Patient Responsibility in Readmissions

There has been lots of discussion over the past year about readmissions. With healthcare reform, it is estimated that we can save billions over the next 10 years by addressing this problem.

The new regulations will cut federal reimbursements for ALL discharges if hospitals have a greater than expected 30-day readmission rate. In FY 2013, the cut is one percent, but it goes up from there. I think everyone agrees this is a problem. I’m sure some would debate if this is the right metric, but it certainly is a tangible one.

For those of you that don’t know…In 2009, the NEJM published the article that set this in motion but you can see some of the discussions before this in this nice piece by Academy Health.

“Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.”

I think the interesting question here is what is the patient’s responsibility post-discharge.

You have several gaping issues:

1. Health Literacy: 2/3rds of US adults over 60 have marginal or inadequate literacy skills and in one study, 81% of patients over 60 couldn’t even understand instructions on a prescription bottle. How are they supposed to navigate the system? (see this site for research on health literacy)
2. Memory: Most patients forget what their physician or nurse tells them. I’d always heard that patients remember about 10% of what they’re told (see NYTimes article on this), but thanks to @trishatorrey, I found this study that showed that 40-80% of information is forgotten immediately. Now, some of this could be addressed by having companions at the encounter (see 2002 paper on this), but there have to be better ways to address this systemic issue.

I guess I would add these two together to equal understanding. How are patients who can’t read and don’t remember going to be successful at home.
This article suggests 12 ways to address readmissions. Additionally, our Chief Medical Officer at Silverlink Communications, Dr. Jan Berger, shared some of our research and also did a podcast on the topic last year.

We’ve always struggled with home monitoring. We can’t force the patient to take the pill. It’s also possible that they get prescribed a medication that they can’t afford and therefore don’t fill. They might have transportation issues and not be able to get to a pharmacy.

Another issue is access to a primary care physician for follow-up after discharge. One study estimated that one in five Americans had limited or no access to a primary care physician.

I don’t know about you, but these statistics scare me. You have people at high risk who are the primary cost drivers in our healthcare system, and they aren’t necessarily equipped or supported to be successful.

Now, we’re going to put the burden on the hospitals to fix this. I agree that it has to start there. The question I wonder is how do we link the patient to this somehow. Is there a way to make them responsible for avoiding readmissions by following the discharge instructions? Is there a way to incent them to be successful? What would we systemically have to do to enable them to be more accountable?

This will require a major effort to address physician and patient interactions, address the discharge process, create a follow-up process to education and monitor the consumer, and ultimately to create a system that provides the support they need to improve their health.

I think we all want the right thing, but I’m sitting here trying to figure out how it gets done.