Is it really fair to penalize hospitals for readmissions?

As new Medicare rules kick in, some 2,200 hospitals nationwide are facing financial penalties for high 30-day readmission rates for myocardial infarction, congestive heart failure and pneumonia. Medicare payments will be lowered by as much as 1%.

Investigators at the Skeptical Scalpel Institute for Evidence-Based Outcomes and Advanced Research (SSIEBOAR, catchy acronym, don’t you think?) have come up with a plan that is certain to lower readmission rates across the board. Some have said the idea should be patented but the institute is not-for-profit and thus is willing to share.

The solution is quite simple—let the patients die. Yes, death reduces readmission rates for all diseases, not just MI, CHF and pneumonia.

Oh, there may be some resistance and relatives of the patients may complain, but at least Medicare will be satisfied and after all, isn’t that why we became doctors?

Another outcome measure, hospital length of stay is also positively impacted by death. For example, if the average length of stay for a patient with a heart attack is 4 days, a patient who dies on hospital day #2 would lower the hospital’s average. Death also results in fewer resources being utilized, which saves the hospital money for those patients whose reimbursement is based on the DRG.

I confess. I’m not serious, and the idea is not original.

There are many issues. In most cases, as length of stay is ratcheted down, readmission rates will rise. One way to reduce readmissions is to keep patients in the hospital longer. And what about the things the hospitals and doctors can’t control? A recent studyfound that only 63% of Medicaid patients with diabetes, hypertension and hypercholesterolemia actually took their medications regularly.

So what is the solution?

Assessing quality of care in hospitals is a difficult task. People like me have complained about focusing on processes such as the Surgical Care Improvement Project because adherence to process measures does not always correlate with good outcomes. However, processes are much easier to track than outcomes.

The problem with outcome measures is that experts can’t agree on which ones to measure. Even something as seemingly straightforward as death can actually be complex. A 2010 paper in the British Medical Journal on this subject was reviewed in a blog, which pointed out the difficulties with death as a benchmark. This holds true even when death is adjusted for risk.

Readmission rates are also controlled by physicians, not hospitals. Even concurrent review of readmissions by hospital utilization staffs has not been effective in reducing these numbers.

There is another factor. Here’s an anecdote that might help you understand the problem. An elderly woman was admitted for congestive heart failure. After a few days of intense medical care, she was discharged. She was readmitted for CHF three days later. When interviewed during her history and physical exam, she admitted that she 1) did not take any of her prescribed medications at home, 2) continued to smoke cigarettes and 3) did not follow her cardiac diet.

Is it really fair to penalize hospitals for readmissions, many of which cannot be prevented?

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • HealthMessaging

    It would be interesting to know the following about the woman you described at the end of your post: 1) if the medications she was prescribed in the hospital were new and if so did she understand why she needed to take them, how and when to taken the medication and whether she could able to get the prescription filled and was able to afford the new medication? 2) what efforts were made to help her stop smoking (did her doctor ever tell her to stop smoking)? and 3) how onerous was the cardiac diet and what were the barriers to her following the diet? 4) what was the patient’s support network like when the patient was discharged?

    In today’s overworked hospitals and physician offices, way too much is taken for granted when it comes to the patient’s motivations, knowledge or abilities to understand and comply with what they may or may not have been told by the hospitalist or discharge team. To make matter worse, discharge instructions are given the patient the last day of their hospital stay just before they are going home.

    My point is that the process is broken – patients, doctors and hospital discharge planners all share in the blame if we need to go there. Rather, it seems we would all be better served by fixing what’s wrong. Wouldn’t you agree? Financial incentives (or disincentives) work in many cases. One has to wonder if we even be having this discussion if hospitals weren’t being financially penalized for not doing a better job. By the way – now that 100% of hospitalists and 50% of primary care/specialists physicians are employed by hospitals – hospitals do bear responsibility for how their employees practice medicine. Wouldn’t you agree?

    If you want to fix things…start by improving the way doctors and patients talk with and interact with one another.

