James Breedin cannot keep track of how often he has been admitted to Howard University Hospital in Washington, D.C., for heart problems. "It's been so many," said Breedin, a 75-year-old disabled truck driver.
One reason for his frequent returns, he says, is that he often can't afford the medications his doctor prescribes to keep his heart problems in check, "so I have to do without." And though his doctors recommend regular physical activity -- a lifestyle change that could also cut the chances he will find himself in the hospital again -- he said 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. But this new policy is likely to disproportionately affect hospitals that treat the lowest-income patients, according to a Kaiser Health News analysis of data from the Centers for Medicare and Medicaid Services.
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Hospitals that served the poorest 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 in the District of Columbia, Johns Hopkins Bayview Medical Center in Baltimore and New York-Presbyterian Hospital and the Mount Sinai Hospital, both in New York City -- low-income people comprised a greater share of the patients than they did at 80 percent of hospitals.
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 the hospital. 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 difficulty understanding the sometimes complex instructions they are given about how to take care of themselves.
"These patients tend to be sicker; 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."
Within 30 days of discharge, one of every four Medicare patients with heart failure is readmitted. The Affordable Care Act, which Congress passed last year, mandated that starting next October, Medicare will penalize hospitals where 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. Although Medicare hasn't finished determining exactly how the penalties will work, the Advisory Board Company, a Washington consulting firm, estimates that as many as 2,300 hospitals may lose money because of the rule, with Medicare dinging the worst performers up to $500,000.
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 would 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. But he said the agency is committed to the readmission penalties, both because it is required to by law and because it believes the penalties will encourage hospitals to make sure patients get the follow-up care they need.
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.
Since then, Rust, now 59, is an atypically diligent patient, said his doctors at the Washington Hospital Center, which Medicare says has average readmission rates. He eats carefully, keeping his salt intake to 1,800 milligrams a day. He washes canned vegetables to get rid of extra salt. He has forsaken the fried foods and fast foods he loves in favor of baked or broiled meat. He walks around the block each morning and takes his pills on schedule.
Yet, 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 and 15 days in May. In September, doctors implanted a $150,000 heart pump, which they hope will stabilize his heart.
"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.