In our last post, we took a look at the new penalties that Medicare will levy on hospitals who commit the crime of readmitting patients with certain diseases within 30 days of discharge. We were astonished to find that Medicare and Obama Administration did not seem to apply any sort of evidence-based criteria when deciding upon the need for this program, nor did they bother to validate the computer model that was used in its creation. As it turns out, these assumptions were wildly off-base in terms of the degree to which hospitals vary in their readmission rates, and the extent to which these readmissions are preventable. Nevertheless there must be a bunch of low-life miscreant hospitals who deserve punishment for the lousy care that causes readmissions, otherwise Medicare would presumably have adjusted their “quality” policies to conform to reality. Just who are these foul institutions anyway, and what do we know about stopping readmissions? Kaiser Health News recently published a list of seven hospitals with worse-than-average readmission rates for all three of the conditions that Medicare will be using to determine penalties: pneumonia, congestive heart failure (CHF), and heart attack. Here are the crummy hospitals it found:
“The hospitals were:
San Juan VA Medical Center in San Juan, Puerto Rico
Florida Hospital in Orlando
Franciscan St. James Health in Olympia Fields, Ill.
Our Lady of the Resurrection Medical Center in Chicago
Beth Israel Deaconess Medical Center in Boston
Barnes Jewish Hospital in St. Louis, Mo.
Brookhaven Memorial Hospital Medical Center in Patchogue, N.Y.
Their rates ranged between 20 percent and 31 percent of patients being readmitted within 30 days of discharge.”
Huh? Beth Israel? The famous one? Barnes Jewish, the teaching hospital for one of the best medical schools in the world? Brookhaven? And since we spent some time during our last post looking at CHF in particular, let’s also consider one of the worst offenders for that condition in particular: The Cleveland Clinic.
“Nationally, the 30-day readmission rate for heart failure is 24.7 percent, according to Hospital Compare. The Cleveland Clinic’s rate, at 28 percent, is worse than the national rate. The same database shows that Cleveland Clinic’s 30-day death rate for Medicare patients with heart failure, at 8.8 percent, is better than the national rate of 11.2 percent.”
Uhm, that would be the same Cleveland Clinic that President Obama praised widely before and after his visit there in 2009, saying: “We need to learn from their successes and replicate those best practices across our country.”
Well, as Medicare measures things, maybe not.
Not long after President Obama’s comments, three investigators at the Cleveland Clinic submitted a letter to the New England Journal of Medicine, questioning the appropriateness of readmission rates as a quality measure. Their arguments were based upon the observation that, using CMS’ own data, there appears to be a strong correlation between readmission rates and patient survival. This is the figure and text they provided in support of their argument:
“We examined the association between risk-adjusted readmission and risk-adjusted death within 30 days after hospitalization for heart failure among 3857 hospitals included in the CMS Hospital Compare public reporting database (www.hospitalcompare.hhs.gov) that had no missing data… A higher occurrence of readmissions after index admissions for heart failure was associated with lower risk-adjusted 30-day mortality. Our findings suggest that readmissions could be “adversely” affected by a competing risk of death — a patient who dies during the index episode of care can never be readmitted. Hence, if a hospital has a lower mortality rate, then a greater proportion of its discharged patients are eligible for readmission. As such, to some extent, a higher readmission rate may be a consequence of successful care. Furthermore, planned readmissions for procedures or surgery may represent appropriate care that decreases the risk of death, but this is not accounted for in Hospital Compare.
These observations are consistent with a recent study of 3999 Medicare beneficiaries in California who were hospitalized at various hospitals with a principal diagnosis of heart failure. Hospitals that used more resources had lower mortality rates.”
In other words, one might be able to save money on healthcare costs by letting more patients die. That shouldn’t be a surprise.
We should note than another study published recently in the Annals of Internal Medicine and also based on Medicare data found that both readmissions and mortality fell as the number of patients seen with CHF by a given hospital and the amounts spent on the initial admission increased. It’s not immediately clear why these trends in readmissions and mortality in this study differ from those of the Cleveland Clinic. We spoke with Dr. Karen Joynt, the lead author of the Annals article, and she believes that it may be due to differences in the data sets used by the two groups of investigators, and whether the data are “risk-adjusted” or “risk-standardized”. Her own analysis actually showed only a small correlation between mortality and readmission, but it would clearly make sense to determine which study best describes reality before initiating a Medicare readmission penalty program.
