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VA Experience Shows Patient ‘Rebound’ Hard To Counter

The Veterans Health Administration,  the largest integrated health care system in the country, has long employed many of the approaches Medicare is pushing on all hospitals to cut unnecessary readmissions. But new data show VA hospital patients are just as likely to end up back in a hospital bed as are patients at private hospitals.

The new statistics underscore how hard it may be for hospitals to stop patients from rebounding back through their doors, a major goal of Medicare as it seeks to curtail the nation’s ballooning health costs.

VA hospital patients aged 65 or older suffering from heart failure, heart attacks or pneumonia returned to a hospital within a month at the same rate as did Medicare patients initially cared for at private hospitals, according to an analysis of the data. The data were published by Medicare last month on its Hospital Compare website

Out of 107 VA hospitals evaluated on the site, only one — based in Portland, Ore. — had significantly lower readmissions rates than did the average American hospital, and that was only for one condition, heart failure. Fifteen VA hospitals had higher than average readmissions rates for one or more of the three ailments tracked by Medicare.

Hospital Type Avg. of Hospital 30-Day Readmis- sion Rates from Heart Attack Avg. of Hospital 30-Day Readmis- sion Rates from Heart Failure Avg. of Hospital 30-Day Readmis- sion Rates from Pneumonia
Non-VHA Hospitals 19.9% 24.8% 18.4%
VHA Hospitals 20.6% 25.2% 19.2%
Source: Kaiser Health News analysis of Medicare’s Hospital Compare data.

“It makes you wonder how much hospitals can really control readmissions if a place like the VA cannot have dramatically lower rates,” said Dr. Ashish Jha, a Harvard School of Public Health professor who also practices medicine at the VA Boston Healthcare System and advises the department’s leadership.

“This is an organization that has been very focused on effective discharge planning,” Jha said. “This is what the federal policymakers are trying to push the country towards. They’re trying to create the kind of accountability the VA already has. On most other issues, the VA does very well, and yet on this one metric, not so much.”

Dr. Peter Almenoff, a senior VA official, said the results “validate the fact that our care is as good as or better than in the private sector.” He said that while the VA tracks readmissions to its own hospitals, it wasn’t aware of the total picture, including readmissions to private hospitals, until Medicare published the data. “We’re trying to understand why they come back, or go to local hospitals,” said Almenoff, assistant deputy undersecretary for quality and safety at the VA.

By one estimate, readmissions cost Medicare $26 billion a year, with one in five patients landing back in the hospital within a month. Many experts say that while some of the returns are necessary, others could be avoided if hospitals made more of an effort to prepare and oversee patients after they leave.

But the current payment method used by Medicare and many private insurers can work against that, since hospitals are often eager to fill up their beds to earn more. “Currently, it’s not always in the best interest of hospitals to do this work because they get paid for every admission,” said Patricia Rutherford, a vice president at the nonprofit Institute of Healthcare Improvement in Cambridge, Mass.

To remedy this, the federal health care law instructed Medicare to begin reducing payments to hospitals where unusually high numbers of patients are readmitted.  Medicare is also experimenting with other ways of paying hospitals and doctors so they have financial incentives to ensure patients don’t return to hospitals. And a series of other programs the Obama administration has launched aim to avoid common problems for discharged patients, such as not getting the right medication, missing follow-up checkups and not adhering to doctors’ instructions on how to best recuperate.

VA hospitals are further along in these areas than most private hospitals, experts say. For instance, the VA has electronic medical records so the doctors who treat patients after leaving the hospital know all about their medical conditions. Also, VA doctors generally are salaried and thus lack the financial incentives of the fee-for-service payment system under which most hospitals operate, which reward more procedures and admissions. Studies have found the VA does better than most hospitals in following appropriate guidelines for the best care to give patients. 

Yet an analysis of the new data show that among older heart failure patients, 25.2 percent treated by the VA were readmitted, compared to 24.8 percent initially hospitalized elsewhere. Among heart attack patients, 20.6 percent treated at VA hospitals were soon readmitted, compared to 19.9 percent of patients at other hospitals. For pneumonia patients, 19.2 percent treated by the VA were readmitted, while 18.4 hospitalized elsewhere were readmitted. None of these gaps were substantial.

Kenneth Kizer, who led the VA’s health system when Bill Clinton was president, said that about half the people who use the VA health system also have insurance such as Medicare or Tricare that pays for doctors, hospitals and rehabilitation facilities outside the VA. Patients that see those outside providers may not reap the benefits of the VA’s coordinated system, and therefore are at risk of the kind of disjointed care that afflicts non-military patients.

“There’s a significant part of the population that isn’t getting the advantage of an integrated system,” said Kizer, who is credited with improving the system in the 1990s.

The data published last month on Hospital Compare provided the first time that readmission rates for VA hospitals could be compared with those of more than 4,000 private and public hospitals. The data include readmissions within 30 days between July 2007 and June 2010.

While VA hospital patients tend to be poor or disabled, the readmissions for both VA and Medicare patients were adjusted by federal officials to take the degree of patients’ sicknesses into account. Hospital Compare rated most facilities as average in readmissions, but identified some as having significantly higher or lower rates.

The VA hospitals with worse than average readmissions rates for at least one of the three conditions tracked by Hospital Compare are located in: Baltimore; Chicago; Dallas; Huntington, W. Va.; Little Rock, Ark.; Lexington, Ky.; Long Beach, Calif.; Memphis, Tenn.; Muskogee, Okla.; New York City; Northport, N.Y.; Providence, R.I.; St. Louis; San Juan; and Tampa, Fla.

Shannon Brownlee, a researcher at the nonprofit New America Foundation, said that the VA’s average readmission rates were in some ways an achievement, given the extensive problems in the system before it was revamped. The VA’s history shows “that you can take the worst performer and drag it upwards,” she said.

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