By Nahede Khosrovi
The twin pillars of education and health care present parallel challenges to policymakers. Outrage and panic on one end, and critical scrutiny on the other, decry the US’s prohibitive expenditure and inferior results in these areas. The common goal may be simple – improve quality, lower costs, and provide a better experience – but approaches and outcomes vary dramatically.
Classically, success is determined by the bottom line, by the treatment of a disease or symptom in hospitals, and by graduation rates and standardized test results in schools. Metrics-focused outcomes can be valuable, but legislation based on them can be difficult to implement successfully. The test-driven No Child Left Behind Act (NCLB) was intended to drive better practices; instead it brought widespread wreckage to schools serving poorer populations.
Under the Obama administration, the government is trying to move health care away from fee-for-service and towards pay-for-performance. This direction has incentivized providers to focus on quality of care and patient engagement, giving rise to such measures as Accountable Care Organizations (ACOs), payment “bundles” for certain disease states, and penalties for hospitals with high rates of preventable readmissions. The Centers for Medicare and Medicaid Services (CMS) uses risk-adjusted hospital readmissions rates as an accountability measure, but key takeaways from the disastrous NCLB legislation can help prevent similar, unintended consequences from sweeping the medical world.
Just as NCLB unintentionally quicksanded schools serving poor and minority students, the use of hospital readmissions rates as the sole determinant of hospital discharge quality could unfairly reduce payments to institutions caring for large disadvantaged populations (e.g., patients who are elderly, poor or disabled, non-English speakers or those with low literacy levels, and people without home support or access to transportation). NCLB decisions were made by policy-makers who were far-removed from the realities of a disadvantaged classroom, and a similar caution has been voiced regarding the clinical relevancy of strict readmissions policies based solely on administrative data.
Across care team roles, concerns tend to lump around patient discharge. Discharge and aftercare processes, therefore, seem a reasonable focal point. Proven methods to reduce hospital admissions include the use of interpreters for non-English speakers, the “Teach Back” method, seven-day follow-up visits, telemonitoring technology for chronic patients, robust post-acute services, and effective nurse staffing (a nursing staff operating under heavy overtime will be less able to provide quality discharge teaching, and this indirectly drives up the rate of ER visits and readmissions).
But hospitals, even high performing ones with exceptionally low readmissions rates, do not have across-the-board standardized evaluation metrics and audit processes. Disparate medical record systems, varying levels of local expertise, and limited resources present significant challenges to collecting the standardized data and comprehensive information that could spell the difference between fair and helpful readmissions incentives and a quagmire.
Medicare spends around $17.4 billion dollars a year on avoidable patient readmissions and wants to improve this figure. The “tough love” approach to fostering accountability in education torpedoed, but on the positive side we have extensive dialogue surrounding the pitfalls in that endeavor. Thoughtful use of that information, along with industry-specific information gathered directly from patients and care team members, can help hospitals successfully navigate transitions to better care at lower cost.