Consider four psychiatric patients, all discharged from an inpatient unit on the same day following stabilization of an acute psychotic episode. A week later, the following events takes place:
Arnold’s symptoms return and in despair he commits suicide.
Barbara’s symptoms return and she goes on a cocaine binge, fueling her aggressive tendencies to the point where she punches a cop, landing herself in jail.
Carlos’s symptoms return and he becomes convinced that his apartment is full of listening devices. He moves to living under a bridge far from town.
Derrick’s symptoms return, and, having learned about his illness in the hospital, he recognizes the problem and returns to his site of care. He is admitted for 24 hours, re-stabilizes, and is then maintained as an outpatient in the community.
So, why would some powerful players in our health care system consider Derrick to have had the worst outcome? Because he and not the others was re-admitted to care within 30 days of discharge.
This situation is not unique to psychiatry. Last week, I went to a meeting of cardiologists who are grappling with the same reality. Medicare ratings, consumer groups and an increasing number of insurers are pressuring cardiologists to have shorter lengths of stay and fewer rapid (i.e., within 30 days) readmissions. The desired outcome has become a measure of health care utilization rather than health. As this tail increasingly wags the dog, hospitals face some perverse incentives. If you aggressively monitor your patients after discharge, you are more likely to catch a symptom that warrants re-admission (Presuming you have this funny idea in your head that the health care system should try to save people’s lives). Likewise, if the hospital is in a location that provides easy access and its admission procedure poses minimal burearaucratic barriers — normally things we would cherish — re-admission is more likely and the hospital’s rating and level of reimbursement may go down.
If you follow the logic of the anti-readmission crowd out, you arrive at the conclusion that the best hospitals are those that close and those that kill every patient on the surgical table, because both types of facilities have a re-admission rate of zero.