Hospitals Torn On Reducing Repeat Admissions
What doesn't kill you, only makes you a repeat customer.
It's no joke to the health care system, though. Repeat customers to hospitals are seen as a big problem. But it's complicated. Sometimes the hospitals themselves may profit from some patients' frequent visits. But it costs a lot money for the people who pay hospitals: Medicare, Medicaid and private insurers.
As with many other problems in the health care system, unnecessary hospital readmissions are associated with worse treatment and health outcomes as well as higher costs to taxpayers — as much as $17 billion a year by one estimate.
Starting next fall, the Department of Health and Human Services will begin penalizing hospitals if their Medicare readmission rates are higher than expected for three conditions: heart attacks, heart failure and pneumonia. In the first year that penalties kick in, 1 percent of hospitals' a Medicare payments will be withheld, and the amount will increase in subsequent years.
Hospitals are working on ways to combat readmissions. On a recent weekday, Josuely Claudio, visited a clinic at Mount Sinai Hospital in New York that targets patients with complicated, chronic health problems who come in way too often.
The 53-year-old has congestive heart failure, diabetes, high blood pressure and a stomach problem that makes him gag almost constantly. "Sometimes I dehydrate, and I don't know if it's my blood glucose or high blood pressure, low blood pressure," Claudio says.
He was inconsistent about taking insulin and various medications, keeping doctors' appointments and maintaining a healthful diet. So when Mt. Sinai created its Preventable Admissions Care Team, or PACT, last year, Claudio was a natural candidate. He joined in late 2011 and has had biweekly visits to the clinic.
Usually he meets with a social worker and nurse practitioner, and occasionally sees a doctor. The idea of this transitional care is to make patients more self-sufficient and not wind up in the emergency room.
Mt. Sinai's readmission rates for heart failure are among the worst in the nation. Hospital administrator Claudia Colgan challenges how the federal data on readmissions are gathered, but she concedes that getting readmissions down is a top priority. It will take a major "culture shift" to do it, she says.
Historically, readmissions have been lucrative for Mt. Sinai — and for many hospitals.
Sure, paying for avoidable care might be bad, if you're the government or a private insurance company. For those being paid, repeat customers like Claudio are money in the bank. Dr. Eric Coleman, from the University of Colorado, says for too long hospitals have benefited from a system that rewards them for excessive care. A hospital might get 15 to 25 percent of its revenue from readmissions.
But Dr. Ashish Jha, in the latest New England Journal of Medicine, argues readmissions aren't the best indicator of unnecessary care — even though they're an easy target for budget-cutters. The Harvard University professor notes many of the hospitals with the highest readmission rates also serve the poorest areas with the biggest health problems.
"Readmissions are caused by what hospitals do, who the patients are, and what's happening in the community," he says. "You want hospitals to fix the things they can, but you don't want to punish them for taking care of poor people, and you don't want to punish them for being located in a poor area."
There are some signs Mt Sinai's work is getting results. In the program's first full year, its 500 patients have had a 40 percent drop in readmissions and a 55 percent drop in emergency room visits.
In the 12 months before he joined the PACT program, Josuely Claudio had 20 emergency room visits and overnight admissions. Mt. Sinai billed Medicare almost $140,000 for his treatment. In the last 12 months, he's had seven emergency room visits and overnight admissions, costing taxpayers a little more than $54,000.
Mt. Sinai is absorbing almost all of the costs of those twice-a-week clinic visits. The PACT program this year will cost the hospital about $1 million, and it's not clear how long Mt. Sinai can foot the bill for PACT — especially, if it turns out to be cheaper just to pay the penalty.
MELISSA BLOCK, HOST:
This is ALL THINGS CONSIDERED from NPR News. I'm Melissa Block.
LYNN NEARY, HOST:
And I'm Lynn Neary. Millions of Americans are discharged from hospitals each year, only to return within 30 days. As many as three-quarters of those patients had problems that could have been prevented.
