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When Medicare “Cuts” are Medicare “Savings”

In a post titled “Slowing Down that Revolving Readmissions Door” the New America Foundation’s Joanne Kenen writes about avoidable readmissions. “I once interviewed a patient who literally could  not remember how often he had been hospitalized within just a few months,” Kenen recalls, referring to a story published in the Washington Post last year.

There, she reported that “one of five Medicare hospital patients returns to the hospital within 30 days–at a cost to Medicare of $12 billion to $15 billion a year—and by 90 days the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks.”  Within a year, two out of three are back in the hospital—or dead—says Jencks who consults on this issue for the Institute for Healthcare Improvement (IHI).

This is money that health care reformers could use as we expand care to the uninsured. It’s worth noting that what many call “Medicare cuts” are really “Medicare savings”—billions that could be reclaimed if we rescued patients from that revolving door.
Under reform legislation, hospitals with particularly high rates of avoidable readmissions will have Medicare payments reduced, beginning in 2011. I would guess that some private insurers will follow Medicare’s lead.

Going forward, Medicare will be using financial carrots as well as sticks. When it  begins “bundling” payments to hospitals and the doctors who treat the patient before he enters the hospital, while he is there, and after he is discharged, hospitals and doctors will have a greater reason to collaborate, and will share in the savings when smooth transitions lead to fewer re-admissions.

But do we know how to avoid readmission?

Kenen reports on a study which  provides more medical evidence showing that, indeed, we do know how to reduce high readmission rates among the million or so Medicare patients with heart failure who are hospitalized each year. Drawing on data from more than 30,000 Medicare patients, the study found that hospitals that follow up for a week after discharge bring down the hospitalization rates significantly. The study drew on quality-improvement data that 225 hospitals provide to the American Heart Association.

But too often, poor follow-up, lack of communication between doctors who care for patients in the hospital and their regular physicians; miscommunication between doctors and patient, and poor coordination and medication management during transitions from hospital to home or nursing home cause patients to “bounce back.” Kennen offers a simple example of poor communication: “I’ve spoken to heart failure patients who had been told to follow a low-salt diet but had no idea that meant they had to avoid high sodium processed foods. They thought it was just about the salt shaker on the table.”

UCSF’s Bob Wachter also has looked at Jencks work, and highlights some of the more interesting findings:

•    Like so many things in health care, there was striking geographic variation in readmission rates – from a low of 13% in Idaho to 23% in Washington, D.C. [See map below]

•    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. [Medicare will need to pay attention to its bills. If a patient is admitted to hospital B less than 30 days after being discharged from hospital A, hospital A should pay the penalty.]
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Rates of Rehospitalization within 30 Days after Hospital Discharge (Source: JAMA)

Hospitals Are Acting Now

Hospitals are not waiting for Medicare penalties to kick in. In September of 2008, the Society of Hospital Medicine (SHM) announced that it was starting a pilot project in eight hospitals called Project Boost (Better Outcomes for Older Patients Through Safer Transitions) designed to avoid unplanned or preventable readmissions and emergency department visits within 30 days after discharge. In March of 2009, the project was expanded to 24 other sites, and recently, SHM announced that it is working with Blue Cross and Blue Shield of Michigan and the University of Michigan, to launch a new 15-site version of the program.

This pilot, which will begin in the fall, is taking the project one step further. All of the institutions involved are concentrated in one state and united by a single payer. Most importantly, the hospitalists are reaching beyond the hospital walls to include outpatient physicians.

For more on creative solutions that some hospitals are trying—including using nurse practitioners as a “bridge” from hospital to home—see Kenen’s full post.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-DrivenMedicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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19 replies »

  1. “Here is your warrantee, Mr. Smith. It says you have received the maximum benefit for the money and time allowed for this hospitalization. We suggest you stop smoking, lose weight, take your medicines as prescribed, and see your PCP. Failure to comply will allow us to bill you directly and collect from you personally for the next 30 days for any further care for this diagnosis. You are free to return but it will not be free. If you are bleeding, hold pressure, all bleeding stops. If you can’t breathe, breathing is overrated. If you need to come back, then make up a new complaint.”
    Fine print from future discharge instructions?

