Medicare Bounce-Back Hospital Admissions

Summary and Comment |
April 1, 2009

Medicare Bounce-Back Hospital Admissions

  1. Neil H. Winawer, MD, FHM

Rehospitalization rates among Medicare beneficiaries are unacceptably high.

  1. Neil H. Winawer, MD, FHM

In February 2009, we reviewed a report on a standardized discharge intervention that lowered the incidence of rehospitalization (JW Hosp Med Feb 2 2009). Now, another study clearly demonstrates the extent of the bounce-back admissions problem.

An analysis of 15 months (2003–2004) of Medicare beneficiary data revealed that 20% of older hospitalized patients were readmitted within 30 days, 34% returned within 90 days, 45% returned within 180 days, and 56% returned within 1 year. Researchers found no charges for outpatient physician visits for half the patients who were rehospitalized within 30 days (after medical discharge to the community).

Diseases associated with the highest 30-day rehospitalization rates were congestive heart failure (27%), psychoses (25%), vascular surgery (24%), and chronic obstructive pulmonary disease (23%). Although patients with chronic conditions tended to have higher rates of readmission, patients with acute conditions also often were readmitted within 30 days (e.g., 20% of pneumonia patients).


In this study, the cost of unplanned rehospitalizations in 2004 was estimated to account for US$17.4 billion of the $102.6 billion in hospital payments from Medicare. A large percentage of bounce-back admissions appear to be related directly to poorly coordinated transitions of care. Given that a woeful percentage of patients attend follow-up visits, tremendous improvement might be possible if patients were seen by their primary care physicians within a few weeks after discharge. The Medicare Payment Advisory Commission (MedPac) has recommended that the Centers for Medicare and Medicaid Services (CMS) inform hospitals of their risk-adjusted readmission rates and provide lower payments for hospitals that have high rates of readmissions for certain conditions. Whatever policy is implemented, I agree with the editorialist’s view that hospitals and primary care providers need shared incentives and accountability for solving this problem.


Reader Comments (9)

Allan S Brett

Many readers commented on the possibility that too-early discharge from the hospital is a major cause of bounce-back admissions. I went to the original article to see whether it included any data on this matter. Table 3 shows that people whose index hospitalization was short (less than half the DRG expected length-of-stay [LOS]) actually had a lower rate of bounce-back hospitalization, and those whose index hospitalization was long (more than twice the DRG expected LOS) actually had higher rehospitalization rates. At first glance, these figures seem diametrically opposed to the idea that too-early discharges are a major cause of readmission. But on further thought, I’ll bet these figures aren’t very helpful, for the following reason: An extremely short LOS -- less than half the DRG expectation -- is probably a marker for a less-sick patient. And a very long LOS -- more than twice the DRG expectation -- is probably a marker for sicker patients. What we really need to know is individual patient-level data on whether patients are clinically stable on the day they’re discharged. The Medicare database that was the source of the New England Journal study doesn’t provide this information.

I just saw another study that sheds some light on this topic (see Palacio C, et al. A comparative study of unscheduled hospital readmissions in a resident-staffed teaching service and a hospitalist-based service. Southern Medical Journal 2009;102:145-149). In this study from a large urban teaching hospital, the probability of readmission decreased significantly as LOS increased. This observation doesn’t prove cause-and- effect, but it supports readers who believe that too-early discharge is one cause of bounce-back admissions.

Allan Brett, MD, Editor-in-Chief, Journal Watch General Medicine

Competing interests: None declared

Julie E. Yoon

Even with close MD follow-up as with hospital-to-rehab or hospital-to -nursing home transfers, there are still a fair number of bounce-backs. I share others' feelings that it has a lot to do with pressure to discharge and poor transmission of pertinant data. Upon arrival of patients to our facility, I am indundated with xeroxed chart notes of little relevance and a very shoddy d/c summary. Medication errors are very common.

Competing interests: None declared

Anita M Brown

It would seem that providing more patients with after care in the home could prevent some of these readmissions. Unfortunately, some insurance companies are cutting home care benefits. The cost savings should be apparent. It has been demonstrated that end-of-the-week discharges from acute care feel abandoned and have a higher incidence of readmission.

Competing interests: None declared

Kayla I Brodkin

Often geriatric syndromes including falls, delirium and adverse drug effects remain undetected during hospitalizations. It is not until a patient is discharged home to the demands of resuming pre-hospital self- care that the inadequacy of disposition planning is identified. In addition to potential unidentified acquired functional deficits predisposing an elderly or chroncally ill individual to falling, I suspect the high rate (24.6%) of 'psychosis' responsible for <_30 d="d" readmission="readmission" rate="rate" may="may" reflect="reflect" undiagnosed="undiagnosed" untreated="untreated" delirium="delirium" from="from" the="the" index="index" hospital="hospital" stay.="stay." more="more" involvement="involvement" of="of" geriatricians="geriatricians" and="and" multidisciplinary="multidisciplinary" care="care" teams="teams" to="to" disposition="disposition" elderly="elderly" impact="impact" rates="rates" for="for" this="this" cohort="cohort" vulnerable="vulnerable" individuals.="individuals." h4="h4"/>Competing interests: None declared

Colleen M Campbell

I'm curious to know if anyone has data on readmissions of older adult patients who were originally seen in and discharged from the ED after a fall.

Competing interests: None declared

C. A. Evans

I know that they patients here are advised to see me, and even have appts. made for them with me, by the hospitalists. I am NOT capable of FORCING them to show up. The hospitalist is not capable of that either. When is someone going to take notice that the patient and/or their family has some large part in the ongoing problem?????

Competing interests: None declared

emanuel goldberg

the hospitals are now rewarded for earlier discharge. although failure of followup may be a problem it is also clear that premiums for early discharged based on arbitrary guidelines for what is a reasonable time to keep a person in the hospital will inevitably lead to early readmission. I was offerred a premium as were all attending physicians as part of a medicare program to facilitate early discharge by sharing in the "savings"i refused having seen several of my patients prematurely discharged and requiring re-admission.

Competing interests: None declared

Thomas D. Franklin

Another factor in the bounce backs is probably too early discharges. There is a tremendous amount of pressure to get the patients out the door. A more comploete predischarge mandatory checklist is a good idea.

Competing interests: None declared

R.D. Bartucci

Like any other physician familiar with the impact of the diagnosis- related groups (DRG) reimbursement paradigm upon hospital care for Medicare clients, I'm very interested in learning to what extent these high rates of unplanned readmission - and the costs associated therewith - are due to pressure upon attending physicians to get these patients discharged "quicker and sicker."

Competing interests: None declared

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