The cost of recurring care

Many hospitals are judged by how few recurring patients they see.

For most businesses, attracting repeat customers is a primary goal. A loyal clientele often translates to stocked cash registers and word of mouth advertising that’s hard to beat. But unlike the retail or culinary worlds, the medical field is different. Doctors, nurses and clinicians do their best to see as few returning patients as possible, hoping that once a patient leaves, he or she will remain well enough to never need treatment again.

Unfortunately for a small number of patients repeated hospitalization for recurring problems is needed. Not only do these return visits cause a good deal of emotional strain for the patients and their families, but they’re responsible for a sizable portion of the nation’s growing medical costs as well. The Journal of the American Medical Association (JAMA) recently released a study showing that a small group of recurring patients (about 2.9 percent) were responsible for nearly 20 percent of hospital admissions, and almost one-quarter of inpatient charges. All together this small population of “frequent flyer” patients are costing the health care system close to $3.4 billion.

Of course there are complex and chronic conditions that require recurring treatments like chemotherapy or dialysis, but the JAMA report shows many of the readmissions of children who are continually in and out of the hospital might have been avoidable with improved inpatient and outpatient care coordination, care planning and community health care support.

Jay Berry, MD, MPH

To explain why a relatively small percentage of patients are contributing disproportionately to medical cost, and what can be done to rectify the problem, Jay Berry, MD, MPH, a hospitalist from Children’s Hospital Boston’s Complex Care Service and lead author on the study, has been blogging on the subject. The following is an excerpt of his writing, taken from an ongoing series published by Vector, Children’s Hospital Boston’s science and innovation blog.

Everywhere you turn these days, there’s an airline, grocery store or coffee shop pushing a “frequent flyer” or “rewards” program. You know the gist – the more money you give these businesses, the more discounts they give back to you and the more money you “save.” In theory, these programs are win-win: customers like frequenting the same business; businesses love holding onto satisfied customers.

But when I was a medical student, and overheard a nurse call my patient a “frequent flyer,” I wondered, “Who gets the ‘reward’ in that frequent flyer deal?” I hoped this child, a 4-year-old boy with cerebral palsy, was benefiting from being admitted over and over again.

I asked around: “Hey, why is this kid admitted so frequently?” The nursing staff was miffed. “It’s just ‘him.’ That’s just the way it is.”

I asked my attending physician, who was ultimately in charge of the patient while in the hospital. “I don’t know. I only work in the hospital a few weeks a year. I’ve never admitted this patient before. I don’t help care for this child in the community.”

The boy’s parents told me, “When we’re here in the hospital, he does just fine. But when we go home, he always gets sick again.”

That seemed odd. What was triggering this child (who I’ll call Jim) to become repeatedly sick at home? His hospital health records showed four hospitalizations within the last year – all for vomiting. He had a feeding tube in his stomach to receive nutrition. Why would his vomiting always get better when he was admitted and get worse at home?

To see the entire series, visit Vector and learn more about “Jim”, his treatment and the efforts Children’s staff is making to lessen the number of “frequent flyer” cases they see. Are you the parent of a “frequent flyer” patient? Have ideas on ways Children’s staff can improve both inpatient and outpatient care to help cut down on recurring visits? Please let us know via the comment sections here and at Vector.