One of the ways Democrats hope to reduce health care costs in Medicare and Medicaid is measuring effectiveness and quality, and paying accordingly.
Because Paul Ryan is a celebrity and very bold and brave, everyone just accepted his completely unsubstantiated claim that the one and only way to reduce Medicare and Medicaid costs is for the federal government to stop paying for health care, and instead have patients pay out of pocket for it.
The PPACA is still law, and the cost control measures are moving forward, although there aren’t any poorly spelled signs or people in colorful costumes attesting to that fact.
We all pay too much for health care, and we can’t keep doing that. Here’s one way to address the problem, instead of dodging it, offering up sacrifices to Ayn Rand and praying it gets cheaper:
Five of Florida’s major public and non-profit hospitals scored so poorly on return rates for Medicare patients that they will get preference this summer in a grant program to fix the problem, government documents show.
This means too many of the Medicare patients they discharged were readmitted a few days or weeks later to the same or another hospital. Federal officials see this as an indication that the patients may have been discharged too soon or without adequate plans for follow-up. It’s as if these hospitals had revolving doors.Federal officials said they identified the hospitals with the highest readmission rates in order to assure they get preference when grants are handed out to community agencies this summer to find effective strategies that address the problem.
“The thinking is that they have the most room for improvement,” said Donald McLeod, press officer at the Centers for Medicare and Medicaid Services.
What this exercise shows is the lack of coordination in the U.S. health care system, said Linda Quick, president of the South Florida Hospital and Healthcare Association. “This is historically a chronic problem that the system of episodic care creates for patients and facilities,” she said. “People go home and have no real incentive to be compliant with instructions they get from physicians or institutions and they end up returning, needing additional attention.”
CMS posted the list quietly in March on its web site, in a section describing a demonstration project that would be funded by the Patient Protection and Affordable Care Act. The project, called the Community Based Care Transition Program, invites organizations to form partnerships with hospitals to improve follow-up for discharged patients so that the readmission rate can be lowered.
The data used for the file cover hospitalizations of Medicare patients from July 2006 through June 2009, CMS’ McLeod said. They are the same data used for the profiles in the Hospital Compare web site, and they are adjusted for severity of disease of patient populations.The hospitals that scored in the bottom quartile on this list will suffer no financial consequences, he said. However, in 2013 CMS will begin a new phase in health reform, the Hospital Readmissions Reduction Program (HRRP), which will lower payments to hospitals that have high bounce-back rates.
The Community Based Care Transitions Program (CCTP) goals are; to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measureable savings to the Medicare program. The demonstration will be conducted under the authority of section 3026 of the Affordable Care Act of 2010.
Xboxershorts
Highly recommended reading for anyone who has an interest in reducing health care costs. This is Atlantic City’s pilot project for specialized delivery to high cost consumers of health care:
http://www.rwjf.org/reports/grr/056351.htm
reflectionephemeral
The US has one political party for people who are interested in policy results, and another political party for people who are heavily invested in resentment of out groups. Compare the ACA to the Ryan plan to determine which is which.
Thanks for highlighting this story, which somehow never gets told. Jon Chait had a fine post on this a while back.
kay
Thanks for finding that. I read it, and it really is good. What gets lost is how inhumane it is to keep treating people piece by (expensive, emergency) piece. They never get better. They’re full-time patients.
Jager
Make sure the staff washes their hands between patients for a start, my Dr neighbor says this is a huge problem in hospitals.
Roger Moore
@reflectionephemeral:
Fixed that for Mr. Chait.
Xboxershorts
Systemic poverty is the single most expensive problem facing society today. With it’s tendrils affecting education, health care, crime, nutrition….every aspect of society, systemic poverty contributes to the total cost for everyone.
The RYAN plan seems to pretend this systemic poverty doesn’t exist.
What a fraud.
Mudge
The Repugs are interested in neither details (see the ACA bill is toooo loooong whining) nor facts. They will rebuff both with a hand wave and a lie.
Zagloba
I’m too lazy to go digging through the internals; were the patients in question coming off of extended hospitalization or off emergency-room treatment only?
