RAY SUAREZ: Welcome to Need to Know. Thanks for joining us.
The debate about president Obama’s sweeping healthcare reform bill was fierce and it continued through last month’s presidential election. But now, with the president’s re-election, we know that the affordable care act will not be repealed. House Speaker John Boehner even called it “The law of the land” just days after the election. And, some of the most important elements of the plan are already being rolled out. This week, and in the weeks ahead, we’ll examine key aspects of the law that have gotten very little attention, even though they affect millions of Americans. Our new series is called “Prescription America.” This week we look at an element of the healthcare reform package designed to improve care for the elderly once they have been released from the hospital. The idea is simple: Medicare payments to hospitals would be withheld, if older patients are readmitted too often, too soon. The plan is to encourage more coordinated care once a patient gets home. Are the penalties fair? Will they work? Our medical correspondent, Dr. Emily Senay, has our report from New Brunswick, New Jersey.
NURSE TERESA: My name’s Teresa. I’m one of the nurse practitioners here. How are you?
FREDDA KERNER: I’m doing well thank you.
NURSE TERESA: I’m here to see you because you came up on a special list.
FREDDA KERNER: A special list of what?
NURSE TERESA: You’re on a special list of patients who are back here. To tell you the truth Medicare is now looking at this very closely.
EMILY SENAY [narration]: THERE’S A NEW PROGRAM HERE AT ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL IN NEW BRUNSWICK, NEW JERSEY LIKE MANY OTHER HOSPITALS AROUND THE NATION. IT TARGETS PATIENTS LIKE 84 YEAR OLD FREDDA KERNER – WHO THE HOSPITAL CALLS A FREQUENT FLYER. THAT’S BECAUSE SHE KEEPS COMING BACK.
SHE WAS FIRST HOSPITALIZED IN JANUARY WITH ABDOMINAL PAIN. TEN MONTHS LATER IN NOVEMBER, SHE WAS READMITTED WITH PNEUMONIA.
EMILY SENAY: Did you know that you were getting weaker and having more trouble breathing at home?
FREDDA KERNER: Oh yes yes yes.
EMILY SENAY: Do you want to come to the hospital again?
FREDDA KERNER: No, as nice as they are, I really would rather stay home.
EMILY SENAY [narration]: THE HOSPITAL IS CERTAINLY INTERESTED IN PROVIDING BETTER CARE FOR PATIENTS…BUT THAT’S NOT THE ONLY REASON TO KEEP SOMEONE LIKE FREDDA KERNER FROM BEING READMITTED. ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL IS ALSO TRYING TO AVOID MEDICARE PENALTIES FOR WHAT THE GOVERNMENT CALLS “EXCESS READMISSIONS.”
IT’S A NEW POLICY THAT WENT INTO EFFECT THIS PAST OCTOBER AS PART OF THE AFFORDABLE CARE ACT – MEANT TO SAVE THE GOVERNMENT MORE THAN A QUARTER BILLION DOLLARS JUST OVER THE NEXT YEAR.
SINCE TWO THOUSAND AND TEN, THE FEDERAL GOVERNMENT HAS BEEN KEEPING TRACK OF READMISSIONS RATES AT MORE THAN FORTY-SEVEN HUNDRED HOSPITALS AND POSTING THAT INFORMATION ONLINE.
THEY’RE LOOKING TO FIND IF PATIENTS ARE READMITTED WITHIN THIRTY DAYS FOR THREE SPECIFIC CONDITIONS: HEART ATTACK, HEART FAILURE AND PNEUMONIA. AND BECAUSE FREDDA KERNER HAS PNEUMONIA – SHE’S ON THE HOSPITAL’S WATCH LIST. DOCTOR JOSH BERSHAD IS THE CHIEF MEDICAL OFFICER AT ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL.
EMILY SENAY: Was the readmission rate here too high?
DR. JOSH BERSHAD: I think it was. And in one category, for pneumonia patients, it was shown to be too high. It was worse than expected.
