By ROBERT WACHTER

I like readmissions. Well, that didn’t come out quite right, did it?

What I mean is that I like focusing on readmissions as a potentially actionable quality measure. I believe that it’s possible to prevent many readmissions, thereby improving quality and lowering costs. And compared to mortality (the other hot outcome measure), the need for case-mix adjustment is a bit less critical, and there is no such thing as “a good readmission.”

I also like DRGs. Paying hospitals a fixed fee for a given diagnosis has created the only corner of sustainable capitation in our healthcare system, one that is otherwise awash in inappropriate expenditures driven by the dominant fee-for-service payment structure.

But the DRG system created a big black hole, and it is time to fill it. It’s called the post-discharge period. And one large part of the detritus emerging from that hole is readmissions.

You probably saw this week’s NEJM study by Stephen Jencks (a former Medicare official and now a Baltimore-based consultant), and my pals Mark Williams and Eric Coleman, of Northwestern and Colorado, respectively. The study found that 20% of Medicare patients are readmitted within a month of discharge, and one-third return within 90 days. Even more remarkably, by a year out more than half of patients (56%) discharged from an acute care hospital are re-hospitalized. The authors estimate that the cost of preventable readmissions was $17 billion in 2004 (the study year), which would make it more like $25 billion today.

Although the frequency and cost of readmissions were reasonably well known before this study, the paper was chock-full of interesting findings and observations:

• Like so many things in healthcare, there was striking geographic variation in readmission rates – from a low of 13% in Idaho to 23% in Washington, D.C.
• There were also variations by DRG, with the highest readmission rates in patients with heart failure, psychosis, vascular and cardiac surgery, and COPD – pointing the way toward targeted interventions.
• More than half the patients readmitted within 30 days appeared not to have had an outpatient visit between hospital discharge and readmission, perhaps another target for intervention.
• Most (70%) surgical patients who are readmitted come back for a medical diagnosis such as pneumonia or UTI.
• Approximately 30% of readmitted patients come back to a different hospital, so hospitals will underestimate the extent of their readmission problem by looking solely at their own bounce-backs.

Now that we know that readmissions are frequent and costly, the next questions are: Are they preventable? Do they reflect poor quality care? And, if yes and yes, what clinical and policy maneuvers might help prevent them?

The Obama budget plan depends on figuring this out. The budget, which aims to save $300 billion (which used to seem like a lot of money) in Medicare/Medicaid costs over the next decade, includes a projected $26 billion in savings from “driving down hospital readmission rates for Medicare patients” – both from preventing the costs of the readmissions themselves and by lowering payments to hospitals with excessive readmission rates.

The policy issues are worth thinking through a bit. Until this decade, DRGs gave hospitals an incentive to shorten length of stay and cut hospital costs for their Medicare patients, but provided no market signal to improve quality or safety. The incentive to shorten length of stay remains, but it is now accompanied by a variety of initiatives (error and quality reporting, pay for performance, Joint Commission visits) that create at least some inducement for hospitals to maximize value (quality divided by cost), and not just efficiency.

Up till now, this broader value incentive was focused, laser-like, on care delivered within the four walls of the hospital. Hospitals could do quite well managing length of stay and costs and (more recently) scoring well on their publicly reported quality measures and accreditation surveys. The closest the present system came to putting any skin in the post-discharge game was public reporting of the presence or absence of documentation of a discharge plan for adults with heart failure or kids with asthma. Not a very high performance bar.

The manifestations of this myopic focus on hospitalization as the unit of analysis can be seen in the paucity of attention that hospitals give post-discharge care. Studies have chronicled a litany of post-discharge disasters (summarized in this marvelous Primer on post-discharge adverse events by my colleague Sumant Ranji in our federal patient safety portal, AHRQ PSNet): nearly 20% of patients experience adverse events within 3 weeks of discharge; 40% of patients are discharged with tests pending, and many of these balls are dropped; 15% of discharged patients have a discrepancy in their medication lists; and only the rarest discharge summary finds its way to the desk of the primary care physician by the time a patient is seem for his or her first post-discharge visit.

