Tuesday, March 31, 2015

Keep 'em in the hospitals!

Well, speaking of twists in the usual story, check out this op-ed by Joseph Doyle, John Graves and Jonathan Gruber in the Boston Globe, suggesting that patients should spend more time in hospitals before going on to post-acute care elsewhere. Excerpts:

[O]ur research shows that a major source of the waste [in health care spending] comes after a patient is released from the hospital. Hospitals that discharge patients to expensive skilled nursing facilities are raising costs and reducing care quality.

We . . .  find that for those patients there is a substantial benefit to receiving higher spending while in the hospital: Being treated at a hospital that provides more aggressive treatments and accrues high levels of spending at the time of the health emergency leads to about a 10 percent reduction in the likelihood of death compared to being treated at a low-spending hospital. 

It turns out that what is really going on is excessive use of skilled nursing facilities post-hospital discharge. Patients who go to hospitals that have a high rate of discharge into SNFs are much more likely to die than those who are transported to hospitals that send their patients home instead. ... [H]ospitals that use SNFs more than average are not providing good enough care to their patients. These findings confirm what has been suspected by many: Coordination of care post hospital discharge is a primary source of waste in the health care system, of both money and lives.

Our findings suggest that, at a minimum, the existing system should also track hospital use of expensive post-acute care and penalize them for it just as they are penalized for a high readmission rate. 


Ray Collins said...

My first thought is that discharge to a SNF is being used in an attempt to avoid Medicare re-admission penalties. In hospital appeals of individual re-admissions, are hospitals pointing the finger at the SNFs as the cause of the re-admission? Don't know the answers to these questions. As I say, these are the first thoughts that came to mind. I do know from first-hand experience that hospital discharge communications with SNFs is at least as bad, if not worse, than the case when someone is discharged to their home.

Paul Levy said...

Plus, if they die more often at SNFs, you don't have to worry about readmission, right?

Anonymous said...

Wouldn't patients being discharged to SNF be sicker and the logic would follow. Going home would tend me to believe they are healthier and not needing as much care.

Paul Levy said...

Good point. I think they assert that their study corrected for that, but worth the question for sure.

Unknown said...

This op ed left many unanswered questions hopefully explained in the actual underlying research report. The major question would be why is such odd ball research analysis even appearing in the Globe?

Then when you get down in the weeds, I would add to anonymous' observation. Given that the research is said to be based on Medicare data means that people who went to a SNF were admitted first -- not just observed -- at an acute care facility and that their admission lasted for three days. And they are only people who came to the acute care in the first place under an emergency situation, not just a scheduled knee replacement. And they came by some ambulance lottery that can only apply in a few urban areas. So the whole research seems to be based on a slice of a slice of a slice of what even at the top line is a very small slice of the Medicare population (those who use Part A in any given year)

Unknown said...

In Massachusetts, both our overall high utilization of SNFs post hospital discharge compared to national norms, as well as the the variability of discharge to a SNF among hospitals, does not appear to be tied to patient characteristics-- according to the findings of our HPC staff.

See our 2014 Cost Report:


Paul Levy said...

Thanks, Paul!