Abandoned Patients

It does not happen often, but it does happen: patients, usually elderly, are admitted to a hospital, cannot make their own medical decisions, and no family members can be found to help with those decisions or post-hospitalization care.

iStock_000001497717XSmallSo the patient remains in the hospital – sometimes for weeks, sometimes for months.

This can especially be a problem for private safety-net hospitals, which typically serve communities with larger numbers of low-income, elderly, and homeless residents.
When a number of such cases occurred over a short period of time in one Washington, D.C. hospital, that hospital turned to its local hospital association, which created a “guardianship task force” to examine the problem and explore potential solutions.

Learn more about the problem and the solutions the task force developed to deal with this occasional but very expensive problem – keeping such patients in the hospital costs about $2500 a day – in this Washington Business Journal article.

Medicare Readmissions Program Unfair to Safety-Net Hospitals, Study Finds

Medicare’s readmissions reduction program penalizes hospitals based largely on the patients they serve rather than their performance serving them, a new study has concluded.

According to the report “Patient Characteristics and Differences in Hospital Readmission Rates,” published in the journal JAMA Internal Medicine,

Patient characteristics not included in Medicare’s current risk-adjustment methods explained much of the difference in readmission risk between patients admitted to hospitals with higher vs lower readmission rates. Hospitals with high readmission rates may be penalized to a large extent based on the patients they serve.

Among those two dozen social determinants of health: patient income, education, and ability to bathe, dress, and feed themselves.

jama internal medicineThe study found, for example, that the worst-performing hospitals under Medicare’s hospital readmissions reduction program have 50 percent more patients with less than a high school education than the program’s best performers.

The study’s findings echo NAUH’s long-held and oft-expressed belief that the readmissions reduction program is unfair to private safety-net hospitals because it lacks appropriate risk-adjustment in response to the very conditions identified in the study – a belief NAUH has shared on numerous occasions with Medicare officials, including in this June 2015 correspondence (on page 4) with the Centers for Medicare & Medicaid Services (CMS).

To learn more about the study, see this Washington Post story. To find the study itself, go here, to the web site of JAMA Internal Medicine.

Medicare Proposes Addressing Health Disparities

The Centers for Medicare & Medicaid Services (CMS) has unveiled its first plan to reduce health disparities among Medicare beneficiaries by addressing social determinants of health.

Medical EquipmentThe plan, produced by CMS’s Office of Minority Health and titled “The CMS Equity Plan for Improving Quality in Medicare,” will seek to improve care for

…Medicare populations that experience disproportionately high burdens of disease, lower quality of care, and barriers to accessing care. These include racial and ethnic minorities, sexual and gender minorities, people with disabilities, and those living in rural areas.

This is the very population served in disproportionate numbers by many of the nation’s private safety-net hospitals.

The program will focus on six priorities:

  • expanding the collection, reporting, and analysis of standardized data
  • evaluating disparity impacts and integrating equity solutions across Medicare programs
  • developing and dissemination promising approaches to reducing health disparities
  • increasing the ability of the health care workforce to meet the needs of vulnerable populations
  • improving communication and language access for individuals with limited English proficiency and persons with disabilities
  • increasing physical accessibility of health care facilities

To learn more about The CMS Equity Plan for Improving Quality in Medicare, see this CMS news release.

Socio-Economic Status Affects Health, Study Shows

A new study by California state public health officials has concluded that demographic factors have a major influence on individuals’ health.

Among the social determinants of health specifically cited in the study are education, employment status, gender identity, race and ethnicity, income, and sexual orientation.

iStock_000005787159XSmallIn Portrait of Promise: The California Statewide Plan to Promote Health and Mental Health Equity, the California Department of Public Health’s Office of Health Equity identifies and describes the socio-economic determinants of health that influence health status and proposes interventions for overcoming those challenges.

NAUH has long pointed to such challenges as one of the chief distinctions between private safety-net hospitals and the typical American hospital.

See the report here.

Report on Public Health and Health Care

The Institute of Medicine (IOM) has published a report summarizing its February workshop that explored the relationship between public health and health care.

According to the IOM, the workshop

iom_logo… was designed to discuss and describe the elements of successful collaboration between health care and public health organizations and professionals; reflect on the five principles of primary care–public health integration (which can be applied more broadly to the health care–public health relationship): shared goals, community engagement, aligned leadership, sustainability, and data and analysis; and explore the “elephants in the room” when public health and health care interact: what are the key challenges and obstacles and what are some potential solutions, including strengths both sides bring to the table. The workshop presentations reflected on collaboration in four contexts: payment reform, the Million Hearts initiative, hospital – public health collaboration, and asthma control.

Because of the nature of the communities they serve and the work they do, private safety-net hospitals are often important parts of public health efforts in cities across the country.

Find the IOM report Collaboration between Health Care and Public Health: Workshop Summary here.

30-Day Readmission Standard Flawed, Study Suggests

A new study raises the possibility that Medicare’s policy of penalizing hospitals that readmit patients within 30 days of their discharge may be flawed.

According to a new report in the Annals of Internal Medicine, risk factors for readmission often change within those 30 days.

In addition, patients with chronic medical problems are more likely to need readmission. Even the time of day of discharge appears to affect patients’ likelihood of readmission, with those discharged between 8 a.m. and 1:00 p.m. less likely to be readmitted.

