The cost of caring for patients who need readmission to California's acute care hospitals represents half of the Medicare and Medicaid bills incurred in the state, or $31 billion and $10 billion respectively for one year.
That's according to a new report that looks at repeat patient admissions by age, region of the state, payer, and race. The report is one of the few in the country to track readmissions for 365 days after initial hospital discharge.
Readmissions also accounted for $11 billion or 36% of charges to private insurers and $1 billion of the costs paid by patients for their own care.
"Readmissions are an important issue because the are expensive, can involve additional difficulties for patients and caregivers, and often can be preventable," said David Carlisle, director of the Office of Statewide Health Planning and Development, which prepared the 2005 data report. "Our hope is that data can spur discussion on lowering rates of readmissions to affect change in direct patient care, discharge planning and case management."
Also somewhat surprising is the percentage of readmissions by illness category.
Patients diagnosed with psychosis at first admission represent 6.1% of all readmissions in that year, compared with patients with heart failure, who represent 4.2% of all readmissions and patients with pneumonia, who represent 3.8%. This indicates that psychiatric, heart failure, and pneumonia patients were readmitted more often–some more than nine additional times within the first 365 days of their initial discharge–than patients with other illnesses.
Readmissions are an increasing focus for providers as government and other payers launch efforts to penalize hospitals with greater than average readmissions that might be avoided with better inpatient care or discharge planning.
However, the state's report does not distinguish which readmissions were potentially preventable, nor which were for elective procedures stemming from a condition unrelated to the original admission.
"It's a starting point," says Mary Tran, OSHPD research scientist and author of the report. "Hospitals, insurance companies, and any kind of provider can use these to look at their own rates to see where they can improve."
The document looked at 1.67 million hospitalizations in 2005 at 459 California hospitals-about 10% of the hospitalizations in the country–and found that 36%, or 601,656 patients, had at least one readmission within the next 365 days.
While 63% of patients in 2005 were not readmitted at all for the next 365 days, 19% were readmitted just once, 8% twice, 4% three times, 2% four times, 1% five times, 1% six times, 1% seven times, 1% eight times, and 4,305 patients were readmitted nine times or more.
Also, of those 601,656, 13% or 10 came back within the week, and one-third returned within a month. However, the report did not share the findings for severity of disease or condition.
Whether these patients had been hospitalized in 2004 was not evaluated.
The report also finds tremendous regional variation within the state. For example, for hospitals within Los Angeles County, the readmission rate was 1.73 readmissions per person per year, followed by Riverside, San Bernardino, and San Diego counties, 1.61 per year. The San Francisco Bay area, San Joaquin Valley, Sacramento Valley, and mountain area counties had lower rates, 1.59, 1.55, 1.53, and 1.49 respectively.
The report says other papers examining the issue of readmissions see them as related "mainly to problems with discharge planning and care coordination after discharge.
"In this analysis, it appears that patients that have readmissions may already be ‘sicker' at their first visit. These patients had a longer length of stay at their first visit, were more likely to have a medical rather than a surgical condition, and were more likely to be admitted via the emergency room than the patients with just a single visit."
Debby Rogers, vice president of quality and emergency services for the California Hospital Association, says the report is valuable in that it gives diagnoses for those patients most likely to be repeatedly readmitted.
But she emphasized by looking at any readmission as far out as 365 days doesn't say much about whether the hospital could have prevented the readmission.
"It's hard to know what to infer from this," Rogers says. "It's hard to fault the hospital if someone is readmitted for something nine months later."
The California report goes much farther than Medicare's Hospital Compare Website, which gives only 30-day readmission rates for hospitals in three conditions: heart failure, pneumonia, and heart attack.
Among other findings in the report:
- Almost all patients admitted for removal of appendix or hysterectomy had just a single admission.
- Among patients initially admitted with heart failure, emphysema, or kidney failure, more than half required one or more readmissions within a year.
- While the likelihood of being readmitted increased with age, the likelihood of having a large number of readmissions dropped dramatically for people over age 85, a group which had the lowest average number of readmissions, 1.9 per person per year.
- Blacks had a larger average number of readmissions per patients per year than patients of other races, but Hispanic patients were least likely to have at least one readmission.