Birger Johnson MD.com

When you went out to shovel snow last winter, you never anticipated the consequences: a heart attack and admission to the hospital. Nor did you expect to undergo a cardiac catheterization which would reveal coronary arteries blocked with cholesterol plaques requiring bypass surgery. Nor that the surgery would require splitting your breastbone with a saw to reach the affected arteries and a lengthy incision along your leg to harvest the blood vessels which would serve as the grafts needed to bypass the blockages.

But that was only the beginning. Soon you would learn that the hospital would be discharging you within three days of your surgery, your chest still sore, and weak as a kitten. You were anxious to go home but your wife was relieved to learn that you would be going to a rehab facility for at least a week. But when your insurance company decided that your time was up, you were still moving pretty slowly and your leg ached from the surgery. Your wife was a mess, worried about how she was going to be able to take care of you and manage to keep her job as well. So where to turn?

Here is where home health steps in. They provide assistance in adjusting to the new medical regimen that you have been given; provide physical therapy at home to help you until you are able to participate in an outpatient cardiac rehab; and, if you live alone, provide some home care services as well. However, no surprise, they are now going to be subjected to the same restrictions placed on hospitals and nursing homes. They operate on a very thin financial margin and they are now going to be subjected to the same penalties for early returns to the hospital. This despite the fact that physicians today rarely, if ever, see their patients at home.

To make matters worse, they are having restrictions placed on them regarding who can and who cannot utilize those services (ie: what is “medically necessary”). It must be noted that not all insurance companies are doing this. Some recognize that this may be the least expensive alternative to keep folks from returning to the hospital. But guidelines for its approval assume that one size fits all. That what’s appropriate for a fifty-five year old married individual is the same as that for a ninety year old individual living alone.

Hospitals, nursing homes and home health agencies are now, in many cases, trying to collaborate to keep the costs of care down while still preventing serious complications from developing in their patients served. But no matter how you slice it, they are trying to provide care with ever decreasing funds. And consequently, many home health agencies are experiencing financial crises and several are being forced to shutter their operations.

This leaves the remaining agencies servicing an ever-expanding geographic area. In practical terms, this means that your help is coming from further away, and in inclement weather, (snow storms and the like), services may frequently be delayed or unavailable.

Without these services, what other options exist? Are you left to your own devices? Well, without transportation you pretty much are. However if you can avail yourself of some means of transport, there are outpatient physical therapy services available. But again you will find yourself limited in how much you might be able to benefit. If you are slow in progressing, not meeting treatment objectives fast enough, you may find your benefits terminated. And even if you are progressing, each session has a co-pay and these can accumulate rapidly, resulting you having to terminate your benefits due to cost considerations.

So while options exist for care beyond the nursing home, their availability is shrinking and the the amount of money involved often limits that availability still further. But unfortunately, while hospitals, nursing homes, and physician services make up a large portion of the costs of care, there are other drivers of health care spending.

Next time we will explore the current trends in medical testing and treatments. And why it seems that your doctor doesn’t want to perform the tests for you that you expect from watching TV and reading the most recent issue of your health care quarterly.

Rehabilitation facilities. Aren’t those just nursing homes? Do you mean to tell me that if I don’t go home from the hospital, that I’ll have to go to a nursing home? I’m barely fifty. I don’t need that.

Such are the concerns voiced over and over in recent days. That hip replacement that you underwent may only allow you to benefit from two days in the hospital. But if you’re lucky, you may be able to get your insurer to pay for another week in a rehabilitation facility. Or if you had a severe heart attack, perhaps requiring open heart surgery, the same may be possible for you. The more complicated your hospital stay was, the more likely you might qualify for a short rehabilitation stay.

But what happened to the true rehabilitation hospitals? Unfortunately they have been a victim of cost cutting. They are now limited to patients who might have required prolonged ICU stays, on artificial ventilation, who truly have complex, ongoing medical issues which, in the past, would have required ongoing hospital care. For less complex patients, nursing homes have had to step up.

But aren’t nursing homes limited to the elderly, who have no one to care for them? Historically yes. But nearly twenty years ago, when the need for further in-patient care was required beyond a patient’s approved hospital stay, nursing homes began to step up their game, developing robust therapy departments for that purpose. And space was set aside in their buildings for subacute patients; that is patients that were expected to remain in the facility for limited periods of time. And in many cases, the therapy departments began to emerge as more robust even than many in-hospital departments, simply because patients weren’t staying in the hospitals long enough to benefit from a robust therapy department.

