Urgent Discharge: What's the Rush?

Rehospitalization within 30 days of an initial acute coronary syndrome or heart failure event has now become a CMS quality measure that will affect overall hospital Medicare payments. It has been appreciated for some time that rehospitalization for these diagnoses has been unacceptably high.

A recent report indicates that a greater percentage of U.S. patients who experienced a STEMI are more likely to be rehospitalized within 30 days, compared with other Western countries (14.5% vs. 9.9%, respectively). That report (JAMA 2012;307:66-74) indicates that the increase is directly related to the shorter length of hospital stay in the United States. Among the 17 countries included in the report, the average duration was shortest in the United States (3 days) and longest in Germany (8 days). Predictors of readmission other than length of stay include the age of the patient and the presence of heart failure. The most interesting part of the story is how we arrived at this state of affairs.

For those of you who were not yet born or are too young to remember when Medicare was passed into law in 1965, I will give you a little history. And for those of you who were around at the time, I will provide a reminder.

As you undoubtedly know, Medicare, in addition to paying physicians’ fees also pays hospital costs. In the period between 1965 and 1983, using a payment system that was defined as "reasonable and allowable costs," Medicare payments to hospitals increased 10-fold, from $3 billion to $37 billion. In consequence, Congress passed a law in 1982 that created a prospective payment system for hospitals using diagnosis-related groups establishing a payment schedule for specific diagnoses, which included acute myocardial infarction and heart failure. With this schedule, hospitals were paid a fixed rate regardless of the number of procedures performed or duration of hospitalization. In order to minimize costs, hospitals accelerated discharges and shortened hospital length of stay. Emergency admissions resulted in urgent discharge.

In order to expedite the process of admission and discharge, hospitalists were hired to accelerate that process since practicing internists and cardiologists were not available to push the paperwork through fast enough to get the patients discharged quickly. Hospitals saw this additional layer of doctors caring for patients as financially profitable. As a result, hospital stays decreased markedly and payments to hospitals decreased by 52% from 1985 to 1990 and by an additional 37% between 1990 and 1995. Everyone seemed to be very happy with this, including the hospitals, Medicare, and doctors. As far as I know, patients were not consulted.

Cardiologists at that time were telling themselves how benign an acute MI is and began doing accelerated discharge after percutaneous coronary intervention. We prided ourselves on how patients could be discharged to home within 24-36 hours, but never actually reached the ultimate goal of a "drive-through PCI." The fact that patients with acute MI and heart failure were frequently readmitted was good business since each admission resulted in further Medicare payments both to the hospital and the doctors. Urging by some physicians to develop plans that could educate patients and develop discharge follow-up systems was met with incredulity by hospital administrators who saw readmission as a revenue source and discharge planning as costly.

It is important to emphasize that readmission not only reflects an important morbidity event, it also carries with it the potential for increased risk of mortality. In the report cited above, one-third of the deaths after hospitalization for a STEMI occurred within the same 30-day post-event period. The recent emphasis on decreasing door-to-balloon time, although effective in shortening that period, has had little effect on the mortality associated with an acute myocardial infarction. It is reasonable to assume that in placing a greater emphasis on insuring that patients are ready to leave the hospital, we can improve mortality and morbidity of both the ACS and heart failure patient. There really is no urgency to discharge patients other than improving the bottom line, and that imperative may no longer be relevant.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Rehospitalization within 30 days of an initial acute coronary syndrome or heart failure event has now become a CMS quality measure that will affect overall hospital Medicare payments. It has been appreciated for some time that rehospitalization for these diagnoses has been unacceptably high.

A recent report indicates that a greater percentage of U.S. patients who experienced a STEMI are more likely to be rehospitalized within 30 days, compared with other Western countries (14.5% vs. 9.9%, respectively). That report (JAMA 2012;307:66-74) indicates that the increase is directly related to the shorter length of hospital stay in the United States. Among the 17 countries included in the report, the average duration was shortest in the United States (3 days) and longest in Germany (8 days). Predictors of readmission other than length of stay include the age of the patient and the presence of heart failure. The most interesting part of the story is how we arrived at this state of affairs.

For those of you who were not yet born or are too young to remember when Medicare was passed into law in 1965, I will give you a little history. And for those of you who were around at the time, I will provide a reminder.

As you undoubtedly know, Medicare, in addition to paying physicians’ fees also pays hospital costs. In the period between 1965 and 1983, using a payment system that was defined as "reasonable and allowable costs," Medicare payments to hospitals increased 10-fold, from $3 billion to $37 billion. In consequence, Congress passed a law in 1982 that created a prospective payment system for hospitals using diagnosis-related groups establishing a payment schedule for specific diagnoses, which included acute myocardial infarction and heart failure. With this schedule, hospitals were paid a fixed rate regardless of the number of procedures performed or duration of hospitalization. In order to minimize costs, hospitals accelerated discharges and shortened hospital length of stay. Emergency admissions resulted in urgent discharge.

