There’s so many “opportunities for improvement” within the healthcare system. Where to begin?!
For one, I’m currently a hostage of the CO Board of Nursing. Although I’ve successfully completed the ridiculously over-complicated and highly redundant application process, I’m still awaiting approval for my prescriptive authority in order to start working in my new home state. Ironically, the US suffers from a scary healthcare provider shortage, yet The System yields millions of wasted hours that folks like me could have spent seeing patients.
With extra time on my hands, I re-watched this satirical viral youtube video, which equally humorously and accurately describes the results of the current incentive/penalty systems that organizations like Medicare implement. It reawakened deeply-rooted fiery objections to this MO.
Let me back up and explain–in layman’s terms–Medicare’s “Readmissions Reduction Program“. It focuses on the following six diagnoses: heart failure, heart attack/bypass surgery, pneumonia, COPD, hip/knee replacement, sepsis [blood infection]. If a patient is hospitalized for one of these diagnoses and is again admitted to the hospital within 30 days, Medicare will not pay for the admission.
Make sure you take care of the patient the first go-round, so that they don’t immediately “bounce back”. Sounds reasonable right?
Wrong. Very legit studies have confirmed that lower readmission rates don’t equate to higher quality care [like this one too, and another one. And many more]. Having spent two years in a Heart Failure program with a solitary goal to reduce the readmissions of “frequent fliers” to the hospital, I saw at an intimate level the shortcomings of this penalty system. A few of my observations of its flaws are bulleted below.
Now, I don’t think that the folks designing readmission penalties are evil conspirators trying to kick your poor grandma out of the hospital while still sick, greatly increasing her odds of increasing the hospital’s euphemistically stated statistic of “bad outcomes” [i.e. deaths]. No, I’m confident that the individuals creating the rewards and penalties have the best of intentions to promote the health and well-being of the populace.
However, the path to hell is paved with good intentions.
Here are just a few flaws with the program:
- Other Medicare programs penalize hospitals for “prolonged” admissions [a different post for a different day] placing a HUGE pressure on hospitals to discharge patients earlier and earlier. The patients return home, to nursing facilities and senior living establishments sicker and sicker, overburdening these institutions poorly equipped to care for high acuity patients and greatly increasing the probability of readmissions. The policies conflict one another and set each other up for failure, rather than synergistically align for success.
- Hospitals are penalized if the patient is readmitted for any reason**. Trauma from running their car into a brick wall. Having a random stroke. Seek out the ER for shelter, food and/or are actively psychotic since the US infrastructure doesn’t properly address these social needs. It does not actually achieve the goal of better care. Readmission, at best, is a loosely casual relationship to quality of care. Anyone with any knowledge of research would not regard that target end goal as credible. Other legit studies prove that the program essentially penalizes hospitals that care for sicker and homeless patients, thereby taking away funding from institutions that arguably should receive the most investment of resources.
- **As an over-dramatic analogy, it’d be like getting your car tuned up and then driving it off a ditch and then that shop replacing your vehicle. Cause that makes sense..
- Also, the program incentivizes hospitals to pour valuable resources in the wrong directions. Rather than truly improve quality of care, hospitals hire teams to follow “frequent fliers”, buy pesky patients bus fare to far-away places [to stop burdening their isolated system rather than actually address the root cause of their issue], create clever ways to obscure the numbers and other tactics to play the game rather than spend money on initiatives that truly result in better care.
- One such tactic meriting its own bullet: investing a greater amount of money, attention and services in Medicare patients than in those with other forms of insurance [or without insurance]. Turns out, Medicare bases their figures on Medicare recipients only, which hospitals figured out, fueling this trend. ::Personal opinion:: I find it deplorable and unjustifiably unethical to treat patients differently based ONLY on their insurance. Barf.
- When implemented, the “readmission rate” was calculated retrospectively by three years. That’s right. It’s like saying, “hereto forward the speed limit is 25 mph” and going back and ticketing you for speeding three years ago.
- They devised complicated, seemingly objective formulas to determine the threshold readmission rate above which a hospital was to be penalized. However, they did not take into account important factors like the patient population, hospital funding and other factors that heavily influence these rates.
So many more things to name with this program alone! Much less many of the other policies intended to help, and not hurt, the general populace.
What’s a better way? Start from the end and develop successful paths toward it. Truly evaluate programs and ensure they’re actually achieving the end goals. And when study after study proves that the program isn’t working, then ditch it for a new one! Some thoughts on this also warrant a different post–but I’ll let the sting of this information sit for awhile 🙂