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Invited commentary: Financial implications of early hospital discharge and readmission
Invited commentary: Financial implications of early hospital discharge and readmission Stephen J. Lahey, MD, Worcester, Mass
Department of Surgery, Division of Cardiothoracic Surgery, University of Massachusetts Medical School, Worcester, Mass
HOSPITAL READMISSION AFTER cardiac operation, in general, and coronary bypass, in particular, is rapidly becoming an enormously important issue to both health care providers and payers alike. Throughout the decade of the 1990s, pressure to contain health care costs, while simultaneously improving clinical outcomes, led to the identification of several high-leverage areas in the overall process of cardiac surgical care, the most important being hospital length of stay. Through decreases in length of stay, enormous cost savings were realized by hospitals performing cardiac operations. Clinicians and administrators both began to realize that those changes in process, which often led to decreased length of stay, also led to improved clinical outcomes. For example, decreased length of stay in the intensive care unit can only be accomplished through a program of early extubation. Early extubation is most effectively and reproducibly achieved through strict limitation of intravenous fluids intraoperatively, resulting in decreased myocardial edema and possibly decreased dependence on inotropic support, use of intra-aortic balloon pumps, or both. This manuscript by Bohmer et al1 represents an evolution of the many “outcomes” articles published to date. The authors have appropriately highlighted the next inevitable dilemma—what are the clinical and economic implications of implementing those strategies aimed specifically at reducing hospital length of stay? The authors’ analogy of “squeezing a balloon” is most appropriate. Accepted for publication February 15, 2002. Reprint requests: Stephen J. Lahey, MD, Chief, Division of Cardiothoracic Surgery, U Mass Memorial—University Campus, 55 Lake Ave North, Worcester, MA 01655. Surgery 2002;132:16. Copyright 2002, Mosby, Inc. All rights reserved. 0039-6060/2002/$35.00 + 0 11/58/125359 doi:10.1067/msy.2002.125359
16 SURGERY
Interestingly, Bohmer et al1 did not observe any significant increase in readmission or secondary health care services as hospital lengths of stay decreased. However, if a future global reimbursement scheme, as has been proposed, is adopted by Medicare and third-party payers for all cardiac surgical services (including any readmissions, transfers to secondary rehabilitation facilities, or both), the concept of cost shifting will become irrelevant. No longer will institutions attempt to maximize and protect their “Part A” Medicare reimbursement by decreasing length of stay and transferring patients to rehabilitation and skilled nursing facilities that, in turn, can submit separate claims to Medicare. Through global, preset reimbursement schedules, each institution will have to consider and plan for the total cost of providing cardiac surgical care, recovery, and ultimate rehabilitation. Through careful and thought-provoking analyses, such as presented in this article, institutions will have the data to begin to develop mathematical formulas, which currently exist to predict overall outcome (such as that developed by the Northern New England Cardiovascular Disease Study Group). Such formulas will help providers not only predict hospital length of stay and the likelihood of hospital readmission, but also the economic ramifications of manipulations in their systems of care. Data are currently being used to predict long-term functional outcome after coronary bypass operation. By combining standard outcome data with a more global cost analysis, Bohmer et al1 begin to adjust and refine our focus more clearly on the clinical and financial implications of what is happening in cardiac surgical care today. REFERENCE 1. Bohmer RMJ, Newell J, Torchiana DF. The effect of decreasing length of stay on discharge destination and readmission after coronary bypass operation. Surgery 2002;132:10-5.
Department of Surgery, Division of Cardiothoracic Surgery, University of Massachusetts Medical School, Worcester, Mass
HOSPITAL READMISSION AFTER cardiac operation, in general, and coronary bypass, in particular, is rapidly becoming an enormously important issue to both health care providers and payers alike. Throughout the decade of the 1990s, pressure to contain health care costs, while simultaneously improving clinical outcomes, led to the identification of several high-leverage areas in the overall process of cardiac surgical care, the most important being hospital length of stay. Through decreases in length of stay, enormous cost savings were realized by hospitals performing cardiac operations. Clinicians and administrators both began to realize that those changes in process, which often led to decreased length of stay, also led to improved clinical outcomes. For example, decreased length of stay in the intensive care unit can only be accomplished through a program of early extubation. Early extubation is most effectively and reproducibly achieved through strict limitation of intravenous fluids intraoperatively, resulting in decreased myocardial edema and possibly decreased dependence on inotropic support, use of intra-aortic balloon pumps, or both. This manuscript by Bohmer et al1 represents an evolution of the many “outcomes” articles published to date. The authors have appropriately highlighted the next inevitable dilemma—what are the clinical and economic implications of implementing those strategies aimed specifically at reducing hospital length of stay? The authors’ analogy of “squeezing a balloon” is most appropriate. Accepted for publication February 15, 2002. Reprint requests: Stephen J. Lahey, MD, Chief, Division of Cardiothoracic Surgery, U Mass Memorial—University Campus, 55 Lake Ave North, Worcester, MA 01655. Surgery 2002;132:16. Copyright 2002, Mosby, Inc. All rights reserved. 0039-6060/2002/$35.00 + 0 11/58/125359 doi:10.1067/msy.2002.125359
16 SURGERY
Interestingly, Bohmer et al1 did not observe any significant increase in readmission or secondary health care services as hospital lengths of stay decreased. However, if a future global reimbursement scheme, as has been proposed, is adopted by Medicare and third-party payers for all cardiac surgical services (including any readmissions, transfers to secondary rehabilitation facilities, or both), the concept of cost shifting will become irrelevant. No longer will institutions attempt to maximize and protect their “Part A” Medicare reimbursement by decreasing length of stay and transferring patients to rehabilitation and skilled nursing facilities that, in turn, can submit separate claims to Medicare. Through global, preset reimbursement schedules, each institution will have to consider and plan for the total cost of providing cardiac surgical care, recovery, and ultimate rehabilitation. Through careful and thought-provoking analyses, such as presented in this article, institutions will have the data to begin to develop mathematical formulas, which currently exist to predict overall outcome (such as that developed by the Northern New England Cardiovascular Disease Study Group). Such formulas will help providers not only predict hospital length of stay and the likelihood of hospital readmission, but also the economic ramifications of manipulations in their systems of care. Data are currently being used to predict long-term functional outcome after coronary bypass operation. By combining standard outcome data with a more global cost analysis, Bohmer et al1 begin to adjust and refine our focus more clearly on the clinical and financial implications of what is happening in cardiac surgical care today. REFERENCE 1. Bohmer RMJ, Newell J, Torchiana DF. The effect of decreasing length of stay on discharge destination and readmission after coronary bypass operation. Surgery 2002;132:10-5.