Joesph Ouslander and Robert Berenson have a piece in the NEJM amplifying the problem of unnecessary hospitalizations among persons living in nursing homes (NH). The statistics are sobering: 1.6 Million Americans live in a NH, and nearly 1 in 4 who are first admitted from a hospital to a NH are readmitted to the hospital within 1 month. They provide a face to these statistics: a 90-year old with Alzheimer’s disease, CHF and severe left ventricular dysfunctions who develops a low grade fever and chills. The scenario ends up with a hospitalization in which the patient is treated with IV antibiotics paid for by the Medicare program (at a cost of $10,000) and the fever resolves. However, one night during the hospital stay, the patient becomes disoriented, falls and breaks her hip, returning her to the NH in far worse shape than she left it in.
High cost that results in a worsening of quality of life in this type of population is about as bad as it gets.
The authors paint an alternative scenario in which the patient is evaluated in the NH and receives the same antibiotics in her familiar surroundings with fall prevention controls and her fever has resolved a week later at a cost of around $200 to Medicare, and her hip intact. The paper sketches out the hospitalization experience of the dual eligibles (Medicare and Medicaid) in 2005.
The goal is to reduce the avoidable hospitalizations while maintaining access for the ones that are needed. The authors note several caveats lest you think this is such obviously low hanging fruit that we must definitely be on the cusp of solving these problems.
- Misaligned financial incentives between Medicare and Medicaid. For example, after a hospitalization, a dual eligible may become eligible for Medicare Part A SNF funding which in some states may pay 3-4 times the Medicaid per diem rate, providing a strong incentive for a NH to send patients to the hospital. A second example is that any savings that accrue to Medicare by reducing avoidable hospitalizations are not shared with Medicaid, reducing the incentive of Medicaid programs to address this issue. There are many others.
- Not all avoidable hospitalizations can be avoided, so it might be easy to overstate the plausible savings from a program to address these issues. Brad Flansbaum has a nice post on how difficult it is to determine why readmissions occur, who is responsible, and how to fairly and effectively incentivize hospitals to reduce them.
- Many nursing homes do not have the appropriate staff to safely address acute health problems that could be addressed within the NH.
Ouslander and Berenson note that the incentives must be changed to address the issue and list some possibilities based on passed demonstrations and aspects of the ACA. I have written about two polar opposite approaches: federalizing Medicaid and integrated care provided by private insurance, both of which seek to incentivize one payer to make changes. However, the dual eligible Special Needs Plans that now exist undertake almost no such integration. There are profound political barriers to either approach in addition to many practical difficulties.
We have now well identified that the dual eligibles are a vulnerable group that costs a great deal while having numerous quality issues. We need to move ahead and try and evaluate as many models as possible, but the biggest barrier to doing so is the political stalemate over health reform that our nation is currently in. Until we manage to break through that, it will be lots easier to identify big problems than it will be to take practical steps to address them.
update: my fourth grade spelling teacher wouldn’t have been happy with the original title of the post