“An era of restricted revenue”
“The business case for lowering inpatient length of stay”
“As hospitals and healthcare systems pinch pennies”
“The number of avoidable days relative to a benchmark”
“Diagnosing efficiency benchmarks”
Much of the healthcare sector is now focussed on reducing length of stay in hospitals. A key element of healthcare reform is both denying payment to and penalizing hospitals for “inappropriate readmissions.”
This can be good for individual patients as well as for the economy. Hospitals can be very dangerous places to be. Robert Pearl, MD, highlights 4 key reasons for that.* It is the 4th that should raise a cautionary note about this trend: “Hospital stays sometimes result in problems after discharge.”
We’ve seen this potentially combustible mix before. It was then called “deinstitutionalization.”
By 1965, newspaper and movie horror stories had gained enough traction to push politicians to close state facilities and move psychiatric patients into nursing homes and community care. These moves were predicated on the development and provision of adequate community care.
Deinstitutionalization did improve the lot of millions living with “intellectual and developmental disabilities.” It allowed them to escape intolerable conditions in these hospitals and to live with proper support and without stigma. But it was a very different story for Americans suffering from severe mental illness.
And California became “the first state to witness not only an increase in homelessness . . . but also an increase in incarceration and episodes of violence.”
In 1972, a “California prison psychiatrist . . . claimed to be ‘literally drowning in patients . . . who have serious mental problems.’”
“A study of . . . patients discharged . . . between 1972 and 1975 found that 41% of them had been arrested [and] the majority . . . had received no aftercare following their hospital discharge.”
Nationally, by “the mid-1980s, 23% of nursing home residents . . . had a mental disorder.” There was no comparable increase in training or resources. It is estimated that 1/3 of the homeless and 16% of the total jail and prison population have schizophrenia or bipolar disorder.
In 1984, the New York Times reported, “The policy that led to the release of most of the nation’s mentally ill patients from the hospital to the community is now widely regarded as a major failure.”
Today’s healthcare reform is similarly predicated on the provision of appropriate aftercare. Hundreds, perhaps thousands, of apps, techniques and approaches are under development to improve home care and prevent the now-costly readmissions.
Again it is assumed that the market, our states and our communities will provide what hospitals up to now have not. As of Aug 28, 2014, 23 states – only 2 short of ½ – had not elected the Medicaid expansion under the ACA – a bad omen.
Not only was there a failure of will to provide adequate aftercare support for the seriously mentally ill. There was also what an author referred to as “one awkward reality”:
“[T]he economic case for deinstitutionalization – highly appealing to both fiscal conservatives and civil libertarians – turned out to be almost entirely wrong. . . . Effective community-based supports are generally superior to institutional care. They aren’t necessarily cheaper; often the opposite is true.”***
So whither 21st century American healthcare reform?
* Robert Pearl, MD, “4 reasons why hospitals can be very dangerous places to be”
** E. Fuller Torrey, MD, “Ronald Reagan’s shameful legacy: Violence, the homeless, mental illness”
*** Harold Pollack, “What happened to U.S. mental health care after deinstitutionalization?”