Wednesday, July 29, 2009

Healthcare Reform, Readmissions and the Contribution of Disease Management: The Rest of the Story

Did you know that flu shots are effective in the workplace? Or that exercise can reduce the incidence of falls among the elderly? Or that care management can reduce post-discharge rehospitalizations? All three breakthroughs were reported more than ten years ago, yet recent news reports from the Wall Street Journal (‘unusual!’) and National Public Radio (‘a third way!’) are recycling the old news about rehospitalizations with new anecdotes about clinical programs that can successfully reduce readmissions.

[Yawn] The science has been pretty clear on the topic since Michael Rich’s seminal 1996 publication. Other researchers (for example, here and here) have individually confirmed post-discharge care management works quite well, while this review of the peer reviewed literature suggests there are critical ingredients that can help this be state-of-the-art.

Given the recent renewed interest in reducing rehospitalizations since a) Stephen Jenck’s recent New England Journal article (20% readmission rate among Medicare beneficiaries along with the potential of saving a whopping $17 billion), b) the inclusion of readmission data in CMS’ Hospital Compare website, c) post discharge guarantees by an innovative integrated delivery system's health plan and, last but not least, d) proposed bundled hospital and follow-up payments as a part of health reform, the topic is certainly timely and important.

With their renewed interest, hospital administrators and policy-makers agree that these kinds of care programs haven’t taken root in day-to-day fee-for-service clinical practice and the Medicare benefit because insurers don’t ‘cover’ hospitals’ post-discharge care programs. In the meantime, current health reform proposals seem to be tilting toward penalizing hospitals with a stick of high readmission rates. The DMCB can’t tell if the proposed bundling methodology described above will adequately include 'the carrot' of covering the cost of hospital-sponsored post-discharge care coordination.

[Yawn]. Too bad the media is missing out on telling the rest of the story.

We already know that a host of commercial and employer-sponsored insurers include disease management programs. What isn’t being mentioned is that a standard contractual feature in practically all disease management programs is to provide post-discharge follow-up to patients with the key chronic conditions like heart disease and heart failure. That’s why most of the literature on post-discharge readmission avoidance programs typically refer to them as ‘disease management’ in the first place. In other words, the industry has long since developed a viable business model based on this need. It has already entered hundreds of thousands of recently discharged patients in its decade-old post-hospitalization care programs. And they can work.

While most of the reports in the literature describe research-funded ‘hospital-based programs,’ the DMCB suspects the DM organizations have not gotten around to describing their experience in the peer review literature. They're certainly not being called by the Wall Street Journal or NPR. Pity.

That being said, the key ingredients - patient engagement and coaching with monitoring, self-care and close coordination, usually performed by nurses – can be independent of the location and doesn't necessarily have to be hospital based. Until there is good research that says otherwise, the DMCB doesn’t think it makes any difference how the nurse care is funded, just so long as it’s done one way or another. It would appear the 'fit' is better with disease management because of its outpatient focus, its ability to include this with all its other programs and its successful track record. Hopefully, the Patient Centered Medical Home (PCMH) will eventually demonstrate success in this area also.

Hopefully, the architects of health care reform will recognize that when it comes to readmissions, a ten year old disease management solution is already at hand.

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