The 2010 health law is designed to discourage these so-called readmissions and a new study says government policy needs to focus even more on reducing the financial incentives to readmit patients.
Fred Mogul from member station WNYC reports.
MARY MCDONAGH: Your blood pressure is pretty good.
FRED MOGUL, BYLINE: Fifty-three year old Joseuly Claudio comes to see nurse practitioner Mary McDonagh about twice a week.
MCDONAGH: We'll check and see how your lungs are.
MOGUL: Claudio has congestive heart failure, basically a very, very weak heart, plus diabetes, hypertension and severe gastroparesis, a stomach problem that makes him gag constantly.
JOSEULY CLAUDIO: Sometimes, I dehydrate and I don't know which one it is, so I don't know if it's my blood glucose or my high blood pressure, low blood pressure.
MOGUL: Claudio is at a clinic at Mount Sinai Hospital in Manhattan operated by its Preventable Admission Care Team, or PACT. PACT tries to make Mount Sinai's unhealthiest Medicare patients more self-sufficient.
Claudio's been coming to the PACT clinic for more than a year, but Nurse McDonagh says he still needs to be treated with kid gloves.
MCDONAGH: We don't want to put him into pulmonary edema and we want him to know he can come here rather than the emergency room when he doesn't feel well.
MOGUL: Starting next fall as part of President Obama's health care overhaul, Washington will cut hospitals' Medicare payments by one percent if too many discharged patients are back in an overnight bed within 30 days.
Mount Sinai Hospital administrator Claudia Colgan says getting readmissions down is a top priority and it'll take a major culture shift.
CLAUDIA COLGAN: If you are the doctor that's on call and a patient that you have never met before calls and says I have these symptoms, the likelihood is you're going to say, you know what? Go to the emergency room. And what we've really tried to do is not have that happen.
MOGUL: Historically, readmissions have been very, very good to Mount Sinai and to many hospitals. Sure, paying for avoidable care is bad if you're the government or a private insurance company writing the checks for hospital care, but if you're the one being paid - well, repeat customers like Claudio are money in the bank, according to Dr. Eric Coleman from the University of Colorado.
DR. ERIC COLEMAN: There are conflicting incentives when it comes to this problem of hospital readmission. Depending on what part of the country you're in, a hospital might rely on readmissions accounting for anywhere from 15 to 25 percent of their revenue.
MOGUL: Medicare is initially focusing its hospital penalties on readmission rates for three conditions: congestive heart failure, heart attacks and pneumonia. But Dr. Ashish Jha, in the latest New England Journal of Medicine, argues readmissions aren't the best indicator of unnecessary care, even though they're an easy target for budget cutters.
The Harvard University professor says many of the hospitals with the highest readmission rates also serve the poorest areas with the biggest health problems.
ASHISH JHA: Readmissions are caused by what hospitals do, who the patients are, what's happening in the community and you want hospitals to fix the things that they can, but you don't want to punish them for taking care of poor people and you don't want to punish them for being located in a poor area.
MCDONAGH: So we've got good (unintelligible). No dehydration.
MOGUL: Back at Mount Sinai, there are some signs the PACT program is paying off. In the program's first full year, its 500 patients have had a 40 percent drop in readmissions. Patient Joseuly Claudio says one recent evening when he was feeling dehydrated, he didn't dial 911 as he might have a year ago. He's learned to gauge his symptoms better, so he went to sleep and waited for the PACT clinic to open on Monday.
CLAUDIO: I feel more at ease because I have them. I try not to panic, and if it gets worse, I'll call them and they will tell me to come here. Maybe I just need the fluids so I don't have to go to the emergency room.
MOGUL: But Mount Sinai is absorbing almost all of the cost of his twice-a-week clinic visits and it's not clear how long the hospital can foot the bill, especially if it turns out to be cheaper just to pay the federal penalty.
For NPR News, I'm Fred Mogul in New York.
NEARY: This story is part of a reporting partnership between WNYC, NPR and Kaiser Health News. Transcript provided by NPR, Copyright NPR.