Readmissions

Nothing bugs a hospital administrator like lost money.  It drives them crazy.   It gives them nightmares at night.  It is how they are judged by their board.   Readmissions to hospitals, within 30 days, is keeping this curse going now that Medicare is penalizing hospitals if they don’t stop this trend.  In fact, hospitals would be better off financially if those patients succumbed versus leaving and coming back in (how is that for a potential plot twist for a movie?).  Here is a link to a great article in the WSJ which explains this more and here are some highlights:

  •  The Center for Medicare and Medicaid Services said it is trying to reduce “avoidable hospital readmissions, which cost Medicare $26 billion a year and affect nearly one in five beneficiaries.” The approaches include better discharge planning, home-based follow-up and patient education, according to the federal health agency.
  • A study led by researchers at Yale University of four million patients aged 18 and older with multiple conditions in three states found nearly 20% ended up back at the hospital within 30 days. Emergency-department visits accounted for about 40% of post-discharge hospital-care use, which the researchers said indicates more attention is needed to prevent such emergencies, even though they may not result in readmission. High rates of ER visits after hospital discharge may reflect shortcomings in care in the transition from hospital to home, they added.
  • Another study of three million Medicare patients from 2007 to 2009 by researchers at Yale and Columbia University found that nearly 25% of those with heart failure, 20% of heart-attack patients and 18% of those with pneumonia were readmitted within 30 days, often for the same condition but also for a wide variety of other diagnoses.

So you would think fixing this would make things better, right?  Not so:

  • A study led by the Colorado Foundation for Medical Care found that communities that created programs to improve care transitions in a program funded by Medicare were able to reduce readmissions compared with those without such programs, but not enough to drive them down significantly as a percentage of hospital discharges.

You see, Pay-for-Performance does not work!   Sure, better coordination is needed.  Sure, more social services are needed.  Sure, quicker follow-up with the doc is needed.  Let’s keep working on that.  I am all for system improvements but the one thing that is never mentioned is that patients don’t have any skin in the game.  You can’t stop some heart failure patients from going home and marinating themselves in salt.  You can’t stop some COPDers from literally living in a terrarium of toxic smoke.   And yet we doctors, who know and understand this, will just let the “smarter” people make the rules…..evidence be damned.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  8 comments for “Readmissions

  1. February 2, 2013 at 10:57 am

    I know that there are certainly patients who return immediately to the same bad habits. But certainly not all of them. (After my heart attack, I quit smoking) But it’s easy for hospitals to blame the patients, and shrug their shoulders and say”non-compliant patients–it’s not our fault”. But why do patients go back to their bad habits? And what about the ones who really try? Instead of always placing the blame elsewhere, we should look at WHY it happens that way and how we can help change it. Personally, I’m finding the idea of the “medical home” intriguing, and am looking forward to participating in one (as a patient).

  2. Michael S Braun MD
    February 1, 2013 at 3:13 am

    Here’s a little tip…these patients are being re-admitted because they are really sick and just a slight change from their baseline results in decompensation
    I see these people within a week of discharge and they still are re-admitted…it has little or nothing to do with “transition of care” and everything to do with them teetering on the verge every day of their life

  3. Diane
    January 31, 2013 at 10:37 am

    Come on, Doug! We know how to make P4P work for family docs. Get rid of all your sick patients, keep only the healthy ones. When the sick ones finally go to the ER for treatment, they’ll be that much closer to deaths door. No repeat visits. Problem solved.

    • Doug Farrago
      January 31, 2013 at 11:30 am

      LOL

  4. Kathy Wire
    January 28, 2013 at 10:26 am

    The article in the NEJM was written by Harlan Krumholz. n engl j med 368;2. http://www.nejm.org/doi/full/10.1056/NEJMp1212324 As I reread it, it’s more a summary of existing data than a study that tests an approach. I’ve also seen articles that have tested a hospital unit that was really a LTC environment in a hospital…areas to gather with other patients, meals in a small eating area outside of the hospital room and walking to each. They were designed to help prevent this post-hospital syndrome and have had some success. My general point is that sometimes patients harpoon their own good health, but hospitals manage to do the same thing and we need to stop that.

    • Doug Farrago
      January 28, 2013 at 10:39 am

      I agree, Kathy. Hospitals, by no means, are innocent. They are guilty of having too many administrators and paying them too much. They squeeze nursing and boss around doctors. They get away with whatever they can that helps their bottom line and so I do see your point. But the ends don’t justify the means. P4P is bad medicine.

  5. Kathy Wire
    January 28, 2013 at 9:26 am

    Once again, I will play devil’s advocate. This time from two perspectives: as a recent surgical patient and as a risk and safety consultant for hospitals and nursing homes. Long-term care has focused intently on maintaining nutrition, mobility and socialization in residents because it makes them better. Hospitals (and I’ve worked with them for 30 years) have said, “we don’t do that.” Now, there is good research(can’t lay my hands on it at this moment) showing that when hospitals pay attention to the underlying “custodial” aspects of health, patients are stronger and better when they go home, and they avoid all sorts of diagnoses that would land them back in the hospital. Yes, some continue to smoke and eat unhealthy diets. But there is much more to it. And I would argue that without the pay for performance initiative on readmissions, few would have bothered to look at the issue. Because hospitals didn’t think it was their problem.

    • Doug Farrago
      January 28, 2013 at 10:16 am

      Tough to prove that. I can only say that P4P hasn’t been proven. Also, when you force (with penalties) to look at one criteria than many other criteria are ignored.

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