It's Easy to Get In, But Harder to Get Out: Post Hospital Syndrome or "PHS"

Bad for your health?

When the Disease Management Care Blog was told by the intern, the hospital social worker, the VP for Medical Affairs or the family that an inpatient "was ready for discharge," it had a favorite test to see if it was really true.  The DMCB would walk into its patient's room and ask her to do what she had easily done before she was admitted to the hospital: swing your legs out of bed, stand up and walk across the room.

The DMCB was impressed by how often elderly patients were unable to perform that simple but telling task.

Of course, the best approach was to not let the patient become that debilitated in the first place.  That's the point of Harlan Krumholz's article on "Post-Hospital Syndrome" that was recently published in the January 10 New England Journal.

In it, Dr. Krumholz shares an important secret: being in the hospital can result in starvation, sleep deprivation, muscular deconditioning, confusion and myriad poly-pharmacy side effects.  In fact, it's probably those issues, not the original medical problem that led to the hospitalization, that account for much of the infamous 20% 30-day readmission rate for Medicare beneficiaries.

Dr. Krumholz recommends that hospitals be more attentive to assuring better nutrition, provide a less noisy environment, promote early activity and keep the use of sedative, pain and hypnotic (i.e., sleeping pill) drugs to a minimum. The DMCB seconds that motion and suggests that many of its more savvy colleagues think of this as discharge planning that begins the minute the patient is admitted to the hospital.

And when patients are ready to go home, it's not a matter of continuing outpatient treatment for the initial diagnosis.  These patients need comprehensive assessment and planning.  While the author doesn't come out and say it, the DMCB will: these patients need nurse-led care planning and management that addresses the full spectrum of needs that are too often ignored by hospital personnel in the rush to collect on the DRG and minimize length of stay.

Last but not least, the DMCB recommends adoption of the term "post-hospital syndrome" and wonders if it may not deserve the "PHS" acronym.

Anyone who has ever witnessed a previously well person be unable to stand up and walk will know exactly what it means.

Health Care Reform in the U.S. vs. Other Developed Countries.

Your doctor will see you now!

If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then we'd be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when we're told we're too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

That's why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health reform efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future reform is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

Image from Wikipedia

Medication Errors and Injectable Drugs: The $5 Billion Price Tag

uh oh......

Writing in the latest issue of American Health & Drug Benefits, the Disease Management Care Blog reviews a study on medical errors associated with injectable drugs (go to page 25).

After mining and correlating multiple national data bases, Betsy Lahue and colleagues found believable evidence that 1 of every 400 U.S. hospital injections results in avoidable error.  While that number seems low, that means the average hospital can experience 25 accidents a day.  While the vast majority of these events don't necessarily lead to significant patient harm, the financial toll adds up to more than $5 billion in additional expense.

While $5 billion may not impress the thousands that make up the sophisticated DMCB readership, they also know that there are no simple and single trillion-dollar-coin-type answers to the long-term challenge of rising health care costs. Bending the curve will ultimately involve multiple solutions that include utilization management, payment reform, tort reform, care management, consumerism, attacks on fraud and abuse and and emphasis on increasing medical quality. That also means reductions in all types of medication errors.

The DMCB really likes Lahue et al's paper because most hospitals should be able to replicate much of this study's methodology using their own data bases. That means they can establish a baseline ("25 errors a day") and work to reduce it.  In the meantime, if CMS is truly interested in giving taxpayers their money's worth, they'll also be able to use this information to track this nationally and, perhaps, use it to develop additional value-based purchasing initiatives.

And patients and their families?  Next time they're at the business end of a needle in a hospital, they should wonder if that's one of the 25.  While they're doing that, they should also ask what the local error rate is and what's being done to reduce it.

Image from Wikipedia

Medicare's Expenses Increased by 0.4%? Really? And It's All Because of the Affordable Care Act?

If you're the head of Google and you want to teach about the internet, North Korea is a swell place to visit.  If your goal is air travel safety, the 787 Dreamliner is the plane for you.  If you would like to get the puck from an opposing professional hockey player, saying "please" helps.  And if Medicare costs dip, the Affordable Care Act (ACA) obviously deserves the credit.