Peggy
It is not that few people pay attention to the quality of hospital care, actually many people are passionate about the issue. It’s that they are people who are sick or whose relatives are ill and they are not well organized.
Every disease has a group except for the “Old and Sick”. I’m in AARP, but I never look at what they are doing.
jl
The fragmentation of the US health care system is severe. Coordination between different inpatient services and follow-up outpatient care is difficult. Programs for discharge planning were all the rage around here recently, not because any player in the system had any reason to bother with it. Too often different providers with different areas of exposure to the expense of a readmission are involved in care after discharge. But better discharge planning program was started because of new regulations and standards.
Just in terms of cost effective (oops, sorry, death panelist) drug management, it is a nightmare, because individual hospitals and docs make drug decisions based on individual incentives only, and these are heavily influenced by big pharma marketing strategies.
Peggy
re:Zagloba
Doubt that the study dealt with Emergency Room care, because that is not considered being “admitted” to the hospital. One might arrive at the ER, say with a heart attack, but then be admitted and stay for days or weeks.
trollhattan
Looks like the final stake might soon be driven through the McKinsey “study’s” heart.
http://www.washingtonpost.com/blogs/plum-line/post/mckinsey-releases-methodology-firm-concedes-study-not-predictive/2011/03/03/AGzDV9cH_blog.html
I hope Dems keep this turd in the conversation for awhile, as an example of the rampant healthcare dishonesty being offered forth by you-know-who–the Serious Adults.
Rick Massimo
One of these entities endured two years of being accused of setting up death panels and wanting to kill Grandmas. It’s probably not who you would think.
Southern Beale
Schadenfreude, it’s what’s for lunch:
Apparently people signing up for e-mail alerts from “TeaParty.net” have been spammed for ads to by gold, silverware, reverse mortgages… guess someone knows a bunch of suckers when they see one. Thing is, this group also sponsored the media lounge at CPAC … looks like someone is running a scam on the scammers.
jl
Slightly off topic, but new study says US falling further behind other developed high income, and some less developed middle income countries.
U.S. life expectancy ranks 37th globally despite spending
Monday, June 20, 2011 Last updated: Monday June 20, 2011, 8:08 AM
BY LINDY WASHBURN
STAFF WRITER
The Record
http://www.northjersey.com/news/124172829_Life_expectancy_ranks_37th_globally_despite_spending.html
Life expectancy of U.S. women slips in some regions
LA Times June 15, 2011
By Noam N. Levey
http://articles.latimes.com/2011/jun/15/nation/la-na-womens-health-20110615
Berial
What is the thought process that thinks making individuals buy their own insurance (or simply pay for their own care directly) will drive health care costs down?
I’m sure there is some logic in thinking cost will be controlled this way, but I’ll be damned if I can follow it.
I can see thinking that ‘If everyone has to buy their own insurance they’ll try to get the best bang for the buck’ and/or ‘If everyone has to buy their own insurance they’ll all freak out at how expensive it is’.
But what makes the price suddenly go down from that? All I can see from that is a lot of people dieing from having no ability to pay for healthcare.
The Republicans are selling this as their cure all and loads of people are buying it. What is the attraction?
slag
Ding ding ding ding! Having dealt with our health care system for three different reasons recently, I could go on and on and on and on about this issue. And I’m a fairly young and healthy person. Our absurdly unorganized healthcare system helps make getting old an unhappy prospect.
Cat Lady
We need an AynRandPaulRyan tag, since my weary eyes can’t recognize the difference any more.
Villago Delenda Est
The problem is, across the board, that medical care is inherently not amenable to “market based” approaches, because the demand for medical care is nothing like the demand for consumer goods. You do not “shop around” for cancer treatment, for example.
It’s funny that “moral hazard” only seems to apply to patients, and not to people whose livelihoods depend on patients.
jl
forgot, here is link to the new article on life expectancy. Journal says it is open access, so anyone should be able to see it.
