Ralph Rust of Southeast Washington has struggled for a decade to stay out… (PATRICK TELEPICTURES/ )
James Breedin cannot keep track of how often he has been admitted to Howard University Hospital for heart problems. “It’s been so many,” said Breedin, a 75-year-old disabled former truck driver from Northeast Washington.
One reason for his frequent returns, he says, is that he often can’t afford the medications his doctor prescribes, “so I have to do without.” Another is that he fears exercising outside because of neighborhood violence.
Medicare is preparing to penalize hospitals with frequent potentially avoidable readmissions, which by one estimate costs the government $12 billion a year. Medicare’s aim is to prod hospitals to make sure patients get the care they need after discharge. But this new policy is likely to disproportionately affect hospitals that treat the most low-income patients, according to a Kaiser Health News analysis of data from the Centers for Medicare & Medicaid Services.
Hospitals that served the most poor Medicare patients were nearly three times as likely as others to have substantially high readmission rates for heart failure, the analysis found. At these hospitals — which include Howard, Prince George’s Hospital Center in Cheverly and Johns Hopkins Bayview Medical Center in Baltimore, as well as such well-known medical centers as NewYork-Presbyterian Hospital and Mount Sinai Medical Center, both in Manhattan — low-income people comprised a greater share of the patients than they did at 80 percent of hospitals.
Many of those hospitals already operate on tight margins and fear the new penalties could make it even harder for them to properly care for impoverished patients.
Avoiding readmissions is a particular challenge in the Washington area, where, a government study reported last year, readmission rates are higher than in most parts of the country.
Even at places such as Washington Hospital Center, which Medicare says has average readmission rates, physicians contend with large numbers of poorer patients who have both chronic congestive heart failure and such other maladies as obesity, hypertension and diabetes. Because they often don’t see doctors regularly, these patients tend to arrive at the hospital later in their deterioration, some with their limbs bloated with excess water and barely able to walk.
“Their problems tend to be more advanced,” said James Diggs, Breedin’s cardiologist at Howard. “We have patients who are readmitted almost every two months for heart failure. We almost save a bed for them.”
A revolving door
Heart failure is the most common condition sending Medicare patients back into the hospital. Fluid often builds up when the heart pumps poorly. To get rid of it, doctors prescribe drugs to speed up the heart or make patients urinate more frequently.
But much of the recovery depends on what happens to patients after they leave. Physicians say low-income people often can’t afford the medications they are prescribed or the more healthful food they are directed to eat. They also can have trouble understanding the sometimes complex instructions about how to take care of themselves.
Within 30 days of discharge, one of every four Medicare patients with heart failure is readmitted. The Affordable Care Act passed last year mandated that starting next October, Medicare will penalize hospitals whose patients with heart attacks, heart failure or pneumonia return frequently. By 2014 hospitals with high readmission rates stand to lose up to 3 percent of their regular Medicare reimbursements.
Medicare has set aside money to help hospitals plan patients’ post-discharge care better. Patrick Conway, Medicare’s chief medical officer, said some of that money will be targeted to hospitals with lots of poorer people. “We especially are concerned about safety-net hospitals that take care of a high portion of patients in poverty and racial and ethnic minorities,” he said.
Ways to improve
A heavy load of poor patients doesn’t doom a hospital to frequent returns. Washington Adventist Hospital in Takoma Park and three hospitals in Virginia had average readmission rates even though they had more poor patients than 80 percent of hospitals, according to the analysis.
“We all know there are so many opportunities for hospitals to do better,” said Harlan Krumholz, a Yale School of Medicine cardiologist who helps Medicare analyze readmission rates. “Just sort of saying, ‘It’s not our fault’ and saying, ‘It’s the patient’s fault’ is not the right approach.”
Some hospitals are devising creative approaches to keep high-risk patients from coming back. At Howard, Diggs insists that some patients come to his office daily until their health is stable. He said he also tries to check whether a drug is covered by insurance before prescribing it.