Writing on an HHS website, Richard Kronick and Rosa Po announce that 2012 Medicare expenditures per beneficiary grew only by 0.4% over the 2011 baseline.  They credit the ACA's value-based payment (VBP) system, attacks on fraud and abuse, reduced payments to Medicare Advantage plans, cutting hospitals payments and "innovation."

The Disease Management Care Blog isn't too sure about that.

1. This Kaiser Health News article notes the VPB program withholds 1% of hospital payments and uses that fund to award bonuses in what is really a zero sum game.  And this Health Affairs article suggests the overall financial impact of VPB on hospitals is quite minimal anyway. 

2. While there have certainly been some big fraud and abuse busts, there's plenty of reason to still be skeptical about the ability of Medicare's ossified bureaucracy to catch up with the sophisticated criminal enterprises that are routinely fleecing billions from the U.S. taxpayer.

3. As for the one-time payment cuts to providers and insurers, the DMCB is confident that they'll figure out ways to get their money back.  They always do.

4. The innovations are in demonstration phase.  It's too early to tell.

In addition, the DMCB is surprised that Medicare's 2012 insurance claims were ready to be rolled up and quantitated in early 2013. Check out this telling quote from the website:

"2010 and 2011 statistics are calculated on a calendar year incurred-basis. 2012 statistics are calculated on a fiscal year cash-basis, because calendar year incurred-basis data are not yet available." (bolding from the DMCB).

Last but not least, the DMCB believes the lackluster economy has probably had the biggest impact on consumers' willingness to use their Medicare benefit.  While Kronick and Ro state" Medigap" insurance benefits have protected the beneficiaries from the financial pain of Medicare's out-of-pocket expenses, the expense of using a hospital or seeing a doctor is more than the sum of all those medical bills.

Is the DMCB being too skeptical?  Perhaps, but this particular HHS spin is built on assumptions that are backed by associations that are biased by partisan loyalty.  Taxpayers deserve better.

Image from Wikipedia

Is U.S. Health Care Really THAT Bad?

Is American health care that awful?  Listen to the pundits and it's easy to believe that other developed nations are blessed with 24-7 access to primary care, minimum out-of-pocket expenses and highly integrated electronic record systems and information sharing.

Cathy Schoen and colleagues from the Commonwealth Fund and Harris Interactive say it's not quite that simple.  While the U.S. system could be better and cheaper, there were some areas where is wasn't all that bad.

Their article was published in the December 12 issue of Health Affairs.

The authors conducted follow-up mail and phone interviews of primary care physicians from ten developed countries* who had previously participated in a 2009 quality survey.  Physicians were asked about topics that included their patients' access to care, use of health information technology (HIT) and satisfaction with medical practice. Sample sizes of interviewees from each country ranged from 500 to 2000 and response rates ranged from a low of 20% (Germany) to 48% (Netherlands).

Among the more interesting findings:

The majority of Dutch, French, German And Swiss docs are in clinics with 2 or fewer physicians.
86% of respondents from France said most patients can obtain same day access vs. 22% in Canada. The U.S. rate was 47%, which was higher than Norway and Australia.

The Netherlands (94%) and New Zealand (90%) led the way in access to after-hours care. The U.S. rate was the lowest at 34%.

59% of U.S. physicians said their patients had difficulty paying for health care.  At the same time, only 28% had long waits to see a specialist.  In Canada, the rates were 25% (payment) and 73% (specialists), respectively.  In Norway, 4% had difficulty paying but 60% had long waits for specialists.

Nearly all physicians in Australia, the Netherlands, New Zealand, Norway and the United Kingdom use electronic records.  The U.S. rate was 69%, while in Switzerland, Canada and France it's 41%, 56% and 67%, respectively.

The top four countries reporting that they had "engaged" a nurse case manager were the United Kingdom (78%), the Netherlands (73%), New Zealand (68%) and Switzerland (68%).  The rates in Canada, the U.S and Germany were 44%, 43% and 20%, respectively. 

Transfer of information about an emergency room visit or a hospital discharged occurred less than half the time in Australia, Canada, France, Germany, Switzerland, United States, Norway and the United Kingdom.

