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Denver Health: Low Readmission Rate Not Easy To Emulate

If Denver Health can do it, every hospital ought to be able to do it.

That’s the implicit challenge of the new Medicare penalties for high hospital readmission rates that will be hitting 2,211 American hospitals come October. Denver Health, despite being a safety net hospital, won’t be paying a penalty: It has an enviably low readmission rate.

But there’s a problem says Medicare’s poster child: Denver Health’s quality chief calls the new policy imprecise and perhaps unfair, too.

“The Affordable Care Act has put a ton of pressure on hospitals to focus on this, and my fear is that that is being done at the expense of other quality improvement and safety initiatives,” said Dr. Thomas MacKenzie of Denver Health. “It’s important that we have some incentive in place to try to reduce readmissions; I’m not sure that having a penalty for readmission rates is the way to go.”

Medicare says two out of three hospitals it evaluated failed to meet its new standards for preventing readmissions within 30 days of discharge. The Affordable Care Act now cuts Medicare reimbursements by up to 1 percent for those with the worst readmission rates, ratcheting up to 3 percent in 2014.

Some safety net hospitals call the penalties unfair, because the low-income patients they serve often lack access to follow-up care and medications after discharge. Medicare has pointed to Denver Health, saying it should serve as a model for other safety net hospitals.

But MacKenzie notes that there are a number of aspects at Denver Health that are hard to replicate everywhere. Denver Health, Colorado’s biggest safety net system, includes a 477-bed hospital and eight community primary care clinics. About a third of its patients are uninsured, another third are on Medicaid. The integrated system and low reimbursement rates create both a financial incentive and an opportunity to provide as much care as possible in the lower cost outpatient settings.

“We also are a hospital that is often at full capacity,” MacKenzie says, “so we certainly have an incentive when we’re busting at the seams…to make sure patients aren’t readmitted unnecessarily.”

Denver Health was also an early adopter of electronic medical records. MacKenzie says easy sharing of patient information between the hospital and clinics effectively keeps admissions down. It also helps those recently discharged get priority in scheduling follow-up appointments, putting them at the head of what can be long wait lists at community clinics.

But proud as he is of Denver Health’s low 30-day readmission rate, he’s not sure penalizing hospitals with higher rates is the best path to quality improvements that lead to lower rates.

“It’s a bit of a leap to say that one hospital’s readmission rate being different from another reflects a difference in quality and care,” he said. “Only a proportion of [readmissions] within 30-days are preventable. We think probably a quarter of them are preventable, at most.”

MacKenzie thinks hospitals should only be held responsible for readmissions within three days to a week of discharge. Readmissions after that period, he says, are either more the patient’s responsibility, or medically necessary for reasons beyond the hospital’s control.

“It may be that [hospitals with higher 30-day readmission rates] are providing better quality care, and they’re keeping their heart failure patients that would’ve died at other hospitals alive, and therefore eligible for readmission,” he said.

This story is part of a collaboration that includes Colorado Public RadioNPR and Kaiser Health News.