EMILY SENAY [narration]: IN THE PAST FOUR YEARS, HIS HOSPITAL’S READMISSIONS RATES HAVE BEEN HIGHER THAN THE NATIONAL AVERAGE. AS A RESULT, THE HOSPITAL SAYS THEY WILL FACE PENALTIES OF MORE THAN A MILLION DOLLARS OVER THE NEXT YEAR. THAT’S BECAUSE THEY’RE BEING PENALIZED POINT EIGHT PERCENT OUT OF THE MAXIMUM ONE PERCENT PENALTY OF THEIR MEDICARE REIMBURSEMENTS.
DR. JOSH BERSHAD: I take this as a personal insult. I really do. I take a lot of pride in us doing a good job for patients.
EMILY SENAY [narration]: SO DR. BERSHAD AND HIS HOSPITAL BEGAN TO INVESTIGATE WHY THEIR PATIENTS CAME BACK REPEATEDLY.
EMILY SENAY: What is the problem? Is it a cost problem? Is it a quality of life for the patient? Where’s the rub? Why– why is this an issue?
DR. BERSHAD: I think the problem is multifactorial. I think there are a lot of issues that are related. One, I think our health system is relatively fragmented. You have different types of healthcare that are provided in a relatively siloed arena. So there’s hospital care. There’s home care. There’s physician care. There’s long-term care and nursing homes and rehab centers. And oftentimes, it’s not coordinated among all the different pieces And I think another one is that they’re– people are living longer and people have more chronic medical issues. And some of those medical issues are the type of things that cause people to end up back in the hospital.
EMILY SENAY: So what does that have to do with you? If you’re the hospital and you’ve done everything correctly, you’ve treated the patient’s illness and they’re ready to go home, how does it come back to the hospital, being the ones who have to sort of make sure that the patient doesn’t come back?
DR BERSHAD: This problem of coordination of care was identified, both as an expensive problem and as one that’s not good for patients. And so the onus was put on hospitals. My– my belief is that it’s easy to– there’s about 5000 hospitals in the country. That’s an easy group to start to work with to improve these outcomes.
DR. CONWAY: The issue is approximately one in five Medicare beneficiaries get readmitted within 30 days. So we want that number to go down.
EMILY SENAY [narration]: DR. PATRICK CONWAY — THE CHIEF MEDICAL OFFICER OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES – SAYS THAT, IN FACT, TARGETING MEDICARE CERTIFIED HOSPITALS WAS THE BEST PLACE TO START WHEN THEY BEGAN LOOKING FOR WAYS TO SAVE MONEY.
DR. CONWAY: The best evidence we have says that you know possibly as high as three-quarters of these readmissions could be prevented. We are implementing the program with the goal of better care coordination. And rewarding those hospitals that do– coordinate– care well.
EMILY SENAY: How do you reward those that coordinate care?
DR. CONWAY: Financially, there’s– there’s, you know, they would not see a payment reduction. So essentially we’re trying to put incentives in place that encourage hospitals to coordinate with their community providers so that most importantly the patient, as they transition out of the hospital, they’ve got both the care supports, the communication in the hospital. And then when they go out of the hospital, the hospital is focusing on making sure all that information makes it to the clinicians in the community. So for patients, their care is well-coordinated.
EMILY SENAY [narration]: THOUGH THE READMISSIONS POLICY IS STILL IN ITS EARLY STAGES, DR. CONWAY SAYS IT’S THE FIRST STEP IN IMPROVING THE LARGER HEALTH CARE SYSTEM.
DR. CONWAY: We’re still learning how to orient care better around the patient, but I think directionally if we focus on this sort of patient-centered care and care coordination, I think our health system will perform better.
DR. GROVER: The policy is clearly blaming the hospitals for all of those readmissions—
EMILY SENAY: And it’s not the hospitals, you say?
DR. GROVER: It’s not the hospitals.