In order to expedite the process of admission and discharge, hospitalists were hired to accelerate that process since practicing internists and cardiologists were not available to push the paperwork through fast enough to get the patients discharged quickly. Hospitals saw this additional layer of doctors caring for patients as financially profitable. As a result, hospital stays decreased markedly and payments to hospitals decreased by 52% from 1985 to 1990 and by an additional 37% between 1990 and 1995. Everyone seemed to be very happy with this, including the hospitals, Medicare, and doctors. As far as I know, patients were not consulted.

Cardiologists at that time were telling themselves how benign an acute MI is and began doing accelerated discharge after percutaneous coronary intervention. We prided ourselves on how patients could be discharged to home within 24-36 hours, but never actually reached the ultimate goal of a "drive-through PCI." The fact that patients with acute MI and heart failure were frequently readmitted was good business since each admission resulted in further Medicare payments both to the hospital and the doctors. Urging by some physicians to develop plans that could educate patients and develop discharge follow-up systems was met with incredulity by hospital administrators who saw readmission as a revenue source and discharge planning as costly.

It is important to emphasize that readmission not only reflects an important morbidity event, it also carries with it the potential for increased risk of mortality. In the report cited above, one-third of the deaths after hospitalization for a STEMI occurred within the same 30-day post-event period. The recent emphasis on decreasing door-to-balloon time, although effective in shortening that period, has had little effect on the mortality associated with an acute myocardial infarction. It is reasonable to assume that in placing a greater emphasis on insuring that patients are ready to leave the hospital, we can improve mortality and morbidity of both the ACS and heart failure patient. There really is no urgency to discharge patients other than improving the bottom line, and that imperative may no longer be relevant.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Rehospitalization within 30 days of an initial acute coronary syndrome or heart failure event has now become a CMS quality measure that will affect overall hospital Medicare payments. It has been appreciated for some time that rehospitalization for these diagnoses has been unacceptably high.

A recent report indicates that a greater percentage of U.S. patients who experienced a STEMI are more likely to be rehospitalized within 30 days, compared with other Western countries (14.5% vs. 9.9%, respectively). That report (JAMA 2012;307:66-74) indicates that the increase is directly related to the shorter length of hospital stay in the United States. Among the 17 countries included in the report, the average duration was shortest in the United States (3 days) and longest in Germany (8 days). Predictors of readmission other than length of stay include the age of the patient and the presence of heart failure. The most interesting part of the story is how we arrived at this state of affairs.

For those of you who were not yet born or are too young to remember when Medicare was passed into law in 1965, I will give you a little history. And for those of you who were around at the time, I will provide a reminder.

As you undoubtedly know, Medicare, in addition to paying physicians’ fees also pays hospital costs. In the period between 1965 and 1983, using a payment system that was defined as "reasonable and allowable costs," Medicare payments to hospitals increased 10-fold, from $3 billion to $37 billion. In consequence, Congress passed a law in 1982 that created a prospective payment system for hospitals using diagnosis-related groups establishing a payment schedule for specific diagnoses, which included acute myocardial infarction and heart failure. With this schedule, hospitals were paid a fixed rate regardless of the number of procedures performed or duration of hospitalization. In order to minimize costs, hospitals accelerated discharges and shortened hospital length of stay. Emergency admissions resulted in urgent discharge.

In order to expedite the process of admission and discharge, hospitalists were hired to accelerate that process since practicing internists and cardiologists were not available to push the paperwork through fast enough to get the patients discharged quickly. Hospitals saw this additional layer of doctors caring for patients as financially profitable. As a result, hospital stays decreased markedly and payments to hospitals decreased by 52% from 1985 to 1990 and by an additional 37% between 1990 and 1995. Everyone seemed to be very happy with this, including the hospitals, Medicare, and doctors. As far as I know, patients were not consulted.

Cardiologists at that time were telling themselves how benign an acute MI is and began doing accelerated discharge after percutaneous coronary intervention. We prided ourselves on how patients could be discharged to home within 24-36 hours, but never actually reached the ultimate goal of a "drive-through PCI." The fact that patients with acute MI and heart failure were frequently readmitted was good business since each admission resulted in further Medicare payments both to the hospital and the doctors. Urging by some physicians to develop plans that could educate patients and develop discharge follow-up systems was met with incredulity by hospital administrators who saw readmission as a revenue source and discharge planning as costly.

It is important to emphasize that readmission not only reflects an important morbidity event, it also carries with it the potential for increased risk of mortality. In the report cited above, one-third of the deaths after hospitalization for a STEMI occurred within the same 30-day post-event period. The recent emphasis on decreasing door-to-balloon time, although effective in shortening that period, has had little effect on the mortality associated with an acute myocardial infarction. It is reasonable to assume that in placing a greater emphasis on insuring that patients are ready to leave the hospital, we can improve mortality and morbidity of both the ACS and heart failure patient. There really is no urgency to discharge patients other than improving the bottom line, and that imperative may no longer be relevant.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.