Heart Failure: A Win-Win for Obamacare

 

One of the features we got when we got Obamacare was a new program aimed at reducing hospital readmission rates for various expensive diseases. The primary disease targeted by this new program was heart failure. Heart failure was chosen for the simple reason that spending on this condition accounts for 43% of all Medicare spending, which amounts to up to $38 billion each year.

Obamacare stipulated that hospitals that failed to sufficiently reduce the 30-day rate of readmission for their patients discharged with heart failure would be financially punished. This punishment was set at an amount equal to 3% of the hospital’s total annual Medicare payments. (That’s total Medicare payments for every Medicare patient, not just the ones with heart failure.) Given the shaky margins under which many hospitals operate, and given the size of their Medicare populations, this level of financial punishment was potentially not survivable. It was the medical equivalent of the NCAA death penalty.

So, the law did what it was intended to do. It put hospital administrators into a classic “whatever it takes” mode of operation. And the word went out from administrators to all the doctors (who, we must remind ourselves, are now largely under the pay of those selfsame administrators) that, no matter what, patients discharged from the hospital with heart failure are not to be readmitted, at least until Day 31.

Many techniques were rapidly deployed by physicians and institutions to carry out this prime directive, and too-many-to-count new companies sprung up overnight to sell hospitals various systems, strategies, and technologies to assist them in their efforts. Many of these efforts, in fact, addressed prior systematic shortcomings in the medical care of patients with heart failure, such as poor discharge planning, poor instructions, failed communications between discharging physicians and primary care providers, and failing to schedule follow-up visits. Other efforts took advantage of certain definitional loopholes (such as what constitutes an “admission” versus a period of “observation”).

Some good, I cheerfully agree, was accomplished by some of these efforts.

But, given the nature of the threatened punishment, and given the limited ability of such measures to reliably delay readmission, we must assume that other methods were used which are not discussed in polite society, or at all. Nobody ordered doctors directly and in plain language that they must never, ever readmit a heart failure patient until that mystical Day 31, no matter what. But then, nobody ordered certain retainers that they must kill Thomas Becket either.

On Nov 12, in the Journal of the American Medical Association, Gupta, et al., published an analysis of how well American hospitals have performed under this new law. The investigators analyzed data from 115,245 Medicare patients treated at 416 American hospitals. They report that the 30-day readmission rates from heart failure dropped from 20% prior to Obamacare to 18.4% afterward. This constitutes a substantial improvement.

However, Gupta, et al., also report that the 30-day post-discharge mortality rate for Medicare heart failure patients increased from 7.2% to 8.6% and that the one-year mortality rate increased from 31.3% to 36.3%. This increase in mortality reversed a decades-long trend toward improved survival in patients with heart failure.

My only quibble with Gupta, et al., is their suggestion that this increase in mortality is an unintended consequence of the new readmission program.

Nonsense. It is an entirely predictable and (I submit for your consideration) desired outcome.

Heart failure is usually a chronic, progressive condition that is very expensive and time-consuming to manage, and that almost invariably leads to early death. Major (and very, very expensive) advances in recent years in the treatment of heart failure have led to a substantial improvement in the quality of life of these patients and has somewhat prolonged their survival.

To a Medicare actuary, this means that people with heart failure (who, 20 years ago, would have taken digitalis and a diuretic — for pennies a day — and died within five years), are now living longer and consuming massive amounts of healthcare dollars while doing so.

While every patient is different, chronic heart failure tends to follow a pattern. Early in the condition, right after the diagnosis is made and initial therapy is instituted, patients tend to do quite well for a period of months or years. But as the underlying heart disease worsens, symptoms increase and hospitalizations become more frequent. As a result, when we are trying to prevent 30-day readmissions, we are generally dealing with a person who has had heart failure for some period of time, whose condition is becoming more severe, who is generally more brittle, and who is becoming more and more difficult to treat. Nonetheless, with careful and aggressive management (which may indeed include a number of hospitalizations in a relatively short period of time), these people can often be returned to a reasonably good quality of life for a while — until their next bout of deterioration.

