and joint issues, which led to over 75% of Massachusetts hospitals losing 1.7% of their Medicare payments in the last fiscal year. 60% of all readmissions are due to mental illness or addiction on top of other healthcare issues. Experts believe that an over-supply of hospital beds in the region makes readmission a simpler choice for doctors, when physicians should be focusing on improving discharge instructions and follow-up care for patients to avoid readmission.