Fisher says that if all hospitals put their minds to it, 30% of readmissions at academic medical centers and community hospitals can be avoided, with concomitant savings of a very large chunk of the $26 billion Medicare now spends on readmissions each year.
Fisher and David Goodman, author of Dartmouth's readmissions report, emphasize that the problem of readmissions is also a problem of admissions. Regions of the country with the highest rates have higher rates of both. That indicates that hospitals are being used as the primary sites of care more than they need to be, and that's because until healthcare reform fully kicks in, that's where the money is.
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But payment incentives are starting to change with the creation of accountable care organizations and the federal imposition of fines as high as 1% of Medicare reimbursement for hospitals with higher than expected readmissions poised to take effect one year from Saturday. The names of hospitals said to have "worse" rates than the U.S. average are now posted on HospitalCompare.
But, Fisher has a big worry about what might come next. The whole point of reducing readmissions is to improve care and reduce cost, of course. That means that hospitals need to close down beds that are no longer needed.
That's not what seems to be happening.
"We know from anecdotes around the country that hospitals that successfully reduce readmission rates through effective programs are then recruiting orthopedic surgeons," he says, for lines of service that may not be in the patient's best interest. Types of spine surgery for back pain, for example.
"They're being recruited for surgeries that we know from our work on informed patient choice that if the patients get good balanced information for many of these procedures, they would choose not to have them," Fisher says.
"We are going to need to right-size the healthcare system, and that may very well lead to fewer hospital beds." Until we move to accountable care, we're not going to fix this problem.
In sum, Fisher says, "academic medicine has an opportunity to help us solve this problem. But we don't see a lot of evidence of their having done so in the last five years with this data we show. Why not?"