To Curb Rising Costs, Hospitals Try to Reduce Repeat Admissions

By Joanne Kenen
Kaiser Health News
Tuesday, June 30, 2009

Doctors call them frequent fliers.

They are the patients who leave the hospital, only to boomerang back days or weeks later. They have become a front-burner challenge not only for hospitals and doctors but also for those trying to rein in rising costs.

Typically elderly and suffering from the chronic diseases that account for 75 percent of health-care spending, their experiences of being readmitted time and again reflect many of the deficiencies in a fragmented, poorly coordinated health system geared toward acute care.

Take Margaret White. With better management of her congestive heart failure, she might have avoided being rehospitalized this spring for five days. She's back home again now, doing well, with help from a new monitoring program at Inova Mount Vernon Hospital in Alexandria.

There are many reasons for readmissions, including high rates of medical errors and hospital-acquired infections; lack of communication between doctors who care for patients in the hospital and their regular physicians; trouble getting a prompt doctor's appointment after discharge; missed referrals for home health care; and poor coordination and medication management during transitions from hospital to home or nursing home.

"Transitions are just so dangerous. Every time you move a patient from one setting or facility to another, you have to ask, 'Is something going to go wrong?' " said Joan Teno, a geriatrician at Brown University Medical School, who has often treated her patients in nursing homes for conditions that otherwise would propel them back to the hospital. Teno said the ways nursing homes are paid mean it's often easier for them to let the hospitals take care of sick patients.

Experts don't agree on how many readmissions are avoidable. Dozens of promising initiatives designed to cut down on them are underway. But many experts say sweeping changes are needed in how health care is delivered and how hospitals and doctors are paid -- sensitive issues that confront Congress and the medical industry in the debate on overhauling the health system.

President Obama and health reformers in Congress are looking at many ways to reward quality and emphasize prevention and coordination. Right now, hospitals -- such as Inova Mount Vernon -- that do a better job of preventing readmissions sometimes end up losing money because the health-care system doesn't pay for the extra work they do. Some health reform proposals would change the way hospitals are paid, so that stopping readmissions becomes good business.

One idea is to bundle the payments to hospitals, doctors and perhaps nursing homes or rehabilitation centers, to cover both the hospitalization and those first critical weeks after discharge.

Another proposal is to have Medicare penalize hospitals with high readmission rates for eight common chronic diseases. Members of both parties have been looking at ways of paying primary care doctors more to help patients manage their chronic diseases and avoid trips to the hospital every few weeks or months.

Both doctors groups and the American Hospital Association have agreed that it's time to address readmissions. The association, however, prefers to start with pilot programs to test new payment systems rather than implementing an across-the-board new approach. The AHA also says hospitals should not be held responsible for problems that patients encounter when they're outside the hospitals' control.

Readmission costs are staggering. One of five Medicare hospital patients returns to the hospital within 30 days -- at a cost to Medicare of $12 billion to $15 billion a year -- and by 90 days the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks. Within a year, two out of three are back in the hospital -- or dead. Jencks consults on this issue for the independent Massachusetts-based Institute for Healthcare Improvement.

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