For the past several years, health care reform efforts have focused on reducing preventable hospital readmissions. However, a new study co-authored by Brad Wright, assistant professor of health management and policy at the University of Iowa, suggests that when the rising number of patients hospitalized for outpatient observation is factored in, declines in readmissions disappear.
According to the study, “Commercial payers and state Medicaid agencies have increasingly [required] hospitals to report data on readmissions and…occasionally [link] reimbursement and purchasing agreements to performance. Consequently, although experts continue to challenge the usefulness of readmission rates for assessing quality of care, the rates are now broadly accepted as a measure of hospital quality by payers and policymakers.”
Wright and lead author Amber K. Sabbatini, assistant professor of emergency medicine at the University of Washington, studied data for the period between 2007 and 2015 from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database. They examined claims for emergency department visits that resulted in observation stays and followed these patients to measure 30-day readmission trends. These data were used to compare observation stay readmission trends to inpatient stay readmission trends.
Sabbatini and Wright found that while inpatient readmissions decreased from 17.8% to 15.5% during the study period, 30-day readmissions after an outpatient observation stay increased from 10.9% to 14.8%. The data also showed that repeat observation stays increased from 3.6% to 6.9%.
While some may be tempted to see these results as evidence of hospitals using observation stays to game readmissions measures and avoid the penalties associated with them, Sabbatini and Wright stress that this is not the case. Rather, the study concludes that observation stays should be considered part of 30-day readmission quality measurements in order to ensure that hospitals focus the same amount of resources on preventing readmissions in these patients.
“All patients with an acute condition require timely and coordinated care,” the authors wrote. “Moreover, there is no reason to think that a repeat observation stay is any less preventable or less reflective of the quality of care transitions than an inpatient readmission. Although repeat observation stays cost payers less than inpatient readmissions, they still represent excess costs for the health care system and are meaningful for patients.”
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Researchers at the University of Iowa College of Public Health have been awarded a $1.54 million grant from the National Institute on Minority Health and Health Disparities to study the role federally qualified health centers (FQHCs) might play in reducing disparities in potentially preventable hospital-based care among dual-eligibles.
Approximately 10 million Americans are eligible for both Medicare and Medicaid. According to Brad Wright, assistant professor of health management and policy at the UI and principle investigator on the grant, these dual-eligibles are a disproportionately high-cost population with substantial and often unmet healthcare needs.
“Despite having two sources of insurance coverage, dual-eligibles are one of the most vulnerable populations in the country,” he says. “They often experience high rates of potentially preventable hospitalizations and emergency department visits resulting from disparities in access to primary care.”
Little is known about the relationship between primary care access and the broader continuum of potentially preventable hospital care, which includes not only emergency department visits and hospitalizations, but also observation stays, 30-day return ED visits, and 30-day all-cause readmissions.
“This grant allows us to further our understanding of how we might use FHQCs to improve access to primary care, reduce disparities along ethnic and racial lines, and reduce those costly and potentially preventable emergency department visits and hospitalizations,” Wright says.
A study by University of Iowa researchers found that only a small number of Iowa Medicaid beneficiaries knew about and took part in a new incentive program designed to waive health insurance premiums for enrollees who complete certain healthy activities.
As part of Iowa’s Medicaid expansion efforts, the state created the Healthy Behaviors Program, an optional service designed to waive monthly premiums for Medicaid beneficiaries who get an annual physical and complete a health risk assessment. Launched in 2014, the program was designed to reduce the state’s Medicaid costs by encouraging preventive health practices among beneficiaries.
But Natoshia Askelson, assistant professor of community and behavioral health, and Brad Wright, assistant professor of health management and policy, along with coauthors from the University of Iowa Public Policy Center, found that no more than 17 percent of those enrolled in the Healthy Behaviors Program had a physical examination and a health risk assessment in the program’s first year. The research findings, based on examinations of claims data and interviews with clinic managers and Medicaid expansion enrollees, were published in the journal Health Affairs.
Certain populations, including younger members, men, non-whites, members with fewer interactions with the health care system, and those who have been enrolled in the program for fewer months, were found to be less likely to complete the healthy activities.
“Given that failure to complete these activities is likely to result in members being charged premiums, and non-payment of premiums can result in disenrollment from the program, these findings raise concerns about the possibility of exacerbating disparities in insurance coverage and, ultimately, health outcomes,” says Wright.
When researchers interviewed Medicaid members and clinic managers, they found few people were even aware of the program. The UI research raises questions about whether the incentive program can succeed without expanded communication and promotional efforts.
“If you’re going to do some kind of incentive program, you really need to work hard at developing awareness,” says Askelson.
In addition, the researchers say the findings raise questions about whether a program promoting personal responsibility can be viable in the face of the significant challenges facing many beneficiaries covered under Medicaid expansion.
Researchers discovered that some members couldn’t find an available appointment or a provider to accept their health plan. Others had trouble finding the time or transportation to attend an appointment. This population also tends to be more transient and have lower levels of literacy, says Askelson.