It is entirely predictable that, when we pull out all the stops to delay readmissions until at least day 31 in such patients, we are likely to hasten death in some of them.

The data now bears this out, and any Medicare administrator who affects surprise or dismay at these results is trying to fool us. Contrary to any expressions of regret we might hear (though I have heard of none so far from government functionaries), this program is a raging success. Not only has it reduced short-term spending on hospital readmissions, but also it has reduced longer-term spending on chronic heart failure. It is a win-win.

I will admit to being wrong about this when Medicare apologizes and rescinds or substantially revises its readmission policy for heart failure. Even Henry II, after all, ended up giving public penance for the “unintended consequence” of his ill-considered words.

There are 87 comments.

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  1. MarciN Member
    MarciN
    @MarciN

    DrRich: So, the law did what it was intended to do. It put hospital administrators into a classic “whatever it takes” mode of operation. And the word went out from administrators to all the doctors (who, we must remind ourselves, are now largely under the pay of those selfsame administrators) that, no matter what, patients discharged from the hospital with heart failure ARE NOT TO BE READMITTED, at least until Day 31.

    This was so predictable.

     

    Great post. Thank you.

    • #1
  2. MarciN Member
    MarciN
    @MarciN

    DrRich:They report that the 30-day readmission rates from heart failure dropped from 20% prior to Obamacare to 18.4% afterwards. This constitutes a substantial improvement.

    However, Gupta et al. also report that the 30-day post-discharge mortality rate for Medicare heart failure patients increased from 7.2% to 8.6%, and that the 1-year mortality rate increased from 31.3% to 36.3%. This increase in mortality reversed a decades-long trend toward improved survival in patients with heart failure.

    I just wanted to pull those paragraphs out from the original post and give them some emphasis.

    All I can think of these days is this great scene from Yes, Minister:

    • #2
  3. Gumby Mark Thatcher
    Gumby Mark
    @GumbyMark

    Can we access the Gupta article?  If so, can you provide link?

    • #3
  4. Danny Alexander Member
    Danny Alexander
    @DannyAlexander

    This ought to go on the Main Feed pronto (please).

    • #4
  5. Dr. Bastiat Member
    Dr. Bastiat
    @drbastiat

    Great article.  And so, so true.

    You are correct that they cannot limit the care we provide to our sickest patients and then pretend to surprised that some of them die.

    Sarah Palin was laughed off the stage for discussing “death panels.”  By people who knew exactly what they were doing.

    It’s amazing what you can rationalize once you accept abortion.  Everything else is easy.

    • #5
  6. DrRich Inactive
    DrRich
    @DrRich

    Gumby Mark (View Comment):
    Can we access the Gupta article? If so, can you provide link?

    Here’s the link to the abstract. The full article is a pay-for:

    https://jamanetwork.com/journals/jamacardiology/article-abstract/2663213

    • #6
  7. The Reticulator Member
    The Reticulator
    @TheReticulator

    I’m glad you’re back, and that there is no need to organize a search party. I had been wondering, though.

    • #7
  8. DrRich Inactive
    DrRich
    @DrRich

    The Reticulator (View Comment):
    I’m glad you’re back, and that there is no need to organize a search party. I had been wondering, though.

    Thanks for thinking of me.  I’ve been lurking, but have been too preoccupied to write much here for several months. I have been engaged in writing the 6th edition of my textbook of cardiac electrophysiology which, as you might imagine, has been an endlessly fascinating task.

    • #8
  9. Mendel Inactive
    Mendel
    @Mendel

    The irony here is that we’re criticizing Obamacare for trying to rein in spending by a single-payer system.

    The CHF initiative is definitely worthy of criticism, but I find the real elephant in the room to be the fact that a crucial link in our health care infrastructure  (hospitals) have been frighteningly dependent on single-payer funding since well before Obamacare.

    • #9
  10. AQ Member
    AQ
    @AQ

    Your post is downright Swiftian.  That’s my highest compliment (though my heart aches, as my beloved brother has heart failure.)