EMILY SENAY [narration]: DR. ATUL GROVER IS WITH THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES. HE SAYS THE READMISSIONS POLICY IS FLAWED BECAUSE THE PENALTIES CREATE HEAVIER BURDENS FOR HOSPITALS THAT ARE ALREADY STRUGGLING TO TAKE CARE OF POOR PATIENTS.
DR. GROVER: In fact if you look at the medical literature, what they’ll say is about 75% of the factors in readmissions are really out of the hospitals’ control. If you’re talking about caring for a population who may have no fixed addressed, who may not have a telephone, who may not have people around that can help them once they get discharged, they’re gonna be more likely to end up back in the hospital because they weren’t able to get certain aspects of care.
EMILY SENAY: So why doesn’t the system of penalties take into account the fact that in some areas the patients are just sicker and more likely to be readmitted? Or have less support and more likely to be readmitted?
DR. GROVER: I think the complexity is a challenge. If you think about what happens when you get readmitted to the hospital, there are a whole host of factors. And it may have to do with where you live and your social support, your ability to have access to medication, your ability to access a physician in a timely way. I think the other challenge here is you don’t want to give anybody a pass in terms of taking care of patients.
EMILY SENAY [narration]: BUT DOCTOR GROVER – WHO REPRESENTS UNIVERSITY HOSPITALS THAT LARGELY CARE FOR THE POOREST PATIENTS – SAYS THE POLICY MIGHT ACTUALLY JEOPARDIZE PATIENT CARE.
EMILY SENAY: So in your opinion, is this gonna impact patients?
DR. GROVER: This is gonna impact patients, I think in two ways. One, we’re gonna have to figure out which services to stop providing I think other hospitals are going to be more likely to look at a patient that’s hard to care for, that’s very sick, or very poor, or both, and say, “I don’t wanna treat those patients. Most providers are gonna say, “Why would I take the risk of getting penalized for something I have no control over, when this patient leaves the hospital?”
EMILY SENAY [narration]: DR. BERSHAD OF ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL AGREES IT’S NOT FAIR TO GET PENALIZED FOR THINGS THAT ARE COMPLETELY OUT OF HIS HANDS.
DR. BERSHAD: I think that there needs to be an acknowledgement that some patients are gonna come back, because of their own disease, not because of anything anyone did. The disease process, they’re sick enough that they’re gonna end up back in the hospital.
EMILY SENAY [narration]: HE SAYS HIS HOSPITAL SIMPLY HAD TO START RETHINKING PATIENT CARE.
DR. BERSHAD: The whole concept of that we weren’t doing our best and that could put us at risk financially made us think differently.
EMILY SENAY: From the hospital’s standpoint, the minute the patient is out the door, they’re done. That’s– is that how it’s been?
DR. JOSH BERSHAD: That was the old model. The old model would be– after a patient leaves the hospital– their care transitions to somebody else.
EMILY SENAY: And that’s where the ball gets dropped.
DR. JOSH BERSHAD: Just about every aspect of the process of getting a patient from one health care setting to another was broken.
EMILY SENAY [narration]: THAT MEANT, ONCE PATIENTS WERE RELEASED FROM THE HOSPITAL, THEY MIGHT NOT BE ABLE TO GET AN APPOINTMENT WITH A PHYSICIAN OR PICK UP MEDICATION AT THE PHARMACY.
BECAUSE THE PENALITIES WENT INTO EFFECT JUST TWO MONTHS AGO, AND NATIONWIDE, HOSPITALS FACE OVER A QUARTER BILLION DOLLARS IN PENALTIES…HOSPITALS LIKE ROBERT WOOD JOHNSON HAVE BEEN SCRAMBLING TO SET UP A READMISSIONS REDUCTION PROGRAMS.
