Bringing Clinical and Finance Together to Reduce Readmissions

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Following is the full conversation of Episode 3 of the Hospital Readmissions Reduction Podcast.

Michael:  Welcome to the Hospital Readmissions Reduction Podcast brought to you by BESLER Consulting. This is the podcast for hospital leaders seeking insights and strategies they need to help reduce readmissions at their organizations. I’m Mike Passanante, your host for this podcast, and today we are going to be talking about how to bridge the gap between clinical and finance so we can reduce readmissions in our hospitals. To help me do that, is Dr. Ed Niewiadomski. Dr. Ed has over three decades of experience in direct patient care and health care administration. He is the former Senior Vice President of Medical Affairs and Chief Medical Officer for a community acute care facility in New Jersey. Welcome, Dr. Ed.
Dr. Niewiadomski:  Thank you, Michael. Thank you for having me.
Michael:  My first question I’m going to get to. I have to kind of set it up for you. We’re looking at an environment in healthcare that is very fluid. Models are changing rapidly. We’re seeing the introduction of value-based payments, bundled payments, readmissions are becoming a part of that equation, certainly from CMS. But it’s certainly on the radar screen I think of private payers, and they could very well be looking at ways to penalize hospitals and physicians for not dealing with their excess readmissions as well. So my question to you is, how does this environment change the mindset of hospital leadership when it comes to dealing with readmissions?
Dr. Niewiadomski:  That’s a great question and you’re exactly right where the environment is changing daily. With the advent of the Affordable Care Act – and actually we’re in the fifth year now of the signing of the Affordable Care Act – payment structures are evolving. And the ultimate goal, we’re evolving from a fee-for-service model – which is the more you do, the more you make from a provider perspective – from that model to the higher quality, or the better I do the more I should make. Medicare has started this with its Medicare shared savings plan, which is kind of the step into an ACO, Accountable Care Organizations, where– and then the value-based purchasing model as well which is embedded into the Affordable Care Act.
But what we’re seeing is that this is all evolving to where we are going to be asked, more and more, to manage populations and the health of those populations. And so we’re going to say, “Here’s your population of 10,000 individuals, and here’s X amount of dollars. Spend it as you see fit.” And we’re going to be looking at outcomes and we’re going to be looking at how you’re managing your patients and making sure they’re getting all their screening and preventive-type care, and along with that will be readmissions. We all know that the highest cost center within  the spectrum of care is an acute care stay, and so our goal is to keep our patients healthy and keep them out of the hospital, rather than being paid for episodes of care, we’ll be paid for better outcomes during multiple episodes of wellness.
This is definitely something that’s on the radar screen of hospital leadership.
Michael:  Absolutely. At BESLER, we’re out talking with leaders and hospitals all the time. It’s pretty clear that the finance leadership that we talked to is very much aware of their CMS penalties around readmissions. They see that impact on their bottom line. But, on the other side of the house, it’s really the clinical teams that are impacting patient care and ultimately readmissions. Do you think that finance and clinical are having the right kind of dialogue about readmissions at this time?
Dr. Niewiadomski:  I think at this point in time they are. And I can say that because I think if you look at, as we talked about just a few moments ago, the financial incentives from the hospital perspective and the physician perspective are clearly – more than ever in the history of medicine – are starting to align. And once that occurs and as they continue to align, these conversations become much easier, and bridging that financial and clinical gap becomes much more of a reality rather than the diverging paths that each group took in years past. And what I mean by that is when the– years ago we would talk to physicians about length-of-stay reduction and cost-effective medicine and direct patient care cost per care. It really didn’t mean anything to them because their goal was to provide the best care they knew how, and in a lot of physicians’ minds it was more care is better care. We know that that’s not the case today, and so if we start changing the payment models with these bundled payments, value-based purchasing and such as we talked about, then if we all are accountable for not only the care and the outcomes, but also the dollars that we need to spend to make sure those outcomes are out of high quality, we will all be kind of marching down that same quality corridor and that same financial corridor as well.
Michael:  That makes sense. Let me dig a little bit deeper with you here. Unlike some other pretty well-established functions within the hospital, the players involved in analyzing readmissions information and then trying to remediate readmissions tend to be different from organization to organization. In your opinion, who needs to be at the  table to have a discussion about readmissions?
Dr. Niewiadomski:  I think the readmission reduction strategy, whatever a hospital chooses to implement, clearly is an enterprise initiative. Pretty much every department within the organization needs to be onboard, and certainly we need champions from the administration. We clearly need champions from the medical staff. Readmission discussions need to be placed on every agenda for every meeting in the hospital every month or every quarter. The medical staff leadership need to make this a priority. They need to have champions that are promoting readmission reduction strategies. I think, from an administrative perspective, we need to give the clinical teams the resources that they need to be effective and to implement successful readmission reduction strategies.
