As Medicare figures out how to financially penalize hospitals with high readmission rates, a new Dartmouth Atlas study finds hospitals have made very little progress in ensuring that fewer patients return. One possible reason raised by the study: fewer than half of patients had a follow-up appointment with a doctor within two weeks of discharge.
Dartmouth Medical School professor David Goodman, lead author of the study, said that findings underscore the “chaotic” and “balkanized” state of the medical system, where hospitals can spend thousands on treatments, but then no one ensures the patient’s recovery doesn’t stumble.
Medicare could save several billion dollars a year by cutting unnecessary readmissions, according to government estimates. Hospitals are nervous as Medicare develops the new readmission rules, which were mandated in last year’s health care law. Hospitals with high readmission rates are going to lose up to 1 percent of their Medicare billings starting in October 2012. The penalties will rise to 3 percent in 2014. The American Hospital Association has been pushing back against the rule, saying that ”not all readmissions can or should be avoided.”
The Dartmouth Atlas found that 12.7 percent of Medicare surgery patients ended up back in the hospital with a month of discharge. That rate didn’t change between 2004 and 2009, the time period examined by the study. Readmission rates for hospitalizations that didn’t require surgery rose slightly, from 15.9 percent in 2004 to 16.1 percent in 2009.
Dartmouth found that 21.8 percent of surgery patients saw a primary care doctor within two weeks of discharge to home in 2009. For patients hospitalized for a non-surgical reason, 42.9 percent had a follow-up appointment within 14 days.
Surgery patients were least likely to see a primary care doctor for follow-up in several areas of Louisiana, Mississippi, Georgia and Texas. Lincoln, Neb. had the best follow-up rates. For non-surgical patients, the New York City region had particularly poor rates of follow-up visits for patients hospitalized, the Dartmouth data show, while the highest follow-up rates were in Lincoln and Peublo, Colo.
The Dartmouth report found the highest readmissions for surgery patients in the New York City metro area and the lowest in Rapid City, S.D. and Bend, Ore. The highest rates of hospital non-surgical readmissions were in many parts of Michigan. The lowest rates were in parts of Utah and Rapid City, S.D.
The Dartmouth study found that over five years readmission rates increased in some places, such as White Plains, N.Y. and Aurora, Ill., and dropped in Bismark, N.D. and Elria, Ohio. “I was surprised that there were so few places in the country with any improvement at all,” Goodman said.
In comparing different regions of the country, Dartmouth took the age, sex and race of the patients into account. The study didn’t consider whether some areas have sicker patients than do other regions. Dartmouth thinks that adjustment isn’t necessary, but it’s one of the main explanations used by hospitals in places with high readmission rates, and Medicare takes patient health factors into account on its Hospital Compare website.
The active physician community in McAllen, Tex., which won its reputation as an extreme Medicare spender from previous Dartmouth analyses, shows up in this report in a more favorable light. McAllen’s readmission rates were about average, but follow-up appointment rates for both surgical and medical patients were among the highest in the nation. In this case, from Dartmouth’s vantage, more care may be better, after all.
