Readmissions leave a costly medical trail

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.

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.

•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.

Teno, who has often treated her patients in nursing homes for conditions that otherwise would propel them back to the hospital, 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 under way.

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. Hospitals that do a better job of preventing readmissions sometimes end up losing money because the current 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.

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, said Jencks, who consults on this issue for the independent Massachusetts-based Institute for Healthcare Improvement.

For the population as a whole, including patients too young for Medicare, the readmission rate is 14 to 19 percent for the first 30 days, Jencks said.

Inova Mount Vernon Hospital in Alexandria, Va., is changing the way it deals with some discharged patients.

For example, the hospital began its HeartLink program in November, after Honora Fowler, a nurse, and Lynne Weir, a physical therapist who specializes in cardiac rehabilitation, brainstormed about how to help their congestive heart failure patients take better care of themselves.

Patients monitor themselves daily and call a toll-free telephone line to answer some simple questions about weight gain, swelling and breathing difficulties.

Fowler reviews the answers to see whom she needs to call, whom she needs to keep an eye on for a day or two, who needs their medications adjusted and who better get in to see a doctor right away.

Occasionally, with a patient with advanced disease, she calls a case worker or doctor to suggest it’s time to have a gentle conversation about palliative care or hospice.

“We catch problems faster,” Fowler said.

Because the patients and their families trust her, she can find out what went wrong and how to stop it. Sometimes it’s as simple as persuading a heart failure patient that it’s not OK to splurge occasionally on a bacon double-cheeseburger.

HeartLink is new and small, and the results are anecdotal and preliminary. But other hospitals and doctors say they’re proving that innovative approaches can cut readmissions while providing higher-quality care at lower cost.

Pat Rutherford, a vice president at the Institute for Healthcare Improvement, has been working with hospitals across the country that want to see less of their frequent fliers.

“There are a lot of innovations out there, and we have growing evidence that we can improve this for the patient, to make their experience better and make sure they have a better handoff to a home or community setting,” Rutherford said.

“How many hospitals are ready to step up to the plate? That’s to be determined,” she added. “But more and more are becoming aware that in terms of quality and cost, this could be a huge home run if we do it right.”