By Bernadine Healy, M.D.
As President Obama has it, the nation's sick house is putting us into the poorhouse, and medicine seems not too far behind Wall Street in bringing on our economic woes. Thus, with a few swoops of the presidential pen, Obama has already laid the groundwork for a massive overhaul of America's healthcare system into a more publicly managed, cost-conscious enterprise that focuses more on wellness than sickness. And wellness does come cheap. Driving most government outlays, however, are the many millions of Americans—particularly the elderly—with extremely resource-intensive chronic diseases.
So far, no pain: The reform process meant to reduce the nation's $2.2 trillion annual healthcare spending currently has many belts expanding, not tightening. Billions are being poured into the proposed pillars of health reform—a national electronic medical record for all and comparative-effectiveness research programs that will guide more standardized and coordinated care. Some are skeptical that these will cut costs, but the jury's still out. What's tried and true, however, is the government's power to restrict reimbursement as a means of changing medical behavior. Medicare, which covers virtually all of the elderly by fiat (if elders don't buy into it, they lose their Social Security) has the power to say "No" to expensive treatments. That's great if the care is unnecessary. But the rub is that you can't always tell when you're not at the bedside or if you don't know the medical facts about a given patient.
[Is a call for comparative effectiveness really a call for rationing?]
A classic example of this carrot-and-stick approach is the one President Obama singled out in his February budget request to Congress. To reduce the rate among the elderly of costly readmissions to the hospital after discharge, he laid out a plan to limit Medicare reimbursements if patients are back within 30 days. The budget office scores this as a savings of $26 billion of "wasted money" over 10 years.
No doubt too much hospital is bad for anyone. And the rising readmission rates of elderly patients have led doctors to find better ways to control disease flare-ups, which has resulted in some success at lowering readmissions for heart failure in particular. But some analysts see readmission as a blanket sign of a badly functioning medical system. Others surmise more darkly that it's a gaming of the system, with patients kicked out of the hospital prematurely, only to be readmitted when their payment clock restarts. I'd suggest the reasons are not so venal: As the length of stay in the hospital for acute illnesses has shortened and medicine has advanced, the elderly are living longer with serious and chronic infirmities.
Earlier this month, Stephen Jencks from Northwestern University Feinberg School of Medicine and colleagues analyzed the cases of more than 2 million Medicare patients who were readmitted to the hospital. Roughly 18 to 20 percent of patients were back within 30 days of discharge and 60 percent were back within a year. What's sobering about the findings is that the readmitted patients were really, really sick. In fact, 90 percent of the readmissions during the first 30 days were emergencies.
The conditions most apt to be associated with readmission were heart failure, pneumonia, emphysema, and psychotic breakdowns. Typically, flare-ups of the same or similarly grave conditions brought people back. For example, readmission of those previously in the hospital for congestive heart failure were triggered by another bout of heart failure or heart attack, cardiac arrhythmias, pneumonia, kidney failure.
A sudden struggle for breath in someone with serious heart or lung disease can mean acute deterioration that, left unattended, would lead to an imminent and needlessly cruel demise. It's a call that can be made only by the medical team caring for the patient. Checking the chart to see if the patient has been hospitalized for the same problem recently is routine; such an event indicates a more intractable condition and might even encourage readmission. If that chart check instead results in a decision not to readmit, because of fears of financial penalties or bad performance marks, we've created an ethical monster.
Automatically assuming that readmissions indicate poor hospital care is flawed for other reasons. There's no evidence that the quality of care during the first admission is a significant factor. Instead, some have suggested that it's post-hospital care that's lacking. For example, half of those readmitted within a month in the Northwestern Medicare study had not seen a doctor after leaving the hospital. At first this is concerning—until you realize that Medicare data, however voluminous, do not capture scheduled appointments pre-empted by an emergency hospital visit or phone conversations with physicians that lead to readmission. (Unlike lawyers, doctors don't send bills for telephone calls.)
Others blame an uncoodinated health system. But however sensible it might be to integrate a new level of clinical coordination into post-hospital care to help the elderly, such a move may not save Medicare money or prevent rehospitalizations. The Centers for Medicare and Medicaid Services set up 15 demonstration centers involving 18,000 patients around the country to run controlled trials on different models of care coordination. The results, published in the Journal of the American Medical Association in February, were disappointing: Patients felt better, but the effort had little or no effect on hospitalizations and, if anything, increased Medicare costs. Other countries, with different models of coordinated, single payer, socialized systems of health care, from Canada to Great Britain, Switzerland to Australia, struggle as much if not more than we do with a steady rise in hospital readmissions.
What all medical systems may be fighting here is the formidable nature of disease itself and the fact that decades of medical advances have bettered the prospects of our sick and elderly. But if the answer from on high is that doctors and hospitals stop readmitting these patients, what happens to them? One suggestion that's knocked around, which sounds ghoulish the more you think about it, flicks at a better use of palliative care. But palliative or hospice care is not for those who are treatable. Some 93 percent of those 2 million Medicare readmits were alive a year later—despite, or probably because of, having two or more hospital admissions in the course of that year. In fact, a report from Britain has shown that elderly people admitted two or three times in one year seemed to do better the next year, averaging under one admission, with no intervention.
So, before we start counting the savings we'll realize by keeping elderly sick patients out of the hospital, imagine those patients are your Mom or Dad, your Gram or Gramps. She may have a chronic debilitating disease. It may periodically flare up. He may never be "healthy." But they started paying into Medicare when they were young and robust so it would be there for them when they grew old and sick. Do we change their social contract?