At the busy Veterans hospital where I am an internist, I’ve come to develop a relationship with many of the patients that I frequently care for. No, I don’t currently work in primary care, where such continuity is common and an intended purpose. Instead, I spend much of my time staffing the emergency department and the inpatient wards, two settings where many patients repeatedly present with the same uncontrolled medical conditions, requiring a disproportionate share of hospital resources over time. Such patients are often referred to as “frequent flyers,” a cynical label to be sure, but a frustrating phenomenon for physicians, hospitals, and the health care system.
By some studies, the frequent ED user population accounts for 5 to 8% of ED patients but account for up to 28% of all unique visits. While this group was previously thought to be poor, uninsured, and without primary care, it is more likely that they are on Medicare and Medicaid, are chronically ill, and are high users of overall health care services. In this way, the problems of this group may be related to another, larger problem of excessive hospitalizations, especially preventable re-admissions, a target of excessive medical care costs by health reform. The Medicare Payment Advisory Commission (MedPAC) reported that in 2005, 17.6% of hospital admissions for Medicare recipients resulted in re-admissions within 30 days of discharge, and another study published in The New England Journal of Medicine an astonishing 67% of patients were re-admitted or died in the first year. Heart failure is the leading cause of re-admission; on average, nearly 20% of the 1 million heart failure patients admitted to U.S. hospitals each year are readmitted within a month. The estimated cost to Medicare for unplanned rehospitalizations was $17.4 billion in 2004. The MedPAC study determined cautiously that about 75% of re-admissions may have been preventable, saving nearly $12 billion.
To attack this high cost problem, starting in October 2012, Medicare will start penalizing hospitals with high re-admission rates, as part of the Affordable Care Act’s (ACA) efforts at cost control. Before this, in the ‘80s and ‘90s, managed care, as well as Medicare and Medicaid, pushed hospitals to reduce lengths of stay by paying them less for each subsequent day. This promoted early discharge but no incentive to prevent re-hospitalization, continuing to reward high-tech, high volume, and high turnover. The ACA’s policy change will be a significant shock to hospitals, as those whose re-admission rates fall in the highest quartile for congestive heart failure, pneumonia, and acute myocardial infarction may receive lower overall Medicare reimbursement; though the details are not yet clear.
Hospitals are somewhat unhappy and are not ready. And from what I can see, neither are physicians.
To residents and other physicians in the hospital, a patient who is re-admitted is called a “bounceback.” In response to what looks like their hard work was just futile, they cope by using language that seems to blame the patient, such as “non-compliance,” “refusals,” and “no-shows.” We wish that some patients would just show up to their clinic appointments, take their meds, stop eating fast food, and stop showing up to the emergency room.
But while it may seem that compassion runs thin, in truth, we are ill-trained by medical school to address the complex social and economic barriers that cause non-adherence. Just as important, we feel powerless to influence the broken system that provides no coordination of care. If one spends time on the inpatient wards at the local county hospital, such as Stroger Hospital here in Chicago, one sees that the inpatient social workers are over-worked and the house staff has to pick up the slack. County and state budgets are too strapped to support case managers, and patients lack insurance coverage to access outpatient care, home care, and equipment such as blood pressure machines and weighing scales. Health illiteracy, smoking, and the presence of food deserts affect certain ethnicities and races disproportionately more than others. Even in California, which reduced its preventable hospitalizations by 6.8% from 1999 to 2008, African-Americans living in South Los Angeles were hospitalized for severe hypertension more than three times the state average and more than twice the average for congestive heart failure, asthma, and amputation.
It’s easy to think that physicians are cynical when in truth they’re frustrated to see that the system is out of their control, fragmented and inaccessible.
And it can’t be that patients are enjoying their “frequent flying,” either, as if they’re collecting bonus miles for their recurrent illness. While many do have homelessness and substance abuse issues and benefit from the “three hots and a cot” from hospitalization, this group is a small sample of both the frequent user and the re-admission problem. Instead, more commonly they are patients with multiple chronic medical problems, on a litany of medications that they may not understand, with suboptimal social support. They, too, are frustrated with their re-admissions. But also fearful they will not receive the acute medical care they need when their illnesses deteriorate. For example, at a public forum I attended in March to discuss the ACA, one woman who was a case manager reported that a hospital refused to admit her client for his COPD re-exacerbation because the hospital was afraid of not getting paid by Medicare for the re-admission. “He really did need to be in the hospital. What is he supposed to do?”
Such a swing is bad for patients, if the incentives for hospitals are simply negative, without framework to keep people healthy. In addition, not all re-admissions are avoidable, and hospitals may not be to blame for the re-admissions. As Dr. Josh Freeman, a blogger on medicine and social justice, points out where do patients and their families come in? What about patients who have never expressed advanced directives or end-of-life preferences and for whom palliative care may replace repeated hospitalizations?
While it’s reasonable to hold hospitals accountable, we need more research on the causes of re-admission. The 2007 MedPAC analysis found that over half of patients re-admitted in the first 30 days had no follow-up visit to a doctor’s office after their hospitalization. Accordingly, 13% of readmissions were easily preventable with steps like follow-up phone calls, better medication instructions or providing weighing scales and blood pressure cuffs. Often, as Atul Gawande pointed out in his New Yorker article, “The Hot Spotters,” for those with chronic medical problems, the needs that keep them out of the hospital are much less for physicians or high-tech care and more for low-tech and high-touch care.
These are low hanging fruit, but hospitals aren't paid for these measures. So the ACA will support demonstration projects for payment reform that incentivizes this coordination. Accountable Care Organizations and bundling of payments will hopefully align incentives of primary care, specialists, and hospitals. Medical Homes may bring renewed focus to primary care for multi-modal care coordination. Electronic medical records will link physicians, and more regulation of home health agencies, case managers, and skilled nursing facilities may ensure more consistent quality and prevention of complications.
Ideologues may dismiss such a philosophy and such a coordinated system as government control without personal responsibility. Others say these will help us employ an approach of shared responsibility. For physicians, such philosophical semantics matter little. We just want people to get better… and stay better. Third-party payers want hospital care to cost less. The American public wants both. There is much more work to be done, but with continued research and careful policy, it’s all within our reach.