Watch those bounce-backs

We all know about the bounce-back---the patient who is readmitted a short time following hospital discharge, often with the same problem. The growing primary care shortage along with economic incentives for hospitals to discharge patients ASAP often leads to fragmented (or nonexistent) post hospital care, thus aggravating the problem of early readmissions.

Bob Wachter, writing about this on his blog late last year, noted that on the hospital side we’re not doing a very good job with transitions:

Although we’re not very good at washing our hands, we are terrific at washing our hands of patients who leave our medical radar screens.

Right now hospitals have no incentives to prevent bounce-backs. Keeping patients an extra day or two and making detailed arrangements for post hospital care costs money. So what if the patient bounces back in a week or two---the hospital gets a whole new DRG payment.

Wachter indicated in his post that that may be about to change:

All of this is about to change. Look for oodles of publicly-reported measures of case-mix-adjusted readmission rates coming online in the next few years, which will force us finally to focus on filling the post-discharge black hole. And that won’t be all. How about a measure of the percent of hospital discharge summaries that made it to the primary physician within 72 hours? The Joint Commission is considering it. Or try this one: a consultant doesn’t get paid until there is documentation that his or her consult report made it back to the requesting doc. Impossible? It’s being batted around in policy circles.

Now there are rumblings, via Hospitalist News, that Medicare is considering bundling payments for episodes of hospital care, which it defines as including the 30 days post hospital discharge:

At its April meeting, the commission (MedPAC) unanimously voted to include a bundling recommendation in its June report to Congress. As a first step, physicians and hospitals should be required to report to the Centers for Medicare and Medicaid Services (CMS) on resource use and readmissions during an “episode of care,” which is proposed to include the first 30 days post hospitalization. The data would be confidential initially, but should be made public by the third year, MedPAC commissioners recommended.

Once the resource and readmission data are in hand, CMS should start adjusting payment to hospitals, according to the recommendation. There would be the possibility for gainsharing among hospitals and physicians. The commissioners also voted to
direct CMS to study the feasibility of “virtual” bundling. With virtual bundling, the payment would be adjusted based on aggregate use of services over an entire episode of care.

Gainsharing? It sounds more like loss sharing to me. I don’t know what all the verbiage means, but it could mean a “no pay” policy for readmissions within 30 days.

If this causes hospitals to devote more resources to transitions (read Wachter’s suggestions about the Transitions Officer) it’s a good thing, right? It depends on the inevitable unintended consequences. Financially struggling hospitals may be forced to close. Others will continue to play the perpetual and ever changing game: Medicare sets rules---hospitals adapt---Medicare changes rules---hospitals adapt again---Medicare changes rules again.