  2. “But you’re ignoring that fact that in many cases, the patient does not pick the insurer, his or her employer does. And the employer is primarily concerned about the cost of the insurance–not whether a case manager is making a good judgment”
    This is a lie, employers are greatly concerned in most cases about employee satisfaction with insurance. The cost of insurance is an employee benefit in lieu of wages. They only offer insurance because employees want it. If employees where unhappy with the insurance the employer has lost all their ROI for offering it.
    I know this from working with thousands of employers and see employers change insurance companies because of service.
    You only need to look at Maggie’s previous post to see she has no idea what she is talking about, why would anyone offer kaiser if they only cared about cost? Did you already forget your post from May 6th maggie trying to justify why Kaiser was more expensive yet worth it. You can’t even keep your story strait from one post to the next.
    “but picks a policy based on what he can afford–not based on the quality of care he is likely to receive from an insurer.”
    FYI with few exceptions insurers don’t provide care providers do. quality of care has very little to do with your insurer and almost everything to do with your providers.
    “Case managers are not M.D.s or NPs.”
    Interesting claim, and you base this on what? 3 more hours of study on the internet? who exactly do you think is doing case management? I know my actually working with case managers isn’t the same as your 3 hours of study but we talk to MDs all the time. Routine task aren’t done by the MDs but they sure as hell review everything that is suggested or denied. Why do you even bother making these claims when it is so obvious you have no clue?
    “”Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.”
    This is complete BS and lies. Maybe some but by no means all, far from even norm.
    “(Case managers who work for insurers are usually trained as social workers, not as medical professionals.)”
    I have never once meet a case manager trained as a social worker and have worked with over 100. How many do you know personally Maggie to be making such a claim?
    “For-profit organizations will always make profits a priority. And, as we all know, relatively few for-profit companies put customers ahead of profits.”
    You just managed to contradict your self in the span of two sentences. Is it all or most that put profit first, can’t be both.
    “But this non-profit/hybrid system works quite well in much of Europe”
    By which measure, the fact they are 10 years away from insolvency instead of 5? Would you say the Greek healthcare system works quit well?
    “and over the past 10 years, they haven’t been as “successful” as Medicare in keeping costs down.”
    Actually not true, they have performed better then Medicare at containing cost.
    “But in this caes, the non-profits– Kasier, Geisinger, Intermountain, Peugot Sound Co-operative have been on the cutting edge.”
    Cutting edge of what? They have minimal market share and are stuck in isolated areas, if they were so successful and innovative why can’t they spread outside of their base?
    We’ll just had this to your lies section of your myths and lies series. Either learn what your talking about or give it up.

  3. Maggie,
    I assume this is extension of your earlier articles about reforms.
    Your focus on positive aspects and the optimism is very refreshing.
    However at same time it will be useful to consider the worst case scenario, whereby a lot of supposed benefits are not materialized in time or the systems adapts to maintain the status quo.
    So I am thinking about the scenario of everyone being entitled to everything with near universal coverage and defined plans. Ideally with better outcomes we could afford that too. But what if that doesn’t happen in timely fashion? How will this new scenario pan out where we will have new health services buyer group backed by very fat wallet clamoring for all the services they can.
    Something has to give away. I am not sure what will that be.
    I hope you could look at this scenario as well. We all know that healthcare is bottomless pit. Considering that it would be useful to look at alternative scenario.

  4. Since it is unlikely that readmissions rates will never get to zero, we need some benchmarks that define what good results are on a case mix adjusted basis. We also need transparency so patients and referring doctors can take the information into account. Rather than deny needed care, we should try to ensure that financial penalties and rewards are appropriate.
    I can think of at least four different causes for a hospital readmission, all of which might require different strategies to address. They are:
    1. The patient did not follow instructions with respect to diet, exercise, medications, etc. even when the hospital took the time to be as thorough as possible. The patient and/or the family is at fault here and the hospital should not be penalized financially.
    2. The patient acquired an infection at the hospital that got worse after discharge and resulted in readmission. The hospital should be penalized for these cases.
    3. There were complications related to surgery including swelling, adverse drug interactions, and the like. Surgical procedures including hip and knee replacement, CABG, other heart related procedures, etc. lend themselves best to bundled payments. If hospitals knew they would get one bundled payment to cover the procedure itself plus all care needed for the following 30-90 days, there would be an incentive to make its care process as good as it can be.
    4. The patient is just plain very sick. When my father was in a nursing home for the final year of his life, he had severe heart disease plus diabetes and ESRD. Even though the nursing home made sure that he took his medications and they controlled his diet, he still needed several trips to the hospital to remove fluid that built up in his abdomen. I was told that some people with this condition were in the hospital as frequently as every 6-8 weeks. Neither discharge planning, care coordination nor hospital acquired infections were issues here. Nonetheless, the patients were frequent flyers.
    So, we need different strategies for different problems and issues. Bundled payments can work for surgical cases but probably not as well for non-surgical cases. Capitation might be a reasonable payment approach for primary care but not for specialty, episodic care.
    I know that insurers, both for profit and non-profit have an economic incentive to deny care, at least up to a point because it lowers their medical claims costs. Under the fee for service payment model, hospitals and doctors have an incentive to provide more care because they get paid more. As a patient, I want needed and appropriate care. As a taxpayer and/or premium payer, I don’t want to finance a blank check.

