George Oldt, 82, is afflicted with the double whammy of congestive heart failure and chronic obstructive pulmonary disease, conditions that can make breathing so frighteningly difficult he has to be rushed from his assisted living home in Lewisburg, Pa., to the hospital. It happened most recently in April, and might have happened again in July if it weren't for the close monitoring of a team of health care workers.
Despite the use of supplementary oxygen, he once again found himself struggling for breath. "He called me on Monday [July 22] and said he was having some symptoms," says Sonia Hoffman, Oldt's case manager with Geisinger Health System, his Medicare provider. Hoffman saw him at a nearby clinic and, after consulting with his physician, altered Oldt's medications and made sure he had the prescriptions before he returned home. When she called him later that day, his breathing had improved.
That's good news for Oldt. But it's also good news for a health care delivery system that is searching for ways to keep people out of hospitals.
No doubt, hospitals will continue to dazzle with futuristic robotic surgery, imaging technology that can watch the brain at work and personalized treatments aimed at an individual's unique DNA.
But now, one of the biggest challenges for the future of hospitals is coming up with ways to keep people out.
Hospitals are the most expensive setting for health care delivery, costing between $1,600 and $2,000 a day per patient and consuming $850 billion of the $2.7 trillion spent annually on health care in the U.S.
The federal government says that one in five elderly patients is readmitted within 30 days of leaving a hospital. Many of those readmissions can't be helped, owing to an unanticipated change in a patient's condition or a planned follow-up treatment. But too many are the result of patient confusion over new drug regimens, inadequate follow-up with primary care physicians, or a family's inability to deal with home care. An estimated 12 percent of Medicare patients may be readmitted for such avoidable reasons, according to the Medicare Payment Advisory Commission. Avoiding even one of every 10 of those readmissions could save Medicare $1 billion, the commission says.
Those staggering numbers are behind an Oct. 2012 change in Medicare payment rules. Where once hospitals were paid piecemeal for every admission and procedure during patients' stays, now hospitals are penalized when patients return within 30 days for the same problem, or because of a complication from their previous stay, if the readmission is deemed by Medicare to be unnecessary. There are no rewards given to hospitals that manage to reduce their readmission rates, and hospitals cannot opt out of the penalty program. Some places are already feeling the pain: According to Kaiser Health News, federal records released on Aug. 2, show that Medicare will impose $227 million in fines on 2,225 hospitals in 49 states starting Oct. 1.
The Medicare rule change, which is likely to be followed by private insurers as they move toward similar payment systems, is an attempt to stop the revolving door of hospitalizations. So far, Medicare is refusing payment for unnecessary readmissions for three high cost conditions: heart failure, heart attack and pneumonia. That list is expected to expand by 2014 to include Chronic Obstructive Pulmonary Disease (COPD) and coronary bypass surgery. There are additional penalties for what Medicare deems excessive readmissions overall. It is one step toward turning payment incentives upside down. "It's certainly a challenge," says Bob Malte, CEO of EvergreenHealth in Kirkland, Wash. "Readmissions are a worry of every health care executive I talk to."
Reducing readmissions will be uniquely challenging for America's 5,724 hospitals. Some are part of large health care systems that include home health care, nursing homes and physician practices. Some are rural or urban institutions with very little community support. "There's wide variation in how much control a hospital may have in influencing readmission rates," says Akin Demehin, Senior Associate Director of Policy at the American Hospital Association. The AHA is concerned, he says, that some hospitals will be unfairly penalized if they are in areas with few physicians and other community-based health services.
It is those community services that have helped EvergreenHealth become one of the most successful hospitals in the country at reducing avoidable readmissions. Hospital personnel noticed a decade ago that too many patients were soon back in the beds they had recently vacated. To find out why, administrators started talking to doctors and home health workers. Were physicians seeing their patients within the first week after discharge? Did they make sure patients had easy telephone access to discuss medications? Were home visits done to make sure patients understood instructions for their care, had the proper medications and were not using expired drugs? "Readmissions are nobody's fault," says Neil Johnson, COO of EvergreenHealth. "They're largely a communication issue."
Without enough hands-on support after discharge, patients, nursing home workers and family members can get confused about home treatments or nervous about changes in condition. Before you know it, someone is calling 9-1-1, and the patient is back in the hospital.
To stop the cycle, hospitals have to be more than brick-and-mortar institutions. That's one reason most now call themselves health care systems, because only a coordinated system can attempt to corral all the players a discharged patient needs.
To make it work, it's as though the hospital's services go home with the patient. That, too, costs money, but less than hospital care. The Geisinger Health System compared 85,000 of its patients covered by its coordinated care network, ProvenHealth Navigator, to 150,000 patients not enrolled in ProvenHealth. Those enrolled saw a 40 percent reduction in readmission rates over three years and a cost reduction of 7 percent compared to those without the benefit of the care network.
"When someone comes out of the hospital, we make sure we call them within 24 hours of discharge. We get them back in their primary care doctor's office within three to five days. If they're in a skilled nursing facility, we get a nurse practitioner or physician assistant into those facilities," says Thomas Graf, Chief Medical Officer of Population Health and Chairman of Community Practice at Geisinger Health System.
EvergreenHealth Home Care is the Kirkland, Wash., institution's home health care network . "In the 1980s and 1990s, a lot of hospitals dropped their home health care systems," says Johnson. They weren't very profitable, and they were heavily regulated, making them more of a headache than some hospitals wanted. But EvergreenHealth stuck with its home health system, and now it is proving to be a vital piece of the puzzle in reducing readmission rates.
For congestive heart failure, EvergreenHealth's readmission rate was already low at 14 percent in 2003, compared to a national average of nearly 25 percent. As part of a Medicare demonstration project in 2009, they got that rate down to 6 percent. And today, says Johnson, only 2 percent of patients receiving the system's home health care are readmitted to the hospital.
Slowing the revolving door to hospitals might actually be simple, if all the players in the health care delivery system start doing what hasn't traditionally come naturally: Talking to one another. Only that way, experts agree, can providers make sure patients, their families and caretakers know what to do when they leave the hospital and that patients get the follow-up medical attention they need.
It has worked for George Oldt, and he appreciates the system's simplicity. "If I have any problems at all, I call [his case manager]. If I ain't feeling good, she goes and gets with the doctor and then gets back to me," he says. "Sometimes we talk two or three times a day."
It sure beats a trip to the hospital.