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Bouncebacks: the new LOS

May 2009

For hospitals and hospitalists, bouncebacks are the new LOS. The recent study in the April 2 issue of New England Journal of Medicine (NEJM) that demonstrated a 20% 30-day readmission rate for Medicare patients all but ensures that this latest trend will not be a fad.

My simplified theory (“simplified” being the adjective that most aptly modifies the majority of my theories) on health care reform is this: Radical change will not happen in the next five years. Arguably, we need radical change, but most politicians don’t have the stomach for the type of overhaul that would require both increased nationalization and, more importantly, increased health care rationing (more on that later). Because spending has to be slowed, the next best option is going after low-hanging fruit.

Of course, which fruit seems ripe for the picking is in the eye of the beholder. The beholder is the government, which is eyeing close to $30 billion in Medicare savings over the next 10 years by way of sending people home with a “do not return” order. As we already know, securing a DNR is never easy.

But just because it is not easy does not mean we shouldn’t try to change our ways, and nothing sparks effort like financial incentives. As described in the “Revisiting Readmissions–Changing the Incentives for Shared Accountability” editorial in the same NEJM issue, hospitals currently have little financial incentive to worry about what happens to patients when they leave. Perversely, they are incentivized to reset the DRG clock when patients are readmitted. Similarly for hospitalists, who usually practice due diligence to arrange for outpatient follow-up, once patients are out the door, they are out of mind.

That lack of incentive may be a thing of the past, given that the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare issues including financing, has called for linking payments to readmission rates, as was noted in the NEJM study. Who better for hospitals to partner with than hospitalists, particularly given our growing role in all things metric-driven? I suspect we won’t be the only group of physicians who try to claim rightful ownership of any potential bounty, but I doubt any group will be so well-positioned to actually improve the process.

But what may be lost in the discussion of who gets what and how one goes about earning it are the etiologies of the dreaded bounceback. Let me name three obvious causes, although there are many. Without fixing the following problems, I doubt all our collective efforts will make a major impact on reducing health care costs:

First is the lack of social infrastructure, especially for those who are most likely to return. A Texas-based group named Integrated Care Collaboration reported in April that between 2003 and 2008, nine patients collectively went to a hospital emergency department more than 2,600 times with a variety of complaints including “chest pain.” Although this is no doubt a challenging population, without effective social outreach programs and easy access to primary care clinics, no amount of hospitalist or ED physician intervention is going to have an impact.

Second is the lack of tort reform. We all know that patients with pain above the umbilicus and below the jaw line are eligible for a chest pain rule out, regardless of the fact that they may have had their third negative catheterization last week. So many admissions are defensive, almost to the point of absurdity. Tort reform would go a long way to enable physicians to practice accepted medical standards of care, rather than medicine in which we see every patient as a potential plaintiff.

And now for the big one: the lack of rationing. A significant segment of bounceback patients are composed of, to put it simply, those who are dying.

Unless we as a society are ready to define and place limits on futile care, these hospitalized patients will only be made well enough to be discharged just long enough for them to return. Short of accepted, federally regulated and meaningful health care rationing, we will be left trying to individually educate some segments of society on when “enough is enough.” That’s no easy task given that a significant number of people in our culture believe that only taxes are inevitable.

So queue up your metrics, readjust your dashboard and be prepared to sell hospitalists as the doctors who know that when a relationship is over, it is over.

Breaking up is never easy to do. But if we don’t try to take ownership of transitions of care, just as we have with hospital quality metrics and cost utilization, we will soon learn that nothing good comes from getting back together.