It is no longer enough for hospitals to make patients healthy enough to leave. Now, as part of the Obama administration's health care overhaul, they are spending millions of dollars to keep those patients from coming back, often acting like personal assistants to help them manage their post-hospital lives.
While federal statistics show the effort is beginning to reduce costly and unnecessary readmissions, a growing chorus of critics is asking whether the government policy, which penalizes hospitals that have high readmission rates, is unfair. They are also questioning whether hospitals should be responsible for managing the personal lives of patients once they are released — or whether they should focus on other ways to improve care.
"It's consumed a lot of resources," said Dr. J. Michael Henderson, who focuses on quality and patient safety for the Cleveland Clinic, which attributes its relatively high readmission rate to the fact that it successfully treats a high number of severely ill patients.
Under the new federal regulations, hospitals face hefty penalties for readmitting patients they have already treated, on the theory that many readmissions result from poor follow-up care.
It makes for cheaper and better care in the long run, the thinking goes, to help patients stay healthy than to be forced to readmit them for another costly hospital stay.
So hospitals call patients within 48 hours of discharge to find out how they are feeling. They arrange patients' follow-up appointments with doctors even before a patient leaves. And they have redoubled their efforts to make sure patients understand what medicines to take at home.
But hospitals have also taken on responsibilities far outside the medical realm: they are helping patients arrange transportation for follow-up doctor visits, get safe housing or even find a hot meal, all in an effort to keep them healthy.
"There's a huge opportunity to reduce the cost of medical care by addressing these other things, the social aspects," said Dr. Samuel Skootsky, chief medical officer of the U.C.L.A. Faculty Practice Group and Medical Group.
Medicare, which monitors hospitals' compliance with the new rules, says nearly two-thirds of hospitals receiving traditional Medicare payments are expected to pay penalties totaling about $300 million in 2013 because too many of their patients were readmitted within 30 days of discharge. Last month, the agency reported that readmissions had dropped to 17.8 percent by late last year from about 19 percent in 2011.
But increasingly, health policy experts and hospital executives say the penalties, which went into effect in October, unfairly target hospitals that treat the sickest patients or the patients facing the greatest socioeconomic challenges. They say a hospital's readmission rate is not a clear measure of the quality of care it provides, noting that hospitals with higher mortality rates may also have fewer returning patients.
"Dead patients can't be readmitted," Dr. Henderson said.
"We're using a proxy because it's a convenient proxy — it's just not a very accurate proxy," said Dr. Karen E. Joynt, a health policy expert and co-author of an article critical of the penalties in TheNew England Journal of Medicine this month. Large academic medical centers and so-called safety-net hospitals are bearing the brunt of the new policy, and the authors warn that the penalties could make it even harder for hospitals struggling to care for those patients with the highest needs. The current policy, the article says, "has the potential to exacerbate disparities in care and create disincentives to providing care for patients who are particularly ill or who have complex health needs."
The penalties, which apply to rates of readmission after hospitalization for heart attacks, pneumonia and heart failure, are now calculated at 1 percent of hospital payments but will increase to 3 percent by 2015. Medicare also expects to expand the targeted readmissions to include more kinds of hospitalizations, like those for chronic lung disease.
Some hospitals say they have little choice but to incur the penalties, simply because they have other demands. At Boston Medical Center, which serves a high number of low-income patients, efforts to reduce readmissions, including making follow-up appointments and writing out a simple plan of what to do after leaving the hospital, have been successful for Medicaid patients.
But the medical center chose not to immediately expand the program to all patients, including the Medicare patients who would count toward future penalties.
"We make those trade-offs," said Dr. Stanley Hochberg, the center's chief quality officer. Medicare's focus on readmissions "doesn't necessarily align with our social priorities and medical priorities," he said. Medicare officials say they have listened to hospitals' concerns but defend the policy as heading in the right direction. "It's a very traumatic event to go back to the hospital," said Jonathan Blum, a senior Medicare official. "I'm personally comfortable with some imprecision to our measures."
"The ultimate goal is to have these numbers come down," he said.
Because so many hospital readmissions are tied to social or economic factors, hospitals have a hard time predicting which patients are likely to return, said Dr. Jan Berger, the chief medical officer for Silverlink Communications, a consulting firm. When Marjorie Crear, 66, left Ronald Reagan U.C.L.A. Medical Center after a stroke, she struggled to keep track of her medications and to remember her doctor appointments. Tiffany Phan, a newly hired care manager, helped with those tasks and has also been trying to find public housing with a shower instead of a hard-to-navigate bathtub.
Making it even harder for hospitals is the number of consultants and companies springing up to offer solutions with little hard evidence about which steps are the most effective. "We don't really know very clearly how to prevent more readmissions," said Austin Frakt, a health economist at Boston University.
In some cases, such prevention may take a combination of efforts that differ from hospital to hospital, said Dr. Risa Lavizzo-Mourey, chief executive of the Robert Wood Johnson Foundation, which has been financing pilot programs aimed at reducing readmissions. "One of the key factors we keep emphasizing is that there isn't a single magic bullet to fix everything," she said.
And complicating the issue even further is the possibility of doing harm. In 2011, for example, the Department of Veterans Affairs halted a program in which patients with chronic lung disease were supposed to learn to take better care of themselves when 28 patients in the program died, in contrast to 10 deaths in the group receiving typical care.
"It was just an incredible thing," said Dr. Dennis E. Niewoehner, a researcher from the University of Minnesota who said the findings were "a warning signal" for others thinking about embarking on similar programs. The higher death rate may have been purely chance, he said, but the researchers, who published their findings last year, do not know.