    • #10
  11. DrRich Inactive
    DrRich
    @DrRich

    Mendel (View Comment):
    I find the real elephant in the room to be the fact that a crucial link in our health care infrastructure (hospitals) have been frighteningly dependent on single-payer funding since well before Obamacare.

    You are right about this.

    Another critically important structural change that largely took place before Obamacare was the physicians’ loss of financial independence. For most doctors today, @DocJay being an example of a notable exception, their professional viability utterly relies on keeping hospital and/or Medicare administrators satisfied with their work. Doing their very best for their patients is a nice-to-have, but is no longer their main (or even an essential) professional directive.

    • #11
  12. MLH Inactive
    MLH
    @MLH

    DrRich (View Comment):
    . . .their professional viability utterly relies on keeping . . . Medicare administrators satisfied

    My PCPhysician is changing her practice to a “Direct Primary Care” practice at the first of the year. She has not been tracking her PQRS and . .  well. . . can’t afford refuses to be a Medicare provider anymore.

    • #12
  13. Fritz Coolidge
    Fritz
    @Fritz

    So no actual “death panels” but instead, a legislative decree citing a number of days to elapse between hospital admissions on penalty of forfeiting reimbursements, thus achieving the same end. Marvelous. Thanks for the report.

    Before Obamacare and this rule, my dad died of congestive heart failure. He was first diagnosed at age 85, and his death came just shy of his 89th birthday. As I recall (although I was clear across the country, my sisters were close by), most hospitalizations in his 4-year course resulted from side effects of the medications he was prescribed, requiring periodic in-patient monitoring and tests while re-calibrating his medications.  He had turned down at the outset of his care future measures that he viewed as not worth the effort given his advanced age and that he felt he had had a great life (such as dialysis as his kidney function declined, or even replacing a broken tooth — he’d do without).

    I recall the difficulties and disorienting experiences he went through, at times losing cognitive function, fainting, or dehydration when the diuretics were over-strong, and feel if he’d been made to wait 30 days on some of those occasions, his and his aged wife’s suffering would have increased many fold, even if mortality were not imminent. Practicing medicine may be a humanistic and caring profession, but the roles of actuaries and paymasters are not.

     

    • #13
  14. DrRich Inactive
    DrRich
    @DrRich

    Fritz (View Comment):
    Practicing medicine may be a humanistic and caring profession, but the roles of actuaries and paymasters are not.

    This is why it is so advantageous for the Central Authority to arrange things so the practitioners are fully under the thrall of the actuaries and paymasters.

    • #14
  15. The Reticulator Member
    The Reticulator
    @TheReticulator

    DrRich (View Comment):

    Fritz (View Comment):
    Practicing medicine may be a humanistic and caring profession, but the roles of actuaries and paymasters are not.

    This is why it is so advantageous for the Central Authority to arrange things so the practitioners are fully under the thrall of the actuaries and paymasters.

    We should probably refer to the new form as “single paymaster” rather than “single payer.”

    • #15
  16. MLH Inactive
    MLH
    @MLH

    The Reticulator (View Comment):
    We should probably refer to the new form as “single paymaster” rather than “single payer.”

    • #16
  17. She Reagan
    She
    @She

    Great post.  I only wish that all of these workarounds and dodges could be blamed on Obamacare, although they certainly got worse after 2010.  But the parsing  of admit vs. observation patients, and the penalties for readmits on certain diagnoses within certain timeframes triggering catastrophic fines and penalties goes back a couple of decades prior.  Or so it seemed to me, before I retired in 2010, looking in the telescope from the other end, which in this case was hospital IT, and from which end we were always gathering data from one place to send it somewhere else in order to make a case, or prove a point, or discover incriminating or exculpatory evidence of one sort or another.  An incredible amount of work, at extraordinary expense, for no benefit to any patient that I was ever able to discover.  I think the rot set in quite a long time ago.

    • #17
  18. MarciN Member
    MarciN
    @MarciN

    The system was already bad, and every time someone tries to fix it, it gets worse.

    • #18
  19. Mendel Inactive
    Mendel
    @Mendel

    A question for everyone in this discussion: should we try to do more to rein in Medicare expenditures?

