Reducing Hospital Bouncebacks

Zachary Meisel and Jesse Pines examine the issue of hospital “bouncebacks” — patients who return to the hospital shortly after discharge: “[B]ouncebacks are massively expensive-a recent?study?of Medicare patients found that one in five admissions results in a bounceback within 30 days of discharge, costing the federal government an estimated $17.4 billion per year.”? In the face of new policies that will punish hospitals with higher readmission rates, hospitals are experimenting with programs aimed at improving discharge planning and encouraging attendance of post-hospitalization doctor appointments.? Hospitals are also hiring “transition coaches” and collaborating with outpatient doctors to ensure comprehensive care.? The data on such measures is limited, however, and it’s hospitals that serve the poor that will be most vulnerable to the new policies.? “This type of outside-the-walls thinking is transformational for hospitals and is, at the highest level, a good thing,” write Meisel and Pines. “It’s just unclear whether the best way to bring these changes is through financial penalties based around a less than perfect measure of hospital quality.”[%comments]

Rick Z

Insurance companies deny claims, and make the patient fight to get what is covered.

Hospitals throw patients out, and some of those who need further care will return .... some won't .

Get 'em out, QUICKER and SICKER.

There is little provision for monitoring discharged patients for relapses, or for minor but important care (changing dressings, administering medications).

Tim Miller

The bounceback rate just *might* be related to the fact that insurers have been pushing for shorter and shorter hospital stays, even after major surgery, in a greedy effort to decrease expenses. Not a sincere effort to cut waste, but a greed-induced "hey we can make an extra $20million if we make every patient go home a day earlier!"

For example - my brother had bypass surgery a number of years (10?) back. Like many of these bypass surgeries, new blockage occurred as scar tissue built up around the stents that were inserted. He needed a second operation.

He went in for surgery the same week Johnny Carson went into the hospital for the same operation (I believe). Mr. Carson, of course, stayed in the hospital a full week - he could afford it, and his insurer (if he had one) did not insist he be discharged prematurely. By the time Mr. Carson was discharged, my brother was was in a coma, brain-dead.

My brother's insurer insisted that he be released a couple days after surgery. Because of the short post-op stay, his doctors did not have the chance to notice that the new wounds from the 2nd operation were healing to his sternum. At home he had a coughing fit that caused the wounds to reopen, and he started bleeding internally. By the time he was readmitted to the hospital and made it back into the operating room, his brain had been without sufficient oxygen for too long. He was gone.

"Greed is good"? No - greed kills.



Rick Z and Tim Miller are right to be cynical, however one would note that being in the hospital itself raises risk of disease, and so the better model is to expedite discharges to homecare supervised by nurses (doctors will fight this- the AMA is almost always against efficient reform that will knock down doctor salaries)- anyway, the real elephant in the room is prevention- preventative care is the most effective, yet there's no money to be made in keeping people healthy- no need to be pessimistic, tho- as public healthcare goes bankrupt, we will be forced into preventative care models like Britain has

Dan Feinberg

This is a symptom of a broken primary care system. Without proper primary care, some people end up in the hospital. This proposal forces hospitals to become primary care providers for a month for anyone they discharge. The real answer is to have a medical home outside the hospital that is responsible for the patient, providing primary care to kee the patient out of the hospital, and bears some of the financial burden if a patient does need hospital care. This proposal places that home within the hospital for a month after discharge, but it does nothing to provide that home base of care the rest of the time.

Drill-Baby-Drill Drill Team

Patients should wear rubber discharge gowns.
.....Easier for them to bounce back.


I second the call to increase length of stay within the hospital. As an internal medicine physician who has practiced for 30 years, I've seen the hospital stay for various illness drop by more than 75% in some cases, very often to the detriment of the patients, who then have complications at home instead of at the hospital, and have to be readmitted (Tim Miller's story above about his brother is something I've seen a thousand times).

Blaming the doctors or the hospitals, as the regulations ultimately do, won't get to the heart of the problem. As a physician, I am under pressure from the insurance companies, who call me every single day, to discharge people as soon as possible. If I practice "old-school" and let my patients stay longer, then their insurance won't cover their stays, and they get stuck with thousands of dollars in charges, on top of struggling with whatever illness brought them to the hospital in the first place. I still fight the insurance companies to get my patients more days in-house, but it's become many times more difficult in the past 10 years, and I usually lose. Until this changes, bouncebacks will become the new normal.