Michael:  You’ve been a chief medical officer. What do you think is the best way for a finance professional in the hospital to broach the subject of readmission penalties with someone in a clinical leadership role?
Dr. Niewiadomski:  As with pretty much everything we do today in medicine, and certainly within a structured environment like a hospital, this is all going to be data-driven. What the financial team needs to do is to identify this as an organizational priority – which is readmission reductions, number one – but then behind that, provide data to the clinical team that they can react to. We need to know why patients are coming back,  where the opportunities for improvement lie, identify those opportunities, and then focus our resources in those areas. Years ago, we were very – not reluctant – but I would just say somewhat remiss in not providing this data to the clinicians. And I would tell my medical staff, every piece of data that I have, we want to share with you. The only way you can drive improvement is to have baseline and benchmarks and then steer towards those and have goals to attain trends towards the improvement.
Michael:  So let’s unpack that a little bit. If you had to talk about the types of data that these teams should be looking at regularly to determine their progress, what would you say are some KPIs that they should be paying attention to?
Dr. Niewiadomski:  Yeah, I would look at some key performance indicators, things like what is the severity of illness and how sick are my patients. In other words, implementing a risk stratification score to identify those patients who are high-risk versus not at high-risk for unplanned readmission within 30 days. We should know that on every one of our patients. We need to know things like, what about in the post-discharge period? Is there access to care? Are physicians opening their office to see those patients in a timely way? We need to know just, even one step before that, within the medical staff, who’s providing the in-patient care, and whom within that group, have higher readmission rates? From there we can identify and look at specific physician practice patterns, and perhaps try to streamline that and manage those variations among the caregivers. If we look at results in those within the group who are meeting their core measures as national quality indicators, they will have a real impact on whether or not a patient is readmitted. So if we have these data sets, and we can then share them timely with the medical staff, we will then be able to identify those opportunities to focus our resources.
Michael:  What do you think today is the biggest obstacle to bridging the gap between clinical and finance?
Dr. Niewiadomski: I think, again, the fact that the physicians are always struggling on how to take care of their patients in the best way they know how and trying to be cost-effective as well. And what I mean by that, it’s taken a long time to get physicians to understand that a length of stay of 12 days versus 4 days is truly a quality indicator because it’s no longer where more is better. Being effective and having great outcomes is what our goals are. And I think physicians understand that, and we know now that the longer a patient is in the hospital, the more likely they’re prone to have a fall or a wrong medication or acquire an infection or another hospital-acquired condition. We know now that the longer patients lie around or are immobilized, the longer it takes them to be rehabbed. Then it puts them at risk for other things like deep-vein thrombosis and such. So we now know that we have to be efficient, and we have to look at our patient. We have to understand our patient and provide the highest quality care with now what is becoming a finite number of resources. And I think in years past, we as physicians always looked as resources are unlimited, but they’re really not. And the more we do not take that into account, the more we will all be penalized, not only hospital providers but physician providers as well down the road.
Michael:  So how do you think the interaction between clinical and finance will be different going forward? What will it look like in the years to come?
Dr. Niewiadomski: I think as we were accustomed to in years past, is that we from a hospital perspective were trying every day, in every meeting, trying to get the doctors engaged in looking at the data, sharing the data with them. I think that now the tables are turned a little bit, where the physicians are now looking for those reports. They’re looking for dashboards. Data and outcomes are publicly transparent right now – everything from hospital-acquired infections to readmissions – these are all quality indicators that the public are acutely aware of. And physicians now are actually thirsty for these data points, and they don’t want to be an outlier any longer. They are no longer responding to data, and dashboards, and performance metrics as, “Well, it doesn’t really impact me.” They know now it really does impact them. It impacts them as far as their outcomes with their patients, number one – that’s first and foremost. But it also impacts them on things like they may not be asked to participate in certain networks any longer because they are not performing at the level the rest of their peers are. So that will result in a financial negative impact to them. They’re very concerned about these performance metrics at this point.
Michael: Certainly the future’s going to be different than the past.
Dr. Niewiadomski: Yes, it is. The future is here.
Michael:  It was great having you. Thanks again for coming by and giving us your insights into these issues around readmissions.
Dr. Niewiadomski: Thank you, Michael.
Michael:  If your organization is struggling to develop meaningful readmission reduction strategies and measure your performance against Medicare’s Hospital Readmissions Reduction Program, visit There you’ll find videos, e-books, and other resources to help you develop solutions that may limit your long-term exposure to Medicare penalties. That’s I hope you’ve enjoyed today’s show and will join us again for another edition of the Hospital Readmissions Reduction Podcast.

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