Recently at morning report:
Resident: The patient is a 66 year old woman who had pneumonia and has pretty bad dementia and congestive heart failure and was just discharged from our service 7 days ago. Her family brought her back in. They had her meds all messed up.
When I was a medical student at Charity Hospital in New Orleans it was also known as The Big Free. The hospital name was derived from the order of religious sisters initially brought in to nurse those in the hospital back to health, the Daughters of Charity. The nickname was derived from the fact that there were no charges generated for the care delivered (Free) and the fact that Huey Long built a series of smaller hospitals throughout the state (Little Charities) that provide less comprehensive care.
Resident: Somehow they gave her the antibiotics but forgot to give the diuretic.
We were not introduced to the concept that care costs money in the entire of medical school. People were admitted, people were discharged, procedures were learned, people were readmitted and no bills were generated. I left medical school knowing little about cost. Fortunately for my patients, because no bills were generated, only the state of Louisiana was responsible for the costs my mistakes generated.
In almost all training programs up until very recently, when a patient came back, whether it was the care team’s mistake or the fault of the patient, it was “bounced back” to the previous team. This at worst meant you had one extra patient on your service and, if the patient had insurance, turns out the hospital made extra money. In some cases lots of money.
A 2009 study published in the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found that approximately one-fifth were readmitted within 30 days of discharge and an even more alarming 34 percent were admitted in 90 days. Wait, it gets worse. If we look a year out from discharge they reported 67.1 percent who had been discharged for a medical condition had been readmitted or had died. This revolving door is expensive and cost Medicare $17.4 billion dollars in 2004.
Beginning 2 years ago, Medicare began docking the pay of those hospitals that have a lot of “bounce backs.” Hospital administrators were not happy about this. “There are things we don’t control, and we certainly don’t control patient behavior either,” said Nancy Pratt, chief quality and patient safety officer for Irvine, Calif.-based St. Joseph Health System. “You could do everything right and still end up having a patient readmitted.”
Me: People just don’t forget. That’ll count against us.
Resident: Well it was on the medication reconciliation. The visiting nurse went by the house and went over the meds. I don’t know what else we can do short of putting it in her mouth ourselves.
In the post ACA world, there are no more mulligans. More and more, the care delivery system is taking responsibility for the totality of the care. Hospitals are trying a lot of things in addition to reconciling meds, such as discharge coaching and post-discharge phone contact.
Systems engaged in reducing readmissions are now realizing that the cost of care is not random but is aggregated into a very small number of patients. In this recent article from the New England Journal, investigators in Massachusetts (where there is close to 100% coverage) found that, depending on insurance, the costliest 1% of people accounted for between 14% and 22% of total costs. To reduce readmission in this cohort, care delivery systems would have to provide services such as nurse care managers to work with high-risk Medicare patients, integrating mental health services into broader care-coordination and disease-management models for Medicaid patients, and improved access to low cost specialty pharmaceuticals for young folks with severe illnesses.
Improved care delivery just went from a liability (we make our money off repeat customers) to an asset. As the NEJM authors wrote, “As reform activities shift payment away from fee-for-service models, the incentives to improve care for high-cost patients will continue to grow.” Now we have the opportunity to not only teach the importance of keeping folks out of the hospital, but get paid for it as well.