Kevin Hall

This reflects a gap in care where the financial incentives are failing to support those patients most likely to cost the health systems a lot of money. Most of your readmission cases are people who are dealing poorly with chronic conditions like diabetes, COPD, complications of obesity, etc. - their primary care doctors (if they have one) deal with minor emergencies and the hospitals handle larger, more expensive crises. But once the crisis is past the patients go home to their bad habits and unhealthy lifestyles.

You can cut down dramatically on that through lifestyle change and education programs that provide ongoing support after people leave the doctor's office or hospital. I'm not trying to be insulting, but many people struggle to change their unhealthy behaviors, even knowing they are bad, and require ongoing support or "coaching" to keep them on track.

Providing a financial penalty gives hospitals a reason to put money into these programs. My company is working with a hospital group in Michigan to provide this kind of education and support and we're really excited about filling in this support gap to keep people living a healthier lifestyle. Part of the reason the program was started was financial considerations like the new Medicare penalties.



This is interesting to read considering a recent study at the Cleveland Clinic that raised some serious questions about whether readmissions are actually a sign of lower quality care.

The national readmission for heart failure is 24.7%. The Cleveland Clinic's readmission rate is 28%. Interestingly enough, the 30 day mortality rate on these same patients is 11.2% nationwide but 8.8% at the Cleveland Clinic. Would you rather be readmitted to the hospital or dead?

The big thing is that keeping more patients alive in the first place creates more opportunities for patients to be readmitted.

Another issue is this doesn't get into the reasons for readmission. Heart failure patients for example who are not compliant with their post discharge plan (taking medications, stop smoking, eating healthy, etc.) are much more likely to be readmitted. There is at least an element of patient responsibility here that goes beyond what a hospital can and should provide. A hospital shouldn't keep patients for 3 extra days simply because they can prevent the patient from smoking a pack a day and keep them on a low sodium diet.


Eric M. Jones

I don't know. The faster the hospital throws you out the less likely you are to die from an infection you caught while in the hospital.

Kevin Hall

@Jackson, it's tempting to look at non-compliant patients and say that they should be more responsible. But the fact is that changing our daily habits is very hard. Many people lack the willpower to do it on their own. That lack of willpower leads to worse health and consequently increased costs to the entire health care system.

I'm a big fan of personal responsibility in principle. However, when crafting social policy I've grown to see that sometimes you simply must bow in the face of human quirks and craft your strategy to deal with that to get the desired result. In this case, we're looking at providing additional coaching and support for people that can't or won't lead a healthier lifestyle in order to reduce overall healthcare spending.

It would be great if we could just say, stop eating so much sugary crap and take a 30 minute walk every day and have people do it. But many won't, and we need to find ways to work with people's limitations to make save everyone money and make some people that we'll probably never meet or know about healthier - whichever incentive appeals to you more.



My recent experience was the hospital did not treat the problem my mother went in for ... they concentrated totally on an infection for which she was already being treated. The hospital would not provide the proper mattress and every-two-hour turning that is required for a quadripegic, so I requested we be sent home.

This caused doctors some consternation because their referral was to a nursing home. I said, "she has no assets and is not eligible for Medicaid, so you can put her in if you want but you won't get paid."

Quadriplegic and elder medical care in the USA is bizarro-land. Be prepared for a lack of focus. As her doctor tried to tell me, "the system is broken," but he wanted to pontificate, not work the problem. He finally processed through enough to see that my mom was better off at home. That we weren't there for heroics. After all, she told him, she's DNR.


I don't disagree with you that it's hard and social policies should be crafted with the idea that people may not be able to help themselves.

But I'm not entirely sure we can put the burden on hospitals either and the fact is that a lack of personal responsibility contributes to many readmissions. Some patients could be in the hospital for 3 days, 7 days, 10 days or 20 days but will be readmitted within a week no matter when they leave due a lack of compliance with their doctor's orders. Now maybe some other way can be found to deal with that other than the patient following discharge instructions. But the most cost-effective solution is certainly not leaving them in the hospital which is expensive and has more risk of infection.

This is not the sole reason for patients being readmitted obviously but it certainly contributes.


Remind me again why americans are opposed to public healthcare?