Results [from abstract]
Across US counties, life expectancy in 2007 ranged from 65.9 to 81.1 years for men and 73.5 to 86.0 years for women. When compared against a time series of life expectancy in the 10 nations with the lowest mortality, US counties range from being 15 calendar years ahead to over 50 calendar years behind for men and 16 calendar years ahead to over 50 calendar years behind for women. County life expectancy for black men ranges from 59.4 to 77.2 years, with counties ranging from seven to over 50 calendar years behind the international frontier; for black women, the range is 69.6 to 82.6 years, with counties ranging from eight to over 50 calendar years behind. Between 2000 and 2007, 80% (men) and 91% (women) of American counties fell in standing against this international life expectancy standard.
http://www.pophealthmetrics.com/content/9/1/16/abstract
ThatLeftTurnInABQ
Kay,
I just wanted delurk for a moment to thank you for the work you put in posting on a complex topic like healthcare. I rarely comment on these threads because their subject matter is well outside my professional expertise, amateur knowledge, or (thus far and thank god for that) personal experience. But I always read your posts and appreciate the effort you invest in making an often wonky topic easier to understand for us hoi polloi. Your work is appreciated in ways the comment count doesn’t show.
ETA: ..and the same goes for the other commentors who weigh in with substantive and fact-based information. You know who you are. Thanks!
Roger Moore
@Berial:
It’s the magic of the Free Market(TM), Invisible Hand(TM), etc. The problem is not that our current system is a complete failure of the market to deal with medical care. The Free Market(TM) can never fail, it can only be failed. If costs escalate indirect proportion to how little the government interferes, that’s not proof that the market sucks; it’s proof we haven’t deregulated enough.
slag
Best summary of Free Market Fundamentalism I’ve ever read. And like so many religions, there is no cure for it, which makes quarantine the only viable containment strategy.
ThatLeftTurnInABQ
@Berial:
Just a guess, but I think this is the old Victorian era moralistic argument over Malthusian-crisis issues dressed up in modern clothes. There isn’t enough to go around and so some will have to do without, and trying to help just encourages them, which makes the problem worse. This sort of moralistic logic can be applied to any rationing problem regardless of what the commodity is. Govt relief just encourages the ragged masses in their sinful ways when they should do the proper thing and just die and decrease the surplus population, already. Our latter day moralists don’t spell out quite so baldly as all that because (A) the Benthamites have learned a thing or two about crafting propaganda since the days of Dickens, and (B) we are talking about a domestic population rather than say huddled masses of potato eating Irish or starving East Indians, so explicitly exterminationist rhetoric isn’t quite kosher the way it was in the 1840s or 1870s.
JCT
This issue of patients “bouncing back” after being discharged is not a new problem. The degree of coordination that is involved when a patient leaves the hospital after even a short stay is nontrivial, especially with regards to arranging follow-up appointments (often with multiple doctors), appropriate medications (with often hopelessly complex regimens) and even something as simple as transportation home. Not to mention trying to be sure that the patient can either function independently or has services/family to help.
Even if you are young and in relatively good health this can be daunting after a hospital stay.
Now magnify it by the current state of our hospital care:
1. Patients are older and sicker when they come in
2. Often family is nowhere to be seen or cannot take off work
3. Nurse: patient ratios are down, thus less time is available for the nurse to make sure the patient understands their medical regimen.
4. Docs are under enormous pressure to limit LOS (length of stay = $$$) — this when coupled to the “sicker/older” patients creates much of the bounce-back, folks are simply discharged before they are ready.
5. Continued poor communication between the surgical and medical services on post-op patients (aka bad “hand-offs”)
Unfortunately I could go on and on.
Much of this is, in part, fueled by the lack of good, longitudinal preventative and chronic care in this country — and the cost-cutting measures are not very thoughtful. While I am the first to support getting folks out of the hospital at the first opportunity (before something bad happens…), there has to be a balance. It’s hard to achieve and in this current climate these patient merry-go-rounds flourish.
Southern Beale
Also, too: Republicans have no fucking clue what they’re talking about because they are so isolated from the real world. For example, Tennessee Gov. Bill Haslam, Republican, thinks healthcare consumers need more “economic skin in the game”:
People like this need to DIAF and be reincarnated as a single mother with three jobs and still requiring food stamps who’s on diabetes medicine and has a kid who’s disabled.