  5. I am one of those relatively young nurses who are not YET exhausted, and am eager to move forward. I appreciate you pointing out that hospitals need to give nurses enough time to carry out these added responsibilities necessary to reduce readmissions.
    My concern is that these new initiatives will be costly for hospitals to implement. I foresee that those carrots you speak of may not make it to the nurses who are already overworked and underpaid, at least not initially. From my experience the carrot needs to be dangled prior to any forward motion.
    As Medicare uses financial carrots and sticks, hospitals will give hospitalists and nurses more time to do this very impt. work

  6. Anonymous–
    Here is the American Academdy of Family Physicians’
    guidelines (below) for how the hospitalist (the inpatient care physician) and the family physicain should collaborate.
    As you can see, it’s up to the ED to notify the family physician that the patient is in the hospital, but after that the family phyisican is supposed to get records to the hostpial (FAX if he doesn’t have IT), pick up the phone and “maintain communication with the patient and family.”
    Meanwhile, the hospitalist “should be readily available to discuss the patient’s medical problems and hospital course with the family and should provide timely updates to the family physician designated by the patient. Communication with the family physician is extremely important at the time of any changes in the patient’s status, complications or new diagnoses (e.g. cancer).” Note these are “timely updates” not daily updates unless there is a change in the patient’s status. And the langauge suggsts that either the family physician or the hospitalist shoudl initiate the communication.
    When the patient is ready for discharge “The inpatient care physician should communicate the treatment plan and follow up recommendations to the patient’s family physician or the covering physician on the day of discharge. This may be best accomplished by having the discharge summary dictated and faxed to the family physician.”
    Finally, decisions about patient care while the patient is in the hospital should be made by the hospitalist– according to the AAFP.
    The Society of Hospital Medicine also emphasizes the importance of communication.
    Do all hospitalists do what the guidelines suggest? No.
    Do all family phsyicians get a complete medical record to the hosptial in a timely manner? No. Do all family physicains reach out to the patient and family? No.
    But here are the guidelines– clearly both the hospitalist and the PCP need to follow them.
    (3) If patients present to the emergency department (ED) and the ED physician assesses them, the ED physician should then contact the patient’s family physician to determine if admission is necessary or if close follow up or outpatient work up is more appropriate.
    (4) If admission is necessary, the family physician should communicate information on pre-hospital treatment, work up, co-morbidities and ongoing specialty consultations, along with family and social concerns, advanced directives, etc., to the inpatient care physician who is assuming management of the patient’s care.
    (5) The inpatient care physician will assess the patient at admission and determine the best course of treatment. This may include treat and release, admit for general medical management or admit for medical or surgical subspecialty care, while providing general medical oversight.
    (6) During the period of hospitalization, decisions regarding care, consultation, admission, transfer and discharge should be the sole responsibility of the inpatient care physician in consultation with the patient and, as appropriate, the patient’s family physician and/or family members.
    (7) The inpatient care physician should be readily available to discuss the patient’s medical problems and hospital course with the family and should provide timely updates to the family physician designated by the patient. Communication with the family physician is extremely important at the time of any changes in the patient’s status, complications or new diagnoses (e.g. cancer).
    (8) The inpatient care physician should communicate the treatment plan and follow up recommendations to the patient’s family physician or the covering physician on the day of discharge. This may be best accomplished by having the discharge summary dictated and faxed to the family physician.
    (9) When family physicians refer their hospitalized patients to the care of an inpatient physician, the AAFP strongly encourages them to maintain ongoing communication with the patients, their families, and the inpatient care physician throughout the hospitalization.

