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

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 Thinkprogress.org, we need a public plan.

Postscript for faithful readers: It's good to see that Huffingtonpost.com 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.

Comments

[ResQuality]

Rehospitalization after care is an important marker of a hospital's quality. We are concerned about the quality of emergency room care at Resurrection Health Care hospitals in Illinois. Health care experts have given low ratings to Resurrection Health Care hospitals and both patients and employees have reported issues with patient safety. If you want the full story on the quality of care given at Resurrection facilities, visit our website www.resquality.comm). If you were a patient at a Resurrection Health Care hospital and would like to share your story, please email us at resquality.comy.com.

[PlaceboStudman]

Kudos to you Mr Pollack, for writing such a great article, and for fighting, not only for your wife, but for the needs of all medical patients. I can not tell you how much the hospital re-admission issue has come up in my life, as a disabled person. Unfortunately these were cases where the insurance company had complete control over what the hospital was ALLOWED to administer as care. This often left me with half healed surgical scars, or half healed bed sores, which I was required to take care of on my own at home, because home health care would only come out once to do it for me, to teach me to do it myself. This has happened to me, no less than 10 times in 36 years.

Bu, you and Ms Bergthold are right, this is only the tip of the iceberg. And it doesn't all have to do with insurance companies. I have been on a crusade myself to make people aware of how BigPharma are working hand in hand with the FDA to give us substandard and even harmful drugs that often do more harm than good. Similar to the story Mr Pollack here told, I am fighting against the inclusion of additives fillers and preservatives that lead to kidney and liver failure

[QualityCounts]

An excellent post. You have a wonderful knack of combining the very personal with good science and practical policy. Everything that happens in our health care system makes perfect sense from the point of view of the individuals and organizations providing products and services. The problem is that patients' needs often end up falling through the cracks. The challenge will be to move beyond name calling and simplistic solutions to create a new system that rewards coordinated, cost-effective care instead of penalizing patient-centered providers while paying top dollar for high-tech solutions that often result in more harm than good.

[Harold Pollack - Huffpost Blogger]

Linda makes a great point. As a key leader in the fight for real reform during the presidential campaign, she brings real credibility.

Health reform is about many different things. We have keep our big tent together and fight for reform this year. As a friend put it, we need fire in our bellies and ice water in our veins as we fight for the best final bill.

[Linda Bergthold - Huffpost Blogger]

This wonderful post is chock full of great information for Huffington Post readers who are serious about health reform and improving health care as well. I hope that your readers will comment on their own experiences as well, so that we can all educate ourselves about what to do when we get sick. Getting coverage and health reform passed is only the very first step to improving the American health care system. Whether we have single payer or not, this is not an insurance issue as much as a quality of care issue. What happened to your wife would have happened if we had single payer -- so all you single payer advocates who comment on these sites should support real health CARE reform.
What to do about hospital readmissions? Demand better primary care. Read up on the "medical home" issues http://www.medicalhomeinfo.org/joint%20Statement.pdf - be sure that this concept is included in any reform efforts. And read this column about what works in medical care -- including the mistakes of applying beta blockers to new heart attack patients -- http://well.blogs.nytimes.com/2009/04/02/the-ideology-of-health-care/
No matter what insurance reform we do or do not get, the American medical care system needs lots of help. As patients we need to demand quality of care. But it is scary to think that Professor Pollack, with all his training, had to shout as much as he did to get the right thing done!!