In other words, when it comes to post-discharge care, we suck.

Despite powerful literature that shows that simple interventions – like post-discharge phone calls or the use of a transitions coach – can lead to impressive improvements in post-discharge care and decreased readmission and return-to-ED rates, few hospitals have put these interventions in place. Outside of integrated delivery systems like Kaiser Permanente or the VA, virtually no hospitals have electronically connected themselves to their referring physicians’ offices; everybody argues that Stark laws prevent them from making these hook-ups, but the lack of an incentive to improve post-discharge care has been the more important culprit.

Even hospitalist programs, ostensibly erected to improve value, tend to have a narrow focus on improving care within the building, too often taking an out-of-sight/out-of-mind attitude to their patients’ status after discharge. That said, I’m pleased that hospitalists have taken the national lead in studying post-discharge errors and building programs to prevent them.

As with most things in safety and quality, I’m not arguing that physicians, or hospital administrators for that matter, stop caring about their patients after they’re discharged. Of course they do. But this is 2009 – remember, we’ve discovered that improving quality and safety are largely systems properties, not driven by individual commitment or even individual skill. The question is not whether a hospitalist is skilled and empathic, or whether the patient was discharged at the correct, evidence-based time. It is this: are there robust and sustainable systems in place designed to maximize the safety of patients in the vulnerable post-discharge period? The sad answer is that there are very few such systems.

Accompanying the Jencks study, Harvard’s Arnie Epstein reviews the policy initiatives addressing readmissions – including those that are here today (publishing readmission rates on the Web) and those being actively discussed (financial penalties to hospitals with high readmission rates). But the Cool Kid on the Payment Block is “bundling” – aggregating  payments for doctors and hospitals for a period of time after an illness (an “episode of care”) in an effort to create accountable integrated entities that will improve care across the continuum (the entities somehow have to split up the spoils between hospitals, hospitalists, SNFs, primary care docs, specialists, care coordinators… Have fun with that). Epstein’s verdict: worthy of pilot studies, but “the likelihood that [bundling] will prove to be a successful model is still uncertain.”

Hospitals, of course, moan about all of this new pressure on readmissions – claiming, correctly, that they don’t control much of what happens when a patient leaves the building. “How can you blame us,” goes the lament, “if we can’t find a PCP for a patient, or the outpatient doc chooses to readmit the patient.” Some of this is doubtless true, and the potential for unfairness is real. But some of this bellyaching is a manifestation of learned helplessness, borne of having no incentive to pay any attention whatsoever to filling the post-discharge black hole.

An era is dawning in which hospitals will, for the first time, have to think of the post-discharge period as being, at least partly, their responsibility. Luckily, this is an area in which there are tools ready for the taking (for example, those developed by the Society of Hospital Medicine through its splendid Project Boost), and some early experience to learn from. Some of us, suspecting that this train was coming down the tracks, have been working on the discharge process for the last few years (my UCSF hospitalists have focused on this issue as our main quality initiative for the past year). Others will have to play catch-up ball.

Ultimately, hospitals will have to figure out ways to get a discharge summary in the hands of a PCP by the day after discharge (as opposed to the year after discharge, today’s sad state of affairs); to ensure that patients receive robust and understandable discharge instructions (not simply a check box on a form); and to provide, or facilitate the provision of, a follow-up phone call (or email or Tweet – whatever works!) and, for high risk patients, a post-discharge clinic visit, a discharge or transitions coach (as promoted by Eric Coleman’s “Care Transitions Program”), and/or a high risk case manager. This isn’t rocket science – all of these interventions make sense, are less expensive than an MRI or surgical robot, and are not that hard to implement. They simply take institutional will.

