The ACA and hospital readmissions: A fatal flaw of reform.

The ACA in association with the Medicare Innovation Center has pledged $10 Billion to finance programs designed to improve health care outcome. Much of this money is being rewarded to hospitals and academic institutions, as well as to private organizations that work with hospitals and large medical organizations. A major thrust of Medicare/ACA reform is geared to curbing the hospital readmission rate. It is felt that too many people discharged from hospitals are quickly readmitted, typically within 30 days, and if the ACA can cut that number then it will have made a significant dent in unnecessary health care spending. Across the country, the ACA is pouring its public funding into projects that will accomplish this goal, equating a reduction of readmission to improved health care quality and decreased cost.

How successful are these projects? According to the Kaiser Health News they are an abject failure. A $300 million program to cut readmissions led to poor early results. Of 48 groups paid to improve outcome, 29 groups dropped out or were terminated by HHS for failing to achieve targets, and only 4 groups significantly cut readmissions compared to a control group. In other words, throwing money at the readmission problem did not solve it. Because Medicare and the ACA have used readmission rates as a barometer for progress, their failed attempts to reduce such rates are concerning.

But, speaking as a primary care physician regularly involved in decisions to hospitalize my patients, and speaking as someone who has studied the health care delivery system (I write about this issue in my book), it is clear to me that even if the ACA threw all $10 Billion at this problem, it would still fail. The reason, never addressed by the press or by the hospitals/academic centers that are swallowing federal funds to achieve this elusive goal, is that nothing is being done to curb hospital admission rates; the focus is only on readmissions. Readmissions are only possible after an initial hospital admission. And everything about the ACA (as I have discussed in this blog and in my book) has actually increased the likelihood of people being admitted to hospitals. The culture of our health care delivery system is specialized, test/procedure-oriented, and hospital based. Insurances like Medicare do not pay for meaningful home care, do not financially enable residents of long term care facilities to be treated in their facilities, and reward elders who are hospitalized. All that has been exacerbated by the ACA. When patients are discharged from hospitals they are thrust into the same health care environment that hospitalized them in the first place. There is still no reasonable alternative to hospitalization for many patients, families, and facilities. There is still no incentive for patients to stay home, and for doctors to keep them at home, rather than to call 911 if they are feeling poorly. Nothing in the programs being financed by Medicare’s innovation center changes that reality. You cannot simply insist that sick people go to the hospital when they are sick, but then ask to stay out of the hospital when they are sick within 30 days of a hospital discharge. No amount of money put toward nursing care and education, rather than to meaningful home care, will accomplish that goal. You cannot ask doctors to struggle to keep people at home when they get paid more and have to work less if they send patients to the hospital, especially under new ACA rules, and especially since hospitals, and not doctors, will financially benefit from fewer readmissions. Unless the ACA changes the health care delivery system that pushes patients into hospitals, it will be impossible to lower the readmission rate. And unless the ACA stops paying hospitals and academic centers to solve this problem, when these are the very institutions that profit most from admissions, then a meaningful solution will be a pipe dream.

Steven Brill, in his book America’s Bitter Pill strikes at the heart of the matter of why the ACA will fail under its current construct. By expanding insurance coverage while simultaneously allowing hospitals to spend freely and direct the country’s health care delivery system, costs will escalate and outcomes will decline. It is a great absurdity, evident to any person with common sense, to ask hospitals to cut admission rates, when those rates are their bread and butter. The failure to truly tackle the root of hospital admissions, to provide meaningful home care for those who request it, and to involve primary care physicians in health care solutions rather than to burden them with excessive regulatory busywork, will doom the ACA. Money siphoned through hospitals to solve the problem cannot succeed. Hospitals will do all they can to maintain the status quo. Why would they act in any other way?

The ACA through Medicare’s Innovation Center has also devised systems called Accountable Care Organizations (ACO’s), which I discuss in my book. I belong to an ACO, and the basic premise is that groups of doctors and hospitals who join forces and reduce hospitalizations will be rewarded. It is a worthy cause. But ACO’s operate by essentially asking us to avoid hospitalizing our patients. They employ nurses who can call patients when they are in trouble. Doctors are graded and paid by how many forms we fill out correctly, how many quality indicators we adhere to, and by other measures that have no correlation to patient health or to cost savings, but we are given no resources to help patients to be treated at home, to keep the elderly out of the hospital, and to cut back our paperwork burdens that would help us keep people at home. In other words, we are told to complete a list of templated items mandated by Medicare and to keep people out of the hospital, but are not given any tools to make this happen. It is a reform with no teeth. And, like with the hospital readmission programs, it is being financed by the ACA without any real possibility that it can succeed. Without changing the system at its most basic level, all of these efforts are merely sugar coated reform efforts that squander tax payer money and fool the press and public into thinking that the ACA is addressing the problems plaguing our medical system. It is time that the press actually confronts the real problems and asks more probing questions. Even those of us who supported the ACA can only watch helplessly as it drowns us in its feckless attempts to look pretty, while the health care crisis burns all around us.