But as patient discharges began occurring earlier and earlier, the acuity of their medical issues continued to escalate as well. Soon facilities, which had ramped up their therapy departments, were also being confronted with medically complex patients whose issues had barely had a chance to stabilize. And the medical care that they required, care which had been provided by physicians in the hospital, had now been handed off to nursing staff, many of whom weren’t even registered nurses.

And the facilities were charged with keeping these complex patients from returning to the hospital within thirty days of their discharge from the hospital. And in many cases charged with getting them healthy enough to return home within 1-2 weeks. Complicating matters was the fact that physicians, who nominally provided care to those patients in the hospital, rarely visited these facilities.

Some nursing home chains began to explore hiring their own physicians, to provide a regular presence in the nursing home, allowing hospital level of care to take place within their facilities. However, the cost of providing that care is becoming prohibitive. While hospitals, on average, may receive in excess of $1500 per day for care, the average nursing home is lucky to receive $500 for that same care.

To make matters worse, the value based purchasing guidelines which were implemented for hospitals around 2010, are going into effect for nursing homes as well. In other words, they can also be subject to penalty repayments for prolonged stays and for 30 day bounce backs to hospitals. And with operating margins that are much more limited than hospitals, their very existence is being threatened.

So what can be done as the can keeps getting kicked down the road. If nursing homes will no longer be able to provide care of the necessary length and intensity, where are patients to go?
Certainly keeping many patients in a supervised setting is to be preferred. Maybe step increases in daily rates based on the acuity of care provided may help subacute units to continue to operate. But in the meantime, what are patients to do?

Here’s where home health agencies need to step up their game. But how will this impact the life of the average patient? And do cost controls impact on this important safety valve? For the answers, check in with us next time.

You’ve just had your hip replaced. The doctor comes into your hospital room two days after the surgery, looks at the wound, and pronounces you ready for discharge. You look at him incredulously and reply that you can barely get out of bed on your own. How are you going to manage caring for yourself? You remind him that your brother had the same operation just ten years ago and he was in the hospital for 2 weeks. Or perhaps your mother was discharged after 4 or 5 days and then went to rehab for another 7 to ten days.

He nods at you, smiles, and says that the case manager has told him that you no longer qualify for hospital level of care. He apologizes and then excuses himself from the room. Your hip throbs, the wound drains and you’re left feeling abandoned. How can this be happening?

It’s happening because the insurers have reached a point where they realize that in order to control spiraling healthcare costs, they need to limit the monies spent on expensive, acute, in-patient stays. This also started back in the 1990’s when some insurers began to experiment with care paths. These were algorithms developed by medical and surgical specialists to try to determine how long it should take to complete treatment for different diagnoses. Cardiologists tried to judge what the vast majority of heart attack patients should require for recovery. Orthopedists evaluated the amount of recovery time that a typical surgical procedure should require.

These endeavors were undertaken because insurers looked at their data and found that there was wide variation in how long people spent in the hospital with different diagnoses. Sometimes the variation was dependent on the regional area where they were treated. Sometimes it was based on the age of the individual. But even taking similar patients from the same region the variations could be substantial from one provider to the next.

As a result of implementing care paths, lengths of stay began to drop. So that family member who had an operation done 10 to 20 years ago and was in the hospital for 2 weeks, now, using the care paths, would only qualify for 4-5 days of treatment in the hospital. Anything in excess, the hospital wouldn’t be paid for. And for some time this was the best that insurers could do.

But there was still variation from hospital to hospital and from one provider to another. Some claimed that their patients were just sicker than those in other institutions. Or that they had more treatment options. So insurers decided to take a different tack. This initiative was spear-headed by the Affordable Care Act. As the government began to consider the costs associated with increasing the number of insured individuals, they began to explore further ways to cut costs.

They didn’t need to look any further than the experiments HMO’s had done with tiering physicians, to curb their costs. They presented the concept of value based purchasing. Basically they said that they were going to compare hospitals with their peers. Those whose care was more expensive were going to have to pay money back to the insurer, if their costs proved to be higher than their competitors. However if their costs were lower they would get a bonus payment. But fearing that some institutions would start inappropriately limiting care, they put in certain quality measures. So, for example, if you had patients discharged too early, leading to readmission to the hospital within 30 days of discharge, you would be penalized for this. And hospitals could be penalized for other things as well, including, but not limited to, the number of infections that patients developed in the hospital, the number of deaths that occurred in the hospital and the surgical complication rates.

