MARGARET WARNER: Much of the attention surrounding the health care reform law focuses on questions of coverage and cost.
But the law also includes numerous provisions aimed at changing or improving the quality of care. Hospitals are already starting to deal with one of those changes: new penalties they could face if too many older patients have to be readmitted. And some are asking whether the levies are fair.
NewsHour health correspondent Betty Ann Bowser reports.
BETTY ANN BOWSER: Seventy-year-old retired engineer Daniel Tollins has been in and out of the hospital so often, he’s known in medical circles as a frequent flyer.
DANIEL TOLLINS, Senior Citizen: I have a number of medical issues, any one of which can kill me. But I’m living with all of them.
BETTY ANN BOWSER: Tollins has hypertension, diabetes, a liver condition, and cancer. So on this rainy Boston morning, he’s on his way to keep an appointment he hopes will help keep him healthy.
The appointment is at the gym. It’s just one part of an aggressive program at Beth Israel Deaconess Medical Center in Boston to monitor frequent flyers like Tollins after they’re discharged. Hospital readmissions are expensive. Nearly two million Medicare beneficiaries are readmitted within 30 days of discharge every year, costing Medicare $17.5 billion dollars in hospital bills.
Some health care reformers think hospitals could cut some of that spending if they were more aggressive in following up with seniors in the first 30 days after they go home.
DR. DONALD BERWICK, Former Administrator, Center for Medicare and Medicaid Services: I think the whole direction that health care has to move as a system is toward lifelong continuity of case, in which the hospital becomes a citizen in helping patients through their journey. That means your job is never done.
BETTY ANN BOWSER: Dr. Donald Berwick is the former Medicare chief who directed implementation of the first year of a new program under the Affordable Care Act. It imposes stiff financial penalties on hospitals with high readmission rates, a change that some hospitals believe is penalizing them unfairly. But Berwick says the new penalties are overdue.
DONALD BERWICK: As long as a person is still there in life, then the whole idea of discharge, out of sight, out of mind, that has no place in health care. The fact that I went home six months ago doesn’t mean that hospital still doesn’t have a sense that I’m there and have needs and they want to make sure I’m doing well.
BETTY ANN BOWSER: So far, more than 2,200 hospitals have been hit with $280 million dollars in fines. The penalties apply to readmissions for three specific conditions: heart attack, heart failure and pneumonia, if they occur within 30 days of discharge.
As the program moves forward, by 2015, those that continue to have high readmission rates will lose up to three percent of what Washington pays them to take care of Medicare patients. Beth Israel was among the top eight percent of hospitals to be fined. It was hit with $2 million dollars in the first round.
But, even before that, the medical center was working on a way to more carefully monitor Medicare patients after they leave the hospital. It’s called PACT, which stands for post-acute care transitions.
JULIE COWELL, Beth Israel Deaconess Medical Center: Good morning, Mr. Tollins. It’s Julie from the hospital.
BETTY ANN BOWSER: Julie Cowell is one of 12 nurses and pharmacists working with discharged patients in the PACT program. Many, like Tollins, have multiple chronic medical conditions.
JULIE COWELL: I come in to make sure that first he understands everything that’s happening and then make sure that all the pieces are together. Does he have all the medications that he needs? Are the outside services appropriate for him?
DANIEL TOLLINS: Well, let’s say I need a ride. Let’s say I’m having certain medical problems. She will see to it that she will screen what that is and then make a determination. But she seems to have an ability to know when I need help. She calls me.
BETTY ANN BOWSER: Do you think it keeps you out of the hospital?
DANIEL TOLLINS: Definitely, by all means.
BETTY ANN BOWSER: Dr. Kevin Tabb is the president and CEO of Beth Israel.
DR. KEVIN TABB, President and CEO, Beth Israel Deaconess Medical Center: In the past, we simply gave the patient a prescription and hoped for the best. Now we’re making sure that we are in constant contact with the patients after they are sent out.
It’s those kinds of things, what I call doing whatever it takes, those kinds of things are making a real difference.
BETTY ANN BOWSER: In the early months of the PACT program, Beth Israel has seen a 20 percent drop in readmissions. But as the program director, Dr. Julius Yang, says, there are still mountains to climb.
DR. JULIUS YANG, Beth Israel Deaconess Medical Center: Many of our Medicare patients who are discharged from the hospital on average leave the hospital prescribed 12 or 13 different medications, and that’s just different medications. It could be up to 20 pills a day. To navigate and that is extraordinarily complex.
BETTY ANN BOWSER: And while statistics show that readmissions nationally have declined slightly, some hospital administrators, including Dr. Tabb, have questioned whether the new policy is fair or needs to be adjusted.
KEVIN TABB: Hospitals should take a lot of responsibility. At the same time, I think it’s important to acknowledge that hospitals are only one piece, and if we only effect change among acute-care hospitals and don’t effect change anywhere else, we won’t really get a different type of care.
BETTY ANN BOWSER: And Dr. Yang thinks there is only so much a hospital can do to keep a senior with multiple chronic medical conditions from returning.
JULIUS YANG: Sometimes, I’m driving in a car that has 200,000 miles on it and if it comes back for another issue, it’s hard for me to hold the car repair shop responsible for that.
BETTY ANN BOWSER: In Daniel Tollins’ case, he was hospitalized three times in two months. At least one of those readmissions was because of a new medical problem that was previously undiagnosed.
DR. Ashish Jha, a physician and professor at the Harvard School of Public Health, has been studying the readmissions policy. He questions if it’s fair to hospitals with large numbers of poor patients who tend to be sicker than other seniors on Medicare.
DR. ASHISH JHA, Harvard School of Public Health: If you are a safety net hospital and you have mostly poor patients and mostly chronically ill patients, should we compare you to a community hospital in a wealthy area which has relatively healthy patients? I would say that’s not fair.
BETTY ANN BOWSER: Some early research shows safety net hospitals, like Beth Israel, are receiving higher penalties under the readmissions program than smaller medical centers with a less diverse patient base.
Ironically, many of the very same hospitals that so far have received the highest fines also have some of the lowest death rates.
ASHISH JHA: If readmissions were a really good quality measure, you would think with lower death rates should also have low readmission rates, right, because it’s a good hospital. We actually don’t find that at all.
If you look at, for instance, the U.S. News publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted.
BETTY ANN BOWSER: Dr. Berwick agrees the readmissions policy needs some tweaking, especially as it applies to safety net hospitals. But he argues it’s an important first step.
Right now, Berwick says, Medicare patients find themselves constantly drifting in and out of hospitals in a fragmented, unaccountable world.
DONALD BERWICK: If we’re courageous and if we invest, hospitals will be different. They will be places that actually can think differently about how we could follow Mrs. Jones all the way home and make sure she’s OK for the long haul.
BETTY ANN BOWSER: It will be another year or so before Beth Israel has more conclusive data on its PACT program. In the meantime, statistics don’t mean much to a 70-year old retired engineer who lives alone and faces a cancer diagnosis.
Daniel Tollins will be the first to tell you that what keeps him focused is walking the journey with a nurse named Julie.
DANIEL TOLLINS: It’s a personal touch. It’s coordinating resources that I need. This is what she’s doing.
JEFFREY BROWN: And a postscript to Betty Ann’s report. Dr. Berwick, who played a key role in shaping health care reform in Massachusetts, announced his bid for governor last week.
You can find more of our reporting, including tips for staying out of the hospital after being discharged, on our website.