But it's a much tougher problem than the Dartmouth folks appreciate, she contends. For many teaching and research hospitals, patients come from miles away for specialized kinds of care and then return home, perhaps to a suburban or rural area, where care is taken over by a community physician. And town/gown conflict rears its head.
The hospital discharge planners might send the doctor a fax with instructions for the patient's follow-up care. "But the doctor says, 'No, I know this family. I'll manage them the way I'll manage them,' and throws the fax in the trash," Conroy says.
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In some of these smaller community hospitals and physician practices, she says, "the trigger point for a readmission is lower, or the (care providers in that area) are not involved in the same care pathway that an academic medical center tends to follow."
That's a polite way of saying that communities with hospitals grappling with reduced census may be hungrier for business than academic medical centers, which Conroy says have remained full. And how does a teaching hospital tell a community practitioner or emergency room doctor hundreds of miles away that their patient should not be admitted?
But Fisher says academic medical centers should not be allowed to make that excuse.
"It's implausible that all the variation is explained by hospitals receiving their patients from distant places. I don't think we should let academic medical centers off the hook because their patients might come from a long ways away.