    Dr Rich mentioned that the new developments in controlling heart failure were “very, very expensive”. Should there be a point at which a treatment is too expensive for taxpayer funding?

    Of course the ideal response is to completely reform the Medicare payment structure. But there is zero political appetite for that, even on the right.

    So is there any politically feasible way of controlling Medicare spending that won’t be vilified as ignorant or immoral?

    • #19
  20. MLH Inactive
    MLH
    @MLH

    Mendel (View Comment):
    A question for everyone in this discussion: should we try to do more to rein in Medicare expenditures?

    Dr Rich mentioned that the new developments in controlling heart failure were “very, very expensive”. Should there be a point at which a treatment is too expensive for taxpayer funding?

    Of course the ideal response is to completely reform the Medicare payment structure. But there is zero political appetite for that, even on the right.

    So is there any politically feasible way of controlling Medicare spending that won’t immediately become vilified as ignorant or immoral?

    Tough love without the love.

    • #20
  21. Mendel Inactive
    Mendel
    @Mendel

    MLH (View Comment):

    Mendel (View Comment):
    A question for everyone in this discussion: should we try to do more to rein in Medicare expenditures?

    Dr Rich mentioned that the new developments in controlling heart failure were “very, very expensive”. Should there be a point at which a treatment is too expensive for taxpayer funding?

    Of course the ideal response is to completely reform the Medicare payment structure. But there is zero political appetite for that, even on the right.

    So is there any politically feasible way of controlling Medicare spending that won’t immediately become vilified as ignorant or immoral?

    Tough love without the love.

    Sorry, I don’t follow.

    • #21
  22. MLH Inactive
    MLH
    @MLH

    Mendel (View Comment):

    MLH (View Comment):

    Mendel (View Comment):
    A question for everyone in this discussion: should we try to do more to rein in Medicare expenditures?

    Dr Rich mentioned that the new developments in controlling heart failure were “very, very expensive”. Should there be a point at which a treatment is too expensive for taxpayer funding?

    Of course the ideal response is to completely reform the Medicare payment structure. But there is zero political appetite for that, even on the right.

    So is there any politically feasible way of controlling Medicare spending that won’t immediately become vilified as ignorant or immoral?

    Tough love without the love.

    Sorry, I don’t follow.

    Basically: no.

    • #22
  23. DrewInWisconsin Member
    DrewInWisconsin
    @DrewInWisconsin

    I remember Obama lecturing us that instead of getting a life-saving surgery, maybe everyone should just take pain pills. Today we have an opioid crisis. Any connection?

    • #23
  24. MLH Inactive
    MLH
    @MLH

    now that you are on the main feed, is it heat or heart failure?

    • #24
  25. DrRich Inactive
    DrRich
    @DrRich

    Mendel (View Comment):
    A question for everyone in this discussion: should we try to do more to rein in Medicare expenditures?

    So is there any politically feasible way of controlling Medicare spending that won’t immediately become vilified as ignorant or immoral?

    Unless our leaders are willing to tell us, and eventually, sell us, on the idea that the promises we have made to current and future Medicare recipients will result in societal collapse, there is only one way to attempt to control expenditures: covert rationing. The heart failure readmission ploy is just one example of covert rationing. There are hundreds of others.

    The problem with covert rationing is that it absolutely requires non-transparency; indeed, its requires as much opacity, complexity, inefficiency and confusion as you can muster, so that you can convince the public, the press, your colleagues, and even yourself that, whatever it is you are doing, it’s not rationing. So, covert rationing necessarily produces much more waste and inefficiency than you can possibly recover from whatever actual rationing you can accomplish.

    I for one am ready to listen to ideas for openly rationing healthcare. A public discussion of this necessity, in the proper spirit of problem-solving rather than of vituperation, would trigger all kinds of creative ideas for reforming healthcare in new ways. We need to rethink the roles of doctors, hospitals, and patients, and really take advantage of emerging technology, etc. Only the specter of open rationing might trigger the kind of creative thinking we need. If you want to minimize rationing, make it open.

