Saturday, April 04, 2009

Healthcare Reform Reading -- Robert Wachter on Readmissions and Aftercare

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term "hospitalist" in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as "an epidemic" facing American hospitals. His posts appear semi-regularly on THCB and on his own blog "Wachter's World."

Here's a link to my acronyms post. And here's another one that includes DRG (Diagnosis Related Group)

“Mr. Obama, Tear Down These (Hospital) Walls”

...when it comes to post-discharge care, we suck.

Despite powerful literature that shows that simple interventions – like post-discharge phone calls or the use of a transitions coach – can lead to impressive improvements in post-discharge care and decreased readmission and return-to-ED rates, few hospitals have put these interventions in place. Outside of integrated delivery systems like Kaiser Permanente or the VA, virtually no hospitals have electronically connected themselves to their referring physicians’ offices; everybody argues that Stark laws prevent them from making these hook-ups, but the lack of an incentive to improve post-discharge care has been the more important culprit.

An era is dawning in which hospitals will, for the first time, have to think of the post-discharge period as being, at least partly, their responsibility. Luckily, this is an area in which there are tools ready for the taking (for example, those developed by the Society of Hospital Medicine through its splendid Project Boost), and some early experience to learn from. Some of us, suspecting that this train was coming down the tracks, have been working on the discharge process for the last few years (my UCSF hospitalists have focused on this issue as our main quality initiative for the past year). Others will have to play catch-up ball.

Ultimately, hospitals will have to figure out ways to get a discharge summary in the hands of a PCP [Primary Care Physician] by the day after discharge (as opposed to the year after discharge, today’s sad state of affairs); to ensure that patients receive robust and understandable discharge instructions (not simply a check box on a form); and to provide, or facilitate the provision of, a follow-up phone call (or email or Tweet – whatever works!) and, for high risk patients, a post-discharge clinic visit, a discharge or transitions coach (as promoted by Eric Coleman’s “Care Transitions Program”), and/or a high risk case manager. This isn’t rocket science – all of these interventions make sense, are less expensive than an MRI or surgical robot, and are not that hard to implement. They simply take institutional will.

I, like you, don’t know where the money will come from for all of this. But we do know that readmissions are terribly expensive and just plain bad for patients. With unplanned readmission rates at 20% and higher, it is high time that we got to work on this problem. When it becomes less expensive to prevent a readmission than to neglect the post-discharge period and help contribute to one, someone will find the money to improve care.

I recall a story from a book review a couple of years ago that reminds me of this problem. Don't remember the name of the book or author, but she wrote the book in the aftermath of being the principal caregiver for her husband following his hospital discharge following a stroke or some other debilitating conditioin which left him physically unable to do anything for himself. She was basically tossed out to be on her own with no coaching or followup. The following Q & A sticks in my mind.

"What was the worst thing you were faced with?"

"Catheterizing him. I had no idea how to go about it and no one to show me."

Follow-up, April 10

Maggie Mahar's post, Patients Who “Bounce Back”: Obama’s Remedy, links to the same piece by Bob Wachter

One in five Medicare patients returns to the hospital within 30 days of being discharged according to a recent article in the New England Jour al of Medicine.

White House budget director Peter Orszag read the study and noted that, according to the study’s authors, readmissions accounted for about $17.4 billion of the $102.6 billion in hospital payments that Medicare made in 2004 (the year the study was done.). “That would be more like $25 billion today,” says Bob Wachter, chief of the Division of Hospital Medicine at the University of California San Francisco. (UCSF)

Reducing readmissions serves as just one example of how we are going be able to afford to provide all Americans with high quality care—by saving $25 billion here, and $25 billion there. As I have suggested in the past, the fat cannot be found in one section of our health care system. It s marbled throughout the very, very expensive meat. Wasteful spending on drugs, devices, unnecessary procedures and windfalls to for-profit insurers must be cut, along with reimbursements to some hospitals and physicians that are not providing good value for our health care dollars.

Lots more at the link. Maggie Mahar is indefatigable.

I came across a shockingly ignorant editorial by Ramesh Ponnuru appearing in the NY Times two days ago. The Misguided Quest for Universal Coverage exposes in a few paragraphs how out of the loop this otherwise bright man must be. With breezy nonchalance he paddles about a children's play pool talking about insurance, oblivious to the coming train wreck which is health care inflatiion, a threat to America's economic future than may loom bigger than the subprime mortgage. The mortage crisis will eventually unwind (I'm not aware of any mortgages in America extending past the next thirty years, although in Japan I hear they have 100 year arrangements with families instead of individuals.) but the swelling of the cost of health care shows no signs of stabilizing, much less reversing.

Stuff like that would be embarrassing if it were not so widespread. It goes to show that there is a large population of comfortable, well cared for people who don't have a clue how broken the system has become.

Maggie's best image:
...the fat cannot be found in one section of our health care system. It s marbled throughout the very, very expensive meat.

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