WITH THE HELP OF FOUR MILLION DOLLARS IN FUNDING FROM THE ROBERT WOOD JOHNSON FOUNDATION – THE HOSPITAL CREATED WHAT DOCTOR BERSHAD CALLS “BRIDGES” FOR THE PATIENTS. THE FIRST ORDER OF BUSINESS — CREATING AN ELECTRONIC DATABASE THAT WOULD EASILY CONNECT THE HOSPITAL WITH 200 DOCTOR OFFICES IN THE COMMUNITY.
DR. JOSH BERSHAD: We used to fax notes to the next providers, handwritten little notes and we used to hand one to the patient saying, “Hey, here’s what happened and, you know, you need this.” And follow-up and now that’s– we’ve made that system electronic. We’ve built it in as you must do this. We used to not make appointments for people. Now we make appointments for people.
EMILY SENAY [narration]: NURSE TERESA DEPERALTA RUNS THE PROGRAM AND SHE SAYS IT ALL STARTS WITH HONING IN ON THE “FREQUENT FLIER” PATIENTS – LIKE FREDDA KERNER.
NURSE TERESA: Our goal is really to try to keep you at home, maybe find out if you problems sooner so you can go and see your doctor rather than come back to the hospital – ok?
EMILY SENAY [narration]: BUT KEEPING ELDERLY PATIENTS OUT OF THE HOSPITAL IS COMPLICATED BUSINESS. THERE’S ALWAYS A FAMILY MEMBER OR CARE GIVER WITH KERNER AT HOME, ESPECIALLY SINCE SHE CAN’T PREPARE HER OWN MEALS AND HAS TROUBLE WALKING. SHE ALSO TAKES TEN PILLS DAILY…IS ON AN OXYGEN TANK….AND JUST RECENTLY, SHE’S LEARNED THERE’S ONE MORE THING SHE HAS TO PAY ATTENTION TO.
EMILY SENAY: So now you’ve just been told you have diabetes. So that’s a new condition to manage.
FREDDA KERNER: And to control as far as food that I eat and all of that and the medications that I take.
EMILY SENAY: Do you think you could sort it out all on your own? If they just told you what to do here at the hospital?
FREDDA KERNER: Not completely, no.
EMILY SENAY: You need the help?
FREDDA KERNER: I think I need the help.
EMILY SENAY [narration]: SO THE HOSPITAL’S TEAMED UP WITH A VISITING NURSES GROUP….SENDING NURSES LIKE MARIA WALSH TO CHECK OUT AND REPORT BACK ON KERNER’S LIVING SITUATION – EVERYTHING FROM WHAT’S IN HER FRIDGE TO HER MEDICINE CABINET.
FREDDA KERNER: I usually only have the shrimp once a week.
NURSE: Once a week? Water Pill.
FREDDA KERNER: What is that for?
NURSE: Is this for the coughing?
FREDDA KERNER: Oh I don’t take that then.
NURSE: For allergies?
FREDDA KERNER: Oh allergies, yes, yes.
NURSE DEPERALTA: We have older patients. They do not want to waste any medicine, so they have old medicines they don’t throw out, you know. And they get totally confused when they go home.
NURSE: Well, you have two bottles of it here.
FREDDA KERNER: Right, right.
NURSE: And they’re both the same dose.
FREDDA KERNER: Yeah.
NURSE: You know, not to take?
EMILY SENAY: This doesn’t sound like very complicated stuff, meeting a patient in their home and– and going through it. It’s not high-tech. It’s not—
NURSE DEPERALTA: It is not high tech. All that it really is, needs is being there– you know, being there for the patient.
EMILY SENAY [narration]: SIMPLE STEPS BUT ROBERT WOOD JOHNSON’S DR. BERSHAD SAYS FOR HOSPITALS TO PROVIDE THAT MANPOWER IS NOT EASY.
DR. BERSHAD: It’s resource-intensive. It requires a lot of time and effort from a lot of people and it requires things to happen that are outside the normal forum of what you do. And that’s the biggest challenge.
NURSE: What did you eat last night for dinner?
FREDDA KERNER: You’re asking me a difficult question. What did I have? Big Mac.
