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When Being a "Frequent Flyer" Isn't a Good Thing

July 29, 2009
by Mark Hagland
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As federal healthcare reform legislative activity moves into a white heat of discussions and negotiations on Capitol Hill, one thing is certain: whatever plan ultimately passes Congress, if one does, there will almost certainly be incentives in the reform legislation to try to bend the healthcare cost trajectory of the Medicare program, which, without major intervention, is headed in a very tough direction for the country.

And one focus within that area will almost certainly be the chronically ill elderly, whose healthcare expenses account for as much as 75 percent of the nation’s annual Medicare costs. The term for these individuals that physicians have long used is “frequent flyers”—a term we all are familiar with from the airline/travel industry, though here applied rather ironically to healthcare delivery and financing.

The reality is stark: as the Washington Post reported at the end of last month, “Readmission costs [for this population] are staggering. One of five Medicare hospital patients returns to the hospital within 30 days—at a cost to Medicare of $12 billion to $15 billion a year—and by 90 days, the rate rises to one of three, according to an analysis of 2007 data by Stephen Jencks,” an article in the June 30 Post notes. “Within a year, two out of three are back in the hospital—or dead. Jencks consults on this issue for the independent Massachusetts-based Institute for Healthcare Improvement,” the newspaper’s article adds.

Of course, some in healthcare have long known about—and have been trying to do something about—the “frequent flyer” problem. Disease management and care management programs have been around for decades now, and have often made great progress in averting readmissions and improving the health status of high-utilizing seniors. But the reimbursement system has consistently frustrated broader progress.

Now, it appears that healthcare reform legislation might put into place a number of possible reimbursement innovations, including such concepts as accountable care groups, and possibly even medical home models, that might be piloted very soon, and that could ultimately be incorporated in core Medicare reimbursement systems.

Interest in such innovations is definitely bipartisan. But for any such experiments or innovations to succeed, they will need very intensive and extensive data and information system support. Smart CIOs and smart hospital and health system organizations are already laying the foundations for the information systems that can make innovative reimbursement schemas work. But it will take a lot of planning, development, and strong implementations in order to truly facilitate new payment arrangements.

CIOs whose organizations have already been participating in private-sector and Medicare pilot projects could have quite a leg up when it comes to being prepared to support emerging new reimbursement systems. In the process, they could become real leaders for our healthcare system, as our country attempts to seriously address a problem that continues to call out for leadership and innovation, both for the sake of cost savings and for the sake of the patients whose “frequent flying” is a sign of failure for all the stakeholders in the healthcare system.



Agreed - this is such a timely topic. Chronic disease care (not necessarily in elderly patients) is such a hot-button issue and I believe it will continue to be, particularly when questions about reimbursement are raised. Just look at how heated discussions get when there is talk of insurance plans covering weight loss and smoking cessation programs. People can be 100% in favor of a concept, but when it comes to paying for it, it's often a different ball game.

Thanks Mark, Daphne and Kate for your perspectives. I especially appreciate the link, Daphne, to the readmissions story. I appreciated the options elaborated there regarding bringing about change:

One way, he says, is to rate or score a hospital and then tweak its payments.
The second is to make the discharging hospital responsible for some or all of the costs of a re-hospitalization.
A third is to actually do some public shaming.

I'd like to also remind interested readers about my related post, a doctors view of the discharge-readmission cycle, called A Leap of Faith

Disingenuous treatment of readmission problem

I'd like to re-iterate two points:

1) A re-admission is not on the whole equivalent to poor or bad quality.  Painting it that way attributes a misleading picture.

2) In the comments I added a section that could be called, "what's a CIO to do?"  with a hospital documentation example.  If there are clearly defined, reasonable discharge criteria that are objectively met, and the patient fails the trial of out-patient management, hasn't the care provider fulfilled their obligation to quality care? 

A failure of post-discharge care,

for system reasons, (unavailable or under funded post-acute care)
for patient reasons (worsening underlying illness or non-compliance), or
for an inappropriately early discharge

require different management interventions.   HCIT can play an important role in lessening each of those causes, and can lead to critical early detection and treatment that saves lives and money.

Daphne, Kate and Joe,
Thank you all for your terrific comments!
And, Joe, I agree with you completely, we need to distinguish between readmissions and poor-quality outcomes from previous admissions. I think what's most important to keep in mind is not that a readmission is a "failure" of the system, but rather how it underscores the "fix-a-problem" mentality that runs through our health care system, and through our reimbursement system, most of all. I honestly believe that once patient care organizations are given both the responsibility and the reimbursement to take care of patients in a more holistic and comprehensive way, we'll save many billions of dollars annually because we'll be more proactive in patient care and in wellness care. Just my two cents' worth!

Great post Mark. Steve Jencks speaks so astutely on this topic. I interviewed him for my last months HCI story on readmissions. Disease management is a great option but until the reimbursement model changes, it's going to be tough.