By Jordan Rau
December 19, 2011
Washington Post

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 <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001211/>  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.

Shady Grove Adventist Hospital in Rockville has some of the highest readmission rates in the nation — 29.2 percent of heart failure patients rehospitalized within 30 days — and treats more poor patients than do a majority of the nation’s hospitals, according to the KHN analysis.

Shady Grove officials said that a challenge common to all hospitals — to keep patients on a healthful, low-salt diet — is made harder there by the large numbers of Salvadoran patients who come to their institution. Shady Grove tries to provide a bilingual staffer to explain to patients how to take care of themselves after discharge. The hospital also provides them with low-salt recipes for ethnic dishes.

Shady Grove and Washington Adventist also have arrangements with nearby pharmacies to provide medications to poor patients free or at cost.

Johns Hopkins Bayview said in a written statement that it is “working diligently” to prevent its heart failure patients — many of whom are not only very poor but also drug or alcohol addicts — from returning to the hospital. Officials at Prince George’s Medical Center did not respond to requests for an interview.

Even doctors who press their patients about their post-discharge arrangements sometimes don’t get honest answers from those who are embarrassed about their financial circumstances, said Boise Barnes, a primary-care doctor in Southeast Washington. “There’s pride involved,” he said. Others do take medication, he said, but then “they feel better, and they don’t come back” for follow-up appointments.

It’s complicated

Strategies such as having nurses call to check on discharged patients can be harder to implement with a poor population. “Sometimes the address they give us isn’t even the right address. Sometimes they don’t have telephones,” said Alfred Bove, a cardiologist at Temple University Hospital in Philadelphia.

While low-income patients offer greater challenges for hospitals, the insurance that typically covers them — Medicare and Medicaid — does not pay as well as do private carriers. That means that hospitals that treat many of them often have to operate on tighter budgets.

The new readmission penalties may make this worse, said Steven Lipstein, president of BJC HealthCare, which operates Barnes-Jewish Hospital, a medical center in St. Louis with an above-average number of poor people and high readmission rates. “If you pay the hospitals less or the doctors less who take care of people with difficult life circumstances, then it stands to reason that fewer of them will do that,” Lipstein said.

There is a racial concern in readmissions as well. A study by Karen Joynt and Ashish Jha, two researchers at the Harvard School of Public Health, found that patients discharged from hospitals that treated the most blacks had much higher readmission rates — for both black and white patients — than patients from hospitals that served few minorities.

“The big confounding factors in readmissions are often nonclinical issues: ‘I don’t have anyone at home to take care of me,’ ‘I don’t have any transportation,’ ” said Chas Rhoades, chief research officer at the Advisory Board, a consulting firm based in Washington.

A diligent patient

Ralph Rust’s decade-long struggle to stay out of hospitals involves some of the factors that cause patients to be readmitted frequently. Rust, a Southeast Washington man who is covered by Medicaid, said that for years he was hospitalized as often as three times a month at Howard University Hospital.

Many admissions, he said, were of his own doing. He skipped his medications and kept eating foods his doctors told him to avoid. At one point, his weight ballooned to 340 pounds. “I’d take my pills one day, feel pretty good, then I’d skip a day,” he said. “I didn’t realize what I was doing to myself.”

When Rust was transferred to Washington Hospital Center in 2008 to get his pacemaker replaced with a defibrillator, he had a change of heart. That was partly due to the stern talk his doctors gave him and their new diagnosis that he had an irregular heart rhythm, he said. It was also his own realization that he was going to die if he did not change his ways.

Since then, Rust, now 59, is an atypically diligent patient, his doctors said. He eats carefully, keeping his salt intake to 1,800 milligrams a day. He has forsaken fried foods and fast foods in favor of baked or broiled meat. He has shed much of his weight. He walks around the block each morning and takes his pills on schedule.

Even these good habits could not keep Rust from readmission. In January, he was rehospitalized for four days. A week later, he was back for 17 days. In May, the head of the Washington Hospital Center’s heart failure program, Samer Najjar, ordered him back after he gained 15 pounds of fluid in a week. Rust was hospitalized for 15 days. In September, the doctors implanted a $150,000 heart pump.

“It’s nice to think hospitals control all of the pieces in this puzzle,” said George Ruiz, who runs the hospital center’s heart failure outpatient clinic. “But even though hospitals can do amazing work, they sometimes have very limited resources to address all the ills of a community.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health-policy research and communication organization not affiliated with Kaiser Permanente.