In an April 2021 published JAMA study, it was concluded that “18% of readmissions within 90 days of hospital discharge were for a potentially preventable cause”. There is a lot to unpack in this statistic. The piece additionally mentions that “several comorbidities, a lower income, and a public primary payer” were associated with potentially avoidable readmission. The article concludes by stating that better coordination of post-operative care in the outpatient setting would help to lower the overall readmission rate.
There are several facts in this study that stick out specifically in terms of value-based care (VBC). The first and foremost is the transition of care from an inpatient setting to an outpatient setting. In episode-based programs, this is referred to as site-of-service shifts and is commonly cited. With the current fee-for-service (FFS) model, there is no built-in encouragement of communication between the various components of care. In episodic VBC programs, care coordination is a critical core attribute. Since the surgeon and/or facility is responsible for both the cost and quality of the care throughout the entirety of the episode, including the 90-day post-period that the study looked at, it is financially in their best interest to ensure that care is delivered in a timely and appropriate manner. It also encourages the full sharing of needed patient data that might be important for both upstream (ex: PCP) or downstream ( ex: physical therapist) providers who are seeing the patient outside of the surgical event. In the FFS model, what often ends up happening is the burden is placed on the patient for these important details related to care management and care coordination. Since patients are fallible, forgetful, and might not understand all the “important” details, effective communication is critical. Designing programs that focus on open and timely communication between providers not only ensures better quality care for the patient but has been shown to improve overall patient satisfaction.
Another focal point of interest is the comorbidities. Surgeons can rarely treat comorbidities in any long-term way, but are directly impacted by them. Comorbidities raise the risk of complications during the surgical procedure, but can also complicate recovery efforts. This is where the patient’s primary care provider (PCP) comes into play. By promoting and disseminating information and open communication between the PCP and the surgeon, the patient’s comorbidities can be properly managed before, during, and after surgery. The PCP can focus on ensuring that any medications that might contribute to, or mitigate, otherwise avoidable complications are addressed and called out. Additionally, the PCP can highlight urgent potential risk factors that need to be addressed prior to the surgery, and finally, as a trusted advisor, the PCP can help guide the patient through the healthcare process, including care transition to and from the surgeon. The current disconnect that is exacerbated by FFS arrangements between PCPs and specialists (especially hospitalists and surgeons) leads to a lot of risks taken on by the patient. This is clearly statistically shown in the study. VBC focuses on improved outcomes. And doing so puts the focus squarely on what is best for the patient, which means tearing down the silos.
The fact that lower-income is a risk factor for readmissions comes as no surprise to anyone in healthcare. Lower-income means a host of potential barriers to adequate access to care. If a patient has to pay a copay every time they have to have physical therapy, it would be a struggle for that patient whose budget is already stretched tight with payments due to the surgery to adhere to the post-acute PT recommended regimen. That patient may also not have reliable transportation or be able to afford medications. These are all real and hard decisions someone has to make after having a major life event, like surgery. Though there is a real push to better understand the impact of being poor in America’s healthcare system and the impact on those individuals, this study highlights how unnecessary increased costs and poorer outcomes impact others in the system as well. As VBC mandates somewhat forcibly restrain the healthcare industry on where to focus, it can also target these known barriers that contribute to risk. In an episode of care, all the follow-up components are pre-priced, with no additional monetary expectations for the patient. Knowing the full member benefit of the program upfront is a massive relief and motivator to follow through on the care, especially for someone of a lower socioeconomic status. Ensuring that the care can meet the patient where they are, and not introduce barriers, is critical to mitigating or even eliminating more expensive, avoidable complications and readmissions.
Lastly, the article states that rates are higher when the payer is public. This is in part, to both the low income and high-risk comorbidity components. It is worth calling out this potential risk attribute separately because of the mission of CMS’ CMMI. As the programs CMMI have developed continue to mature, CMMI is starting to evaluate, tweak and merge programs together to find the right payment levers to move healthcare towards their mission to lower costs and improve care. CMS has a higher at-risk population than commercial insurance and in turn, more incentive to address the potential risk components. CMS also has such a large population of members that they can sway the market in real and meaningful ways. Hopefully in five years’ time, if this study is repeated, the numbers will show significant improvement.
Studies like this help to highlight areas of opportunity to not only lower costs and remove “waste” but to improve care as a whole. Behind every one of those statistics are patients who are facing many varied challenges, while trying to live their lives as pain-free as possible. They, more than anyone, want these surgeries to be successful and without complications. Making sure that the mechanisms are in place that focus on improved patient outcomes allows the system to comprehensively, and likely, more successfully achieve this goal. VBC is the set of mechanisms that will allow that to happen.
Assessment of Potentially Preventable Hospital Readmissions After Major Surgery and Association With Public vs Private Health Insurance and Comorbidities
Potentially Preventable Readmissions After Surgery
Centers for Medicare & Medicaid Services – Our Mission