Hospital re-admissions are hitting Medicare patients particularly hard.
Otherwise known as “bouncebacks,” MedPage Today reports on a recent NEJM study showing that, during a 15-month period, 20 percent of hospitalized Medicare patients were re-admitted with 30 days of discharge.
When you consider how few outpatient doctors accept Medicare, compounded by the appointment shortage that many primary care physicians face, it’s no wonder that these elderly patients who are discharged from the hospital rarely have appropriate followup.
As the author of the study wryly notes, “It’s pretty clear that simply giving patients a phone number to call for a follow-up appointment is not enough.”
Two solutions proposed use the stick approach, namely, financial penalties for high re-admission rates, and publicizing those numbers to the public.
Of course, that really circumvents the real issue, which is the lack of primary care doctors who take new Medicare patients, and of those that do, the need to improve their appointment availability.
Similar Posts:
- 9 patients, 2,678 ED visits, $3 million dollars
- Pending lab tests are not in hospitalist discharge summaries
- How soon should patients receive their test results?
{ 11 comments }
Kevin,
Thanks for sharing this article. In the process of health reform, this is going to be a big topic. It rears its ugly head with Medicare and Medicaid but it is a problem across the board with both the insured and uninsured.
When health plans and CMS start reimbursing and recommending docs based on quality including readmission rates for same initial diagnosis, I think we will see some change of philosophy about how much we focus on compliance and appropriate follow-up. Sure there is patient responsibility, but the structure has to be in a place where patients understand their role at a more granular level.
Also, health plans have to change their reimbursement guidelines so that clinicians can spend the time they need with patients to produce long-term health outcomes that don’t result in readmission or exacerbated morbidity.
How many of these patients were readmitted within a few days – or, in the case of my 80-year-old father – within a few hours after being discharged?
I think it’s important to recognize that some readmissions are simply due to sending patients home too early, or sending patients home who then develop complications related to their hospital stay. (In my dad’s case, a hospital-acquired infection.)
My aging relative was hospitalized about once a year in the last years of her life.
She was in a nursing home so follow-on care was provided.
How many of these folks are going home and are almost bed-ridden to the point where getting them to a doctor for follow-up is a major production for their family or similarly aging spouse?
Perhaps home visits would help?
That or physicians might stop seeing people that have a higher chance of a bounce back.
Hey doc. I posted about this several days ago. I’m actually surprised the numbers aren’t higher. The fact that just over 50% of patients were admitted in the next year was shocking. I would suspect that number is closer to 100%. I suspect the other 50% don’t get readmitted because they have died.
Many people get readmitted because they should be in hospice or have a Do Not Transfer To Hospital status. We have a lot of irrational medicine going on behind those hospital walls. FREE=MORE medicine that does nothing to change outcomes. Only delaying the inevitable.
I refer to them as the
Medicare #2 Population
Also remember, that many admission are done out of legal reasons, not medical. Fear of that 1/100,000 chance of a bad outcome. It’s just easier to admit them to watch them then to send them home and hope everything goes OK.
Blaming money makes us sound mercenary and blaming paperwork makes us sound lazy. IMO the bottom line is that there are too many aged patients with too many complicated medical problems with too little “in home” resources and too few of us in primary care to handle the demand.
This is a classic example of a study which is only meaningful with further analysis or with a comparison group. Were the re-admissions felt to be due to too early of a discharge? How does this group compare to a group with other insurance? Did the availability of primary care (say, by region) affect the results? How do we know what the number ’should’ be? As others have pointed out, many of these people are very ill, so their having another reason to come into the hospital is not all that surprising. Was it for the same problem as the original admission, for example?
All of these questions are relevant, and I believe, necessary, in order to come to some sort of oonclusion about the matter.
I’m the one who posted above about my dad. For the record, he is not frail nor does he have a bazillion chronic conditions. In fact this was only the second time in his entire life that he’s ever been in the hospital. He responded very well to the IV antibiotics and he’s back at home and doing extremely well – in fact better than a lot of people 20 years younger than him.
My point is that not all readmissions are created equal. Not all Medicare patients are doddering on their last legs. Sometimes they develop unavoidable complications, and sometimes they just don’t get the best of care. My dad might have been spared some of his ordeal if it hadn’t been for an inexperienced idiot PA at his doctor’s office. She didn’t recognize he was getting in trouble, she wasn’t aggressive in doing something sooner, and it was pretty clear that vital facts were not being reported to the doctor. So the seeds for this readmission were probably sown way upstream, before my dad even entered the hospital.
I’m in my last 6 days as a primary care internist. Let me give you two examples from today alone.
1)65yom with new cholangiocarcinoma. Discharged from an unaffiliated hospital with no records. He has end stage inoperable heart disease with EF 15%, insulin dependent DM, large stage 3 sacral pressure ulcer from said hospital stay and is unable to stand independently, blindness, obesity and COPD. He “bounced back” in three weeks. Is this shocking?
2)65yom with alcoholism, cirrhosis, oxygen dependent COPD, DM2, heart disease now with portal vein thrombosis and superior mesenteric vein thrombosis. Unaffiliated hospital discharges him on coumadin with follow up within 24 hours in our office. He refused to come in to see us for 10days until he got drunk, he fell down, he had a head injury and he stumbled into our office. He was seen as walk in and had an unreadably high INR (machine goes to 10 only). Shocking bounce back anyone?
Are we supposed to take these people into our homes? Both had visting nursing – one refused to let them in. The same gentleman refused rehab. There is only so much a primary doctor can do for some people.
Kevin, I don’t know if you see hospital patients or if you go to the nursing home. I suspect not, although I may be wrong. Do you provide house call ? If not, why not ? Isn’t the big MSG you belong to, the way to go ?
These patients (most of them) are very debilitated, like Happy Hospitalist writes. These people have MRSA, ESBL organisms, multiple lines, tubes, dementia, low albumin, anemia, pressure sores. There is no way to treat all these problems, no point in treating them. They get readmitted because they die, pure and simple. There are exceptions but not many.
I think that as a society we need to rethink where we draw the line… and who is ultimately responsible for caring for the patient – the hospital, government or the family in the long run. The elderly folks who are seldom able to function independently keep getting re-admitted. I’m sure that if we were to look back at why people are getting re-admitted it’s probably because no body is available to care for them adequately after discharge. There is only so much a pcp, hospitalist, visiting nurse or a SNF can do!
Comments on this entry are closed.