  7. Barry–
    You suggest that if insurers don’t please their customers, they will lost customers, and this in turn, will displease shareholders.
    But you’re ignoring that fact that in many cases, the patient does not pick the insurer, his or her employer does. And the employer is primarily concerned about the cost of the insurance–not whether a case manager is making a good judgement . ..
    In many other cases, the patient has a choice of insurers, but picks a policy based on what he can afford–not based on the quality of care he is likely to receive from an insurer.
    Case managers are not M.D.s or NPs. Decisions about how long someone should remain in the hospital, who should be readmitted, and how discharges should be handled to avoid unnecessary readmissions are medical decisions, not business decisions. They should be made by medical professionals who have been trained to be aware of conserving resources while providing the best possible care.
    By contrast, “Case Management Mentor” describes how case managers who work for insurance companies are required to meet quotas:
    “Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.
    “This insurance company case manager informed me that he is reminded on a regular basis of the ramifications of not meeting the established monthly length of stay goals. In extreme situations, insurance companies will terminate case managers that do not meet objectives.
    “Depending on the time of month and how the insurance company’s case manager is faring, hospital case managers can expect different volumes of cases designated for medical director review and potential medical necessity denial.” http://blogs.hcpro.com/casemanagement/2009/10/understanding-the-insurance-company-case-manager%E2%80%99s-goals-can-help-hospital-case-managers/
    This is why we want case management done by case managers who are RNs and work for the hospital, not the insurer. (Case managers who work for insurers are usually trained as social workers, not as medical professionals.)
    Medicare is setting out to make medical professionals (and hopsitals) more aware of limited resources by using financial sticks and carrots to reward better outcomes at a more affordable price.
    But the patient– better outcomes– must came first. If we do that, we’ll find that costs come down. (Unnecessary readmissions are not good for patients and usually mean that they didn’t get the best care and follow-up after discharge.)
    For-profit organizations will always make profits a priority. And, as we all know, relatively few for-profit companies put customers ahead of profits. That’s why we say “caveat emptor”–buyer beware. It’s up to he cusomter to be alert, to demand a good product, to return it and insist on a refund if it’s defective.
    But in the case of healthcare, you can’t return a bad surgery and insist on a refund. Most importantly, the buyer is a sick person. 80% of our healthcare dollars are spent when we are very sick. And we don’t know enough about medicine to make medical judgments. (Just as you didn’t know enough to judge whether the hospital was sending you home too early). This is why we have to rely on medical professionals who put the patient’s interest ahead of their own interest. (This is the definition of a professional, particularly in medicine.)
    This is why for-profit companies should not be making decisions or setting priorities for healthcare. I’m reasonably certain that, under reform, many for-profit insurers will not survive. The regulations and requirements– that they spend 85% of premiums on care (for large groups), that they provide comprehensive coverage will no “holes” in the policy, that they cover the sick without gouging them, that they cannot cancel a policy when you become sick–and finally that they must justify premium increases to state regulators– all of this means that only the very best will survive.
    Not all of the non-profits will survive. Many of the Blues are terrible– (when I refer to non-profits, I’m never referring to the Blues.) But the best non-profits will flourish. And since each Exchange must offer at least one non-profit, more non-profit insurers will crop up across the nation. (Maybe we’ll finally get Kaiser Permanente in New York.)
    Ultimately,I think we’ll wind up with a hybrid system much like the systems in all of continental Europe—-with tightly regulated non-profit private sector insurance as well as government insurance (Medicare/Medicaid–and I hope Medicaid will become a federal program and part of Medicare.)
    If the non-profit insurers don’t do a could job, people may begin to call for more government insurance for people under 65–“Medicare for All”– we’ll see.
    I personally would like an alternative to government insurance just in case I don’t respect/trust the people in power in Washignton at some point down the road. I wouldn’t want to be trapped with only one choice.
    Finally, Barry I realize that, from a political point of view, you feel strongly that for-profit companies should be involved. But this non-profit/hybrid system works quite well in much of Europe–it’s not at all clear why it wouldn’t work here.
    Meanwhile, as a for-profit industry, health insurance hasn’t done very well. Low profit margins, lawsuits that insurers lose–and over the past 10 years, they haven’t been as “successful” as Medicare in keeping costs down. (And Medicare has hardly been “successful’–it’s just done better than the private insurers.) Now, under Berwick, Medicare will be given the freedom to do what it nees to do with much less interference from Congress and lobbyists.
    People always say that it comes to innovation, for-profits are better. But in this caes, the non-profits– Kasier, Geisinger, Intermountain, Peugot Sound Co-operative have been on the cutting edge. And, back in the mid 80s, before the for-profit insurers took over the market, there were many more very good non-profit health insurers. (I wrote about this while I was at Barron’s.) I’d like to see some of them come back.

