Opinion: Stop Blaming Business Side of Healthcare for Readmissions

If this keeps up, healthcare professionals who work on the revenue cycle side of the business are going to get a complex.

In a new report sponsored and published by the Robert Wood Johnson Foundation, physicians and other clinical staff interviewed repeatedly blame hospital financial policies and guidelines as one of the main sources behind high readmission rates.

Fortunately the report also includes a hard look at the data, which instead found that “many of these readmissions are caused by inadequate discharge planning, poor care coordination between hospital and community clinicians, and the lack of effective longitudinal community-based care.”

“The Revolving Door: A Report on U.S. Hospital Readmissions” is really two reports in one. “After Hospitalization: A Dartmouth Atlas Report on Readmissions Among Medicare Beneficiaries” is an ongoing study of readmission data of millions of Medicare patients conducted by The Dartmouth Institute for Health Policy & Clinical Practice. The second part, “Hospital Readmissions From the Inside Out: Stories From Patients and Health Care Providers,” consists of interviews of 16 patients, four family caregivers, and 12 healthcare providers (none from the business side of healthcare) by Perry Undam Research/Communication. This anecdotal survey can hardly be taken seriously as it reeks of PR, an attempt to put a human face on hard data, but ends up being primarily a pass-the-buck exercise, at least by the clinical staff interviewed. Some of the blame for high readmission rates belongs to the financial side of healthcare, the report claimed the clinical staff said:

Pressure to discharge quickly sends some patients home before they are ready.
Some doctors feel they are caught in a squeeze play. Hospital administrators carefully monitor length of stay—they are eager to send people home because the longer a patient stays the less money they make. Thus, providers said that the prevailing pressure is to discharge patients as early as possible. This can lead some patients to be discharged too soon, before they are ready. A family practice physician in New York explained, “So now [they tell you], ‘Doctor, you cannot keep that patient. Are you having the patient on any IV solutions? No? The patient is drinking, the patient is on pills. The patient has to go home.’ So it’s a lot of pressure also from the hospital to send him home. Patients with just a little improvement, even if sometimes you feel like this patient belongs there still, it’s a lot of pressure because of the economic reasons.” The same physician explained that hospitals frown upon providers who keep patients in the hospital longer than the recommended number of days. He said, “And if you have an unacceptable number of days that your patients stay in the hospital, they’ll talk to you.” On the other hand, providers also recognized that longer stays can also increase the likelihood that bad things, like infections, could happen to patients.

Money drives current hospital discharge policy.
The reasons to discharge patients quickly from hospitals are financial, according to the health care providers who were interviewed, and are a result of the current reimbursement system. An emergency room physician who practices in Virginia explained, “I think hospitals, because of reimbursement issues, are often motivated to get patients out ASAP. So they get a fixed amount of payment for a given DRG [disease-related group] and whether the patient’s in the hospital for two days or 10 days with congestive heart failure, they get the same amount of money. So they want to get the patient out… and they can do that. But what they can’t do is necessarily keep the same patient from coming back to the emergency room a week later with the same problem.” A hospital-based nurse practitioner in Washington, D.C., addressed the same theme when she said, “The length of stay is one of the big buzzwords in the hospital. When you are here 10 days, 15 days, you know people are always looking, ‘How can we get this person out?’ There is the feeling there’s some financial [pressure].” A New York nurse made a similar comment when she said, “It’s just the whole system [pressuring us to discharge too soon]. You know they’ll be saying, ‘Discharge, discharge, discharge.’”

Fortunately the hard data refutes these myths, as the same financial pressures can be found in Bend, Ore., where the readmission rate is 7.6 percent, and in the New York City region (where many of the anecdotal interviews were conducted), where readmission rates are 16 percent and higher.

The Dartmouth report determined that in nine cases, high readmission rates have been reversed by employing a series of strategies focused on discharge management with followup — “generally by an advanced practice nurse—patient coaching, disease/health management, and provision of telehealth services.”

What would have made this report more useful would have been for the anecdotal interviews to be based on the findings of the Dartmouth report, rather than asking a handful of patients and professionals for their opinion. We need results, not finger pointing. There’s more than enough blame to go around.