Why should a primary care physician consider readmission rates as a reasonable quality-of-care indicator?

“Readmission rates apply to hospitals.  As a primary care physician, I don’t have control over hospitals so why should I be on the hook for this?”  This is a question that comes up in the context of key performance indicators in advanced payment models.

When we get into discussion, primary care physicians (PCPs) typically identify several challenges:

• I don’t control readmissions, I control things like prescribing the right medicine or ordering the appropriate test.
• Hospital discharge and thus readmission is the work of the discharge team and has nothing to do with me.
• Hospitals don’t inform me when my patients are admitted, so you’re asking me to weigh in on something I don’t know has even happened.
• I’m running as fast as I can just to keep up with the daily work in my practice and now you’re asking me to do more.

Let’s start with quality of care.  High performing health systems have in place a foundation of high performing primary care.  High performing primary care provides four functions:[1]

• Access
• Person-focused care over time
• Comprehensive services
• Coordination of care across the entire continuum of healthcare delivery

An essential point of advanced alternative payment models is to better align financing and quality measurement with work more likely to lead to better outcomes for people and populations.  

Outcomes have, in the past, focused more on process indicators (e.g. the rate of prescribing the right medicine or ordering the appropriate test), and are now expanding to include higher-order outcomes: ones more likely to improve through better communication and coordination of care (e.g. potentially preventable readmissions, admissions, ED visits).

It is reasonable to consider these higher order outcomes as indicative of an evolving and improving system of care delivery.  Improving a rate of readmission is more likely when hospitals and PCPs communicate well and coordinate the care of the individuals they serve.

The concerns above describe the gap between the current reality and a vision of a high performing health system¹ (Starfield et al).  Improving readmissions requires real changes in the tools we use, the work we do, as well as investments in primary care to enable the full scope of work including coordination of care across the entire continuum.

Some suggestions:

• Primary care is under-resourced and over-worked. They need:
  • Electronic tools that support rather than distract from their work.
  • To not spend time reporting on their work.
  • Compensation models aligned with outcomes not volume.
  • Staff and other resources to engage in the full scope of high functioning primary care
• Hospitals can:
  • Leverage technology to alert PCPs of admit/discharge/transfer.
  • Provide comprehensive care management data as part of a collaborative and seamless transition of care.

PCPs and hospitals working well together are more likely to solve problems that get in the way of seamless transitions of care.  Both can have an impact on readmission rates as well as other key performance indicators: potentially preventable hospitalization, potentially preventable emergency department visits.  The more we align our payment, measurement and technologies to support this work, the more likely we are to see improvements.

L. Gordon Moore, MD, is senior medical director for Populations and Payment Solutions at 3M Health Information Systems.

[1] Starfield, Barbara, Leiyu Shi, and James Macinko. “Contribution of Primary Care to Health Systems and Health.” The Milbank Quarterly 83, no. 3 (September 2005): 457–502. doi:10.1111/j.1468-0009.2005.00409.x.