  8. Maggie,
    I think healthcare is one of those fields where anecdotes can be used to make just about any point one wants to make. In the case of the UCLA patient, if she contracted an infection there, maybe that was a potentially preventable event. If so, transparency related to hospital acquired infection rates of all types would be useful information to both patients and referring doctors. It could also drive hospital managements and the doctors who work there to do the root cause analysis that could drive infection rates down. Paul Levy’s leadership at BIDMC in this area shows that it works.
    I don’t know enough about how private insurers or Medicare try to determine after the fact whether or not a readmission was necessary. Medicare might just be inclined to give hospitals the benefit of the doubt and not try to make the judgments because there could be too much subjectivity involved. You keep saying that private insurers’ first responsibility is to shareholders so their incentive is to deny care whenever possible. I keep saying that private insurers can’t please shareholders unless they please customers first. If they don’t, they soon won’t have any customers or shareholders.
    Even though I’m not a believer in anecdotes either, I’ll pass a couple along because they are relevant to this issue. First, when I had my quintuple heart bypass surgery at a NYC teaching hospital in 1999, I spent less than a day in the CICU and a bit over three days in a step-down unit before they were ready to send me home. I complained that I felt like I could use another day to recuperate in the hospital. They said that I would be better off recovering at home because I was at risk for developing an infection if I stayed in the hospital any longer than absolutely necessary. When the car pulled into my driveway, I could barely make it the 30 feet to my front door under my own power. In the end, my recovery went smoothly and the hospital was right to send me home when they did.
    Someone I know recently had a triple bypass at a hospital in another large city. Not long after he was discharged, his blood pressure dropped to a dangerously low level. His family called 911 and he was taken to a nearby hospital but not the one where he had the surgery. They told him, incorrectly as it turned out, that he had pneumonia. He was ultimately taken back to the hospital where he had the surgery where they determined that one of his medications was working “too well” and was adjusted. He also has diabetes and requires kidney dialysis.
    Drug interactions are tricky business. When I left the hospital following my surgery, I had 9 prescriptions to fill which I thought was a bit much. I was told I was getting off easy as some patients go home with as many as 25 prescriptions! Most of them only need to be taken for a few days to a couple of weeks.
    I suspect that this is a highly complex issue encompassing everything from whether hospitals are doing everything they can to minimize infections to the adequacy of discharge planning including ensuring that adequate help is available from family members to arranging for professional caregivers to make home visits to confirming that the patient understands what he or she needs to do and when. It makes sense for private insurers to be willing to spend the money to ensure good discharge planning in order to minimize expensive readmissions. For hospitals, the better job they do on discharge planning, the more revenue they lose from avoided readmissions. Even a shared savings scheme would probably leave them a net loser from a financial standpoint.

  9. Not sure how much this matters outside Medicare. Looking at our population we don’t have many readmissions at all. Those that are I usually prefer the person had been discharged and readmitted then keep them in the hospital for 2 months while they are dieing.
    Cutting the number of hospital infections and follow up to repair botched surgery or retrieve tools we would obviously like to eliminate but I don’t think readmissions is the right tool to measure this or address it.
    Blanket tracking and grading by number of readmissions makes as much sense to me as lowering the reimbursement of all radioology becuase some providers abuse it, your addressing the problem but doing nothing to solve it and most likly creating worse issues.

  10. Maybe the hospitalist and the hospital nurse after:
    a. Not informing the PMD the patient was admitted
    b. Not keeping the PMD up to date on the daily hospital treatment of the patient despite access to all the fancy, expensive HIT that a poor primary doc can’t afford or learn to use
    c. Not informing the PMD about the patients’ discharge
    should just take over primary care of any patient admitted to the hospital. Or do you suggest they just send them back to the PMD after the 30 or 90 day bounce back period has expired with the same lack of informaton that hospitalists have become expert at not providing?
    Exactly who do you think will want to do outpatient care (MD or NP or PA) under these conditions? Another nail in the coffin of the outpatient MD. Thanks Maggie!

