Flawed Logic = Flawed Healthcare Reform Policy Decisions

Cary Gutbezahl, MD and President, Compass Clinical Consulting

Research reported in a recent New England Journal of Medicine showed:

• Almost one-fifth of Medicare patients are re-admitted to a hospital within 30 days
• Over one-third are re-admitted within 90 days
• More than three-quarters of the re-admissions were following medical admissions, suggesting that the vast majority of hospital admissions were not scheduled admissions (most medical admissions are urgent and emergent, as are many surgical admissions). 
• More than half of patients who were re-admitted within 30 days did not see a physician prior to readmission.

The implied assumptions underlying the research design are also important.

The study implies that because 50% of re-admitted patients had no outpatient physician visits (as determined by invoices), their care was sub-optimal. This logic is flawed.

The facts of this research provide important information to focus further investigations into reducing healthcare costs.  The study, however, has significant limitations.

No one seems to notice that this research reported in April 2009 is based on the patients who were admitted in the Fourth Quarter of 2003 and followed through the end of 2004.

Thus, the effects of programs to reduce complications during the past few years such as the surgical complication reduction programs, acute myocardial infarction and congestive heart program were not included.

First, physician visits are not the only way to monitor patient compliance with treatment plans and clinical status. Many patients receive outpatient treatment from home health agencies. Some patients are admitted to skilled nursing facilities which require an examination shortly after admission (it isn’t clear whether the data revealed that these patients did not see a physician, which might suggest a methodological flaw). It also isn’t clear whether re-admission was more likely in nursing home patients than patients who were discharged to home, or whether re-admissions were more likely in patients discharged home with nursing care. In discharge planning, these supplemental care resources are associated with an assessment that the patient is at higher risk for re-admission. These patients are monitored, even if the physician does not see the patient.

Second, the observation that 50% of re-admitted patients were not seen by a physician may be skewed by the distribution of admissions within the 30-day period (shorter periods between hospitalizations had higher rates of not seeing a physician). However, it is concerning that only 25% of re-admitted patients at the 30-day mark had not seen a physician.

Medicare Demonstration Project

The results published in NEJM should also be considered in relationship to the recently reported finding of a Medicare Demonstration Project that showed that most “disease management” programs did not have a beneficial effect upon preventing subsequent problems. Disease management programs provide nurses who have frequent contact with patients to monitor compliance and screen patients for early signs of deteriorating care. Nurses contact the patient’s physician when the nurse is concerned about the patient’s clinical status.

How can these the NEJM results be reconciled with the Medicare Demonstration Project?

First, there is too little information in the NEJM article to understand why re-admissions occur. No patients were interviewed and no discharge instructions or medical records were reviewed. Instead of providing data, the authors cite reports showing reduced re-hospitalization rates based on better discharge planning (one of which was written by one of the authors). By the way, these studies did not cite physician visits as a preventative intervention for re-admission.

The Potential Impact of Flawed Logic on Healthcare Policy

There are several problems with transferring the responsibility for preventing re-admissions to hospitals through changes in reimbursement. This assumes that the causes of re-admission are known and that they are preventable. Additionally, the prevailing opinion is to punish hospitals for re-admissions. This will result in less money to hospitals that are already struggling to cover their costs. Although there is no evidence that hospitals are responsible for readmissions, it seems like policy-makers are trying to push the responsibility for reducing re-admissions to anyone they can accuse.

Another issue in holding hospitals accountable for re-admissions is patient choice over home health care agencies and skilled nursing homes. How can hospitals be accountable for re-admission rates when the patient has the choice over which home health agency is used or to which nursing home that patient is admitted? Does the patient lose choice or does the hospital get stuck with the risk when there is no ability to control the post-acute care provider?

By the way, let’s not forget that patients do decline and eventually die, despite the best medical treatment.

Policy-makers are rushing to find a culprit so they can utilize penalties to cover some of the cost of healthcare reform. But flawed logic will lead to bad policy.

As Henry Mencken wrote over 50 years ago:

      “For every complex problem, there is a solution that is simple, neat and wrong.”

When we are making healthcare policy, let’s make sure we really understand the issues and when we see any evidence that some of our conclusions are flawed, let’s step back and count to ten before we make errant decisions. 

Filed Under: Clinical Improvement • Featured Articles

Tags: Healthcare Reform Policy, Hospital Readmissions