Or how about just any average person who is afraid of getting sick because they will then have to choose between healthcare and house payment/rent.
Seriously, Republicans are just too out of touch from reality.
BTW, Haslam is from a really wealthy family. He earned his money the old-fashioned way, he inherited it. So Haslam talking about how consumers are insulated from costs is just really rich.
Elliecat
“Incentive”?”Compliant”? Have you ever gone home with discharge instructions when you’re still sick or in pain?
I’ve gone home after something like a simple outpatient surgery with four or five pages of discharge instructions that were confusing, repetitive and impossible to get one’s mind around when sick or in pain (in one case, it took me about eight hours to figure out that I could safely be taking about three times as much pain med as I was).
I imagine the kind of folks in this situation no doubt have multiple medical problems and medications and possibly no help at home. Their discharge instructions might be lengthy and elaborate. Throw in someone being elderly, perhaps not super-literate, forgetful, exhausted, feeling lonely and abandoned….
I just hate this sort of blaming the (sick) patient thing. I can’t help but think that some sort of program with followup—homevisits by nurses or other trained people to lay out instructions in simple, plain language, to organize medications, set up and make clear followup appointments, etc.—might initially be expensive but after time save huge amounts in terms of return hospitalizations and the like.
jl
Decided to spend lunch looking for international data on readmission rates, with no luck yet.
But here is an interesting post from a very centrist health policy thinktank, rebutting some GOP Congressional nonsense on health care.
Putting Lipstick on U.S. Health Expenditure Data
Richard B. Saltman
http://healthcarecostmonitor.thehastingscenter.org/richardsaltman/putting-lipstick-on-u-s-health-expenditure-data/
jinxtigr
Next up, hospital emergency rooms refuse to accept repeat customers to protect their own funding, in “No-one Could Have Foreseen These Consequences!”
flounder
Sounds like part of the problem is people are discharged with instructions and then they don’t follow them, and part of the solution pushed by Obamabi is making providers follow up to encourage people to follow through on their treatment.
Too bad everyone important knows that hassling people to finish their antibiotics after being sick or keeping up their exercise after knee replacements is the ultimate in tyranny and communistic thinking.
jl
Here are interesting stats from Commonwealth funds international health surveys.
US has fewer reported gaps in discharge planning that any other developed high income country surveyed.
But patients with chronic illnesses and recent hospitalizations report more readmissions for complications after discharge:
US: 18%
Canada, Netherlands: 17%
Australia, New Zealand: 11%
UK: 10%
Germany: 9%
France: 7%
2008 Commonwealth Fund International Health Policy Survey of Sicker Adults
http://www.commonwealthfund.org/Content/Surveys/2008/2008-Commonwealth-Fund-International-Health-Policy-Survey-of-Sicker-Adults.aspx
jl
@30 flounder – June 20, 2011
I agree. But some commenters here assuming that most of it is patients’ fault. I’m not so sure.
My impression is that many patients need some kind of physical rehab therapy or skilled nursing care before going home, and that it is very difficult to schedule that. Result is patients sit in hospitals waiting for space (at great expense), or sent home without tools to follow instructions safely (in terms of either following medication protocol, or simply not falling down or starting to bleed when they try to follow instructions, so risking readmission)
Evolved Deep Southerner
@ Xboxershorts
Your ass had better be glad eemom’s not on here right now. She’d dog your ass over that superfluous apostrophe.
Roger Moore
@jl:
Why do I suspect that the key word in that sentence is “reported”? Maybe that statistic would change radically if we had health care monitoring worth a damn, rather than trusting the hospitals to tell us about their mistakes.
Triassic Sands
This is a curious statement indeed. Wouldn’t the primary incentive anyone would have to “be compliant with instructions” they get from doctors be their own desire to feel and get better? Are we really so completely dominated by the dollar that money is the only thing that can get us to make sensible medical choices?
To some extent, I fear, the answer may be “yes,” but we need to change that. Should someone stop smoking because it is bad for them (and everyone around them) or because it is expensive? Should someone take medications as directed because to do so will improve their health or because they paid a lot of money for them?
