After reading my last post on ACOs you may be wondering how an ACO consisting of primary care physicians can hope to save money on the costs of the Medicare patients attributed to them when so much of the care is beyond their control.  After all, the beneficiary can see any specialist they choose, and many hospitalizations can take place without the PCP’s knowledge.  That’s true, so there may always be components of a person’s care that cannot be well-coordinated, but there are still a lot of opportunities that an ACO can address if they are willing to invest in the system changes that are necessary.

I’d like to spend the rest of this post explaining why focusing on the transitions of care that a patient goes through is a prime target of most ACOs.  When I use the term “transition” it applies to any change of care setting for a patient.  It includes going from their home into a hospital, from a hospital to a rehabilitation hospital or from the hospital back to their home.  At each of these transitions there needs to be a communication of all elements of the care the patient has been receiving and what needs to continue or be changed going forward.  This is especially critical for a patient with multiple chronic medical problems such as high blood pressure or diabetes.  Probably the time when most miscommunications take place is when a patient is discharged from the hospital to their home.

Transitions of Care – Hospital Discharge

When a patient is discharged from an acute care hospital after being treated for something like severe pneumonia or a heart attack, someone from the clinical staff gives them a written copy of discharge instructions and discusses those instructions with them to make sure the patient understands them.  Unfortunately, what was often clear in the hospital isn’t so clear at home.  Lack of clarity around discharge instructions can lead to complications, reversal of the improvement that began in the hospital and hospital readmission.  There are studies that find that about 50% of these readmissions can be prevented.

Size of the Opportunity

Medicare estimates that 20% of patients discharged from a hospital are readmitted within 30 days.  One example of the financial consequences can be found in data for Knoxville, TN published by Qsource, a Quality Improvement Organization (QIO).  They found that in 2009 14% of the approximately 188,000 Medicare beneficiaries in Knoxville were hospitalized.  Consistent with Medicare’s national findings, 20% of those individuals had one or more readmission which cost $57 million and the 241 beneficiaries who had 4 or more readmissions had costs totaling $10 million.  Not every readmission is preventable, but when you look at the issues that lead to many of them, there are clear opportunities to improve the quality of care and prevent unnecessary and costly readmissions.  The challenge is to identify those whose readmission can be prevented and deliver the needed information and services to keep them healthy.

In the next post I’ll discuss some new regulations from Medicare that focus on the readmission issue and other strategies that can be used by ACOs.

For Your Health – Dr. Bob