  11. Elizabeth–
    Thanks much for your response.
    You write: ” Patient education is a very important aspect of our jobs as nurses, making sure our patients are well educated on their diagnosis and how to prevent any reoccuring problems can also help cut down on readmissions.”
    I totally agree.
    I would add only that hospitals need to give nurses enough time to do this. This is an area where hospital administrators need to re-set priorities–and in some cases–hire more nurses.
    Under reform ,with a major increase in fudning for nursing and nursing education we will have more nurses–but we have to think about how we use them.

  12. Barry–
    I agree that insurers could provide value-added here, and I hope that they will.
    But the danger is that they will simply reward hospitals for not re-admitting, without evaluating whether the readmissions was needed. (Again, by law, a for-profit corporation’s first responsiblity is to its shareholders, not to its customers.)
    Recently I sat next to a well-known doctor at a health care dinner who descirbed how his (well-insured) sister-in-law, who was very ill, couldn’t get re-admitted to UCLA after she had been treated there–and became sicker.
    Because of his position, he was able to go through several layer of the bureaucracy to reach someone who explained: our record with the private insurers isn’t good–we have too many re-admissions. So we’re not going to re-admit our sister-in-law. We’ll be in trouble with the insuers.
    “What can I do” he asked. The person at UCLA recommended another, not terribly good (but not terribly bad) hospital, saying, “their readmission people aren/t that good and aren’t watching the numbers that the insurers watch. They’ll probably let her in”
    (None of this had to do with whether she needed to be re-admitted.)
    Ultimately, his sister-in-law was readmitted to the second hospital, and died there.
    Would timely readmission to UCLA have made the difference? No one knows.
    If she had received better care at UCLA and hadn’t needed re-admission (If memory serves, she picked up an infection at UCLA, but there may have been another reason she needed to go back to the hosital) would she have survived? No one knows.
    Barry, the doctor who told me this story is not a liberal. He is definitely to my right. So this wasn’t about ideology. But this also wasn’t the first time he had seen this.
    Admittedly, it’s only anecdotal evidence. But it is troubling, and suggests that we need govt’ regulation.

  13. Bev M.D.
    Bev — that anoymous PCP’s comment is, as you suggest, discouraging.
    Unfortunately, PCP’s have not done a really good job of following up on patients discharged from hospitals.
    To be fair, this may be because they don’t even know the patient was discharged– the hospital never communicated with them!
    This makes it clear that the ball is in the hospital’s court– to communicate with the PCP about discharge. Then the PCP needs to get back to the hospital about the date it has set for the patient’s follow-up appt., and whether the patient shows up for that appt.
    Unfortunately PCPs often don’t get back to the hospital about the follow-up, or whether the patient showed. (As I’ve explained in earlier posts, PCPS are overworked , and in small practices don’t have the help and health IT they need to stay on top of everything.)
    This is why the hospital nurse or nurse practioners is in an ideal position to act as a bridge. She is in contact with the hospitalist.. She & the hospitalist has access to all of the records about the patient, from the point of admission. The hospital pays the hospital nurse and the hospitalist a salary. Unlike the outside PCP (who is paid fee-for-service), the hosptailist and nurse are paid for the time it takes to contact the PCP, the patient, the family and follow up.
    As Medicare uses financial carrots and sticks, hospitals will give hospitalists and nurses more time to do this very impt. work.

  14. Exhausted M.D.
    Exhausted– I’m happy to say that, for once, I agree with much of what you say– namely that all of these factors lead to readmissions:
    “Premature diagnosis, narrow minded therapeutic interventions, uneducated patients, impatient family, overworked staff, cost focused decision making, complicated medical situations, less than adequate follow up access or home nursing underestimations, or, heaven forbid, sick people who are not going to get better and have learned the behavioral mod to just go back to the hospital for that quick fix, immediate attention, and genuine but mislead notion that the health care system can cure it all.”
    But I am far more hopeful that we can change the system.. Not overnight. My guess is that it will be 10 years after the 2014 roll-out starts (i.e. 2024) before we see substantive restructuring of how care is provided, how we pay for it and what we pay for. I look forward to seeing that.
    I don’t think the current reform plan is a panacea.
    I think it’s a pretty good start given the current politics.
    And people like Don Berwick (Obama’s nominee to head up Medicare) and many others understand in positions of power in DC (Orszag, Zeke Emmanuel, etc. ) know full well just how difficult this will be, and how long it will take. They have few illusions. They too have been working in the trenches–delivering care, and trying to reform the system.
    But they also understand that there is absolutely no point to saying “this can’t be done.” What good would that do?
    You may be personally exhausted– I believe and respect that. But we need to look at the larger society and larger profession as a whole. There are many relatively young doctors, nurses and public health experts who are not exhausted, and who are eager to move forward.
    They are the future.

