The Wall Street Journal - Cutting Repeat Hospital Trips -- Simple Idea, Hard to Pull Off
By Ron Winslow and Jacob Goldstein
PITTSFIELD, Mass. -- One prescription for slashing billions of dollars from America's health-care spending will come down to questions like this: Can hospitals persuade discharged patients such as Betty Beauchaine to pass up a Fourth of July hot dog?
Mrs. Beauchaine, a 75-year-old great-grandmother who suffers from heart failure, was admitted to the Berkshire Medical Center here twice in June, with fluid accumulation in her lungs that left her short of breath.
Berkshire Medical has launched an unusual initiative in recent years to prevent heart-failure patients like Ms. Beauchaine from ending up back in the hospital shortly after they have been discharged. As part of its efforts, it recently advised patients not to eat franks at holiday cookouts because their salt content could promote dangerous fluid retention.
Mrs. Beauchaine recalls approaching the food table at an Independence Day picnic: "I told the girl, 'I'm going to have a hot dog. If I'm dead in the morning, I'll never know.'" In the morning she was back at Berkshire Medical Center.
The government spends an estimated $12 billion a year on "potentially preventable" readmissions for Medicare patients, according to the Medicare Payment Advisory Commission, an independent congressional agency. U.S. leaders are trying to reduce such costs as they wrangle this week over how to retool the country's health-care system. Though private insurers also pay for readmissions, these charges are especially prevalent among the elderly covered by Medicare.
"Medicare has been paying for quantity and not for quality," says Barry Straube, Medicare's chief medical officer. "The goal is to not pay for things that shouldn't happen."
Lawmakers agree on the need to drive down readmissions, but not on how to do it. Efforts like those at Berkshire Medical require hospitals to become deeply involved in the lives of their sickest patients after they leave the building. Some patients aren't always willing, or able, to heed hospitals' advice. The biggest sticking point may be this: It isn't in these institutions' financial interest to keep people from coming back.
Some lawmakers want the government to help fund services like those provided by Berkshire Medical. A bill introduced earlier this year by Colorado Sen. Michael Bennet, a Democrat, would authorize Medicare to pay for arranging follow-up care and training for recently discharged patients, as long as the services reduce readmission rates.
Many lawmakers want to crack down on care providers that don't keep their readmissions in line. The House of Representatives' health-overhaul bill calls for cutting Medicare reimbursement to hospitals that have high readmission rates for heart attack, pneumonia and heart failure. President Barack Obama's proposed budget would penalize hospitals in the highest quartile of readmission rates for certain conditions. The chairman of the Senate Finance Committee, which is expected to release a health bill soon, has called for similar penalties.
Hospitals are already under pressure. Early this month, Medicare published 30-day readmission rates for heart attack, pneumonia and heart failure for every hospital in the country, in the belief that publicizing the figures would spur hospitals to address the issue.
The complexity and cost of reducing readmissions can be seen at the 309-bed Berkshire Medical Center in western Massachusetts. The center, part of the nonprofit, two-hospital Berkshire Health Systems, last year opened a clinic where heart-failure patients can seek consultations without checking back in. This spring, it launched a telephone system that monitors released patients' weight and other vital signs to prevent small changes from developing into full-blown health emergencies. Its team of visiting nurses regularly calls on patients at home.
As a result, the hospital says, readmission rates for these patients have fallen. But it isn't reimbursed for much of its efforts. "You do it because it's the right thing to do," says Diane Kelly, the hospital's chief operating officer. "But doing the right thing is getting expensive."
Heart failure, which afflicts five million Americans, costs the health-care system $37 billion annually, according to the American Heart Association. Hospital care accounts for 80% of the tab. An analysis of Medicare data published this year in the New England Journal of Medicine, one in five patients discharged from the hospital is readmitted within 30 days. For heart-failure patients, the rate is about one in four.
The condition occurs when the heart is unable to pump enough blood to the body. Fluid then accumulates in the ankles and lungs, leaving patients with shortness of breath, sapped energy and a sensation of drowning. Treatment includes diuretics to help reduce fluid buildup and drugs that help the heart work better.
But many sufferers' care is complicated by other maladies, which can lead separately to hospital stays. Edwin Zajac, a 74-year-old retired quality-control inspector at a former General Electric Co. plant in Pittsfield, is representative. He was diagnosed with heart failure in 1995 and has diabetes, high cholesterol and atrial fibrillation, a heartbeat disorder. He has had quadruple-bypass surgery, two cancer operations and multiple hospitalizations for pneumonia and other problems.
"I've got everything," says Mr. Zajac, now a regular at Berkshire Medical's heart-failure clinic. "I've been told I'm weird. I just believe I'm medically complex."
For such patients, there are ways to reduce round trips to the hospital. The analysis in the New England Journal of Medicine suggested that 52% of Medicare patients readmitted within 30 days for heart failure hadn't seen a doctor since discharge, suggesting it is important to set and keep post-release appointments. Sudden weight gain of even a few pounds can signal an impending decline -- one that can often be stemmed by tweaking medications or diet.
