Trying to Make 30 by Pat Conrad MD

Last week, CMS released a study that is, to grossly understate, “controversial.”  In what may be the most damning indictment of government medicine ever produced, a study of the so-called “longitudinal multipliers” of Medicare cost projections claims to demonstrate that average beneficiary longevity beyond a certain “programmatic sustainability threshold” is deemed “counter to the best interests of the elderly population.”  In plain language, the longer Medicare patients live, the worse it is for the survival of the program.  The study’s editors suggest serious examinations of those programs that extend “non-meaningful survivability beyond population benefit goals.”  While the authors do not suggest specific ways to cull the herd, they do call for “innovators [to] … further improving population quality goals over less quantifiable individual encouragements.” 

And admittedly, what you just read above is complete, made-up, parody bullshit.  Hope you enjoyed the link.  But the stuff I made up is not a lot worse than CMS arbitrarily punishing hospitals (and patients) for readmissions within 30 days.  Like all the other made-up, parody, bullshit that passes for “quality metrics”, this particular goal translated into “we’ll save money by not treating sick people.”  Cost overruns never before imagined by the architects of institutionalized compassion have led to desperate attempts to save money, which led to stupid thinking, which we now see, has gotten people killed (okay, this is a real link).  If someone is discharged from the hospital, then odds are they were already sicker than the average Joe.  So being sicker than the baseline population, this person would be more likely to need (re) hospitalization sooner than others.  The answer became to directly financially threaten hospitals, and indirectly threaten doctors, which equates to blaming them for the clinical outcome, absent any evidence whatsoever.

“This financial penalty and public reporting led to hospitals putting pressure on clinicians to reduce 30-day readmissions and keep patients out of the hospital. So, the clinician trying to respond to the pressure and incentive has a patient who is at home and not doing well but they’d been hospitalized 21 days before and you’re in this dilemma. The clinical situation may necessitate hospitalization. You want to do the right thing for the patient, but maybe if I can buy a little more time and leave them at home, take that little extra risk it will work out OK and if they get hospitalized beyond 30 days that is OK.

There are patients being shunted from the ER to an outpatient observation unit rather than being hospitalized because of Medicare policies. Now, that patient can no longer for qualify for home health or skilled nursing facility or other resources because they were not hospitalized.”

Those of us who are actual practicing physicians can see that this weird dis-incentivizing would lead to rationalizing less care for some, in order to help the hospital so that they might help more in the future.  Outcomes can indeed improve with close home follow-up, if it actually occurs, if the patient actually met criteria.  And as the article notes, not a few of these patients are from the lower socio-economic side of the tracks, more likely to be sicker to start, non-compliant, and more likely to earn the treating hospital a penalty for premature readmission.  Every ER has its frequent fliers, and the ones that are already sick tend to come in sick, leading the ED doc to readmit them anyway, whatever the hospital wants or CMS deems.  Sure, some administrators might pay a friendly visit to the ED, just to say hi, no email, nothing written down, just a chance to offer encouragement and maybe a little advice.  The hospitalists won’t like those visits either, squeezed as they are between the clinical (and medico-legal) necessities of the ED and arbitrary CMS rulings.

And yet, here is a study showing that “As many as 10,000 heart failure patients could die prematurely each year because of misguided efforts that keep them out of the hospital to avoid the financial penalties attached to higher readmissions.”

But that only works out to 200 patients per state ever year, which is not too bad, and it is conserving important Medicare resources, right?

107560cookie-checkTrying to Make 30 by Pat Conrad MD