Medicare Carefully Looking at the Cause of Hospital Readmissions

A 2009 study published by the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found:

• 20% of patients were readmitted within 30 days of discharge
• 34 % of patients were readmitted in 90 days of discharge
• 67.1% of patients percent were readmitted one year after discharge or had died

This revolving door effect cost Medicare $17.4 billion dollars in 2004 and the problem continues to escalate.

Medicare is responding by collecting data on all hospitals and will keep a running three-year average on readmission rates. Those hospitals having high rates will be financially penalized.

According to a Medicare Payment Advisory Commission study, 75 percent of all 30-day hospital readmission are preventable and if they can be avoided, the quality of patient care will improve. Higher rates of hospital readmission are associated with infections and other complications acquired by patients during hospital stays.

In a pilot project in which hospitals were paid bonuses and held accountable for better outcomes and less bounce backs, quality improved and readmission rates fell substantially.

The cause for patients having to readmit patients after a hospital stay seems to fall into one of the following categories:

1. Lack of communication between patient and doctor
2. Complete lists of medications missing from patients
3. Follow-up appointments were never made or communicated
4. Wound care or other instructions were confusing or never received
5. No official hand-off from one physician to another
6. Insufficient monitoring of patients after discharge — especially regarding medications

Medicare does not currently pay hospitals for monitoring or mentoring patients after discharge.

According to Dr. Richard Senelick, neurologist, and medical director of the Rehabilitation Institute of San Antonio, certain patients are at a particularly high risk for ending up back in the hospital within 30 days.

“You are more likely to end up in the hospital if you are older, African American, on Medicaid, and are discharged to a Skilled Nursing Facility (SNF),” says Dr. Senelick. “The data suggests that the first three have less access to follow-up and primary care,” adds Dr. Senelick. “Discharge to a SNF, what used to be called a nursing home, is particularly worrisome. Medicare spent $21 billion dollars on SNF, approximately one half of all of the dollars spent on post-acute care (home health, rehabilitation facilities, SNF, and long-term care.)”

A study by the Journal of the American Geriatric Society noted a “greater risk of multiple complicated transitions in patients initially discharged to SNF” and “a lower risk of multiple complicated transactions for patients initially discharged to rehabilitation facilities.”

Skilled Nursing Facilities are cheaper than rehabilitation services, but is it really cost effective to Medicare and private insurance companies to have patients continue to return to these facilities after discharge?

To avoid being readmitted after a hospital stay, Dr. Senelick recommends that you find the discharge planner and start to ask questions, including:

• Am I in a high risk group for readmission?
• Am I able to participate in the decision of where I will be going after the acute care hospital? What are my other options besides a Skilled Nursing Facility?
• Did I receive all of my prescriptions and in the event I don’t understand them, who will help me?
• Do I have all my follow-up appointments scheduled at the time of discharge? Insist on an actual appointment, not just a phone number to call a doctor.
• If I do not feel like I am ready to leave and an extra day would make a big difference, how can you make this happen?
• Who will be calling me at home to see how I am doing and whether I have what I need?

“The last step may be the most important one in preventing re-admissions,” advises Dr. Senelick. “This is the critical follow up necessary to make sure you have what you need to continue to improve at home. The hospital doesn’t want you back anymore than you want to go back, so asking the right questions can help you avoid bounce back.”