Attention to these issues can reduce readmission for heart failure by as much as 30% to 40%, according to pilot projects studied by Yale cardiologist Harlan Krumholz. But the services in such projects often don't qualify for reimbursement by private and public health plans. In a 2005 study, Dr. Krumholz and his colleagues reported that 13 of 15 successful projects to reduce readmissions were canceled after special funding for them ran out.
"These hospitals knew they had something that worked," Dr. Krumholz said. "But they couldn't come up with a business model that could afford it."
Berkshire Medical's efforts took root in 2005, when it joined an American Heart Association initiative to reduce heart-failure deaths in the hospital. It bolstered care inside the hospital, ensuring its medications conformed to the latest guidelines and assigning additional staff physicians to manage patients' treatment during their stay.
Yet its rate of returning patients was actually rising, the center discovered. In 2007, 65 of its 251 patients admitted for heart failure -- or about 26% -- were back for at least the second time in 30 days. That was up from about 20% in 2005.
Even before the 2007 data were in, Gray Ellrodt, Berkshire's chief of medicine, says he and his colleagues had diagnosed the problems. The breakdown was occurring not in the hospital, but in the transition to home.
That spurred more changes. The center began more aggressively reducing patients' fluid levels before discharge, lest a salty meal land them back at the admissions desk. Instead of reminding patients to schedule follow-up visits with their doctors, staffers now book the appointments themselves and check to make sure they happen. They review medication regimens during discharge meetings, verifying that patients have enough pills to last until their upcoming checkups. Nearly half of patients are visited by a nurse within 24 hours of discharge.
"They go over the whole nine yards," says Anna Bedard, 78 years old, who entered the program earlier this year.
Mrs. Bedard, who has diabetes and kidney disease, suffered a heart attack in December 2007. She was hospitalized in January for heart failure, then again a few months later after a reaction to an unrelated procedure. Even before her April discharge, nurses gave a list of off-limits foods to her daughter, who lives with her.
"She cleaned out the refrigerator and the cabinets so there was nothing there to tempt me," Mrs. Bedard says.
Nurses checked her home for tripping hazards like loose rugs. On subsequent visits, they have reviewed her medicines to make sure she's taking her prescribed 12 pills a day. They check her blood sugar, lungs and heart, and monitor for fluid buildup by measuring the circumference of her calves.
Mrs. Bedard was also among the first to use the hospital's new $55,000 telephone system that relays patients' daily weight, heart rate, oxygen levels and blood pressure. "Good morning," a voice from the system says each day at 8 a.m. "It's time to take your vitals."
In May, the device told nurses Mrs. Bedard had gained a few pounds. She was given an additional diuretic and within a couple of days her weight fell back to previous levels. "I call it my conscience," Mrs. Bedard says.
Such efforts aren't foolproof. Some patients refuse to let visiting nurses into their homes. Others have trouble weighing themselves because they can't balance on the scale or read the numbers. Many find it hard to follow complex care regimes.
Berkshire Medical issued its hot-dog warning, for example, in clinic and home consultations just before the Fourth of July holiday. A typical frank's 1,000 milligrams of sodium could be enough to trigger a hospital admission. "We force our patients to learn to love hamburgers," says Alicia Ferrarin, a cardiology nurse practitioner who coordinates Berkshire's heart-failure improvement effort.
Mrs. Beauchaine says she didn't hear the message. The heart-failure patient -- who is also diabetic, has had a kidney transplant and spent more than four months this year in two hospitals and a nursing home for kidney and other problems -- knows hot dogs aren't good for her. She says she eats them a few times a summer, at picnics.
Ms. Ferrarin determined the holiday hot dog may not have been the only problem. Mrs. Beauchaine had also eaten a plate of baked beans, which are high in salt. Plus, Mrs. Beauchaine and her husband were getting daily lunches from a local Meals on Wheels program, which Ms. Ferrarin says can be higher in sodium than some patients can tolerate.
"They're really sitting on me for the salt," says Mrs. Beauchaine, who was discharged on July 19. Her husband canceled the meal service and bought lower-sodium frozen dinners. "In the last [several] days, my weight has been pretty steady."
Enid Borden, the president and CEO of the Meals on Wheels Association of America, says the program is aware of sodium risks for the elderly and says most of its meals' salt content is low.
Early results from Berkshire Medical's initiative are promising. According to the Medicare figures published this month, the center's 30-day readmission rate for heart failure was 23% for 2006 through 2008, in line with the national average of 24.5%.
But the hospital says that for 2008 alone, its 30-day rate fell to 18.6%. Among the regular visitors to its new heart-failure clinic, the rate is about 3%. Berkshire Medical figures that worked out to about 30 fewer heart-failure admissions than the year before -- or, based on reimbursement of about $7,500 per case, about $225,000 in lost revenue. It estimates salaries and other operating costs of the program amount to about $500,000.
Dr. Ellrodt projects the hospital is on course for a 17% readmission rate this year. "This is as complicated as it gets in health care," he says.