    Steve Wilkins, MPH
    Mind the Gap

  • disqus_9lY9qa7kF1

    I completely agree with you, but I’ll give you a more egregious example than the one you ended with. We’ve had patient’s at our hospital treated for MI/CHF, discharged and then readmitted for broken bones due to falls within the 30 period that were totally unrelated to the original admission. Guess what? The hospital doesn’t get paid for that because Medicare is not run by doctors, but by bureaucrats that know nothing about medicine. So, we lose out on money due to no fault of our own. Great rules guys…Thanks for nothing!

  • Dike Drummond MD

    To add a little balance here … there are also multiple studies showing decreased readmission rates with hospital based programs that reach out to patients in the immediate post-discharge period with either phone calls and/or home visits by non-physicians. These programs would not exist without this measurement of readmission rates and they are improving people’s lives in the post discharge period.

    These people do the mind numbingly simple things like
    - Reinforce the messages of discharge like take your meds and don’t smoke
    - Make sure the patient is able to pay the rent and the heat is on
    - Bring in additional services when needed
    - Make sure they have a ride to the follow up visit
    - Check for early signs of disease recurrence – like weight gain in CHF – and take early action before the scheduled follow up visit

    Traditionally a hospital discharge is very much like abandoning the patient after a period of intense treatment and hoping they survive until their recheck in 2 weeks. These services fill in the gaps and create a real continuum of care and they are working.

    Dike Drummond MD

  • Skeptical Scalpel

    Thanks for the comments. There is a recent study that showed that patients who were called frequently actually were readmitted more often.

    The story about the patient readmitted with fractures is classic.

    I don’t have any of the details of my anecdote but I know the MD involved. He is very good with discharge planning and preventive care. It’s not always the doctor’s fault.

  • Senior Housing Forum

    It is clear that physicians are a big part of the problem and yet they seem to get a free pass in these discussions.

  • southerndoc1

    You expect every SNF to have an in-house MD 24/7? Yeah, that makes sense.

    • PcpMD

      That’s not what’s most frustrating part. He wants this without having to actually pay for it. To actually pay for 247/7/365 in-house physician coverage at each nursing home in the united states would be … a little spendy. Then there’s that whole pesky thing about a national physician shortage (though I suppose if the doctors never went home, and never had dinner, and never had a family, they could probably make due…)

      • Margalit Gur-Arie

        They can pay for it and they most likely will. They will not pay for an in-house physician in the classic meaning of the term, but they will eventually pay for remote tele-medicine services, initially provided by some for-profit entrepreneurial venture employing on-call local docs (retired or part time), and then off-shore docs for night coverage (initially US board certified) and as the financial crisis gets worse, any off-shore docs working for a fraction of what the local docs expect, and before you know it, you will have cut off of the limb you’re sitting on.

        I really don’t understand why the medical profession is insisting on shooting itself in the foot and in the process devolving medical care in this country to a more “global” standard.

        • Skeptical Scalpel

          Interesting point of view. You may be right. But how long will it take and who will pay for it even at outsourced rates?

          • Margalit Gur-Arie

            Considering that Medicare/Medicaid is rather slow to move, I would assume that it may take a while, but it is rather inevitable. If you look at all the second rate services proliferating out there, from retail clinics to tele-docs for consumers, and radiology readings or ICU remote services and even hospitalists, all of which are basically taking away business from locally established physicians, first to compensate for “shortages” and then to replace more expensive delivery models and eventually to render those obsolete, then I think the writing is on the wall.

            If any of these things can save Medicare and Medicaid and private payers money, they will eventually be adopted and paid for. Unless practicing physicians can figure out a way to retake control of medicine, this technology enabled for-profit race to the bottom will be hurting many people, doctors included.
            To go back to the nursing home subject, why can’t a bunch of internal medicine practices that are already seeing some patients in these facilities, get together and create an on-call program shared by all physicians to care for these patients? Why not pitch it to the State Medicaid plans and see if they’ll be willing to share the savings back? I bet they will….

          • Skeptical Scalpel

            You pose intriguing questions. I take issue with one of your comments though. I can’t speak for some of the “second rate” things you mentioned. But my experience over the last 4 years with outsourced radiology readings from 8 pm to 8 am has been very positive. The readings are usually quite accurate and although it is a bit of a chore, one can discuss findings with them by phone.

