By ANISH KOKA, MD

Eugene’s wife is on the phone.  She has been taking care of Eugene for 41 years.  I supposedly take care of his heart, weakened by two prior heart attacks.  I say supposedly because his wife does all the heavy lifting.  She makes sure he takes his medications when he should.  She watches his weight every day and occasionally administers an extra dose of diuretic when his weight climbs more than a few pounds in a day.  And perhaps most importantly, she calls me when Eugene’s in the hospital and things seem wrong to her.  This is one of those phone calls.  They were in the ER, Eugene hadn’t been responding to his diuretic as he normally does, and his breathing seemed more labored to her.  The ER physician wanted to send them home – she was hoping I would weigh in.  Not surprisingly, she was right, Eugene needed to come into the hospital.  I used to be surprised when the ER wouldn’t call me for complex cardiac patient having an acute cardiac problem.  Not any more.

There is a clear culture shift that is obvious to those who have spent any time in the ER over the past ten years.  Low risk patients used to be managed and discharged from the ER, and higher risk patients were quickly admitted to the hospital for management by specialists.  This used to be a source of tremendous friction with the ER in my younger years, as I would try to explain to ER physicians that every single chest pain in a patient with known coronary disease did not deserve admission.  I seldom have this conversation with the ER anymore.  What changed?

There are no singular reasons to explain culture shifts in health care, but the withering appraisal of the 800 pound gorilla that pays hospitals (otherwise known as Medicare) creating programs to penalize hospitals for admissions and readmissions may have something to do with the admission phobia that now reigns in emergency departments.  As is true for most recent changes that have resulted in seismic shifts to how care is delivered to patients, these changes were enacted with no evidence and little debate among the practicing physician community.  This is state of the art in the 21st century when it comes to health care policy – programs implemented at the direction of Congress that fundamentally change the nature of care being delivered to patients are forced through. Doctors comply with the latest mandate of the state, and patients without consenting, end up as hapless guinea pigs in a grand experiment.

There are a number of programs in force at the moment – mostly passed under the auspices of the Affordable Care Act (ACA).  Section 3025 of the Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP) which required CMS to reduce payments to hospitals with excess readmissions, effective for discharges beginning October 1, 2012. The readmission penalties initially related to heart attacks, heart failure, and pneumonia, but have since expanded to include COPD, and hip and knee replacements.  The latitude afforded CMS that relates to payment reform is incredibly expansive.  Section 3021 of the ACA created the Center for Medicare and Medicaid Innovation Center (CMMI) for the purpose of testing ‘innovative payment and service delivery models to reduce program expenditures’.  Congress provided the Secretary of Health and Human Services (HHS) with the authority to ‘expand the scope and duration of a model being tested through rulemaking, including the option of testing on a nationwide basis’.  Language in the law seems to provide some protection to patients by mandating that models must ‘reduce spending without reducing the quality of care, or improve the quality of care without increasing spending.’  Of course, in reality, the models tested have a seemingly infinite time horizon to demonstrate benefit, and quality of care delivered is at times measured by the same folks designing the model.

Witness the results of CMMI’s flagship model to fix health care – the Accountable Care Organization.  The most recent 2015 data shows that the taxpayer wallet is $216 million dollars lighter because of ACO’s.  There is no evidence that patients enrolled in ACO’s are living longer or healthier. Perhaps more troubling – there is no data regarding possible negative impacts of ACOs either.  One would hope for consternation among the policy making class or in the political class about a flagship program proving to be more expensive to the taxpayer with no hard positive clinical outcomes attached – a finding that seemingly in direct contradiction to the law.  Instead of consternation, one finds politicians and policy makers convinced these programs work – the problem must lie in our ability to measure these programs.  These programs clearly work – we just don’t know how.

Yet as I try to puzzle through the changing landscape of healthcare and how it appears to have affected patients I have tremendous concern about what we exactly we are incentivizing.  The drive to reduce hospital readmissions for instance is a mission conceived primarily in an effort to reduce the cost of care – quality of care is a secondary concern in this mission.  It should come as no surprise then, that aligning incentives in this manner has resulted in a significant reduction in 30 day readmission rates.

The Department of Health and Human Services proudly shows this figure as an example of the success of the ACA under the headline ‘New HHS data shows major strides made in patient safety, leading to improved care and savings’.  But is this a metric patients with heart failure care about?  The message to ER’s that I work with is clear – patients who come back within 30 days of heart failure are NOT to be readmitted.  The work around is to have them managed in the observation unit by ER staff not trained to manage sometimes complex heart failure readmissions.  The end results are at times not pretty.  Don’t just take this n-of-1 physician’s word for it.  Heart failure mortality that (age adjusted) had declined from 2000 through 2012, increased from 2012 to 2014.

I hesitate to posit causation from correlative data such as this – but it is certainly interesting to see the increase in HF mortality begins the same year that CMS rolled out a program to reduce HF readmissions.  This should make sense to most clinicians who manage patients with heart failure.  The initial intent of the law to reduce heart failure readmissions was to prevent discharges of patients admitted for heart failure who were not ready to leave.  Since hospitals get paid the same amount for a certain diagnosis whether they stay 1 day or 10 days, bean counter administrators with MBAs have placed significant pressure on clinicians to keep the length of stay to a minimum.  The result, not surprisingly, was a group of patients leaving before they were ready to leave. The heart failure readmission penalty sought to make hospitals more accountable for keeping patients out of the hospital.

The positive effect of the readmission penalty is that many hospitals now devote resources to patients with heart failure after they go home.  Nurses call to check for weight gain, and pharmacists make sure patients are taking their heart failure medications as prescribed among other interventions.  The negative effect of the readmission penalty is that some percentage of heart failure readmissions are not preventable.  Heart failure is a morbid life threatening state.  Some patients admitted to the hospital for their first heart failure admission are at the beginning of a downward spiral that no amount of nurse, pharmacist, or care manager interventions will solve.  These are our most vulnerable patients, in dire need of the highest level of care modern medicine can provide.  Failing to recognize this, and failing to readmit this subset of patients is a death sentence.  The decision to readmit this group of patient is frequently being made by ER physicians, who are handicapped by not being heart failure specialists, and more importantly are frequently meeting these patients for the first time.  Add to this marching orders that come from some cubicle that stresses not admitting patients recently discharged for heart failure, and you have a very plausible case for why heart failure mortality has increased as heart failure readmissions have fallen.

The final insult, that I could not make up if I tried, is that in 2016 CMS imposes a maximum penalty of 0.2% of DRG payments for high 30 day mortality, compared with a 3% maximum DRG penalty for excess 30-day readmissions.  So it is better from a hospital standpoint for patients to die after being discharged than be readmitted.  It is a testament to the bizarre world we currently live in that a recent article in the Journal of the American Medical Association (JAMA) examining misaligned incentives blandly concluded”… patients would much rather avoid death than readmission.” Yes, indeed.  Here’s hoping that for Eugene’s sake this message pricks the bubble our current policy leaders live in.

Anish Koka, MD is a cardiologist based in Philadelphia.