    • #25
  26. Mendel Inactive
    Mendel
    @Mendel

    And the problem with overt rationing is that conservatives will yell “death panels!” until the idea is scrapped.

    Or, like the SGR, pass it and then defer it every year for a decade until finally putting it out of its misery.

    Let’s be real: there’s zero public appetite for overt rationing. We can rightly criticize the Obamacare architects for trying to be too clever, but the truth is they took the only politically feasible approach.

    • #26
  27. Mendel Inactive
    Mendel
    @Mendel

    I agree about covert rationing being destined to backfire. There’s no way to squeeze a huge savings from any program without palpable effects.

    The biggest area where I  see potential for real savings that might be politically feasible is in negotiating drug prices. Of course, since many drug companies also need Medicare spending to stay afloat, while consumers are typically shielded from the actual prices of their drugs, this would also be a lopsided battle.

    • #27
  28. DocJay Inactive
    DocJay
    @DocJay

    Cardiologists did reasonably well until a decade or so ago.  They often had the means to do ultrasounds and nuclear medicine tests in facilities they owned.   To combat what Medicare viewed as aggressive self-referrals for these tests Medicare cut the reimbursement to the point where cardiologists could not do well at all.  Cardiologists began working for hospitals instead and all these tests go transferred to the hospital where the charges are ramped up to 3x the previous cardiology office based charge.  A 2000 dollar nuclear study back then  is 6000 now ( I may be wrong Dr Rich, please correct me, I believe there’s lots of variation).

    So now cardiologists are almost all tools of hospital administrators, yet another person in the room between a doc and a patient.

    It seems to me that almost all of health care fiscal policy involves issues that cannot be discussed out of fear.  Rationing is the biggest issue.  It has to happen and does in covert ways.

    Is the American population too chicken to have a real dialogue about resource allocation?

    • #28
  29. DocJay Inactive
    DocJay
    @DocJay

    DrRich (View Comment):

    Mendel (View Comment):
    A question for everyone in this discussion: should we try to do more to rein in Medicare expenditures?

    So is there any politically feasible way of controlling Medicare spending that won’t immediately become vilified as ignorant or immoral?

    Unless our leaders are willing to tell us, and eventually, sell us, on the idea that the promises we have made to current and future Medicare recipients will result in societal collapse, there is only one way to attempt to control expenditures: covert rationing. The heart failure readmission ploy is just one example of covert rationing. There are hundreds of others.

    The problem with covert rationing is that it absolutely requires non-transparency; indeed, its requires as much opacity, complexity, inefficiency and confusion as you can muster, so that you can convince the public, the press, your colleagues, and even yourself that, whatever it is you are doing, it’s not rationing. So, covert rationing necessarily produces much more waste and inefficiency than you can possibly recover from whatever actual rationing you can accomplish.

    I for one am ready to listen to ideas for openly rationing healthcare. A public discussion of this necessity, in the proper spirit of problem-solving rather than of vituperation, would trigger all kinds of creative ideas for reforming healthcare in new ways. We need to rethink the roles of doctors, hospitals, and patients, and really take advantage of emerging technology, etc. Only the specter of open rationing might trigger the kind of creative thinking we need. If you want to minimize rationing, make it open.

    I just asked this question.  I am ready for this conversation too.  In The Open!

    • #29
  30. DrRich Inactive
    DrRich
    @DrRich

    Mendel (View Comment):
    Let’s be real: there’s zero public appetite for overt rationing. We can rightly criticize the Obamacare architects for trying to be too clever, but the truth is they took the only politically feasible approach.

    Let’s be real, part 2: Covert rationing did not begin with Obamacare. It’s been the chief (only) mechanism we’ve used for cost control for 40+ years. And, the purpose of Obamacare was not actually to control costs, improve efficiency, or expand the number of people who have insurance.

    The purpose of Obamacare, to my mind, was to officially centralize control of the entire healthcare system, and thereby, to achieve central control over nearly every aspect of everyone’s life. This, finally, will allow the enlightened experts to achieve the societal perfection they have in store for us, perfection that is always just around the corner.

    • #30

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