How to Reduce Hospital Readmissions

Last week I wrote an article about the Commonwealth Fund study on the under-performing U.S. healthcare system. As I noted in that post, the U.S. excels at charging too much for healthcare, hemorrhages money for non-essential spending, creating charges for non-medical related expenses, and denying patient access to healthcare, all with no effective means of controlling costs to consumers.

Corporations buying and selling hospitals and clinics, providing exorbitant administrative salaries, and at the same time denying patient access to health care are excellent recipes for a dysfunctional healthcare system. The Commonwealth Fund article indicates the U.S. not only under-performed all the other developed countries studied, but the U.S. was also in a class by itself when it came to comparison to the ten other developed countries.

This week The Incidental Economist posted research on hospital readmission rates and discussed how these readmission rates could be reduced.

It should be noted that the issue of a readmissions is remarkably complex. Let me be the first to say that I’m not condoning readmissions in any way or trying to justify them. In my mind, there are very few good reasons for a readmission. They should be kept to an absolute minimum. Congress addressed the hospital readmission problem with a bill to track these rates. An NIH article links readmission rates to lack of post discharge care options:

The high human and financial costs of readmissions spurred Congress to authorize the Hospital Readmissions Reduction Program (HRRP) in 2010….Hospitals with thirty-day readmission rates above risk-adjusted national averages may face penalties in the form of reductions in future Medicare payments.

The problem with this legislation is that it misses the mark on many levels. The last thing that healthcare providers and consumers need is more government belligerence, threats, and draconian punishment. The number one reason to avoid government belligerence is that belligerence does not solve any problems for anybody, but more importantly, consumers suffer.

So, belligerence, rather than being helpful, harms providers and consumers. More importantly, this law is ineffective. For example, it is based on counting hospital readmissions. The tracking fails to note a patient who could benefit from readmission or who has been admitted to a different hospital.

I remember the story of a surgery patient years ago. The patient ureter was ligated at one hospital, the ureter was re-implanted at another hospital, and the patient died at yet a third hospital. None of these admissions showed up as readmissions because the watchers were watching the hospitals and not the patients.

Another way to circumvent this “watching” legislation is to treat a potential readmission in the outpatient department, the emergency room, or in the clinic. The point here is that those watching readmissions have a completely ineffective tool and don’t even know it.

Years ago, when government belligerence and draconian punishment were in their infancy, there were doctors who objected to ineffective monitoring and illogical punishment. Even in 1992 when we wrote Modern Medicine: What You’re Dying to Know, we told the story of a doctor who learned the lesson the hard way. At that time, we could keep our obstetric patients in the hospital until they were ready to go home. We could keep our surgical patients in the hospital until they were ready to go home. We could keep our Coumadin management patients in the hospital until they were ready to go home.

The insurance companies pay physicians to review patient charts and render a decision to cut short the time for management of patient care in the hospital. The doctor in our Modern Medicine story responded to the paid insurance reviewer that if there were any problems from what he, the treating physician, considered a premature discharge, then the costs of any problems arising from the premature discharge should be billed to the insurance company and the doctor working for the insurance company. The paid doctor reviewing the charts for the insurance company was so incensed by the treating physician's note that the paid insurance company doctor wrote a note reprimanding the treating physician even though the treating physician wrote a truthful and accurate note in the patient chart.

Since that time 30 years ago, physicians trying to provide good care for their patients are running through a minefield. Physicians never know when their patient care is going to trigger a blast of belligerence from any number of government watchers. What the legislators creating these laws don’t understand is that this kind of belligerence and punishment is creating a remarkable shortage of physicians. After training for 16 years, older doctors are retiring sooner rather than later and younger doctors work about four years before looking for other ways to use their years of training besides taking care of patients.

The authors of this National Institute of Health study cited by The Incidental Economist post consolidated data about the readmission of newborns from 2013 to 2019 from the Centers for Medicare and Medicaid Services (CMS), the American Hospital Association (AHA), the Census Bureau, and the Health Resources and Services Administration (HRSA). The sample size was impressive with over 3000 hospitals included. The point of the study was apparently to associate post-discharge care options with readmissions which might be potentially preventable through improved quality of care. Somehow the study makes no quality-of-care connection between the insurances hiring physicians to read patient charges and to declare the hospital stays are too long. The study is looking for ways to fix the readmission problem once it happens rather than how to prevent the problem in the first place.

What's amazing to me is why good discharge planning would be need to be investigated by anybody. I can remember when sending patients home the correct way with correct understanding and correct follow up was something that we all learned and did. Insurances didn't make the decision. Physicians did.