DMCB takeaways:

If other developed nations are role models for the U.S., large clinic systems are not necessarily the way to go.

There may be an inverse correlation between patients' ability to pay for care and access to specialist care.

The U.S. is in the middle of the pack when it comes to EHR use.

Nurse-led care manage is not uncommon overseas and a 43% rate in the U.S. is higher than generally realized.

Timely transmittal of emergency room and hospital discharge information seems to be a problem everywhere.


*Australia, Canada, France, Germany, Switzerland, United States, Netherlands, New Zealand, Norway and the United Kingdom

Seven Things You Need to Know About 2011 Health Care Spending

If you're interested in learning more about the latest U.S. health care cost trends, everything you need to know is in this article in the January 2013 issue of Health Affairs.

Or you could rely on the Disease Management Care Blog to point out the article's 7 most important points.  Use them to impress your colleagues and stymie your foes:

1) The data only go up to 2011; we'll have to wait another year before we'll know about 2012.

2) 2011 health care spending, as a percent of gross domestic product, remained at 17.9%.  The overall economy was slow and that took its toll on the health care sector.

3) That comes out to $2.7 trillion or $8,680 in health care spending per person.

4) While the percent remained stable, the economy experienced modest growth in 2011. The health care sector, thanks to an overall growth rate of 3.9%, kept pace. Prices for services grew less than the demand for services.  As we grow older, demand is likely to grow.

5) Medicare and private insurance grew faster than the economy, which was offset by Medicaid cost cutting by the states.

6) If the past is any guide, when the U. S. economy rebounds, health care spending is likely to accelerate and resume its march toward becoming 20% of GDP.

7) The relative stabilization of 2011 health care costs is independent of the Affordable Care Act.  Many of its important provisions (such as the mandate) don't kick in until 2014.

The Centers for Medicare & Medicaid Services (CMS) Gets Nudged to Do Something About Shared Decision Making (SDM)

Medicare tackles the shared decision
making requirement in the ACA

In a recent New England Journal of Medicine article, Emily Lee and Ezekiel Emanuel point out that it's high time for the Centers for Medicare and Medicaid Services (CMS) to wake up and do something about Section 3506 of the Affordable Care Act.

That's the section of the law that deals with "shared decision making" (SDM):

"The Secretary shall establish a program to provide for the phased-in development, implementation, and evaluation of shared decision making using patient decision aids to meet the objective of improving the understanding of patients of their medical treatment options...."

In particular, they argue that CMS should expedite the creation of an independent entity that would certify and implement patient decision aids and begin piloting SDM among Medicare beneficiaries who are contemplating having one of the 20 most frequently performed procedures (a list can be found on page 3).

And they don't stop there. 

They recommend that Medicare's coverage for the "top 20" should be made contingent on the documented delivery of SDM to the beneficiary

"To give such a requirement teeth, full Medicare reimbursement could be made contingent on having documentation in the patient's file of the proper use of a decision aid for these 20 procedures. Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

In contrast to the NEJM readership, the thousands of regular visitors to the Disease Management Care Blog aren't surprised. They've known all along that "shared decision making was an important if unknown part of the Affordable Care Act.  To them it's not news that SDM is an evidence based approach that combines patient engagement with physician participation to optimize the utilization of potentially harmful therapies.

Pity that CMS leadership isn't regularly reading the DMCB.  Whether a NEJM article by one of D.C. health care mandarins spurs CMS to action remains to be seen.

Stay tuned!

The Latest Cavalcade of Risk Is Up!

In an apologetic fit of better-late-than-never, the Disease Management Care Blog announces that the latest Cavalcade of Risk is up.  Its themed after the Mayan non-apocalypse and has a number of links that take you to bloggery on topics that range from restraint of trade to health insurance exchanges to genetic testing to worker's comp.  There is something for everyone interested in business and insurance risk.

Enjoy!

The Latest Health Wonk Review Is Up!

The latest Health Wonk Review is hosted by Brad Wright of the eponymously named Wright on Health.  In it, you'll get to read the latest insights from bloggers around the U.S. who have something insightful to say about the endlessly fascinating world of health care policy.

Enjoy!