But let’s put all this talk of trading lives for readmission aside for a moment. Do we know what causes readmissions to prevent them? If so, what does that cost? These questions were the topic of a July 28, 2009 Wall Street Journal article (subscription required) entitled “Cutting Repeat Hospital Trips — Simple Idea, Hard to Pull Off”. It tells the story of Bershire Medical, a hospital determined to keep its patient with CHF out of the hospital, and some patients who are either so oblivious, or so medically complex, that it seems like an impossible task
One patient with CHF who had been placed on a severely salt restricted diet for her disease:
“recalls approaching the food table at an Independence Day picnic: ‘I told the girl, “I’m going to have a hot dog. If I’m dead in the morning, I’ll never know.” In the morning she was back at Berkshire Medical Center…
But many sufferers’ care is complicated by other maladies, which can lead separately to hospital stays. Edwin Zajac, a 74-year-old retired quality-control inspector at a former General Electric Co. plant in Pittsfield, is representative. He was diagnosed with heart failure in 1995 and has diabetes, high cholesterol and atrial fibrillation, a heartbeat disorder. He has had quadruple-bypass surgery, two cancer operations and multiple hospitalizations for pneumonia and other problems.”
In response, Berkshire Medical launched a remarkably expensive and labor-intensive effort to facilitate each patient’s transition from the hospital to home. This included not only technology like a $55,000 phone system that relays patients’ daily weight, heart rate, oxygen levels and blood pressure, but also dozens of additional staff:
“The center began more aggressively reducing patients’ fluid levels before discharge, lest a salty meal land them back at the admissions desk. Instead of reminding patients to schedule follow-up visits with their doctors, staffers now book the appointments themselves and check to make sure they happen. They review medication regimens during discharge meetings, verifying that patients have enough pills to last until their upcoming checkups. Nearly half of patients are visited by a nurse within 24 hours of discharge… Nurses checked her home for tripping hazards like loose rugs. On subsequent visits, they have reviewed her medicines to make sure she’s taking her prescribed 12 pills a day. They check her blood sugar, lungs and heart, and monitor for fluid buildup by measuring the circumference of her calves.”
The good news is that these efforts appear to be paying off in terms of fewer readmissions. There are two pieces of bad news: first, none of these extraordinary efforts are reimbursed by Medicare. This means that the tab is actually being picked up by patients who self-pay, or have private. Think of it as an additional stealth “Medicare Tax” on private payers who are already overburdened with skyrocketing premiums and out-of-pocket payments. Second, if every hospital in the country where to take this approach, the cost of healthcare in the U.S. will rapidly rise beyond anyone’s ability to pay.
“…The hospital says that for 2008 alone, its 30-day rate fell to 18.6%. Among the regular visitors to its new heart-failure clinic, the rate is about 3%. Berkshire Medical figures that worked out to about 30 fewer heart-failure admissions than the year before — or, based on reimbursement of about $7,500 per case, about $225,000 in lost revenue. It estimates salaries and other operating costs of the program amount to about $500,000.”
A net cost of almost three-quarters of a million dollars for one hospital, one disease, and one year. Let’s extrapolate this to 3,100 hospitals included in Medicare’s readmission penalty program, and assume that a similar recurring annual loss will be incurred for each of the three diseases that Medicare has singled out. The resulting additional tax on Americans who are paying for healthcare privately will be over $2.3 billion annually. That’s ten times the amount of money that the Health Care Advisory board has estimated that Medicare itself would otherwise claw back from hospitals in the form of annual penalties.
There are two obvious lessons in all of this. First, that readmission rates probably have very little to do with “quality” and what went on in the course of the original hospitalization, and a great deal to do with what happens after the patient is discharged. The second lesson is that it’s a piece of cake for Medicare to obtain over-the-top quality healthcare for its own patients, as long as it’s being financed by private employers, private insurance and self-pay patients.
There is, of course, one alternative to accepting readmission penalties or forcing private payers to foot the bill for special programs. American hospitals could simply begin to decline to accept Medicare patients as long as the readmission penalties stay in place. Do any of our readers happen to know how that would pencil out for the average acute-care hospital?