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.
It is also not entirely clear what hospitals should do to prevent bouncebacks. A frequently cited factor in high readmission rates is poor access to clinic doctors for follow-up. One study reported that in half of bouncebacks, the patient didn't have a scheduled doctor's appointment between the first and second hospitalizations. But several subsequent research studies have shed doubt on the assumption that getting people to their doctors' appointments after discharge will prevent bouncebacks. A recent study in the Journal of the American Medical Association found that hospitals with higher rates of follow-up appointments after discharge had lower bounceback rates, but the differences between the poor follow-up hospitals compared with the best follow-up hospitals were really minimal: 23 percent vs. 20 percent. A Mayo clinic study also found no correlation between follow-up appointments and subsequent bouncebacks.
Another bounceback-prevention measure that jazzes policymakers is improved discharge planning—including clear instructions on changes in medications and doses, counseling on dietary restrictions (an essential part of preventing heart failure relapses), and careful explanations on how to identify worrisome symptoms. But there, too, the data aren't convincing: A recent study found that better planning is not strongly correlated with lower readmission rates.
The lack of data supporting these two most promising bounceback-busters are troubling, given the potential for unintended consequences of punishing hospitals with high readmission rates. Patients at the highest risk for readmissions are those with the fewest personal resources—for instance, no cash and transportation to get to the pharmacy and fill expensive prescriptions. Hospitals that care for the poorest patients (many of whom have multiple medical conditions and no routine primary care) may be unfairly stung with penalties for higher readmission rates. Maybe worse, hospitals could attempt to game the system by enacting policies that keep readmissions at bay but are not good for patient care. For example, emergency physicians like us may be pressured to keep returning patients in the ER instead of admitting them to an inpatient unit where they would receive more comprehensive care.
Nevertheless, quality and budget experts are pushing ahead in their quest to reduce readmissions. Despite the objections we've raised, we think this is probably for the best. These programs have already led to some fundamental improvements. Many hospitals are abandoning the belief that they can't do anything for the patient after he leaves the hospital. Some have hired transition coaches to work directly with patients and families to help them manage their post-hospital care. Hospitals and outpatient doctors have also started to collaborate around "episodes of care," ensuring that the patient not only gets the right hospital care but also the right post-discharge care, in effect tearing down the silos that limit big-picture solutions. This type of outside-the-walls thinking is transformational for hospitals and is, at the highest level, a good thing. It's just unclear whether the best way to bring these changes is through financial penalties based around a less than perfect measure of hospital quality.
Now, instead of a wheelchair ride to your car and a fist full of prescriptions, hospitals may be doing more to ensure a smooth, safe landing to keep you from coming right back. But open questions remain: Will these new incentives be enough for hospitals to invest in costly programs to keep patients healthy outside of the sliding glass doors? And, more importantly, will they be sustainable over the long term?
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.