The U.S. has one of the highest hospital readmission rates in the world. About 20 percent of Medicare patients wind up being readmitted within 30 days after discharge, according to government data. In Canada and England, that figure is only about 8 percent. Hospitals have tried a variety of strategies including patient counseling and home visits to lower readmissions, with mixed results. The office that administers Medicare is hoping that new financial penalties, part of the Affordable Care Act, will push hospitals to tackle the problem more aggressively. This year nearly two thirds of the hospitals in the U.S. will be penalized for having high readmission rates and will lose a combined total of $280 million in Medicare reimbursements. The cut in payments is scheduled to increase from up to 1 percent this year to 2 percent next year, and then to 3 percent in 2015.
The problem of hospital readmissions is challenging because the reasons behind them are complicated and varied. For example, heart failure and pneumonia are two of the most common diagnoses associated with hospital readmission, but a study published in 2009 found that most patients who return to the hospital after having one of these conditions do so for seemingly unrelated problems, such as injuries or adverse drug reactions. Similarly, some studies have suggested that decreasing the length of hospital stays lowers readmission rates, whereas others have linked shorter hospital stays with increased readmissions.
Still, experts have argued that hospitals could go a long way toward reducing readmissions just by ensuring that patients receive proper follow-up care after discharge. To this end, some hospitals are partnering with retail clinics, such as Walgreen's TakeCare and CVS's MinuteClinic. These clinics have pharmacies on site, flexible hours and typically don't require appointments. Plus, many patients are already visiting these stores to shop, adding a convenience factor that a doctor's office or urgent care center can't match. Research suggests that these clinics have become increasingly popular since they debuted in 2006. A study published in the journal Health Affairs last fall found that visits to retail clinics quadrupled between 2007 and 2009.
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Last summer the University of California, Los Angeles, began a partnership that connects its hospitals to 11 CVS clinics. Improving patients' access to follow-up care after hospital discharge is a primary goal. “A lot of patients getting discharged from the hospital don't have a primary care giver to follow up with, and even if they do, they might not be able to get an appointment right away,” says David Feinberg, CEO of the U.C.L.A. Hospital System. CVS has similar partnerships in other cities, including Cleveland and Atlanta.
So far, data on the success of the U.C.L.A. partnership are only anecdotal, but Feinberg and his colleagues are so satisfied with the results that they're expanding the program into three more clinics. “I just think it's great for the convenience factor,” he says. “This brings us out into the community in a way that I think could be really beneficial.”
Past attempts at managing heart disease and other chronic illnesses at commercial clinics have not always been successful. A 2011 study of eight such clinics published in The New England Journal of Medicine found that none reduced hospital visits or readmissions. But those clinics weren't directly integrated with hospitals, says Nancy McCall, a health care policy expert at RTI International and co-author author of the study. “That seems to be necessary to have any impact on reducing readmissions,” she says. The CVS hospital-partnered clinics, in contrast, are connected to hospitals' electronic health records systems, enabling coordinated care between the two teams.
Some clinicians have expressed concerns that the standard of care might be lower at retail clinics, which tend to be staffed by nurse practitioners instead of doctors. The current data, however, suggest that the clinic patients are receiving quality care, says Ateev Mehrotra a policy analyst with dual appointments at the RAND Corp. and the University of Pittsburgh and the co-author of the Health Affairs study.
Another problem, though, may prove to be an obstacle to the clinics’ making a big dent in readmission rates: Despite their growing popularity, their numbers in the U.S. are still relatively small, Mehrotra says, which could limit the scope of their hospital partnerships.
