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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.