Uncle Sam soon will step up what may be a positive trend: getting hospitals and nursing homes to halt the unacceptable boomeranging of elderly patients between them. But will Trump officials be as quick with health care providers as they have been with poor, sick, and old patients to employ not just carrots but also sticks to get better outcomes?
The nonprofit, nonpartisan Kaiser Health News Service deserves credit for looking ahead to this fall, when the administration aims to accelerate the end of perverse incentives that have hospitals and nursing homes shuttling the sick and elderly between them far too often. As Jordan Rau of the news service reported:
With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions. Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such re-hospitalizations occur 27 percent more frequently than for the Medicare population at large.
Rau goes on to explain how government policies on paying providers leads to harmful patient care:
The revolving door [between hospitals and nursing homes] is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days. But nursing homes have their own incentives to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes. Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a ‘bed-hold’ fee when a patient is hospitalized. None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection.
David Grabowski, a Harvard Medical School professor, told Rau that hospitals and nursing homes, basically, have followed an awful adage: “When in doubt, ship them out.”
They also worked under the possibility of Medicare fines. These sought to reduce hospitals’ high readmission rates, curtail their premature discharges, and encourage them to deal with better nursing homes to their mutual benefit. And what Uncle Sam deems to be “potentially avoidable readmissions” declined to 10.8 percent in 2016 from 12.4 percent in 2011, U.S. data show.
Medicare administrators hope to make readmissions fall more by not only imposing fines but also by offering financial incentives (carrots) for hospitals and nursing homes that do so, Rau reported. But reading his story can be so aggravating that there may be temptation to find an oak cudgel and to set in after hospitals and nursing homes that not only have gamed Medicare’s system but harmed frail, vulnerable patients, too.
He says, for example, that a senior got caught in patient ping-pong after a hospital sent her too early to a nursing home after she had hip surgery. Staff at the home, ill-trained and over-taxed, dropped her, fracturing her just-repaired hip and sending her into a painful new ordeal of surgeries and re-hospitalization. In another case Rau describes, a hospital and a nursing home failed to communicate, repeatedly, causing a patient to go into a fatal tail-spin when staffers didn’t give her thyroid meds for a condition clearly ordered and shown in her medical records.
This is unacceptable. In my practice, I see not only the harms that patients suffer while seeking medical services but also the damage that can be inflicted on some of the most vulnerable among us, notably frail seniors subjected to nursing home neglect and abuse. It’s great to see policy measures that free the old and sick from bureaucratic dodges that can only harm them.
But Rau’s story doesn’t describe (or maybe I missed them) what punitive actions, if any, that Medicare or Medicaid took against institutions involved in the most egregious situations he reported on. Instead, it took lawsuits in the civil justice system to give patients and their families some fair and just due after their mistreatment.
Let’s see if hospitals and nursing homes do better about the negative cycle of readmissions when receiving “bonuses,” rather than just getting hit with fines. As Rau reported:
Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital. Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.
It’s worth noting that when patients ── old, chronically sick, poor, and, yes, young, disabled, and middle-class, too ── have dealt in recent days with Trump officials running Medicare and Medicaid, two of the nation’s key social support programs, they’ve gotten more sticks than carrots. The president and his staff not only have sought to wring ever greater amounts out of these programs, even while working with Congress to give $1.5 trillion in tax cuts to wealthy corporations and the rich, but they also have assisted states in imposing new reporting and work rules for benefit recipients.
These are harsh and unhelpful. The Kaiser Family Foundation, a nonprofit, nonpartisan, and independent organization that seeks to improve U.S. health care, has just issued its analysis, finding just 6 percent of adult Medicaid enrollees, newly targeted by states’ work requirements, are not already working and are unlikely to qualify for an exemption. Meantime, the work requirements may create hardship for recipients because nearly a third of Medicaid adults say they never use a computer, potentially putting their coverage at risk in states requiring online reporting.