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Readmission or the Egg?


If you heat water sufficiently, you get steam. When you cool the steam, you get water again. Using the same process for chocolate—more “busy” than water and composed of multiple ingredients—will take you from solid to liquid and back again. So why won’t this technique also apply to the egg?

Eggs, or egg whites to be specific, are made up almost exclusively of the protein albumin. The chains of amino acids in proteins are normally configured in elaborate and precise folds, spirals, and sheets. Upon heating, the albumin becomes denatured and alters its molecular structure in such a way that it unfolds and adheres to itself in a dysfunctional manner known as aggregates. In the end, albumin permanently changes from clear to white and retains a rigid form.

No intervention has been successful in returning albumin to its original viscosity and color—not cooling, not anything. The caveat is that there is exciting research being done with naturally existing heat shock proteins called chaperones that have the potential to return proteins to their native state. This research has enormous implications for treating diseases such as cystic fibrosis and Alzheimer’s.

It may seem idiosyncratic that while we can manipulate water and chocolate, we can’t unfry an egg. The answer is, simply, that proteins are too complex for simple logic or techniques.

In its June report, the Medicare Payment Advisory Commission (MedPAC), the group that advises Congress on issues affecting the Medicare program, formulated recommendations for amending the construct for payments to hospitals based on their readmission rates. The rationale for targeting readmission rates, according to MedPAC, is to create favorable financial incentives for hospitals that achieve lower readmissions. Sounds simple enough. The MedPAC report identified potential savings of $12 billion given a 13.3% rate of “potentially preventable readmissions” within 30 days. Not only does it sound simple, it sounds compelling for quality and financial imperatives.

SHM has long identified transitions of care as one of the most vulnerable events for patients. Some of the earliest presentations at SHM meetings vividly described the “voltage drop” of information that can occur when a patient enters or leaves the hospital—not to mention during intra-hospital transitions. SHM has embraced transitions of care as a core competency in hospital medicine, has built a quality improvement resource room online for care transitions of older adults, and in July year co-sponsored a summit on transitions of care.

By recommending changes in payment methodology to hospitals, MedPAC is isolating the facility from the intricate composite of systems and processes involved in transitions of care.

Readmission rates are commonly considered a proxy outcome measure to reflect the broader issue of quality of care transitions at the time of hospital discharge; however, we must be clear that these two entities are not nearly synonymous. A hospital readmission does not necessarily reflect a poorly executed hospital discharge, and high-quality discharges do not absolutely prevent hospital readmissions. The challenge with improving transitions of care and reducing preventable readmissions lies in the systems, processes, facilities, and people involved.

To drive lower readmission rates, MedPAC is suggesting a bifurcated strategy: public reporting and altering payment schedules to hospitals. I believe the former, combined with appropriate public education on the multifactorial nature of readmissions and how to interpret the data, can be a positive step toward improving care transitions. The more transparent the healthcare system becomes, the more frank conversations we can have in the pursuit of higher quality care. Those conversations open the door to understanding the complexity of care processes and the dependency of various resources and stakeholders on one another. They also help to confront the brutal truth of care transitions: that there must be shared accountability for ensuring our patients receive the support they need, where and when they need it.

By recommending changes in payment methodology to hospitals, however, MedPAC is isolating the facility from the intricate composite of systems and processes involved in transitions of care. While I realize the analogy is a bit of a stretch, this approach strikes me as similar to applying the logic of cooling to unfry an egg. A generally simple tactic to address a highly complex issue. Just as albumin has precise folds, spirals, and sheets to allow it to perform its proper function as a protein, so too must the healthcare system provide proper coordination, communication and support services to ensure proper health and well-being of patients.

Restructuring hospital payments in no way addresses the role of physicians in the hospital, physicians in the ambulatory or sub-acute setting, home-care agencies, other vendors, caregiver compliance, patient self-care, or chronic disease management. MedPAC’s proposal holds one party accountable in a scenario where only joint accountability will render the results we desire. In a recent article in the Harvard Business Review, Roger Martin eloquently describes a common coping mechanism people use to address complexity and ambiguity—simplification whenever possible. Within organizations, “When a colleague admonishes us to ‘quit complicating the issue,’ it’s not just an impatient reminder to get on with the damn job—it’s also a plea to keep the complexity at a comfortable level.”

I do not mean to imply incentives are not important; they are vital to stimulate change and manage behavior. That being said, I also believe incentive programs often beget unintended consequences and may drive undesirable behavior.

Would MedPAC’s proposal cause hospitals to become apprehensive about accepting more complex cases? Even the best severity-adjustment methods account for only a fraction of the variations among patients, so hospitals may feel compelled to screen or select out certain complex populations as opposed to relying on severity-adjustment measures to account for true differences in patient outcomes.

Don Berwick, MD, the CEO of the Institute of Healthcare Improvement (IHI), is often quoted as saying, “Every system is perfectly designed to achieve the results it gets.” If this is so, a singular focus on incentives and penalties directed toward hospitals will bring either unilateral facility actions and/or a lack of leverage to effect needed improvements in the rest of the care system.

Alternatively, the Centers for Medicare and Medicaid Systems (CMS) could focus on several areas that constructively address the interdependent systems and multiple stakeholders involved in transitions of care. CMS could:

  • Adopt a public reporting system for readmission rates for hospitals according to select discharge diagnoses. Transparency likely will drive some improvements via the “Hawthorne effect,” and it will serve as a common basis for key parties discussing the issues to drive improvement;
  • Advocate that public reporting should be accompanied by rigorous public education on transitions of care. Such education should include a clear outline of the complexities, interdependencies, and pitfalls common to care transitions, and should also include clear steps patients and caregivers can take to play an effective role in the process;
  • Participate in the development of improvement tools to address readmission rates. IHI is a terrific example of an organization that has created such a device to improve hospital mortality rates. Their Mortality Diagnostic Tool identifies potentially avoidable hospital deaths;
  • Sponsor collaborative meetings with key industry organizations to discuss the issues, gain consensus on standards and expectations, and promote necessary change; and
  • Take the framework of reporting, education, improvement tools and practice standards to create aligned incentives across facilities, providers, vendors, and beneficiaries.

While it’s tempting to seek simple answers to complex issues, they often fall short of the best solution. As leaders in healthcare, we must embrace complexity and find answers that reflect an integrated and aligned approach. We must acknowledge that accountability for high-quality transitions of care and reductions in readmissions has to be shared. With the support of CMS, SHM, and other agencies and professional organizations, we have every resource available to improve this vulnerable time in the lives of our patients. Only then will we have an environment suitable to unfry the egg. Or perhaps we’ll engineer an environment where the egg is never fried in the first place. TH

Dr. Holman is the president of SHM.

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