When I was in medical school, we were taught that the hospital discharge was an important part of the admission. No matter what the patient was admitted for, when they were discharged the “team” would spend a bit of time putting the patient back into his or her rightful place in the community. The nursing staff would work on making sure the patient could perform the tasks needed to complete any care not completed in the hospital and make sure the patient was aware of his or her medical regime and limitations. The medical team would focus on any health care loose ends, in addition making sure all of the chronic medications were correct and up-to-date. The hospital provided social services folks, whose job it was to assure adequate support in the community or to assist with the transition to another care setting would work with families to make sure everyone was comfortable with the plan. The team was actually measured on its readmission rate, where readmissions were considered to be a bad thing and cause for the dreaded “morbidity and mortality” conference to see what could have been done better.

A funny thing happened in the intervening 30 years. People got sicker, sure, but they also are a lot more prone to be readmitted to the hospital. This article in Health Affairs Health Policy Briefs identifies several reasons:

Differences in computer systems often make it difficult to transmit medical records between hospitals and physician practices.  As a result, physicians often do not know when their patients have been released and need follow-up care.

Well, that could be overcome with a fax machine and besides, technology has gotten better, not worse. We used to give people copies of their discharge summary…what else?

Current payment policies create disincentives for hospitals to invest in smoother care transitions. For example, although Medicare does not allow hospitals to bill for readmissions that occur within 24 hours of discharge, it does pay full price for most readmissions that occur after that time.

So disincentives to provideing good care means what?

This means that the prevailing financial incentive for hospitals is to not expend resources on improving care transitions because a poor transition often leads to readmission, which generates additional revenue.

So because we (the taxpayers or the other insured people) are paying $50,000 for an MI, we have to pay another $500 for the right thing to happen on day 3? That doesn’t sound right. There most be something else…

Some analysts believe that Medicare and Medicaid payment policies have unintentionally created incentives to unnecessarily transfer patients back and forth between hospitals and nursing homes. Their suspicion is that nursing homes, which are primarily paid by Medicaid with generally low payment rates, unnecessarily transfer patients to hospitals to qualify for more generous Medicare payment rates when their patients return to them after discharge.

Lending credence to this claim, researchers have found that states with lower rates of Medicaid spending on dual-eligible patients under age 65 (people who are eligible for both Medicaid and Medicare) have higher rates of Medicare spending on these patients, and vice versa, suggesting that providers are “gaming” the system.

The article goes on to talk about how the Affordable Care Act through the Center for Medicare and Medicaid services has put into place several mechanisms to reduce readmissions that may or may not be strong enough but at least they are a step in the right direction.

In this weeks New England Journal of Medicine there are two essays. One, by President Obama, discusses the law and the potential for future enhancements. The other, by Mitt Romney, discusses his intention to repeal the law and replace it with “common sense” reforms. If I felt repeal was a possibility I would worry that “common sense” won’t prevail in such a complex market where there is apparent collusion between health care entities to game the system. I do worry for my profession as it seems we are either wittingly or unwittingly involved in this effort at extracting money from third party payors. I believe this falls under the category of “First do no harm.”

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