Today we are so far down the rabbit hole of misunderstanding that the healthcare industry now considers 12 to 24 hours of hospitalization for a vaginal birth a normal process. Nobody questions what care is missing with this short stay. More importantly, nobody seems to connect between shortened hospital stays in obstetrics to readmissions. Nobody questions how harmful insurances actively restricting access to healthcare is related to readmissions. Oh, there are attempts to see if better postpartum care would fix the problem, but no one is looking at the root of the problem—insurances shortening hospital stays which results in poor and inadequate discharge instructions.

While I was an obstetric student, getting our moms, dads, and babies ready to go home was our biggest and most important task. The idea was to send parents and children home with everything they needed to be ready for the postpartum period. If mom and baby were having a hard time with breastfeeding, bottle feeding, or anything else, they could remain in the hospital for four or five days or until we, the physicians, thought the patients were ready to go home. We also had the time to spend with the patients to discuss how things would go at home.

Today mothers are sent home before babies develop jaundice, failure to thrive, infections, meningitis, or pneumonia. Mothers are sent home before they get postpartum infections or anemia from bleeding. Improving quality of care to prevent readmission of women or their babies is only going to be accomplished by allowing longer hospital stays. A paper by R Luciano acknowledges the connection:

Discharge of the term newborn is a critical issue in perinatal care. The average length of stay of the mother-infant dyad after delivery declined steadily from 1970 until the mid-1990s (early discharge ≤ 48 hours, very early discharge ≤ 24 hours after birth) [1]. Several subsequent studies [2–5] have reported that too short a hospital stay can place an infant at risk for significant jaundice, feeding difficulties, hypernatraemic dehydration, undetected infections, ductal-dependant cardiac lesions or gastrointestinal obstruction and may result in readmission [6–8].

In my 6000 births, I can recall only one mother readmitted to the hospital. She had a whopping kidney infection, which I treated successfully. I saw very few complications in my office and almost no postpartum depression.

I always saw my moms and dads one week after the mother's hospital discharge, not the old standard single visit in six weeks. Since I owned my own clinic, I could provide needed care for free. Other developed countries provide postpartum care for their patients, some up to a year after delivery. In this country, insurance, not physicians, limit patients to one postpartum visit unless there’s some kind of complication. This kind of denial of access to needed care by insurance companies simply prevents physicians from providing the prevention that is worth a pound of cure. To my knowledge there has never been a study comparing the cost of an office visit to the cost of hospital readmissions which result from lack of access to needed care.

Denying access to care does not save money!

I’m old enough to remember the time before payers turned obstetrical care on its head. I am also old enough to remember when the insurance companies decided that they knew much better than the providers how long a patient should stay in the hospital.  

Lest I haven’t made myself perfectly clear above, I’m quite certain that a shortened postpartum hospital stay combined with inadequate patient education produces all kinds of risks for postpartum families.

Let’s look at what should happen during an effective postpartum stay. In the first place approximately 20 percent of that time is spent on issues such as vaginal bleeding, episiotomy care, bowel movements, bladder infections, milk let-down, and ability to breast feed. Secondly, 80 percent of the postpartum time is spent on the baby. Can the baby eat? How much trouble will the baby have with jaundice? Does the baby have a Group B strep or other kind of infection? Does the baby have pneumonia? Does the baby have respiratory distress? Are there any undetected heart defects? Will the baby develop intestinal obstruction? These potential problems will not manifest themselves on day one or two. So mom, dad, and the baby go home not really knowing what kinds of complications can arise, much less how to recognize problems early and consult their doctor.

The payers simply can’t give up the notion that denying access to care is a great way to control their budgets. It would make much more sense to rather than deny care, to ask the right questions. Why does healthcare in the U.S. cost so much more than in other developed countries? Why are maternal morality rates so much lower in other developed countries. 

After 50 years in health care I can truthfully say I have observed that the best healthcare is the cheapest healthcare. There should be no place for harmful payer attempts to save money. The best and cheapest healthcare would be based on appropriate need and not a perverted version of appropriate need limited by lack of access. The best healthcare based on identifying appropriate need is always going to be the cheapest healthcare in the long run.

Sooner or later the U.S. legislators need to address the real issues of our under-performing and outrageously expensive healthcare system if the system is going to survive. But first legislators have to actually acknowledge what the problems are. The U.S. legislators and government healthcare agencies should avoid looking for reasons to punish physicians and instead be investigating how other developed countries provide cost-effective healthcare for all.