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Medicare Bounce-Back Hospital Admissions

Rehospitalization rates among Medicare beneficiaries are unacceptably high.

In February 2009, we reviewed a report on a standardized discharge intervention that lowered the incidence of rehospitalization (JW Hosp Med Feb 2 2009). Now, another study clearly demonstrates the extent of the bounce-back admissions problem.

An analysis of 15 months (2003–2004) of Medicare beneficiary data revealed that 20% of older hospitalized patients were readmitted within 30 days, 34% returned within 90 days, 45% returned within 180 days, and 56% returned within 1 year. Researchers found no charges for outpatient physician visits for half the patients who were rehospitalized within 30 days (after medical discharge to the community).

Diseases associated with the highest 30-day rehospitalization rates were congestive heart failure (27%), psychoses (25%), vascular surgery (24%), and chronic obstructive pulmonary disease (23%). Although patients with chronic conditions tended to have higher rates of readmission, patients with acute conditions also often were readmitted within 30 days (e.g., 20% of pneumonia patients).

Comment: In this study, the cost of unplanned rehospitalizations in 2004 was estimated to account for US$17.4 billion of the $102.6 billion in hospital payments from Medicare. A large percentage of bounce-back admissions appear to be related directly to poorly coordinated transitions of care. Given that a woeful percentage of patients attend follow-up visits, tremendous improvement might be possible if patients were seen by their primary care physicians within a few weeks after discharge. The Medicare Payment Advisory Commission (MedPac) has recommended that the Centers for Medicare and Medicaid Services (CMS) inform hospitals of their risk-adjusted readmission rates and provide lower payments for hospitals that have high rates of readmissions for certain conditions. Whatever policy is implemented, I agree with the editorialist’s view that hospitals and primary care providers need shared incentives and accountability for solving this problem.

— Neil H. Winawer, MD, FHM

Published in Journal Watch Hospital Medicine April 1, 2009

Citation(s):

Jencks SF et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009 Apr 2; 360:1418.

• Original article (Subscription may be required)
• Medline abstract (Free)

Epstein AM. Revisiting readmissions — Changing the incentives for shared accountability. N Engl J Med 2009 Apr 2; 360:1457.

• Original article (Subscription may be required)
• Medline abstract (Free)

Reader Remarks:

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• bounce backs
  Thomas D. Franklin, retired orthopedist, Palo Alto, 2 Apr 2009 1:51 PM EST
  Another factor in the bounce backs is probably too early discharges. There is a tremendous amount of pressure to get... [more]
• DRG impacts - ''Discharge quicker and sicker''
  R.D. Bartucci, 2 Apr 2009 1:51 PM EST
  Like any other physician familiar with the impact of the diagnosis- related groups (DRG) reimbursement paradigm upon hospital care for... [more]
• what do you expect?
  emanuel goldberg, 2 Apr 2009 1:51 PM EST
  the hospitals are now rewarded for earlier discharge. although failure of followup may be a problem it is also clear... [more]
• oh wow, now it's my fault that they don't follow-up
  C. A. Evans, outpatient office, 3 Apr 2009 12:51 PM EST
  I know that they patients here are advised to see me, and even have appts. made for them with me,... [more]
• Fall related readmissions
  Colleen M Campbell, Public Health, 3 Apr 2009 12:51 PM EST
  I'm curious to know if anyone has data on readmissions of older adult patients who were originally seen in and... [more]
• Homecare
  Anita M Brown, 7 Apr 2009 2:05 PM EST
  It would seem that providing more patients with after care in the home could prevent some of these readmissions. Unfortunately,... [more]
• Readmission rates related to underdiagnosed geriatric syndromes
  Kayla I Brodkin, 8 Apr 2009 7:16 AM EST
  Often geriatric syndromes including falls, delirium and adverse drug effects remain undetected during hospitalizations. It is not until a patient... [more]
• hospital to nursing home
  Julie E. Yoon, Geriatrics, St John's Home, 14 Apr 2009 10:32 AM EST
  Even with close MD follow-up as with hospital-to-rehab or hospital-to -nursing home transfers, there are still a fair number of... [more]
• Remark from Journal Watch editor Allan Brett
  Allan S Brett, University of South Carolina, 22 Apr 2009 6:19 PM EST
  Many readers commented on the possibility that too-early discharge from the hospital is a major cause of bounce-back admissions. I... [more]