Practice Management

Sneak Peek: The Hospital Leader blog – Oct. 2017

‘Sicker and quicker’ discharges are raising costs more than you think


You Have Lowered Length of Stay. Congratulations: You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. Diagnosis Related Group (DRG)–based and capitated payments expedited that shift.

Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and, as best as possible, use what measures they could as a proxy for quality (readmissions and hospital-acquired conditions). Providers balanced the harms of a continued stay with the benefits of added days, not to mention the need for cost savings.

Dr. Bradley Flansbaum DO, MPH, MHM is affiliated with Lenox Hill Hospital in New York City.

Dr. Bradley Flansbaum

However, the narrow focus on the hospital stay – the first 3-7 days of illness – distracted us from the out weeks after discharge. With the acceleration of the turnaround of inpatient stays, we cast patients to post-acute settings unprepared for the hardships they might face. By the latter, I mean, greater frailty risk, more reliance on others for help, and a greater need for skilled support. Moreover, the feedback loop and chain of communication between the acute and post-acute environments did not mature in step with the faster pace of hospital flow.

I recognize this because of the cognitive dissonance providers now experience because of the mixed messages delivered by hospital leaders.

On the one hand, the DRG-driven system that we have binds the hospital’s bottom line – and that is not going away. On the other, we are paying more attention to excessive costs in post-acute settings, that is, subacute facilities when home health will do or more intense acute rehabilitation rather than the subacute route.

Making determinations as to whether a certain course is proper, whether a patient will be safe, whether families can provide adequate agency and backing, and whether we can avail community services takes time. Sicker and quicker; mindful of short-term outcomes; worked when we had postdischarge blinders on. As we remove such obstacles, and payment incentives change to cover broader intervals of time, we have to adapt. And that means leadership must realize that the practices that held hospitals in sound financial stead in years past are heading toward extinction – or, at best, falling out of favor.

Compare the costs of routine hospital care with the added expense of post-acute care, then multiply that extra expense times an aging, dependent population, and you add billions of dollars to the recovery tab. Some of these expenses are necessary, and some are not; a stay at a skilled nursing facility, for example, doubles the cost of an episode.

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