Certainly, a heavy load of poor patients doesn't doom a hospital to frequent returns. "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 so he can monitor them until he is assured their health is stable. He said he also tries to check whether a drug is covered by insurance before prescribing it.
But even some of the most prestigious hospital operators, such as Johns Hopkins, struggle to prevent frequent readmissions of poor patients. In Baltimore, Johns Hopkins' flagship hospital has average readmission rates, but its Bayview Medical Center's rates are high. One of the big differences is that Bayview's patients are not only poorer but also often addicted to drugs or alcohol, which poses additional challenges. Bayview said in a written statement that it is "working diligently" to reduce readmissions.
Some techniques that hospitals are using to avoid readmissions, such as having nurses call patients shortly after they go home to check in on how they're recovering, can be harder for 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.
Mount Sinai has discovered some of its patients don't follow their written discharge instructions because they can't read. In those cases, the hospital will send social workers to accompany patients to their grocery store "and point out 'these are the labels that work for you and the ones that won't,' " said Claudia Colgan, a Mount Sinai executive. "These are lifelong things you're trying to change," she said. "They're not 30-day problems."
While low-income patients offer greater challenges for hospitals, the insurance that typically covers them -- Medicare and Medicaid -- does not pay as well as private carriers. That means that hospitals that treat many poor patients 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.
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 Medicaid enrollee in Washington, D.C., said that for years he was hospitalized as often as three times a month.
Many admissions, he said, were of his own doing. He skipped his medications and kept eating foods his doctors told him to avoid. "I figured I knew more than a doctor does," he said.
After a stern lecture from doctors in 2008, Rust said he realized that he was going to die if he did not change his ways.