Another nerd issue that matters for health reform: Preventing needless (re)hospitalization

Another nerd issue that matters for health reform: Preventing needless (re)hospitalization
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Last year, my wife got sick and ended up taking in an unexpected vacation in a cardiac ICU. After a scary week, I brought her home. We called the academic medical practice where her internist and asked for an appointment. The telephone gatekeeper, apparently finding no computer data field for: "40-something nubile woman with no apparent risk-factors has heart attack," responded: "We have no available appointments...."

Less than 48 hours after being discharged from a intensive care unit, she was out of the hospital, and no one medical seemed all that interested or willing to see her.

As a trained health services researcher, I knew one tool to address this situation: Repeated begging and pleading. Twelve rather unpleasant days later, we got in to see the internist. Good thing. A brilliant diagnostician, he deduced that my wife hadn't had a heart attack after all. He also determined that she was receiving excessive doses of a powerful beta-blocker that put her resting pulse below 50 with roughly the metabolism of a sleeping lizard and some ugly bruising. I presented the full gory story, including my own blunders, here. My wife is fine. I'm relieved she didn't end up back at the same hospital ICU.

Others aren't so lucky. The latest New England Journal of Medicine has an excellent article by Stephen Jencks, Mark Williams, and Eric Coleman on this issue. They analyzed Medicare claims data to examine the issue of unplanned re-hospitalization among Medicare recipients. Their findings provide a good example of the quality challenge facing our healthcare system, and why we need some serious reform. It's not cheap, either. Rehospitalizations cost Medicare about $17 billion.

About 20% of hospitalized Medicare patients are rehospitalized within 30 days. Sometimes this is wise and appropriate. Other times, this reflects poor medical management and the failure of our inpatient and outpatient care systems to provide effective and coordinated care.

To me, the article's money quote was:

In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization.

Got that? People leave the hospital and are readmitted without so much as entering a doctor's office in-between. Poor discharge planning and meager help to patients trying to understand and follow prescribed therapies are key causes of this problem. Our system's poor support for primary care is a big piece of the puzzle, too. For example, it is troubling that the average pay of dermatologists is double that of internists.

Arnold Epstein wrote an accompanying editorial noting an analysis of 18 studies of congestive heart failure patients in eight countries. These studies showed that comprehensive discharge planning with the right supports and guidance reduced readmission rates by 1/4 and improved patients' quality of life.

Some years ago, I was exposed to this work as a member of an Institute of Medicine panel that explored whether Medicare should reimburse nutrition counseling and related services. I was surprised by the impact on real people of often-low-tech services by dieticians and others. The grooves of our current financing system accommodate a $40,000 hospitalization more easily than they accommodate a dietician's $200 home visit showing a heart failure patient how to do healthy cooking.

The work by Jencks and colleagues underscore the importance of health services research to improve and monitor quality. This kind of work also highlights the value of having a large public plan--here the biggest one, Medicare--to improve care. Medicare provides a huge and detailed database so that clinicians and researchers can find more effective and economical approaches to patient care. Independent of this latest work, Medicare has been providing informal feedback to hospitals regarding rehospitalization and other quality measures.

More generally, Medicare and other public payers have the scale and leverage to use quality measures to really improve care. Private insurers certainly work to improve quality. Public players have some better available tools. For these reasons, and for many others detailed by, we need a public plan.

Postscript for faithful readers: It's good to see that has thrived in my absence. I wanted to mention that most of my health policy blogging now appears at the New Republic's new web section, The Treatment. (My latest is here.) In this season when health policy wonkery matters more than ever before, you should check it out.

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