NYT Article Ignores Critical Role of Health Plans in Reducing Hospital Readmissions

Today’s New York Times/Kaiser Health News article highlighting efforts by hospitals to reduce readmissions ignores the critical role of health plans in helping patients get the care they need and avoid unnecessary, preventable readmissions.  Health plans have prioritized this issue and have put in place programs to help patients get appropriate follow-up care when they are discharged from the hospital.  Data show these programs are working and that patients in private Medicare Advantage (MA) plans are being readmitted to the hospital at a rate 13-20 percent lower than those in the fee-for-service (FFS) part of Medicare.

Last month, Medicare started fining hospitals that have too many patients readmitted within 30 days of discharge.  According to a previous study published in the New England Journal of Medicine, nearly one-fifth (19.6 percent) of Medicare FFS beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34 percent were rehospitalized within 90 days.  Moreover, half of patients who were rehospitalized within 30 days did not have a physician visit between the time of discharge and rehospitalization – suggesting that one of the reasons patients ended up back in the hospital was lack of needed follow-up care.  Preventing avoidable hospital admissions and readmissions protects patients from the risks associated with inpatient settings, such as infection, and is an indication that patients are getting the care and services they need on an outpatient basis to stay healthy and avoid complications that can lead to hospital readmissions.

Health Plans are Helping Patients Get the Care They Need

Health plans have prioritized reducing preventable hospital readmissions and have put in place programs and services to help patients receive appropriate follow-up care.  As noted in a recent AHIP publication, health plans are helping patients get the care they need by:

  • Expanding patient access to urgent care centers, after-hours care, and nurse help lines to give patients safe alternatives to emergency rooms for non-emergency care.
  • Arranging for phone calls and, in some cases, in-home visits by nurses and other professionals to make sure that follow-up appointments are kept, medications are being taken safely, care plans are being followed, medical equipment is delivered, and home health care is being received.
  • Offering intensive case management to help patients at high risk of hospitalization access the medical, behavioral health, and social services they need.
  • Arranging for home visits by multidisciplinary teams of clinicians, who provide comprehensive care, teach patients and their caregivers how to take medications correctly, and link families with needed community resources.
  • Revamping physician payment incentives to promote care coordination and improved health outcomes.

According to an article in Managed Healthcare Executive, health plans are in an ideal position to identify readmission risks.  From the article:

“Health plans are probably in the best position to make headway at reducing readmissions,” says Anna Sommers, senior health researcher with the Center for Studying Health System Change in Washington, D.C. and co-author of a research brief on the role of physician visits in reducing readmission rates. “Physicians on the front line do not have the tools to identify patients who are at risk of readmission. They often don’t even know that their patients have been discharged from the hospital.”

By contrast, health plans have information from claims data, risk adjustment analysis and predictive modeling to identify patients at high risk of hospitalization in general and readmission in particular. Using this data, Sommers suggests that health plans can act as an intermediary between hospitals, primary care physicians and specialists to facilitate communication at the time of discharge.

Research Shows that Health Plans have Lower Hospital Readmission Rates than FFS Medicare

AHIP’s Center for Policy and Research has conducted a significant amount of research comparing hospital readmission rates in private Medicare Advantage plans to the FFS part of Medicare.  The research clearly demonstrates that seniors and people with disabilities enrolled in a Medicare Advantage plan have significantly fewer hospital admissions and readmissions than those enrolled in the original Medicare program:

  • According to a study published in the American Journal of Managed Care (AJMC), unadjusted 30-day readmission rates for MA patients were approximately 14.5% from 2006-2008, 22% lower than FFS. Taking into account risk adjustment and demographic information, data from the same time period show MA 30-day readmission rates to be 13% to 20% lower than traditional Medicare FFS rates.
  • According to a study in Health Affairs, people with diabetes in a special-needs plan had seven percent more physician office visits; nine percent lower hospital admission rates; 19 percent fewer hospital days; and 28 percent lower hospital readmission rates compared to patients in FFS Medicare.
  • A study analyzing data from nine states found reductions in risk-adjusted hospital readmission rates averaging 14-29 percent among seniors in Medicare Advantage compared with Medicare FFS enrollees.

The full series of reports on hospital readmissions are available here: http://www.ahipresearch.org/hospitalreadmissions.html.


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