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Wednesday, May 15, 2013

Hospital readmissions: What exactly is the deal with this?

Medicare has been costing the government a scary amount of money for many years, and the very popular program, established in 1965 under President Lyndon Johnson to pay for health care for seniors, has undergone many changes since its inception. Because the government funded program was a very deep pocket from which the sick could pay hospitals and doctors, it influenced the cost of medicine and the volume of health care in a pretty profound way.

In 1983, Medicare began to pay hospitals for care of patients in a way that was felt to be likely to reduce unnecessary and expensive care. This was the Inpatient Prospective Payment System, the IPPS. Instead of paying a hospital for everything that was done to a particular patient, which would potentially encourage higher costs and higher utilization of services, Medicare began to pay hospitals a certain amount for each kind of sickness. These categories of sickness were called Diagnostic Related Groups (DRGs). If a patient had a particularly bad pneumonia, the hospital would get a certain amount of money, encouraging them to treat the patient as quickly and cheaply as possible. Doctors were still paid according to how much they did, but hospitals received a bundled payment for stuff such as bags of IV fluid and antibiotics and CT scans. Many hospitals closed, and the ones that survived learned to discharge patients earlier, use less expensive resources, use the DRGs that paid the most (as much as they could without defrauding the government) and also shifted some of the costs to patients who were insured by private companies.

There was concern that hospitals could game the system by discharging a patient, potentially too early for the patient to really make it at home, and then readmit the patient to the hospital and get paid again. And, indeed, that does happen. As physicians we were (and are) strongly encouraged to get our patients out of the hospital at the first reasonable moment, and the constant nagging and puppy eyes of the discharge planners would often make us send patients home before we felt it was wise to do so.

In 2011, Medicare announced that it would pay hospitals less for taking care of patients if records showed that the hospitals had too many readmissions of Medicare insured patients within 30 days of discharge. This is really quite a random number, based loosely on how long it takes the moon to orbit the earth (actually 27.3 days.) It was thought that, if a patient came into a hospital, got fixed up properly and was discharged, that patient should stay well for slightly longer than it takes the moon to go around the earth. So if that patient came back to the hospital before the moon made it entirely around the earth, it was likely that some mistake or carelessness had been committed. Equally randomly, it seems to me, they decided to look at just three diagnoses, heart failure, myocardial infarction and pneumonia, to start with.

I'm all for punishing hospitals for convincing me to discharge patients early against my better judgment, but that is not what is happening, in my recent experience.

I have taken care of several patients, readmitted before 30 days had passed, in the last few weeks. Their stories are varied, but don't really represent poor care. The Journal of the American Medical Association has occasionally visited the concept of hospital readmissions, and some of the articles are excellent, exploring the idea that readmissions don't necessarily represent dangerous care and that they are indicative of a population of patients who don't have adequate access to good medical care outside of the hospital (look at this article for a good discussion, though you only get the first page because JAMA is proprietary.)

So I'd like to look at some of the examples to see if there is a pattern.

1. 50-year-old man with alcoholic cirrhosis who lives on the street and has just recently been diagnosed. He has no insurance and no regular doctor, and though we give him an appointment to see a doctor after each discharge, he never makes it to these appointments, sometimes because he gets sick with massive ascites before he can get there.

2. 88-year-old woman, discharged after a long battle with pneumonia to her home and pets, returns to the hospital weak and short of breath. She appears to have worsening chronic lung disease on further evaluation and be too weak to return home. It was still worth a try!

3. 29-year-old woman, uninsured and with very bad luck and two forms of cancer, discharged to assisted living, returns in a day, short of breath and anxious. She has been too anxious to actually take her anxiety medications, and hasn't yet seen her oncologist back for treatment of both cancers which are still quite active.

4. 60-year-old man with dialysis-dependent kidney disease who was very grouchy and obstructive in the hospital, returns after a day in a nursing home because he is grouchy and obstructive.

5. 87-year-old woman with end-stage kidney disease, also on dialysis, has been in the hospital approximately once per lunar orbit for 18 months for problems such as pneumonia and urinary tract infection, admitted with shortness of breath and a large collection of fluid in both lungs.

I'm thinking that a really great and very motivated outpatient doctor who goes the distance and visits patients in their homes and treats patients for free and lets the homeless ones crash on her couch could have averted all of these readmissions. I'm also thinking that this particular doctor is not just a dying breed but virtually nonexistent.

In the absence of this doctor of whom legends are written and ballads are sung, a good hospital will continue to be a (very expensive) refuge. The costs to those patients who have no insurance in this group are huge, but they have no resources and will never pay, and the hospital knows this and stays afloat in some other way.

It's hard to know what to do with our well-established cultural belief that everyone needs dialysis at the end of life unless they vigorously oppose it, which is what results in frequent readmissions of patients with end-stage kidney disease. Clearly the fact that a hospital is usually the only place that a person with no resources whatsoever can get good medical care will continue to drive frequent readmissions of this group of people.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health care so expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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