If the answers to these and similar questions favor the financial incentive, then the stupidity and ignorance of the American people has probably reached a point where it’s time for evolution to weed us out.
jl
@34 Roger Moore – June 20, 2011
The reported gaps were from a patient survey. So it was recently discharged patients reporting on whether they were given a written treatment plan, were told who to call if something went wrong, etc.
So, I think US probably on par or better than the other countries included in the survey.
I think the following explanation is more likely: the US health care industry is so fragmented and inefficient, that even if the US performs better on certain measures (for example, that specific measures giving the patient a written treatment plan and instructions), those measures make little difference in outcomes.
How much difference does a written treatment plan and instructions make, if you should not have been discharged in the first place? Or, you should have been discharged to rehabilitation for two or three days, but were sent straight home because rehabilitation had no space for you.
El Cid
__
Not only will they kill the elderly with Death Panels, now they’re gonna stop you from going back to the hospital if you’re still sick!
The Democraps are trying to kill us all to impose Sangria law by Kenyonesian shock homo troops who will give us all abortions.
Mnemosyne
That’s the incentive, but my question is how many barriers are thrown up for people who want to be compliant but run into trouble? Can they call that doctor, or an advice nurse, or someone who can tell them what to do if the medication makes them start vomiting uncontrollably at 5 a.m.? Or are they unable to get through and have to use their own (possibly impaired) judgement to figure out what to do?
If you’re sent home with instructions that you don’t understand or have trouble complying with because of complications that arise at home and there’s no one you can contact to help you, it’s almost as useless as not being sent home with instructions at all.
genghisjon
Until we can get rid of this.I was told by a nurse at mayo in rochester minn that being on the bottem rung of the ladder I should expect to be treated like this.At another timeI was treated for for hep c,it was the worst fucking expirence of my life.They screwed up tests,tryed to blame others,did’nt due tests for problems I had told them about.It became a nightmare.
Just because your at a major clinic dos’nt mean mean you are going to get major care.
Monala
@ El Cid (#37): They already used that one on Michelle Obama during the ’08 election cycle. One of her jobs at the community liaison director (or some such title) for the University of Chicago Medical Center was to try to connect emergency room patients with primary care clinics and doctors, thereby helping them get care before their conditions turned into emergencies. I saw more than one article screaming about how Michelle O. was trying to deny people hospital care.
mclaren
Well said. The big problem here is that measuring the effectiveness and quality of health care is extremely difficult, verging on impossible.
The most effective health care is preventive care. That’s health care that heads off hugely expensive illnesses. But really good preventive health care only shows up with negative results many years later — how do you measure that?
Arguably the single best form of preventive health care in America would be to change American eating habits. Get rid of fast food entirely, ban pizza, ban stuff like calzone (“heart attack on a plate”). Eliminate sugary high fructose corn syrup-laden carbonated sodas entirely.
This would pay off in a huge reduction in coronary artery disease but that immense reduction decades later wouldn’t show up for 20 or 30 or 40 years, and moreover, the public wouldn’t stand for it. Being told you can’t eat pizza and you can’t eat a McDonalds sludgeburger would cause an armed revolution in America.
The closer you get in time to the death of the patient, the easier it is to measure health care outcomes (did the patient die or recover?) but the harder it gets to measure true effectiveness. Consider: spending $100,000 on a team of life-saving surgeons to prevent a terminal cancer patient from dying tomorrow is a great outcome, but the effectiveness is nil, ’cause the terminal cancer patient is gonna die anyway.
Kay means well, but Democrats have to face the brutal reality that the areas of society in which costs are exploding are exactly those areas in which effectiveness is difficult or impossible to meausre.
Costs are exploding in American higher education and in American health care. Both of these are notoriously difficult to measure effectiveness. What a graduate does with a 4-year college education turns out to have a lot to do with the student; a clown like Dubya can go to Yale and learn nothing. The effectiveness of any given medical treatment turns out to have an enormous amount to do with ancillary and seemingly trivial policies followed by the hospital: for example, instituting a simple checklist for surgeons and nurses turns out to dramatically reduce post-op infections and fatalities. This is entirely separate from the success of the surgery.
