James Breedin cannot keep track of how often he has been admitted to Howard University Hospital for heart problems. "It's been so many," said Breedin, a 75-year-old disabled former truck driver from Northeast Washington.
Ralph Rust meets with Dr. George Ruiz at Washington Hospital Center. Rust has struggled for decades to stay out of the hospital.
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." Another is that he fears exercising outside because of neighborhood violence.
Medicare is preparing to penalize hospitals with frequent potentially avoidable readmissions, which by one estimate cost the government $12 billion a year. Medicare's aim is to prod hospitals to make sure patients get the care they need after discharge. But this new policy is likely to disproportionately affect hospitals that treat the most low-income patients, according to a Kaiser Health News analysis of data from the Centers for Medicare & Medicaid Services.
Hospitals with the highest proportion of poor 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, Prince George's Hospital Center in Cheverly and Johns Hopkins Bayview Medical Center in Baltimore as well as nationally known medical centers such as New-York Presbyterian Hospital and Mount Sinai Hospital in Manhattan — low-income people comprised a greater share of the patients than they did at 80 percent of hospitals.
Many of those hospitals already operate on tight margins and fear the new penalties could make it even harder for them to properly care for impoverished patients.
Avoiding readmissions is a particular challenge in the Washington area, which has higher rates than most parts of the country, according to a government study conducted last year.
Even at places such as Washington Hospital Center, which Medicare says has average readmission rates, physicians contend with large numbers of poorer patients with congestive heart failure, a chronic condition, while suffering from such other maladies as obesity, hypertension and diabetes. Because they often don't see doctors regularly, these patients tend to arrive at the hospital later in their deterioration, some with their limbs bloated with excess water and barely able to walk.
"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."
A Revolving Door
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. 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 trouble understanding the sometimes complex instructions they are given about how to take care of themselves.
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 whose 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.
Dr. Samer Najjar meets with colleagues at the Washington Hospital Center. Dr. Najjar cares for Ralph Rust, one of several patients with chronic conditions that continue to be readmitted to the hospital.
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 will 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.
Ways To Improve
Certainly, a heavy load of poor patients doesn't doom a hospital to frequent returns. Washington Adventist Hospital in Takoma Park and three hospitals in Virginia had average readmission rates even though they had more poor patients than 80 percent of hospitals, according to the analysis.
"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 their health is stable. He said he also tries to check whether a drug is covered by insurance before prescribing it.
Mt. Sinai has discovered some of their 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 Mt. Sinai executive. "These are lifelong things you’re trying to change," she said. "They're not 30-day problems."
Shady Grove Adventist Hospital in Rockville has some of the highest readmission rates in the nation -- 29.2 percent of heart failure patients rehospitalized within 30 days -- and treats more poor patients than do a majority of the nation's hospitals, according to the KHN analysis.
Shady Grove officials said that a challenge common to all hospitals -- to keep patients on a healthful, low-salt diet – is made harder there by the large numbers of Salvadoran patients, many with limited English, who come to their institution. Shady Grove tries to provide a bilingual nurse, doctor or interpreter to explain to patients how to take care of themselves after discharge. The hospital also provides them with low-salt recipes for popular ethnic dishes.
Shady Grove and Washington Adventist also have arrangements with nearby pharmacies to provide medications to poor patients at cost or for free.
Johns Hopkins Bayview said in a written statement that it is "working diligently" to prevent its heart failure patients -- many of whom are not only very poor but are also drug or alcohol addicts -- from returning to the hospital. Officials at Prince George's Medical Center did not respond to requests for an interview.
Even doctors who press their patients about their post-discharge arrangements sometimes don't get honest answers from those who are embarrassed about their financial circumstances, said Boise Barnes, a primary-care doctor in Southeast Washington. "There's pride involved," he said. Others do take medication, he said, but then "they feel better, and they don't come back" for follow-up appointments.
Some techniques that hospitals are using to avoid readmissions, such as having nurses call patients to check in on their recoveries, can be harder with 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.
While low-income patients offer greater challenges for hospitals, the insurance that typically covers them -- Medicare and Medicaid -- does not pay as well as do 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.
There is a racial concern in readmissions as well. A study by Karen Joynt and Ashish Jha, two researchers at the Harvard School of Public Health, found that patients discharged from hospitals that treated the most blacks had much higher readmission rates -- for both black and white patients -- than patients from hospitals that served few minorities.
"The big confounding factors in readmissions are often nonclinical issues: 'I don't have anyone at home to take care of me,' 'I don't have any transportation,' " said Chas Roades, chief research officer at the Advisory Board, a consulting firm based in Washington.
A Diligent Patient
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 Southeast Washington man who is covered by Medicaid, said that for years he was hospitalized as often as three times a month at Howard University Hospital.
Many admissions, he said, were of his own doing. He skipped his medications and kept eating foods his doctors told him to avoid. At one point, his weight ballooned to 340 pounds.
"I figured I knew more than a doctor does," he said. "I'd take my pills one day, feel pretty good, then I'd skip a day. I didn't realize what I was doing to myself."
When Rust was transferred to Washington Hospital Center in 2008 to get his pacemaker replaced with a defibrillator, he had a change of heart. That was partly due to the stern talk his doctors gave him and their new diagnosis that he had an irregular heart rhythm, he said. It was also his own realization that he was going to die if he did not change his ways, he said.
Since then, Rust, now 59, is an atypically diligent patient, his doctors said. 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 has shed much of his weight. He walks around the block each morning and takes his pills on schedule.
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. In May, the head of the Washington Hospital Center's heart failure program, Samer Najjar, ordered him back after he gained 15 pounds of fluid in a week. Rust was hospitalized for 15 days. In September, the 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."