  15. Hmmm, readmissions, always a delicate topic these days. And what are the common factors? Premature diagnosis, narrow minded therapeutic interventions, uneducated patients, impatient family, overworked staff, cost focused decision making, complicated medical situations, less than adequate follow up access or home nursing underestimations, or, heaven forbid, sick people who are not going to get better and have learned the behavioral mod to just go back to the hospital for that quick fix, immediate attention, and genuine but mislead notion that the health care system can cure it all, if you just get enough.
    Overpopulation, overexpectation, oversimplification, and yet underestimation. Health care is a multifaceted process, yet, let’s be honest, the average patient does not want to hear this, the truth. When people want to start dialogue about what are the real measures to impact on health care for real, positive, effective change, a lot of them are not going to like the answers.
    It’s like looking at the car after the accident. You don’t want to hear it is a total loss. But, you can’t drive it off the lot at the pound! A finite system, filled with people looking and expecting infinite answers. And you expect politicians to be supplying the responsible answers? Wow, this is how far we have decayed? And we look to the Ms Mahars’ for answers and guidance.
    Well, Bruce Hornsby had a nice lyric in a song about 20 years ago: That’s just the way it is, some things will never change; Ah, but don’t you believe them!
    So, readers, who do you believe? Yes, I go by an alias, so that does create doubt, I respect that. But, I have and still work, for now, in the trenches of daily health care interventions, and I tell you this with nothing else but pure truth and honest intent: this health care deform legislation will damage health care for quite a long time, and the people selling this either do not have your best interests at heart, or, their unintended naiveness or foolish hopefulness is preyed on by others who want them to jump on this boat. And it is going to sink.
    But, hey, Ms Mahar has the words and stats to tell you she is right, the system is fair and balanced, and the dissenters have no clue what they are talking about.
    Pay no attention to the man behind the curtain. Right, Ms Mahar? You know, when you picture it, Obama’s face does fit well in place of the Wizard Hologram. But, who has the balls to be the proverbial Dorothy and tell him, “you’re not a nice man!”
    And that is not an attack on Democrats, that is an attack on the system that we stupidly allow to persist!

  16. When Paul Levy’s blog ran a post on this subject a few weeks ago, an anonymous PCP commenter contested the validity of readmissions as a quality indicator and observed:
    “As a PCP, the idea of having a hospital-based nurse call a discharged patient hurts my head. Why not get in touch with me and have my staff handle this?”
    http://runningahospital.blogspot.com/2010/04/lean-update-readmissions.html
    I think the two sides need to get together and decide whose responsibility this really is. Right now, the onus is on the hospital simply because it takes the lumps if a readmission occurs.

  17. On its most recent quarterly earnings conference call, UnitedHealth Group management stated that they were able to reduce hospital inpatient bed days per thousand Medicare Advantage members by 8.3% over the last three years. In a follow-up conversation, I was told that the main reasons for this were better care coordination and more thorough discharge planning. It appears that this is one area where private insurers don’t need to wait for Medicare to provide leadership. Perhaps insurance company case managers are providing some value added here.

  18. I have to agree with Maggie. Hospital readmissions are a very big problem today. The hospitals are too busy trying to get the patients in and out and not give the patient enough time to heal before shipping them out to a nursing home/rehabilitation center or back to their home. Often times these patients get readmitted for the same problem shortly after their discharge which in the long run costs Medicare or the Insurance Company more money. I worked in a Rehabilitation/Long-term care facility for over ten years and often times we send a patient to the hospital and within 24 hours the hospital tries to send them back. I think we need to make sure as hospital staff that these patients are well enough to be discharged so we can cut down on the readmission rates.Patient education is a very important aspect of our jobs as nurses, making sure our patients are well educated on their diagnosis and how to prevent any reoccuring problems can also help cut down on readmissions.

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