Out of the Box Thinking on Avoiding Hospital Readmissions. Stop Trying

As a cardiac electrophysiologist, I’m pretty far removed from public policy.  But I have to admit that I was interested in the latest move by CMS to cut their Medicare payment rates to hospitals by invoking pay cuts for hospital readmissions.  The Chicago Tribune‘s article is enlightening and filled with some interesting anecdotes after the first round of pay cuts were implemented:

(1) The vast majority of Illinois hospitals were penalized (112 of 128)

(2)  Heart failure, heart attack, and pneumonia patients were targeted first because they are viewed as “obvious.”

(3) “A lot of places have put a lot of work and not seen improvement,” said Dr. Kenneth Sands, senior vice president for quality at Beth Israel.

(4) Even the nation’s #1 Best Hospital (according to US News and World Report) lost out.

So what’s a hospital to do?

I have a suggestion based on other observations in regard to government-imposed pay-for-performance measures that have cost hospitals and clinics across the land untold billions to implement and still have failed to demonstrate even a break-even financial proposition for hospitals.

Stop trying.

From the looks of things, Medicare’s going to cut even the finest hospital’s pay.  Everyone will suffer, just some more immediately than others, but woe to the hospital that works to understand why.  This is not the intent of this measure.  The intent of this measure is to cut payments.

Therefore, if we do not commit excessive funds to this endeavor and instead work to support the people on the front lines as they do their job, cost savings will more likely be realized than if 500 more administrators and nurse coordinators are put on the job.  Like putting cash under your mattress in a down market, they’ll be way ahead.

Hiring more people is expensive because of their salaries and benefits.  Writing programs to do this is also expensive.  All kinds of people are expensive because of the training they require for new government initiatives like Pay for Performance (which has NOT been shown to affect outcomes by the way) and avoidance of hospital readmissions (little proof of sustainable goals can be achieved, a la quote #3 above).

So just help the professional people you already have do their jobs caring for patients to the best of their ability.  Make this the mantra rather than new unproven approaches.

Call me silly, but my bet is that hospitals would do WAY better off financially in the long run if they stopped trying so hard to follow unproven legislative initiatives.

Westby G. Fisher, MD, (aka Dr. Wes) is a board certified internist, cardiologist and cardiac electrophysiologist practicing at NorthShore University HealthSystem in Evanston, IL. He is also a Clinical Associate Professor of Medicine at the University of Chicago’s Pritzker School of Medicine. He blogs at Dr.Wes, where this post originally appeared.

16 replies »

  1. Let’s make physicians a deal: You stop worrying about preventing readmissions and other unnecessary care that may or may not be in your control to fix, we make you salaried and at a compensation that matches that of doctors in all the other industrialized countries in the world, i.e. 3 times median nation income instead of 5 times median national income.

    What? You don’t like that deal? Shocking.

  2. I don’t think Dr. Wes is suggesting that we PAUSE. I will certainly let him chime in here, but I think he is serious that we STOP the irrational jumping through whatever hoops the politicians and bureaucrats come up with. It is an overdue approach. We have been jumping though hoops for decades now and this needs to be a rallying cry.

    The idea that MOST hospitals are being penalized on the basis of some fabricated measure is an outrage.

  3. Pausing means what Dr. Wes is suggesting here. Just stop this juggernaut of insane administrative complexity in layer after layer of measuring and reporting all sorts of things to all sorts of places, just because we can.

    Washing hands and respectfully treating others and simple checklists for initiating procedures have nothing to do with the crazed measurement and punishment movement aimed solely at saving a couple of bucks in a sad zero sum game.

  4. Margalit, I couldn’t agree more. But I think we can do both. From my experience working in hospital settings, it is possible for all kinds of clinicians to have tunnel vision. Especially with complex care, it’s hard to say what could prevent or what could best treat certain hospital-acquired conditions. Just as airplane pilots weren’t the ones who figured out that their hierarchical approach to communicating resulted in plane crashes, but changing that has saved countless lives. I don’t know what pausing means, but I’m all in favor of listening to a lot of voices – physicians and others as well. Patients especially.