So hospitals are now incentivized to get patients out of the hospital sooner rather than later. Even if the amount of time in the hospital is less than the experts would have predicted, based on previously developed care paths for a certain diagnosis.

But if this value based purchasing was introduced by the Affordable Care Act, can’t we simply repeal the Act and go back to things the way they were before? Unfortunately not. As commercial insurers saw this concept developing they were quick to jump on the band wagon. So this method of having hospitals competing against each other is now the norm and, unfortunately, here to stay.

So if your perception is that it feels like you’re getting the bum’s rush out of the hospital, without adequate time to recover, it may be more than a perception. But how do hospitals keep patients from returning to the hospital prematurely? Or from dying prematurely? This conundrum has resulted in the emergence of nursing homes morphing into rehabilitation facilities and in home health care businesses becoming more robust. But does this simply kick the can down the road; simply causing increased costs to appear in different health care sectors? And are they subject to the same pressures that the hospitals now face? Tune in next time and we will discuss this.

So is your usual experience in going to the doctor’s office characterized by calling for an appointment, and, if you’re lucky, waiting for several days to be seen? And when you finally get there, you feel that you’re not given the time to address your concerns? Have you even written down a list of your problems, to make your visit more efficient, and your doctor simply tells you that he can only deal with one problem on the list at a time, telling you that you’ll have to make other appointments for each of those other concerns? Have you left, feeling frustrated and ignored? Wondering why the physician would treat you like that? After all, didn’t he go into medicine to help people? Has your anger simmered as you walk out the door?

You may remember some TV physician lending a sympathetic ear to his patients. Or hearing a story about a specialist who calls their patients at home at night, just to see how they are doing. Why isn’t your physician like that? How did the present state of physician care devolve into what is happening today?

To find an answer one need look no further than recent banking regulations which made it much more difficult for new medical practitioners to get loans to start their own practices. Coming out of medical school, saddled with educational debt that, in many cases, exceeds 250,000 to 500,000 dollars, most new providers opt to go to work for hospitals or large medical clinics who can subsidize those loans and start-up costs. And in many cases it has resulted in physician schedules being managed by administrators with no medical training, who feel that the only way to recoup some of their expenses is to ensure that each provider sees patients every ten minutes; not enough time to address complex issues.

As a result, more and more patients are being referred to specialists for evaluation. More and more are referred to urgent care centers or to emergency rooms for treatment. And costs continue to escalate while the ultimate quality of care suffers. This has resulted in physician costs now representing 20% of the total cost of care. However only a small percentage of that is actually going to the primary care physician who ends up feeling as if he is providing medical care on an assembly line.

In Scandinavian countries like Sweden and Norway, where there is a single payer system, to avoid these pitfalls, physicians are given a salary rather than relying on their productivity to determine their income. And education costs to train a physician are not as exorbitant as they are in this country. But, on the flip side, there is no incentive for them to work long hours and care gets even more fragmented, with each provider only responsible for one aspect of each patient’s care.

So while our present system is expensive, and clearly not ideal, there remains no single solution to the current quandary. The employee who can best schedule physicians’ visits is the physician himself. Unfortunately few of them have been trained in how to do this efficiently or with an appreciation for the fiscal realities of supporting his/her practice. And many of the commercial insurers choose not to look at the overall cost of providing care to a patient but rather at the expense of each individual provider’s charges. And, in addition, will provide periodic audits of providers to find out if their visits are medically necessary, a time consuming endeavor for a physician already over-taxed trying to provide that care.

What’s more, insurers have come to the realization that, in the greater scheme of things, the costs generated by individual health providers is not the single biggest driver of the cost of healthcare at this point. Instead, when looked at overall, it is the type of patients seen, whether elderly patients, or those that are chronically ill, that are driving healthcare costs. And these expenses are derived from the expenses inherent in hospital care and home care provided to them. And in the expensive testing and treatment options that now exist. So while managers still try to increase revenue from their employed physician practices by increasing the number of visits per hour, insurers are looking elsewhere to try to limit the rising costs of health care.

Next time we will look at hospital care and explore why the lengths of your hospital stays are shrinking, leaving you feeling prematurely abandoned by the system. Questioning how you could possibly be ready to go home after that surgery or hospital stay.