If you have an aging parent or other elderly relative who is currently hospitalized with chronic heart or lung disease, the good news is he is coming home. The bad news is that he is likely coming home to die. That’s thanks to a strong disincentive for hospitals to readmit chronically ill Medicare patients under a provision of Obamacare. Called the Hospital Readmissions Reduction Program (Section 3025 of the Affordable Care Act added section 1886(q)), the provision took effect on October 1, 2012 and penalizes hospitals for readmitting patients with one of several high-maintenance conditions — heart failure, heart attack and pneumonia — within 30 days of discharge. Two additional expensive-to-manage illnesses, Chronic Obstructive Pulmonary Disease (COPD) and follow-up treatment for coronary bypass surgery, are scheduled to be phased in this year.
In the view of the Medicare Payment Advisory Commission (MPAC), readmission of Medicare patients with any of these illnesses is an admission — of failure on the part of doctors. The government believes that if the correct treatment were administered during an initial hospital stay, these patients wouldn’t need to return. As a corrective measure, the law imposes a hefty fine on hospitals that readmit chronically ill patients. MPAC estimates that the fines collected will ultimately restore $1 billion to Medicare’s depleted coffers.
Currently, one in five elderly patients is readmitted within the 30-day window. Many of the readmissions result from unanticipated changes in the patient’s condition or a planned follow-up treatment. But roughly 12% are caused by patient confusion over new drug regimens, inadequate follow-up with primary care physicians, or a family’s inability to deal with home care. These “avoidable readmissions,” the government insists, are the fault of hospital staffs for not doing a better job of educating patients and/or administering better preventive care.
There are two problems with the approach. One, spelled out in an article at the British medical journal The Lancet, is that some of these chronic diseases in the elderly are tricky to manage. “Frequent readmissions,” the authors note, “might simply reflect the nature of the patient population rather than poor health care.” They add:
A 30-day readmission rate might be a suitable measure of health-care delivery for some conditions or surgical procedures, but for patients with COPD a more sophisticated gauge of success that incorporates medical, social, functional, and economic elements is needed.
The other problem is how hospitals and doctors on staff respond to the penalty. The most likely scenario is that they will now become de facto agents for the law’s death panels, urging Medicare patients at their time of discharge to sign do-not-resuscitate orders and seek “comfort care” instead of future medical treatment.