NURSE: Did you really?
FREDDA KERNER: Yeah.
DR GROVER: Part of the resources that we need in healthcare to reduce readmission are really gonna be more bodies. The challenge is if you’re looking at a policy which, is now as written, taking resources away if you have high readmission rates, you’re not gonna be able to invest money into those additional members of the team and do what’s best for the patient.
EMILY SENAY [narration]: NOT EVERY HOSPITAL HAS A FINANCIAL ADVANTAGE LIKE ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL… REMEMBER THEY RECEIVED A FOUR MILLION DOLLAR GRANT FROM A FOUNDATION TO FIND NEW WAYS TO CARE FOR PATIENTS ONCE THEY LEAVE THE HOSPITAL. DR. BERSHAD SAYS THAT THIS WILL TAKE THEM THROUGH THE NEXT THREE YEARS….EVEN AS MEDICARE PLANS TO INCREASE THE READMISSIONS PENALTY EACH YEAR.
EMILY SENAY: Do you think it’s unfair to ask the hospitals to create this bridge?
DR. BERSHAD: Do I think it’s unfair to ask the hospitals to solely create the bridge? Yes. Do I think it’s unfair to hos– to ask the hospitals to participate in the bridge? Absolutely not. It’s totally fair. Hospital is– I think we’re obligated to provide a good outcome for the patient and to do the best that we can. I think to put the burden solely on the hospitals is unfair.
EMILY SENAY: Do you think at the end of the day, money will be saved ultimately if we create a network of care and prevent readmissions?
DR. BERSHAD: At the end of the day, it’s better for the patient. And usually, when it’s better for the patient, it costs less. You can usually make that equation pretty clearly. It may not cost less for each step in the process, but in the end, it costs less.
RAY SUAREZ: For more about all this, we are joined now by Dr. Michael Sparer – Professor & Department Chair of Health Policy and Management at the Columbia University Mailman School of Public Health. Welcome.
INTERVIEW WITH MICHAEL SPARER
RAY SUAREZ [narration]: THIS WEEK ONLINE…TAKE PART IN OUR WEEKLY POLL. THE TOPIC: PENALIZING HOSPITALS. ALSO, USE THE GOVERNMENT’S ONLINE TOOL TO FIND OUT HOW YOUR HOSPITAL COMPARES TO OTHERS IN YOUR AREA.VISIT PBS.ORG/NEED TO KNOW.
RAY SUAREZ: And now to our regular segment, “American Voices,” featuring diverse voices with diverse points of view. This week, Lynn Reichgott on coordinating care within communities, so those who choose to can “age in place.”
LYNN REICHGOTT: After my father died, my mother had a series of accidents. And she was becoming somewhat isolated in the house. At a certain age, isolation becomes more of an issue. Friends who you have had for years either move away or pass on.
And what ended up happening with my mother she went into an assisted living program. And it turned out to be for her a good experience but she never had the option of doing what it was she preferred. The name of our aging in place organization is called at Home on the Sound.
Being able to age in place is being able to stay in your home in the community where you live or where you choose to live. It means that you can continue to have control over your life, to do what you want to do when you want to do it. And there are supports out there to ensure that the quality of your life is as good as it can be, and you can maintain your independence for as long as possible. While we don’t provide any medical services, we do provide ways for people to stay healthy.
We as a group, first of all, prevent hospitalization because we call people and remind them about doctors’ appointments, and then pick them up and take them.
And we also have trained patient advocates who are volunteers, and they’ll talk about the doctor’s appointment and what questions the patient might have. And will go with that patient to the doctor’s visit, take notes, and ask whatever questions the patient would want asked.
We need more aging in place organizations that have strong partnerships with government and with the health care system. Because we’re not gonna be able to do it on our own.
RAY SUAREZ: That’s it for this addition of Need to Know. For more including our weekly poll, please visit pbs.org/needtoknow.
Scott Simon will be with you next week. I’m Ray Suarez. Thanks for joining us.