  5. Maggie Mahar,

    No one can overlook the fact (see link below) that most of the unnecessary costs in America’s healthcare system aren’t being generated at the bedside level, but instead they are being generated behind the scenes at the administrative level, which is taking on more and more characteristics of a bloated, broken bureaucracy.

    One of main reasons why the burden of bureaucracy is bearing down on our healthcare system is because health insurers, private as well as public, have recently made the decision not to reimburse hospitals if they score too low on so-called “quality standards,” or if either their doctors or nurses fail to document the most minor or, in my view, the most irrelevant details about their patients. Insurers couldn’t care less if doctors and nurses properly diagnose and treat patients, thus improving their outcome and reducing their hospital stay, they ONLY care about finding excuses not to reimburse doctors and nurses for the care they give to their patients.

    So as healthcare insurers hire more chart auditors (i.e. “care utilization managers”), who are very costly BTW, (their salary is roughly 20 to 30% higher than it is for a highly experienced critical/acute-care nurse), to comb through charts looking for shortfalls in quality standards, as well as charting errors and omissions, healthcare providers must respond by hiring more chart auditors (i.e. “care utilization managers”), who are just as costly as the ones being hired by insurers, to detect shortfalls in quality standards, as well as charting error and omissions, and see to it that these things are fixed or corrected. Otherwise, healthcare providers are at substantial risk of not being reimbursed by insurers. This escalating battle — I like to refer to it as an “arms race” — between providers and insurers must be put to a stop before administrative costs (i.e. wasteful red tape) outstrip the cost of providing actual care for patients!


  6. Sandra,
    I am not suggesting that washing hands and reducing infections is a bad thing. I am not even suggesting that “quality” measures are a bad thing.
    All I want to see happen is that we just pause briefly and listen to those who are actually practicing medicine. See if they have something useful to say about the practice of medicine…. Or are we all so certain that we know better?

  7. Let’s make sure we’re talking about the same thing. Yes, it’s hard to say how quality measures that really indicate how well the patient takes care of themselves (diabetes, blood pressure, weight, cancer screening, etc.). But isn’t it a good idea to get people to wash their hands in the hospital? And measure and try to reduce hospital-acquired infections? Many practices in hospitals have changed for the better, and many of them have happened through proceduralizing and enforcing best practices. I hope those efforts are not going to be thrown out because we don’t think monitoring/managing quality pays off.

  8. “Stop trying”

    This is the best advice I have ever read on this blog. The only problem is that it would be precedent setting. After all – how many “unproven” politically derived bad ideas do doctors and hospitals l have to go along with before they draw a line in the sand. The answer is an infinite number. Politicians and the policy experts that they employ can supply an endless list of bad ideas. And I agree completely that this is pure cost control. Nobody can legitimately compare one physician or hospital to another. This idea about hospital readmissions was designed by somebody who had no clue about longitudinal data analysis. The Dartmouth Atlas – really?

    In the meantime – let’s get some representation – Dr. Wes for President of the AMA.

  9. Cynthia–

    Under reform legislation, Medicare Is making across- the-board cut to
    all hospitals.

    Each year for the next ten years, their inflation adjustments will be cut by
    1%. (In other words, if inflation in that year is 3%, Medicare’s payments to hospitals will rise by just 2%.) See http://www.healthbeatblog.com/2011/05/the-medicare-crisis-a-shaggy-wolf-story/

    1% may not sound like much, but as anyone who is good at saving knows, if you save 1% a year over a period of years, those savings are compounded.

    Over 10 years, the Congressoinal Budget Office says that saving 1% a year will reduce Medicare spending by some $196 billion. http://www.healthbeatblog.com/2011/05/the-medicare-crisis-a-shaggy-wolf-story/

  10. The problem with hospitals isn’t that they are providing low quality care — something that the architects of ObamaCare wrongly assume. The problem with hospitals is that they are generating way too much unnecessarily costs. And most of these unnecessarily costs aren’t being generated at the patient care level, they are instead being generated behind the scenes at the administrative level. This is largely why hospitals have become way too top heavy, and why administrative costs are starting to outstrip the cost of providing care.

