Wednesday, December 30, 2009

Top 10 issues in hospital medicine for 2009, issue 8: the abyss of post hospital care

An important NEJM paper published this year reported these findings on discharged Medicare patients:

Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge.

Although differing methodologies make direct comparison difficult these results appear to be worse than those reported in a similar study during the pre-DRG era 25 years ago. It's reasonable to suspect that the arrival of DRG reimbursement made the problem worse. Suddenly Medicare no longer paid for the hospital care patients got, let alone what they actually needed. Hospitals, in order to survive, quickly responded by discharging patients “quicker and sicker.” According to a JAMA report:

Instability at discharge (important clinical problems usually first occurring prior to discharge) predicted the likelihood of postdischarge deaths. At 90 days postdischarge, 16% of patients discharged unstable were dead vs 10% of patients discharged stable. After the PPS introduction, instability increased primarily among patients discharged home. Prior to the PPS, 10% of patients discharged home were unstable; after the PPS was implemented, 15% were discharged unstable, a 43% relative change.

Although the enactment of DRGs, an ill-conceived and reactionary move against the preceding 20 years of gross Medicare largess was, like the health care reform proposals of today, supposed to make care more efficient, it created a mess. Fortunately, back in the 1980s there were plenty of primary care docs to pick up the pieces.

Now things are different. As Medicare continues its increasingly negative cost incentives the primary care work force has diminished. So we shouldn't be surprised that the recent NEJM paper found this:

In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician's office between the time of discharge and rehospitalization.

I remain skeptical about government's ability to improve this situation through external pressure. Meanwhile hospitalists, because their model has aggravated the disconnect between hospital and outpatient care, have an obligation to try and improve discharge transitions. Some programs are trying to lead the way in this effort through initiatives like Project Boost. Unfortunately efforts such as these take resources and may come into conflict with hospitals' business models under the DRG system.

Image courtesy of the Missouri Historical archives.

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