The study also found that social determinants and insurance status also increase the likelihood of readmission within 30 days of discharge.

annals of internal medicineTogether, these and other findings appear to raise questions about the fairness of Medicare’s hospital readmissions reduction program.

These findings also mirror a growing body of research that suggests the program is inherently unfair to safety-net hospitals that serve large numbers of low-income patients who have had limited and sporadic access to medical care during their lives. NAUH has long pointed to the unfairness of this program and supported changes to improve it, most recently in a March letter to the House sponsors of H.R. 1343, the Establishing Beneficiary Equity in the Hospital Readmission Program Act, a bill that seeks to address those inequities.

To learn more, see this Fierce Healthcare report. Find the study “Differences Between Early and Late Readmissions Among Patients: A Cohort Study” here, on the web site of the Annals of Internal Medicine.

Looking at Payment and Delivery System Reform

Last fall the Robert Wood Johnson Foundation brought together grant recipients and national experts to talk about health care payment and delivery system reform design and implementation issues.

rwjfNow, the foundation has released a brief paper that addresses what the experts consider to be the three greatest challenges in the pursuit of such reform:

  • aligning alternative payments with clinician compensation
  • considering social determinants of health in payment reform models
  • repurposing hospital resources

The paper also takes a look at whether health care payments should be subject to risk adjustment to reflect the social and economic barriers to better health and care that some patients face. The National Association of Urban Hospitals (NAUH) has long advocated such risk adjustment in Medicare payments and has endorsed legislation to compel Medicare to introduce such a policy change, including the Establishing Beneficiary Equity in the House Readmissions Program Act of 2015, which was introduced in both the House and the Senate last month.

These issues and more are addressed in greater detail in the new paper “Three Emerging Challenges for Sustained Payment and Delivery System Reform,” which can be found here.

Numbers Link Medicaid Expansion, Diabetes Diagnoses

One of the primary arguments made by the National Association of Urban Hospitals in favor of government reimbursement policies that support the work of private safety-net hospitals is that the patients they serve have had sporadic contact with the health care system over the years and often present with medical problems that go well beyond the immediate reason that brings them to hospitals.

Now comes new information that supports that argument.

The medical testing company Quest Diagnostics has found that the number of Medicaid patients its testing has found to have diabetes has risen more than 24 percent during two recent six-month review periods in states that have expanded their Medicaid programs while the number of such patients found to have diabetes in states that did not expand their Medicaid programs saw only a 0.4 percent increase in diabetes diagnoses.

Because of where they are located, private safety-net hospitals serve higher proportions of Medicaid patients than the typical community hospital and are therefore more likely to be caring for these more challenging patients newly diagnosed with diabetes.

For more information about the Quest findings and their implications, see this New York Times article. In addition, the latest edition of the journal Diabetes Care presents a study on the subject. See that article here.

Congress to Consider Adding Risk Adjustment to Medicare Readmissions Program

A new bill introduced in Congress this week would require Medicare to consider the social determinants of health of the patients individual hospitals serve as part of its hospital readmissions reduction program.

The Establishing Beneficiary Equity in the Hospital Readmissions Program Act of 2015 was introduced as S. 688 in the Senate, sponsored by Senators Rob Portman (R-OH) and Joe Manchin (D-WV), and in the House by Representatives Jim Renacci (R-OH) and Eliot Engel (D-NY) as H.R. 1343.

Medical EquipmentRep. Renacci introduced a similar measure last year.  NAUH endorsed that bill.  This year’s version has bipartisan sponsorship in both the House and Senate.

Since the launch of Medicare’s readmissions reduction program several years ago, NAUH has maintained that it treats private safety-net hospitals unfairly because it fails to reflect the large numbers of especially challenging patients such hospitals serve – challenging because of the many socio-economic barriers to care they face.  In recent years a number of studies have confirmed that bias and this latest proposal seeks to correct this shortcoming in the Medicare program.

To learn more about this proposal, see this news release announcing the bill.  Find the bill itself here.

Low-Income Patients Struggle With Diabetes Management

Low-income diabetics are more likely than others to struggle to manage their condition – even if they have health insurance.

According to a new study published in JAMA Internal Medicine, “Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs.”  The study defines those unmet needs as food insecurity, cost-related medication underuse, housing instability, and energy insecurity.

jama internal medicineThe study, “Material Needs Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources,” found that difficulty affording food led to more outpatient physician visits; trouble paying for medicine and underuse of medicine for that reason led to more emergency room visits and hospitalizations; and all of the material insecurities contributed to increased health care costs.

The study was based on observation of 400 patients served by community health centers in Massachusetts.  It found that 19 percent of those patients had trouble affording food, 28 percent had difficulty paying for medicine, 11 percent struggled to pay for someplace to live, and 14 percent had a hard time paying their utility bills.  Overall, nearly half had trouble managing their diabetes.

The study’s findings reinforce NAUH’s long-held belief that low-income patients are fundamentally more challenging to treat than others and often lack the community and social supports needed to address their medical needs effectively.

Learn more about the study and its implications in this U.S. News & World Report article or find the study itself here, on the web site of the  JAMA Internal Medicine.