Medicaid Disease Management: No Impact on Emergency Room Utilization or Inpatient Costs for Enrollees with Diabetes?

Regular readers of the Disease Management Care Blog know that Medicaid is coming. While many of the nation's Governors have declined President Obama's invitation to run Medicaid the Affordable Care Act way, others have agreed to use the ACA's generous funding to enroll millions of their indigent citizens into this vastly expanded public insurance program.

"No problem!" says the disease management vendors.  For years, they've been offering their services to state Medicaid programs and would be happy to expand their contracts.

Unfortunately, an article by Matthew Conti that was just published in the journal Health Services Research suggests that that may not be a good idea.  The article's title is Effect of Medicaid Disease Management Programs on Emergency Admissions and Inpatient Costs.  The only thing that's missing are the words "The Lack of Any" at the front of that sentence.
   
The article studied the impact of diabetes "opt-out" disease management on diabetic patients' emergency room utilization and admissions in three states' Medicaid programs: Washington (started in 2002), Texas (started in 2004), and Georgia (started in 2005).

These states with were compared to states without diabetes disease management.  These control states were selected on the basis of baseline Medicaid enrollment trends that were similar to the three study states. These control states were Hawaii, Kentucky, Massachusetts, Maryland, Maine, North Carolina, Nebraska, South Carolina and Tennessee.

To perform the comparison, Dr. Conti used the Agency for Health Care Research and Quality's (AHRQ) National InPatient Sample (NIS) from the Health Care Cost and Utilization Project ("HCUP"). These databases contain patient-level and longitudinal hospital information on inpatient stays, including cost, payer, admission type (e.g., emergency, urgent and elective), age, gender, primary payer, and total charges. The span of data that was used went from 2000 through 2008.

A complicated pre-post "difference in differences" model was used to compare baseline vs. follow-up:

1) total inpatient charges/Medicaid enrollment (which averaged $430 per diabetic enrollee, with a 95% confidence interval of $265 to $700) and

2) emergency admissions/inpatient admissions (a ratio of 0.37 per admission with a standard deviation of plus or minus 0.12)  All Medicaid enrollees with diabetes were included in the analysis, whether or not they had been enrolled or opted out.  The author used this approach figuring that if a statewide disease management program enrolled up to a third of eligible persons with diabetes (that was the case in Texas), there should have been an observable impact on the entire population. That's the approach favored by the Disease Management Purchasing Consortium.
 
The results?  No state with disease management had lower emergency room utilization or inpatient costs for their Medicaid enrollees with diabetes. The DMCB couldn't find a table with numbers, but the figures (which can't be reproduced without permission) show little impact over time.

What can readers conclude?  Assuming that, during the period of study, the three states' Medicaid programs suffered from the program's endemic issues of underpayment to providers with a relative lack of access to primary care:

1. "Blanket" call-everyone telephonic disease management cannot make up for fee-for-service Medicaid's shortfalls.  It remains to be seen if the ACA's revitalization of Medicaid will make up for this and increase the parallel impact of disease management. 

2) This also means that Medicaid's experience with disease management can't be generalized to other types of insurance with better provider payment rates and patient access to care.

That being said, the DMCB has two concerns:

1. If the DMCB is reading this right, it appears all persons of any age with diabetes were included in the study, including Type 1 diabetics.  If that's correct, that could have also blunted the impact of any disease management program, since children are over-represented in Medicaid and the impact of remote telephonic coaching in Type 1 is widely viewed (even among the disease management vendors) to be ineffective.  Insulin-requiring kids need lots of face-to-face hands-on care.

2. The DMCB is unfamiliar with the three study states' disease management programs, but if they were set up the "old fashioned way" to contact all persons with diabetes without the modern regard to future risk and "impactibility," then it's little wonder that the programs failed.  State-of-the-art population health management tailors its programs by focusing on subsets of persons with chronic conditions that are most likely to benefit.  Any impact on emergency room use or inpatient charges for these patients would be lost in the data "noise" of everyone else's utilization.

Should Medicaid programs that are facing huge jumps in enrollment abandon Medicaid as a result of this study?  Based on this study, the DMCB doesn't think so.  The findings are interesting, but more research is needed.