I, like you, don’t know where the money will come from for all of this. But we do know that readmissions are terribly expensive and just plain bad for patients. With unplanned readmission rates at 20% and higher, it is high time that we got to work on this problem. When it becomes less expensive to prevent a readmission than to neglect the post-discharge period and help contribute to one, someone will find the money to improve care.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCBand on his own blog “Wachter’s World.”

out-of-sight/out-of-mind attitude to their patients’ status after
discharge. That said, I’m pleased that hospitalists have taken the
national lead in studying post-discharge errors and building programs
to prevent them.

As with most things in safety and quality,
I’m not arguing that physicians, or hospital administrators for that
matter, stop caring about their patients after they’re discharged. Of
course they do. But this is 2009 – remember, we’ve discovered that
improving quality and safety are largely systems properties,
not driven by individual commitment or even individual skill. The
question is not whether a hospitalist is skilled and empathic, or
whether the patient was discharged at the correct, evidence-based time.
It is this: are there robust and sustainable systems in place designed
to maximize the safety of patients in the vulnerable post-discharge
period? The sad answer is that there are very few such systems.

Accompanying the Jencks study, Harvard’s Arnie Epstein reviews
the policy initiatives addressing readmissions – including those that
are here today (publishing readmission rates on the Web) and those
being actively discussed (financial penalties to hospitals with high
readmission rates). But the Cool Kid on the Payment Block is “bundling”
– aggregating  payments for doctors and hospitals for a period of time
after an illness (an “episode of care”) in an effort to create
accountable integrated entities that will improve care across the
continuum (the entities somehow have to split up the spoils between
hospitals, hospitalists, SNFs, primary care docs, specialists, care
coordinators… Have fun with that).
Epstein’s verdict: worthy of pilot studies, but “the likelihood that
[bundling] will prove to be a successful model is still uncertain.”

Hospitals,
of course, moan about all of this new pressure on readmissions –
claiming, correctly, that they don’t control much of what happens when
a patient leaves the building. “How can you blame us,” goes the lament,
“if we can’t find a PCP for a patient, or the outpatient doc chooses to
readmit the patient.” Some of this is doubtless true, and the potential
for unfairness is real. But some of this bellyaching is a manifestation
of learned helplessness, borne of having no incentive to pay any
attention whatsoever to filling the post-discharge black hole.

An
era is dawning in which hospitals will, for the first time, have to
think of the post-discharge period as being, at least partly, their
responsibility. Luckily, this is an area in which there are tools ready
for the taking (for example, those developed by the Society of Hospital
Medicine through its splendid Project Boost),
and some early experience to learn from. Some of us, suspecting that
this train was coming down the tracks, have been working on the
discharge process for the last few years (my UCSF hospitalists have
focused on this issue as our main quality initiative for the past
year). Others will have to play catch-up ball.

Ultimately,
hospitals will have to figure out ways to get a discharge summary in
the hands of a PCP by the day after discharge (as opposed to the year
after discharge, today’s sad state of affairs); to ensure that patients
receive robust and understandable discharge instructions (not simply a
check box on a form); and to provide, or facilitate the provision of, a
follow-up phone call (or email or Tweet – whatever works!) and, for
high risk patients, a post-discharge clinic visit, a discharge or
transitions coach (as promoted by Eric Coleman’s “Care Transitions Program”),
and/or a high risk case manager. This isn’t rocket science – all of
these interventions make sense, are less expensive than an MRI or
surgical robot, and are not that hard to implement. They simply take
institutional will.

I, like you, don’t know where the money
will come from for all of this. But we do know that readmissions are
terribly expensive and just plain bad for patients. With unplanned
readmission rates at 20% and higher, it is high time that we got to
work on this problem. When it becomes less expensive to prevent a
readmission than to neglect the post-discharge period and help
contribute to one, someone will find the money to improve care.

Robert Wachter is widely regarded as a leading figure in the modern
patient safety
movement. Together with Dr. Lee Goldman, he coined the
term “hospitalist” in an influential 1996 essay in The New England
Journal of Medicine. His most recent book, Understanding Patient
Safety, (McGraw-Hill, 2008) examines the factors that have contributed
to what is often described as “an epidemic” facing American hospitals.
His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”