Thursday, November 11, 2010

Hospital Readmissions: Who pays, who decides, and for whom?

I recently attended a Forum on health reform put on by the Sunflower Foundation of Topeka, Kansas in Lawrence. The keynote speaker, John McDonough, PhD, gave an excellent rundown of the contents of the ACA health reform law. Prior to that a panel of experts from state government, that included Sandy Praeger (a Republican), Kansas Insurance Commissioner and former chair of the National Association of Insurance Commissioners (NAIC). She made it clear that the requirement that large insurers spend 85%, and small ones 80%, of their premiums on actually providing health care (infamously known as the “medical loss ratio” in insurance circles) will be taken seriously, and that insurance commissioners in NAIC, which is the group charged with making the recommendations on this issue to HHS, will not blithely allow insurers to load lots of costs not obviously related to patient care (like marketing and paying the folks that deny your claims) into this bucket. Other participants included Andy Allison, head of the Kansas Health Policy Authority, a governmental agency that, in addition to doing health policy runs the state Medicaid program, and several people from area foundations and consumer advocacy groups. One might have thought, listening to the discussion, questions from the audience (largely health advocates and professionals), and the responses to them, that Kansans are not only thoughtful but caring, worried about the health of their neighbors and fellow citizens, and hoping that health reform will really bring about positive change.

So, all the rest of you non-Kansans, keep this in mind when you see who we elect to statewide office, to our legislature, and to Congress. They don’t represent everyone in this state. Maybe their positions don’t even represent their own beliefs but rather crass political calculations. Or, perhaps, financial calculations; looking at where the big contributions are coming from, and serving the interests of those donors.

As panelists discussed what they saw as important parts of ACA, I was struck by the comment of one person, representing a consumer group, that a big way that ACA would save money would be in Medicare not paying for hospital re-admissions. (Actually, the term, in Section 3025 of the ACA, Public Law 111-148, p. 290, the term is “excessive” readmissions.) The assumption here is that the re-admission was a result of inadequate care on the previous admission, premature discharge (motivated, presumably, by the length of stay guidelines that are widely in use by organizations such as, say, Medicare!), etc. This is an attractive idea; after all, if you bring your car in to be fixed, and it breaks down shortly thereafter, should you pay for the second visit to the mechanic? (She didn’t say that; it is my metaphor.)

But, of course, only if it for the same problem, right? Not if the first hospitalization was for a broken leg, and the second for heart failure. After all, if your car had its brakes fixed and the transmission goes 2 weeks later, it is not the mechanic’s fault. Unless, maybe the second hospitalization was for a complication of the first, like say a blood clot in the lung. Especially if the patient was not given proper clot prophylaxis the first time. But what if they were given that prophylaxis and the clot happened anyway? It is not always so simple.

It is not always so simple even when the re-admission is for the same problem. People with advanced chronic diseases have advanced chronic diseases. They can be treated as outpatients, but will frequently decompensate, and require hospitalization. Remember Red, Blue, and Purple: The Math of Health Care Spending (October 20, 2009)? This is one of the main groups comprising the 5% of people who use 50% of the health care dollars; even when they are brought into the hospital and “tuned up” (yes, this automotive phrase is in fact used), even, or especially, when they have spent time in intensive care, they get sick and require hospitalization again. Their body is dying, but modern medical care can do remarkable things to forestall that death, to patch folks up, to send them back home, or to a nursing home -- for a while, until their body resumes its inevitable decline; the closer a person in this condition is to dying, the more frequent the readmissions. To continue the automotive metaphor, it is one thing to bring in a 3 year old car for new brakes and have them begin to fail 2 weeks later and bring it back; it is quite another when the car is 15 years old, has multi-system failure and won’t run, but the great mechanic can patch it up so you can drive it off – when it fails again in 2 weeks, is this the mechanic’s fault?

It is obviously unreasonable to say that you won’t pay the mechanic the second time, or for Medicare or other health insurance to not pay the hospital and doctors for the work they do on the re-admission. It might be reasonable to decide that the person, like the car, is not salvageable beyond the very short term and should not be readmitted, but this is a decision that can’t be made by the treating doctors and hospital, and it is unreasonable to not pay them when the patient returns because they did such a good job of keeping him/her alive the last time. When are these readmissions “excessive”?

So who should make the decision? Ideally, the patient, in consultation with family members or others s/he trusts, maybe even his/her doctor. This is, after all, the idea behind what we call “Advance Directives” such as Living Wills and Durable Powers of Attorney for Health Care. But not everyone has them, not everyone has even discussed their preferences with their family or their doctor, not to mention put their decisions down on paper so that those responsible for making decisions when s/he cannot have both something to guide them and, indeed, something that requires them to do it. Doctors are not paid to have these extensive discussions with people, although many of them do it anyway; the component of ACA that was going to reimburse for these discussions was struck after being maligned as (wrongly) being “death panels” that would “decide to kill your grandmother”.

But who should decide? If an elderly person is demented, cannot communicate, is in kidney failure and heart failure and has been admitted several times, including to intensive care, and kept alive by medical technology, who should decide if they will be readmitted from the nursing home when they get worse? Often the nursing home just sends them. If there is family, they are the ones who currently make these decisions, provided that they can agree. What if the patient cannot swallow without choking, but the family doesn’t want him/her to “starve” – should this person get a big central IV to give basic nutrition, or have a surgical procedure to feed directly into the stomach? The family does not pay, Medicare does. What would you decide? You would never do this to your parent or want it for yourself? Are you willing to be on the “death panel” that overrules the family? What about the similarly demented and sick person who has been admitted to the intensive care unit 3 times in the last year, amazingly “survived” to discharge, and finally, after several later readmissions, finally does die. And the daughter wants to sue because “somebody” must have done “something” wrong? Should we not pay the hospital? Should we tell the ambulance not to pick her up? Will you be the one to tell the daughter that the fact that she has obviously unresolved issues, and that she should have accepted during the first 6-week ICU stay that her mother was going to die soon?

I hope you will be. I hope you will be out there, helping support the healthcare professionals to make the right decisions, not because Medicare is paying but because they are right. And help us to figure out what the right decisions are. While all of us feel differently about those close to us than about strangers, "save money on them, spend it on me!" is not a reasonable, or moral, strategy.

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