In the United States, health care purchasers, consumers, and policymakers are demanding improvements in the quality and efficiency of medical care. A promising approach to meet this demand is the development of what is known as a learning health system (LHS). A learning health system has the capability to continuously study and improve itself. Among many types of benefits it can bring about, the learning health system makes it possible for providers to make faster and better decisions about which treatment options would produce the best outcomes for patients.
Today, the Michigan-based stakeholder initiative, Learning Health for Michigan (LH4M), is proposing the use of a learning health system approach to address persistent health care problems in Michigan. Unwarranted and costly hospital readmissions—which are discussed in this paper—are one example of a problem that could benefit from a learning health system approach.
In 2013, the Center for Healthcare Research and Transformation (CHRT) convened a group of patients, clinicians, researchers, public health professionals, and payers to discuss ways to apply the idea of the learning health system at a state level: to turn Michigan into what might be called a “learning health state.” The initiative was named “Learning Health for Michigan,” or LH4M. Later convenings of the LH4M stakeholder group were organized by the Michigan Health Information Network (MiHIN) Shared Services and the Department of Learning Health Sciences at the University of Michigan Medical School.
Michigan has many resources that are key ingredients for a state-wide learning health system.
Publicly-reported hospital rankings are released annually and are widely publicized by both the sponsors of the rankings and hospitals that are highly ranked as indicators of hospital quality or safety. Meant to be a useful way for consumers to assess hospital quality, these ranking systems produce inconsistent, contradictory, and confusing results, as some hospitals are highly ranked in some systems but not in others.
2014 marked the launch of the health insurance marketplaces and Medicaid expansion under the Affordable Care Act (ACA). These programs expanded health insurance coverage to many previously uninsured residents, resulting in sharp decreases in the uninsured rate both nationwide and in Michigan. Expanded access to health insurance can benefit health care providers, such as hospitals, financially through reducing their uncompensated care burden.
Inpatient hospitalizations account for 32 percent of the total $2.9 trillion spent on health care in the United States. In the majority of cases, it is necessary and appropriate to admit a patient to the hospital. However, patients returning to the hospital soon (e.g., within 30 days) after their previous stay account for a substantial percentage of admissions. Research has shown that many factors—including a patient’s socioeconomic status, clinical conditions, and their communities’ characteristics—can influence acute care hospital readmissions.
Congress created the Disproportionate Share Hospital (DSH) program in the early 1980s to help hospitals offset the costs of providing care to low-income individuals. Medicaid and Medicare each have a distinct DSH program, with a unique structure and financing mechanism.
Beginning October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) began reducing hospitals’ Medicare payments based on 30-day hospital readmission rates. The reductions are based on hospitals’ 30-day risk-adjusted readmission rates relative to national averages. Penalties are imposed for each hospital’s percentage of potentially preventable Medicare readmissions for those conditions. Under the Patient Protection and Affordable Care Act (ACA), acute care hospitals with high readmission rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia may lose up to 1 percent of their Medicare payments for fiscal year (FY) 2013, up to 2 percent for FY 2014, and up to 3 percent for FY 2015.