Alex Azar's Hospital Readmission Is Costly, Not Just Embarrassing

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Alex Azar, our Health and Human Services Secretary, was readmitted to the hospital two days after being discharged with diverticulitis. It shows that in some way medicine is very democratic and that a VIP faces the risk of readmission just like everyone else. 

Diverticulitis is an infection of diverticula, small abnormal outpouchings of the large intestine. Material gets trapped in the pockets and an infection results, one that most frequently responds to intravenous antibiotics and then is followed by five to seven days of oral antibiotics after discharge. The concern with diverticulitis is that the infection may cause these outpouchings to rupture and spread infection within the abdominal cavity itself. That complication requires more invasive care to drain the abscess and usually, at a later date, removing the diseased portion of the large intestine. 

Readmission for diverticulitis runs in the range of six to ten percent, far less than for congestive heart failure which is often three times greater. Readmissions are essential for two reasons. First, they may represent inadequate care during or after hospitalization. In this case, if Azar were discharged and still had an elevated temperature or white blood count (the cells that fight infection), both measures of the acuity of infection; it would represent inadequate care while hospitalized. Or there could be insufficient follow up after discharge. Discharging a patient from a hospital involves handing off responsibility from the hospital team to the primary physicians in the community. Because our electronic health records are not linked as well as they might, discharge instructions and medication changes often are delayed in being communicated or may never be communicated at all. Inadequate communication is a significant source of readmissions although it is improbable in Azar’s case as he is very well connected medically speaking. The most likely cause of his readmission is that his condition got worse despite appropriate therapy, in the medical world – a recognized complication promptly addressed. 

The second reason readmissions are important is because they are costly and usually doubling the cost of care. You can see how inappropriate hospital care or discharge handoffs that fall through the cracks are the types of medical errors that are unacceptable, correctable and can reduce costs. One of the initiatives during the Obama administration was the institution of penalties to hospitals for readmissions, the thought being that a penalty would make hospitals more careful about discharging too soon or inadequately coordinating care after discharge. The results have been a mixed bag suggesting that the stick part of the carrot-stick equation is not always effective in changing behavior. 

Hospitals have been unhappy with readmission penalties for a number of reasons. They can be costly, and HHS can “claw back” up to 3% of their payments roughly a half a billion dollars in 2017 for heart failure, heart attacks and pneumonia –the three largest reasons for medical hospitalization covered under the readmission penalty program. These penalties impact about half the hospitals in the U.S. and most of the hospitals are repeat offenders, only 7% were new to the penalties in 2017. Hospitals are penalized irrespective of the cause of readmission if you were admitted for pneumonia and then broke your hip and returned to the hospital, that counts as the readmission. And finally, the source of a lot of readmissions is in the follow-up care, something that hospitals may need to coordinate but cannot control.