Dartmouth Readmissions Report Shows Scant Progress

"There's no question that our reimbursement systems tend to favor payment for care that occurs in a hospital. Though many would agree that is payment for volume and payment for inpatient care that is irrational today, those are the systems largely still in effect."

The latest report differs significantly from others in that it includes interviews with physicians who are frustrated with the system, and with patients about why they were readmitted and what they think went wrong.

"Some doctors feel they are caught in a squeeze play," the report says. "Hospital administrators carefully monitor length of stay—they are eager to send people home because the longer a patient stays, the less money they make. Thus providers said that the prevailing pressure is to discharge patients as early as possible" even if it's too soon.

"So now [they tell you], 'Doctor, you cannot keep that patient,' "a New York family practice physician explained. " 'Are you having the patient on any IV solutions? No? The patient is drinking, the patient is on pills. The patient has to go home.' So it's a lot of pressure also from the hospital to send him home."

On the patient side, the report criticized hospitals for "not being good learning environments" for many patients interviewed. "The patients tried to absorb all of the information and instruction they received, but found it hard to retain anything. They were tired, ill, and their minds foggy with medications. When they reflected back on the experience, some said they should have asked more questions or pushed for more time with their doctor."

Many patients said they were just too unsure of what to ask.

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