    So it would make more sense, at least to me it would, for Medicare and Medicaid, as mandated through ObamaCare, to simply make across-the-board reimbursement cuts to hospitals, instead of cutting reimbursements to hospitals whenever their quality indicators fall below a certain level. (By the way, most of these so-called “quality indicators,” such as patient satisfaction scores and readmission rates, have little, if anything, to do to improving patient outcome or reducing hospital stay.)

    Basing reimbursement on quality indicators is not only causing hospitals to find more creative ways, thus more wasteful ways, to game the system, but it is also causing hospitals and insurers to waste a lot of precious healthcare dollars on hiring an outrageous number of people, most who are overpaid and over-benefited RNs, to track and monitor these indicators. Thanks to ObamaCare, Medicare and Medicaid are taking a system that’s already riddled with unnecessary costs and making it even more riddled with unnecessary costs.

  11. Sandra says it all.

    And, in fact, many hospitals are making progress in this area. At New York City’s Mt. Sinai, former CBO director Peter Orszag (who is on the board there) tells me that they have been already begun to reduce readmissions. The administration and doctors at Mt. Sinai believe that this is an important. way to lift the quality of care.

    Also, see IHI.org.

    Finally, U.S. New & World Report is hardly a authoritative source as to which are the world’s “finest hospitals.”

    As much research shows, “brand-name” hospitals often offer high quality care (Mayo, etc.) –but not always. (see http://www.Dartmouthatlas.org.)

  12. “hospitals would do WAY better off financially in the long run if they stopped trying so hard to follow unproven legislative initiatives”

    So would practicing physicians.

  13. “Call me silly, but my bet is that hospitals would do WAY better off financially in the long run if they stopped trying so hard to follow unproven legislative initiatives.”

    No, I call you realistic and fair to call it what it is. And as I have written here over and over, the loudest and repetitive proponents haven’t spent one moment as a clinician and yet write voluminous commentary how we doing the work have no idea how to do it.

    Personally, I think most legislators either despise doctors, or are just so clueless on how to deal with medical matters that unfortunately do have to involve government input that they use the hammer as the only tool at their disposal. And some do both, hate and pound away. And conversely, doctors really do not make good politicians because most of us care and live in the gray world that care is, not the stark black and white of politics, especially these past 15 or so years. We can’t negotiate nor try to write laws that take into consideration exceptions and how to account for them, not with this one party crowd of Republocrats.

    And the gray, I think, somewhat terrorizes these entrenched cretins who are the leaders of their parties. Narcissism and Antisocial traits cannot be negotiated with, because, they are the picture of the definitions of rigid and inflexible. Not the traits you want in a doctor, hmmm?

  14. Maybe the incentives are in the wrong place. Hospitals don’t have much control over what happens outside the hospital, and that’s where problems occur that cause readmissions. There’s really a lot known about this subject; there’s just really not much yet done to connect the dots. An example told to me: A patient is discharged after a complicated admission who did not have a physician before admission because he was healthy. He’s referred to home care and given an appointment in one week with a new primary care physician. The home care nurse notices a serious issue within that first week; the hospitalist won’t take a call because he’s no longer in the hospital; the new primary care won’t because he hasn’t yet been seen – the only option is to return to the hospital. These types of situations arise more often than people realize, but hospitals have been slow (and maybe not able) to figure this out. Another admission is usually not the best answer – for many reasons I’m sure you know about. Maybe if physicians would make sure that patients had adequate plans at discharge and made sure there was someone that followed up on a timely basis? With discharges happening so quickly, patients are not always in a position to resume their own care. Perhaps hospital stays are just too short? They are, on average, longer in other parts of the world where healthcare costs are lower.