Reducing hospital re-admissions and bouncebacks isn’t easy

In their most recent piece at Slate, emergency physicians Zachary F. Meisel and Jesse M. Pines tackle the issue of bouncebacks.  That is, the re-admission of recently discharged hospitalized patients.

They bring up good some good points, and point out that, until recently, hospitals really didn’t have any incentive to reduce bouncebacks:

… hospitals have never had a compelling reason to try to prevent bouncebacks. Hospitals are typically paid a flat sum for each inpatient stay—shorter stays equal higher profits. When patients bounce back, hospitals can charge the insurance company twice for the same patient with the same problem. Many hospitals also view bouncebacks as out of their control: If a patient boomerangs back because she doesn’t follow doctor’s orders, it’s not the hospital’s fault.

With health reform, however, things are changing.  In an effort to reduce bouncebacks, hospitals are paid less for re-admissions, and they must publish their bounceback rates.

But there are problems in the zeal to reduce bouncebacks  First, bad care isn’t necessarily responsible for every case.  A patient’s brittle underlying medical condition, for instance, may be responsible.

And second, steps to reduce re-admissions aren’t all proven to work.  The authors cite a study showing that improved follow-up only minimally affected the bounceback rate.

I agree with the authors that it’s probably in everyone’s best interest to reduce re-admissions.  The question is how to do it.  Increase primary care access?  Improve discharge processes?  Those steps are already taken into account and being continually improved.

One interesting idea is having hospitalists provide the follow-up themselves.  After all, they’re the ones that best know the hospital course.  Some programs have their hospitalists do transition care clinics, improving the bridge between hospital discharge and primary care.

I’m not sure of the outcome data surrounding this practice, but it’s one underpublicized idea that may be worth exploring.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • tex

    The blanket treatment of non payment for any bounceback is shortsited and unfair, only the bottom line cost is considered by Medicare. I agree that some bounce backs cannot be prevented, but how to fix it? The early follow visit with PCP/whomever admitted is a good idea rather than the standard “f/u 2 wks” . Better home health coverage would be helpful in some cases too. But sometimes things can’t be helped such as late CHF or surgical site infection manifesting late. These should clearly be covered or appeal-able with proper documentation rather than blanket denied/reduced. Another example of bureaucrats telling docs/hospitals how to practice medicine; and justifiying utilization review nurses jobs……

  • http://www.epmonthly.com/whitecoat WhiteCoat

    Look for longer waits in the ED as potential bounceback patients are shuttled back and forth to the emergency departments by the big taxi with the red spinning lights.

    Once the bounceback policy is implemented, many more patients will be held/stabilized/sent back to nursing home to avoid being labeled a “bounceback.” See you again tomorrow for your next physician evaluation, a slew of additional lab testing, and a return visit via ambulance to the nursing home – all expenses paid by Medicare.

    Costs will increase, not decrease with this policy. Mark my words.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    As a hospitalist I classify bounce backs into three defined groups.

    1) Patients I never expected to bounce back ( missed diagnosis, failure of medical therapy)
    2) People I expect to bounce back with regular infrequency (moderate lung disease, uncontrolled diabetes, morbid obesity, moderate heart failure, lifestyle abusers)
    3) People I expect to bounce back with regular frequency (end stage organ disease with or without lifestyle abuse)
    There are many factors that determine bounce back rates.

    Some things as physicians we can control. The treatment plan. The medications. The evaluation and management.

    Some things the hospital can control. The discharge process. Systems processes. Medication reconciliation. Education and teaching. Post discharge phone calls.

    Some things the primary care doctor can control. How often they see the patient. When they can schedule them in for follow up after hospital discharge

    Some things the patient can control. Not smoking. Not drinking. Taking their medications as prescribed. Exercising. Going to follow up appointments.

    But there are many things we can’t control. As organs fail, they lose their reserve. When you have end stage heart failure or end stage lung disease or end stage dementia, the bodies natural course is failure. That is not a medical process. That is a higher process. What we do in hospitals is delay the failing process.

    All things being equal, either we are going to have to accept death or we are going to have to accept bounce backs as a cost of living.

    There isn’t a single day in seven years where I have discharged a patient without asking myself, “Is this patient safe for discharge?” That is a medical judgment. That’s what I learned in medical school and residency. Am I going to get it right every time? No, But you can bet it is the single most important question I ask myself on the day of discharge.

    Should hospitalists start their own outpatient follow up clinics? I suppose that could be done. But the question is, do you need a physician to follow up on the patient? I liken that process to my hospitals emergency response team which consists of ICU nurses and respiratory therapists.

    I’m not convinced using a hospitalist in a post hospitalization follow up is cost effective use of limited physician resources. Remember, hospital bounce back rates are in the order of under 5%. Do we need to pay a physician’s wage and salary to make routine follow up visits on 100% of patients when presumably 95-98%% of them are stable from hospital discharge.

    I do agree that post hospital follow up could reduce the readmission rate even further. And the bundling of hospital payment and aligning physician payment with that process will certainly drive the hospital follow up process.

    I just think that RNs can fill this void well and consult with physicians when they see red flags.

    I would gladly do a post hospital discharge follow up on patients I took care of. I just don’t think it’s cost effective.

    • jsmith

      Kevin, the Happy Hospitalist nailed this post. Words of wisdom indeed . Please send his post to the our political decision makers or to those in the media that you know.
      Happy, maybe you could reconfigure this t post as an editorial. Maybe Kevin can help it get the attention it deserves.

  • Dr. J

    This is just the latest step in the attrition of most medical specialties from acute care. It’s happening in the emergency room everyday, we’re expanding what we do to cope with what others no longer do. Hospitalists are taking on more and more complex patients, and vastly expanded roles. Soon the hospital will be abandoned to the emerg docs, the hospitalists and the critical care specialists, and a few surgeons with most other specialties offering limited daytime consultation services.
    We keep trying to figure how to be everything to everyone, but try as we might it won’t work. Return emerg visits or out-patient hospitalist clinics are not primary care, nor should we be…

    • jsmith

      Sad but true. The troops are fleeing the field. If primary care’s tailspin is not reversed, things will get a lot worse at the hospital.

  • Marc Gorayeb, MD

    Obama and his politico-technocratic ideologues aren’t going to cut $500 billion from Medicare by reducing services. Not at all; they’re going to eliminate “waste, fraud and abuse” and reduce readmissions, don’t ya know.

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