An article published in the New England Journal of Medicine addresses a serious topic.  High rates of readmission to the hospital after discharge among the Medicare population.  There are number of findings and conclusions as well as some discussion of possible solutions.  However, this site needs to point out some facts and factors that seem to have been “glossed over”.

(1) The Medicare population is by definition mostly older (generally over 65).  This study DID find a statistically significant effect of age on readmission, but seemed to downplay that it was a major role.

(2) The finding of high readmission rates after major surgery, or that there is increased rate of death in the first year after surgery, in this population, can hardly be surprising.  All competent, experienced physicians and surgeons are well aware that major surgery in the Medicare population carries a higher risk of complication and death, certainly to a greater extent than in younger, generally healthier patients with fewer co-morbid conditions (i.e. high blood pressure, diabetes, renal disease, lung disease, heart disease etc.).

(3) There has been a relentless effort by the government and other payers to increase rates of “early” discharge.  This pressure has been applied to hospitals, physicians and nursing staffs.  In fact, in many cases, some of the finest nurses have been recruited to act as paper pushers overseeing lengths of stay, particularly among Medicare (and Medicaid) populations.  This is also true of private insurance plans as well.

(4) Early discharge, with its emphasis on reduction of “hospital days” has often led to pre-mature discharge.  This includes lack of discharge planning.  Few if any hospitals have social service representatives available beyond regular hours or on weekends.  Additionally, most extended care facilities, nursing homes and assisted living centers also have limited access after hours and on weekends.   Lastly, and perhaps most importantly, there is often a dysfunctional and disjointed family attached to the Medicare beneficiary who is ill or recovering from surgery making final planning and decision making tedious and sometimes combative.

(5) Followup with physicians is important, and despite the efforts of many hospitals and physicians (written instructions, phone information, followup phone calls to patients regarding medications, home issues and doctor appointments, etc.) there is still often a lack of compliance among this population.  The many reasons for this can relate to family issues, transportation issues, forgetfulness, or simply lack of compliance.

(6) Lack of adequate reimbursement for step-down care, extended care, rehabilitation, physical therapy, occupational therapy, speech therapy etc., have all contributed to this problem.  If families do not step up, often seniors do not receive the type of after care that most likely will help prevent many of the issues addressed in this publication and the attendant news stories which have accompanied it.

In the end, there needs to be better planning for discharge.  No disagreement about that.  Also, Medicare coverage needs to be redirected and extended to match the realities at play in the Medicare population being served.  In general, this site believes that most hospitals and physicians do an excellent job arranging for after care and planning for followup.  Improvements can always be made.  The suggestions of some that CMS should publish readmission rates of hospitals is frankly silly and counterproductive.  The factors at play here also relate to the demographics of the populations served.  It would be hard to compare the Medicare population of Idaho and Washington DC and not realize that there are significant differences across the board.

The bottom line . . . the more we try to “equalize” care, the more we try to micromanage medical services, the worse things seem to get . . . especially when that equalizer and manager is the federal government.  We need common sense oversight, regulation and reimbursement policies, not punitive actions or data which does not fully contemplate the effects of previous health policy actions . . . jomaxx

One-fifth of hospitalized Medicare patients readmitted within one month of discharge
Many hospital readmissions could be prevented with better follow-up care according to a study in the New England Journal of Medicine. As many as a fifth of all Medicare patients are readmitted within a month of being discharged, according to the study, and a third are rehospitalized within 90 days.  The study suggested that unplanned hospital readmissions cost $17.4 billion” annually and that rehospitalization is a frequent, costly, and sometimes life-threatening event that is associated with gaps in follow-up care.

Study Finds Many on Medicare Return to Hospital – read @ http://www.nytimes.com/2009/04/02/health/02hospital.html?_r=1&ref=health

Rehospitalizations among Patients in the Medicare Fee-for-Service Program – read @ http://content.nejm.org/cgi/content/short/360/14/1418

Readmitted Patients Cost Billions – read @ http://online.wsj.com/article/SB123863554719781215.html

High Rate of Rehospitalizations Costing Billions – read @ http://www.healthday.com/Article.asp?AID=625620

Planning for Your Discharge: A checklist for patients and caregivers preparing to leave a hospital, nursing home, or other health care setting –  read @ http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf

High Readmission Rates Found in Medicare Population – read @ http://www.medpagetoday.com/HospitalBasedMedicine/Hospitalists/13557

1 in 5 Medicare patients readmitted within month – read @ http://www.forbes.com/feeds/ap/2009/04/01/ap6244354.html

Many Medicare patients return soon after hospital discharge – read @ http://www.chicagotribune.com/news/nationworld/chi-medicare_02-webapr02,0,6360786.story

Revisiting Readmissions — Changing the Incentives for Shared Accountability – read @ http://content.nejm.org/cgi/content/short/360/14/1457