          • Margalit Gur-Arie

            My apologies for overly sweeping statements. It is possible that some of these things will end up being just fine, or are already good enough. My concern is the overall trend though. I guess time as always will tell….

  • Skeptical Scalpel

    Andrew, that is an excellent point. I think you have captured the essence of why these types of policies exist.

  • Edwin Leap

    Our hospitalists are endlessly pressured to 1) avoid admissions and 2) discharge as quickly as possible. Then, when they finally admit, stabilize and discharge, and the patients return, there’s a penalty. Of course, many patients in our area are simply non-compliant. They smoke, don’t take their meds or manage their own diets. It’s a game, my colleagues. A shell-game to avoid payment and prop up a failing system. Blame the doctor, blame the hospital. As we move closer to a single payer system, remember that it means a single customer. And we’ll have to do everything to make that single customer happy. It isn’t going to get better. Brace yourselves.

  • Edward Leigh, MA

    Re-admissions is a very complicated topic, however, in studying the interaction of healthcare professionals & patients, I do find issues can improved via excellent communication skills. For example, the readmitted patient with CHF. She did not take her meds — how well were they explained to her? Her caregiver? She continued to smoke cigarettes — did the professionals simply tell her, “Smoking is bad for you. Don’t smoke.” Was she provided info about smoking cessation programs? Was empathy incorporated into the discussion? (Keep in mind, people often act based on emotion, not necessarily information.) Lastly, her diet — was the diet explained well or was she simply given a diet & told to “follow this.” In working with hospitals, I find the education component is often dramatically weak. I am concerned this patient was simply told, “Take these meds, stop smoking & follow this diet. Any questions?” Professionals often say to me, “I don’t have time to explain things.” Think about how much time it takes to deal with a patient re-admitted because they didn’t “get it” the first time.

    • Skeptical Scalpel

      As I mentioned in another comment, I know the MD who took care of the patient in the anecdote from my blog post. He is very thorough about discharge instructions and taking time to explain things to patients.

      I don’t understand why non-physicians don’t believe us when we talk about non-compliant patients. Trust me, they exist in abundance.

      Also, read the comment by Edwin Leap posted 6 hours ago.

  • wahyman

    Anecdotes are not science.
    And hospital discharge instructions can be incomprehensible to patients.
    The question is: Do you actually care what happens to them?
    PS. Upon readmission (everyone starts getting paid again. Could this have anything to do with it?

    • Skeptical Scalpel

      1. I don’t see any science in your comment.
      2. One paragraph in my blog post is an anecdote.
      3. Every hospital that I know of gives patients written discharge instructions. It’s a Joint Commission requirement. Most doctors go over the written document with the patient and family if necessary.
      4. Yes, we care.

      5. For your information, there is no economic benefit for a surgeon if a patient is readmitted within 90 days of surgery for nearly all operations. Our fees are “bundled.” That is, the fee we receive includes 90 days of postop care whether we see the patient once or 89 times during the 90 days.

      • wahyman

        I was not purporting to be scientific, its a comment.
        They get written instructions, but often illegible, unexplained and not understood.
        And after 90 days? Or for other procedures? and the hospital?.

        • Skeptical Scalpel

          You say the instructions are “often illegible, unexplained and not understood.” Upon what data are you basing that statement?

          The 90 day bundle is procedure-specific for the surgeon. In other words, for a readmission related to the original operation, the surgeon would not be paid. After 90 days, any new encounter would be billable.

          Medicare is withholding payment to hospitals on readmissions within 30 days. After 30 days, hospitals will be paid.

          • wahyman

            As befits a comment, my statement is based on personal experience and confirmed by conversations with others, including patient advocates and hospital personnel via the patient safety listserve of the NPSF. What evidence is there to the contrary beyond your personal experience?

  • Edward Leigh, MA

    Hello: I don’t want to imply that physicians or any other type of healthcare professionals are always doing a weak job of educating patients at discharge. Even with the greatest education, some patients will just be non-compliant. However, I do believe there is a group of patients if provided appropriate discharge education will follow through.

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