The Bounceback Problem
Why patients can't stay out of hospitals.
Updated Friday, July 30, 2010, at 3:46 PM
This year has not been a good one for rock singer and Poison frontman Bret Michaels. A lifelong diabetic, Michaels was admitted to the hospital in April for appendicitis. One week after being discharged, he returned with a massive headache caused by a brain hemorrhage. Again, not long after going home, he returned to the hospital with numbness on the left side of his body. He was diagnosed with a mini-stroke—perhaps from a blood clot that traveled from his leg, through a small hole in his heart, and up to his brain. It may seem improbable that someone could be in the hospital three times within 45 days for separate, serious health problems. But it isn't: Hospital bouncebacks are remarkably common.
In medical jargon, a "bounceback" is a patient who returns to the hospital soon after being discharged. Reasons for bouncing back include problems like uncontrolled pain after a procedure, a surgical infection, or unexpected deterioration of the original reason for admission, such as heart failure. In Michaels' case, it seemed as if his three health problems were unrelated, but most readmissions are usually connected in some way. And this is why, even though reasons for bouncebacks vary widely, when a hospital has high bounceback rates, it is commonly considered to reflect poor medical care.
What drives this concern over high bounceback rates? First, bouncebacks are massively expensive—a recent study of Medicare patients found that one in five admissions results in a bounceback within 30 days of discharge, costing the federal government an estimated $17.4 billion per year. Second, large differences in bounceback rates between hospitals can't be easily explained by differences in patients' underlying conditions, suggesting that at least some of these readmissions are probably avoidable. Finally, bouncebacks just feel wrong. Patients don't like to come back to the hospital, policymakers hate spending the extra money on a redo, and physicians are demoralized when confronted again with a patient they just released.
But until recently, hospitals have never had a compelling reason to try to prevent bouncebacks. Hospitals are typically paid a flat sum for each inpatient stay—shorter stays equal higher profits. When patients bounce back, hospitals can charge the insurance company twice for the same patient with the same problem. Many hospitals also view bouncebacks as out of their control: If a patient boomerangs back because she doesn't follow doctor's orders, it's not the hospital's fault.
Now, as policymakers target bouncebacks, things are changing. Hospitals must publicly report their 30-day readmission rates for patients in whom the original reason for admission was heart failure, pneumonia, or a heart attack. Interestingly, it doesn't matter what the reason for the second admission was; it still counts as a demerit. And Obama's new budget rules will allow the Centers for Medicare and Medicaid Services—the group that doles out government health care dollars—to pay less to hospitals with higher relative readmission rates for these conditions starting in 2013.
These changes are not without controversy. Some observers point out that underlying conditions, not necessarily bad care, are what bring patients back to the hospitals they just left. In patients with chronic illnesses, like severe heart failure, it's frequently the case that no hospital stay could cure the problem. And a second admission could actually reflect better or more comprehensive patient care: A report published in the New England Journal of Medicine this month describes data from one hospital that had higher-than-average 30-day readmission rates but lower death rates for their patients with heart failure.
Zachary F. Meisel is a practicing emergency physician, a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania, and a senior fellow at the Leonard Davis Institute of Health Economics.
Jesse M. Pines is a practicing emergency physician and an associate professor of emergency medicine and health policy at George Washington University in the Center for Health Care Quality.
Photograph of a patient on a gurney by Siri Stafford.