More on Hospital Readmissions
All this is courtesy of Austin Frakt:
The problem:
Low-income African American patients [] are up to 43% more likely than their higher-income white counterparts to find themselves back in the hospital within weeks of discharge. As a result, the cost of care for these disadvantaged patients is high, as illustrated by the population of low-income patients who are dually eligible for Medicare and Medicaid. Dually eligible individuals cost twice as much as other Medicare beneficiaries largely because they are 4 times as likely to be readmitted to hospitals for ambulatory care–sensitive conditions. […] (JAMA study)
Making the problem worse:
Most importantly, many post discharge interventions are fundamentally clinical interventions, delivered by a workforce trained to address clinical issues. Paradoxically, intensifying clinical follow-up care [] might actually increase admissions; outpatient medical providers often do not have the tools to address the underlying social causes of poor health and have no choice but to refer these patients back to the hospital when they inevitably fall ill. (JAMA study)
Penalizing providers who deal with the problem:
Because the measure used for Medicare’s penalty is not adjusted for patients’ socioeconomic status (SES), and because patients with lower SES experience higher rates of readmissions, safety-net hospitals on average receive higher penalties under the current regime….
Experts [] noted the futility of discharging vulnerable patients into communities lacking strong networks of primary care and the community support systems necessary to aid patients in their recovery. (Commonwealth study)
And presumably we are certain that the quality of safety-net hospital care is the same as that from hospitals not dependent on low government reimbursements, right?
It is nice to see SES considered. One wonders why it is not in many of the studies of health disparities, the effect of lack of health insurance on mortality, or outcomes under different payment systems.
The quality of care in the safety net hospitals may not be up to snuff, but don’t they, by definition, face the greatest challenges? It seems like it would be counterproductive to penalize them financially — especially if there’s no quick fix they can employ to improve quality.
I think that the financial penalties are a mistake. First they cause problems with capitated care, then they cause more problems by penalizing providers if patients, for whatever reason, need to be readmitted. So hospitals stopped admitting people, keeping them on observation status.
But rather than zapping the whole program because its metrics are flawed and letting patients control the dollars and determine the quality, these authors apparently seek to “fix” them by injecting even more ill-defined metrics like SES into the mix.
The result may well be that group identity politics ends up controlling hospital reimbursement and quality to the detriment of all but those wealthy enough to buy their way out of the mess.
Lower-income populations are less healthy than their higher-income counterparts. Moreover, they are less likely to have a usual source of care. They often exhibit lower health literacy. Acting like this is the result of some mean-spirited discrimination fails to consider this is true Caucasian populations as well as minority patients.
A lot of “discrimination” is actually the result of simple economics.
The Patient Centered Medical Home is being touted as a remedy for these problems. The concept involves doctors, nurses and multiple ancillary medical personnel in the care of patients, and is especially formulated for lower income and SES patients.
However, the CMS is still operating on a 24% cut in reimbursement for Primary Care providers. Additionally, no plan has been put forth for the long term training and recruitment of Primary Care physicians, NPs and PAs.
Therefore, while a good concept, most practitioners are not going to be able to afford this type of practice, especially given the potential pay cuts and expenses from all the other mandates for Medicare and Medicaid providers.
Interesting
“Experts [] noted the futility of discharging vulnerable patients into communities lacking strong networks of primary care and the community support systems necessary to aid patients in their recovery.”
That’s a tough problem.
So, we should be addressing structural poverty rather than the symptom, which is ill health? What kinds of interventions would be appropriate?
For starters we should quit subsidizing poverty. That only creates more poverty.