Monday, October 27, 2008

Say Discharge Planning and Disease Management in the Same Sentence

Whether you ask patients what happens to them after they leave the hospital or review the discharge summaries to determine whether recommended follow-up occurred, the message is the same: a substantial proportion has problems that could have been managed much better in the time around the exit from the hospital (5% in this study), and that needed testing and follow-up never happens (up to a third of the time in this study).

Readers of the Disease Management Care Blog are probably aware that many acute inpatient stays are paid under a ‘Diagnosis Related Group’ or DRG basis. This is a global payment that covers the cost of the entire hospitalization based on the diagnosis and not on the number of days spent by the patient hospital. Accordingly, hospitals have an economic incentive to admit patients (which triggers the DRG payment) and then discharge them as quickly as possible (emptying the bed so another patient attached to a DRG can fill it). The resulting churn can lead to haphazard discharge planning where still sickly patients and their confused families are given complex instructions, lists and brochures while being wheeled toward the front door.

How can anyone tell if patients are being discharged too soon? While measuring the number of subsequent problems in follow-up surveys or comparing the discharge summaries to intended follow-up are useful, a readily available metric is the re-admission rate. If patients are being ‘pushed out’ of the hospital before they’re ready, a proportion is going to come back. The DMCB found this study that indicates a baseline rehospitalization rate within 30 days for persons greater than age 65 is is about 12%. Readmission for the same diagnosis (which is probably a better gauge of how DRGs are being managed) is about 5%. Therefore, it a rehospitalization rate for a hospital is significantly greater than 12% or 5%, respectively (by say, by 2 or more standard deviations), one could infer there might be a problem.

Why is this important? Two reasons:

1. From the point of view of the disease management industry, coordinating care among freshly discharged patients is an important opportunity. The health professionals staffing DMOs are intuitively aware of the breakdowns that can occur in the transition from inpatient to outpatient care. In addition to better discharge planning, a few phone calls to make sure that these patients know who to call if there is a problem and are taking their medications without any side effects could make a big difference in the readmission rate and get it lower than 12 or 5%. For health insurers that want to avoid unnecessary hospitalizations for key enrollees, this looks like a no-brainer. That is, until number 2 happens......

2. Think CMS is not going to continue to build on the success of their non-payment for “never events” occurring in hospital settings? It’s too easy for Medicare and its intermediary payers to detect - through a simple claims analysis – potentially avoidable DRG-based readmissions for beneficiaries within a defined period with the same or similar diagnosis code. The DMCB suspects the Medicare program will eventually wake up to the option of simply denying payment for readmits of some index conditions (for example, exacerbations of chronic heart failure) by rolling both hospital stays into the “same” single DRG payment. What's more, CMS is unlikely to recognize a baseline rate: all will be denied just like the approach to 'never-events.' In response, hospitals will probably work to improve discharge planning by anticipating and managing problems in the discharge period and making sure their patients have adequate follow-up.

That's all well and good. But the DMCB thinks the smarter hospital administrators will also consider the option of contracting with a DMO rather than hiring additional personnel responsible for outpatient care. And while commerical insurers would probably follow suit in denying payment for readmissions, they'll still have an interest in reducing hospital readmission churn and will support hospitals' interest in minimizing readmissions. The DMCB recommends health insurers see if they can contractually deduct a proportion of their DRG payment if there isn't referral to a DMO. Radical thinking, but given the stakes, maybe it's time....

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