ShareThisThe scariest time for many Medicare patients isn't when they go into a hospital -- it's when they leave.
For several decades now, Medicare has been trying to reduce the length of patient hospital stays, based on the reasonable assessment that hospitals are expensive, and a good recovery at home, even with visiting nurse care, or even in a nursing facility, is better for the health of patients as well as that of the Medicare trust fund.
But that's true only if patients stay out of the hospital.
Instead, nearly 1 in 5 Medicare patients who leave the hospital today will be admitted to the same or another hospital within a month.
A study by researchers at Chicago's Northwestern University found this was true based on a review of 12 million patients discharged from hospitals in 2003-04, and Medicare says it sees the same pattern in more current claims data.
The Northwestern researchers also found more than half of those returning to the hospital within 30 days did not see a physician as an outpatient since being released from the hospital.
"We were surprised that more than half of these patients weren't being seen by their primary care doctors before they went back into the hospital. This represents a major disconnect between care in the hospital and outside it,'' said the report's co-author, Dr. Mark Williams, chief of hospital medicine for Northwestern's Feinberg School of Medicine and the Northwestern Memorial Hospital. The study was published in the April 2 issue of The New England Journal of Medicine.
Medicare officials claim up to three-quarters of these readmissions -- which cost the insurance program around $17 billion a year -- are preventable. Officials last year threatened to start docking hospitals for preventable readmissions. Instead, they're going to start publishing the repeat rates later this year on Medicare's hospital comparison Web site -- www.hospitalcompare.hhs.gov, while auditors ponder sanctions.
President Obama has said that getting Medicare readmissions down by improving follow-up care could save at least $26 billion over 10 years.
But more than a few health care critics say there's only so much hospitals can do to correct a problem that extends well beyond their walls.
For starters, there's a national shortage of primary care physicians, one that's particularly acute for Medicare patients because reimbursement rates don't take into account that caring for older patients takes more time, including coordinating care with other doctors, for which there is no reimbursement code.
"They pay for quantity of service, not quality. Hospitals and doctors are rewarded for doing things instead of preventing them,'' Williams said.
For instance, there's no provision to pay hospital pharmacists to go over medication instructions with patients before discharge, comparing what they were taking before hospitalization with what they should be taking when they get home. Research has shown such medication reviews help prevent overdoses, bad reactions to conflicting meds, and returns to the hospital.
National surveys suggest a third of Medicare patients have trouble finding doctors who will see them because of insurance issues.
If a Medicare patient does have a primary care doctor, many practices limit the number of appointments for seniors they make each week both for financial and time management reasons. So even if a patient is told at discharge to see the family doctor within a week or two, it may be difficult to wrangle an appointment.
Many primary care doctors still check in on their patients when they're hospitalized, but many also do not take the time to make such rounds. And the growth of the "hospitalist" specialty -- doctors who only treat patients in hospitals -- may have helped improve inpatient care, but also added to the fragmentation of all patient care.
All too often, the only way a patient's regular doctor finds out he or she has been in the hospital is if the patient lets him know.
Hospitals have discharge planners, home health care agencies have coordinators for new patients, but they seldom talk. And once the patient leaves the hospital, it's hard to find anyone there to answer any lingering questions.
The latest effort to find ways to end the needless return of patients is called the to find anyone there to answer any lingering questions. Care Transitions Project, a set of experiments being funded in 14 communities around the country between now and the summer of 2011.
They are: Providence, R.I., the Upper Capitol Region around Albany, N.Y.; western Pennsylvania; southwestern New Jersey; metro Atlanta (east); Miami, Fla.; Evansville, Ind.; Lansing, Mich.; Omaha, Neb.; Baton Rouge, La.; northwest Denver; Harlingen, Texas; and Whatcom County, Wash.
In each location, health quality improvement experts will work with local health leaders to find out why quick return visits are happening, how transitions are handled now, and then look for customized solutions intended to fit the particular community.
Medicare will monitor the readmission rates for each area and work with regional quality improvement organizations to document the changes in practices made in the various communities.
E-mail Lee Bowman at bowmanl(at)shns.com.
(Distributed by Scripps Howard News Service, http://www.scrippsnews.com)
The Medical Journal