It’s an open question whether it’s even possible to significantly increase the effectiveness of health care in America without changing a lot of the rest of American society. I’ve mentioned high-fructose soft drinks and fast food; but Americans work a lot longer than people in other countries and take many fewer hours of vacation per year. America has one of the worst infant mortalities in the developed world, mainly due to the extreme poverty of American single women with children. To significantly increase the effectiveness of American medical care, we will probably have to change other aspects of our society as well.
In fact, the single most effective health care procedure in the last 200 years was improving public sanitation. Cholera epidemics used to run rampant throughout England and America until public health officials realized it was a good idea to locate wells far from sewers. Then, suddenly, all the cholera epidemics stopped.
These are the kind of complex issues that no one seems to want to talk about. Effectiveness of health care is inextricably linked to public health, and therefore to issues like the gap twixt the rich and poor in America, the quality of our infrastructure, and so on.
mclaren
Here’s a link to a study showing that a simple checklist has the potential to prevent 45% of post-operative fatalities.
Doctors have a god complex and believe that they couldn’t possibly forget to perform simple procedures. But they’re human, and they do. Trouble is, doctors don’t want to admit that, so they resist things like this simple checklist with ferocious tenacity.
kay
Hah! Last year I was a shill for the insurance industry, or that was your fact-free determination of my motive.
I think we’re making a lot of progress, mclaren :)
Incidentally, it doesn’t make any sense to claim we can’t save money on health care by measuring the effectiveness of practice, and then link to a check-list.
The whole point of the check-list you cite is to reduce infection and limit readmission.
HHS or Medicare-Medicaid aren’t going to mandate a check-list, but they are going to measure readmission rates. If hospitals get there by using a check-list, that’s just dandy.
The education comparison is faulty, too. I can measure higher education on several metrics, like graduation rates overall and graduation rates in 4 years. Those stats are widely available and everyone uses them. I would do that, too, because I don’t want to waste tens of thousands of dollars on a school that doesn’t graduate anyone.
Nancy Irving
I hope they’ll base the statistics on whether a patient was readmitted to *any* hospital, not just to the hospital that discharged them.
Otherwise, you’ll probably see a musical chairs game of passing patients among different, poorly-performing hospitals in a mutual attempt to pass the buck.
portia
Long time reader, new commenter here, because this is such a great post and most of the comments have been so thoughtful.
I work in Quality & Patient Safety at a large hospital. I also happen to be a patient at the same hospital today, as my daughter had an emergency appendectomy late last night. We’ll go home today with a one-page discharge instruction sheet that has been carefully written to be understood by anyone with a 5!th-grade reading level. All of the consent-to-treat forms I’ve signed are written the same way so I know exactly what’s been done and why, as well as potential complications.
My PCP uses EMR, and is working to get their system to communicate seamlessly with this hospital’s system. Until then, they’ve been in phone contact 4 times in the last 18 hours. They will call me tomorrow after we’re discharged to schedule a follow-up appointment. We probably won’t need to see a specialist at the hospital again, but when we did, for a heart problem my daughter had surgery for here 18 months ago, we had an appointment with her cardiologist set before we went home. If we have a problem, we live 5 minutes from the hospital and its clinics; some of our patients live more than 5 hours away, with no nearby physician.
And this year, we’ll add readmissions to the quality metrics that we track and analyze to identify the at-risk patients and, hopefully, effective interventions. Thanks to PPACA funding, we have pilot projects in the work to coordinate care for a specific set of patients from point of admission to 6-months post-discharge with a highly complex multidisciplinary team of providers and EBM-based care bundles.
(Aside: surgical checklists are now part of several quality-scorers’ requirements, FYI. I don’t know if they’ll rise to the CMS level, but TJC will make them an accreditation standard, if they haven’t already.)
My points are these: effectiveness measures work, and are evolving rapidly. Patients currently have all the incentive they need to follow instructions: they would like to avoid going back to the hospital, if they can. What they lack is the instructions, coordinated care teams, reconciled medication lists, and support that they need. Happily, ALL of these things are going to start moving rapidly, thanks to the ACA.