Article yesterday in NY Times highlights a NEJM paper that found that almost 20% of Medicare patients are rehospitalized within a month of discharge.
Many Medicare Patients Rehospitalized, Study Finds - NYTimes.com
The paper estimates that rehospitalization costs the system $17 billion and then there's a quote from Dr. Anne-Marie J. Audet of the Commonwealth Fund stating "“Given the current financial situation, this is no longer something we can ignore.”
I'm convinced there's an argument around QUALITY of care, but not convinced that it is a pressing issue for COST CONTAINMENT.
Let's have some fun with maths. Assuming a formal health economy of $2 trillion, readmissions only account for 0.85% of US health care spend. Now let's say I'm being unfair - let's limit to only US inpatient spend of $458 billion in 2006 - that's still only 3.7% of spend. Then one can argue this is a Medicare patient population - and that given their age, one is to expect that a portion of these patients are in their last years of life and will of course need multiple readmissions. So the real question is what is the cost to the system of unnecessary readmissions. Granted, maybe that's what this study did - I need to dig a bit deeper. Regardless the numbers don't work for me to be convinced that there is a pressing cost issue here.
Amy Boutwell, a colleauge of ours and a med school classmate, is quoted by the NY Times in this piece - she now works at the Institute for Healthcare Improvement - let's see if we can get her to comment on the importance of readmissions. Keep a note for comments and hopefully we can get her to post her thoughts!
Subscribe to:
Post Comments (Atom)
Posts
I had a similar thought. The NYT piece says "Readmission rate too high." I don't disagree with this. But saying that it is "too high" implies that there is some right level, and we are above it. What is that right level? Who knows. Some readmissions are appropriate. Some are not preventable. And of course, if we are not readmitting anyone, we are keeping them in the hospital too long. There is an easy way of reducing the number of readmissions: Double the lenghth of stay. If you don't let people out of the hospital until every last detail is solved, they will get readmitted less.
ReplyDeleteI do agree we have barely tapped our ability to prevent readmissions. 20% does seem high. The real question, hard to answer, is what percent of these were really the result of failures of the system - poor discharge planning, lack of follow-up, lack of alternatives to admission, and what percent were patients who were appropriately handled and just got sick. Accounting for this, and Sree's low number get's lower.
Will reducing readmissions signularly save the US healthcare system? of course not.
ReplyDeleteare readmissions a symptom of poor medical decision making? or even of premature discharge? no, actually there is no evidence for that.
readmissions- especially looking at the 30-day readmissions - are prevalent, costly and can be reduced.
the jencks analysis looks at all-cause readmissions - this is a new contribution, as the literature is full of CHF readmissions, which i personally don't put much stock in, as the decision whether i'm admitting someone for CHF flare, hypona, SOB, CAP is highly variable given the realities of patient care and assessments.
all cause readmissions are frequent- about 1 in 5 medicare patients were re-hospitalized within a month of being discharged. is this a medicare problem only? no. all payer data from PA, FL, and peeks at all payer data from where i practice - both the hospital and the state- reveal similar rates- in the 20% range.
so what is the issue? the issue is fragmentation (systems issue), volume-revenue (payment issue), and fragile patients (social medicine issues). all the successful interventions that do *anything* to improve the support that patients get immediately after leaving the hosptial reduce 30 day readmissions by 25%, and some much more so. post-discharge phone calls, patient self management coaching, early post acute follow up (like in 2 days, not maybe in 2 weeks if you can get an appointment) all have been successful in reducing readmissions.
back to the math question.
in a $2T health economy, reducing rehospitalizations will not save medicare. however the jencks article found 30 day readmissions in medicare cost $17B in 2004 alone. a medpac 2007 report found 30 day readmissions cost $15B - pretty close for policymakers. looking at this $15B in readmissions by what is "potentially preventable" (3M PPR methodology) finds 76% of these readmissions were potentially preventable, accounting for >$12B in costs that year.
obama's budget calls for savings from reducing 30 day readmissions of $26B over 10 years. so quick math, that's $2.6B a year. estimates, including mine, find that 30 days readmissions can be reduced in any number of ways by bout 25% realistically, and absent major structural reform. (of course financial implications of this on indivdiual hosptials will require payment reform). so even is we reduced medicare only 30 day rehosptializations, at an annual cost of $17B by 15%, the financial projections in the obama budget would be realized.
to sum up, this is mostly about the "frequent flyers" - think about them. it's the social support, its the health literacy, its the adherence to recommendations, it's about nusing homes not being about to diagnose and treat utis, its about not being able to be seen in the office so they go to the ED for automatic readmit due to practice patterns. readmissions shouldn't be 0, not at all, but physicians know the frequent flyers need something other than another hosptial stay.