There are moments that occasionally arise here in Geezerville when a guy can almost convince himself that sudden cardiac arrest offers a subtle upside. Such a moment occurred the other day as I was reading about the latest systemic glitch in the U.S. healthcare industry.
It’s a lamentable reality that most of us will follow a well-trod path to the grave once we achieve decrepitude: emergency room, hospital bed, nursing home, hospice, cemetery. As much as we’d like to believe we’ll just hum along like a Swiss watch until we expire peacefully in our favorite patio chair on a sunny June afternoon, statistics suggest otherwise. Eight out of 10 Americans die in an institutional setting after a prolonged descent; there’s a reason why housing the elderly is a $136 billion business.
The horrors of life in some nursing homes — abuse, neglect, crumbling facilities, poorly trained staffs — have been sufficiently well-documented in recent years to spur reform efforts at the state and federal level while encouraging the senior set to explore alternatives. But what’s a geezer to do when it’s the government itself that’s causing the problem?
That’s the question that came to mind last week while perusing a Kaiser Health News story describing how Medicare and Medicaid policies encourage scenarios in which the ailing elderly are released from hospitals too soon and shuttled off to poorly equipped nursing facilities, only to be shipped back to the hospital when their conditions predictably worsen and readmitted again to the nursing home to await the next round.
As Jordan Rau reports, this “boomerang” effect is more common than you might think: “One in five Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions, such as dehydration, infections, and medication errors,” he writes. “Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.”
“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’” David Grabowski, a professor of healthcare policy at Harvard Medical School, tells Rau. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”
You could chalk this up to bottom-line corporate cruelty, but longstanding Medicare and Medicaid policies are really at the root of the problem. Because Medicare pays hospitals a set fee based on the average stay for a patient with a specific diagnosis, the hospitals increase their profit margins by discharging folks as early as possible — often shipping them off to nursing homes to complete their recovery.
When the patient arrives at the nursing home, the insurance coverage typically flips to Medicaid, which reimburses facilities at a much lower rate than Medicare or other insurance plans. The recuperating senior may need more attention than the facility is set up to offer, which adds costs and complicates the recovery. If that isn’t sufficient motivation to ship the ailing patient back to the hospital, the nursing home also gets a “bed-hold” payment from Medicaid and 100 days of more lavish Medicare fees when the patient returns from the hospital.
Still-recuperating patients often arrive back at the nursing home feeling disoriented and carrying a fresh infection. And, as David Gifford of the American Health Care Association notes, “They never quite get back to normal.”
Government officials began fining hospitals with high readmission rates in 2013 in an effort to reduce premature discharges and encourage referrals to high-performing nursing homes. And this fall, nursing homes will begin seeing bonuses or penalties based on rehospitalization levels. While those rates have begun to drop slightly in recent years, these regulatory reforms may have unintended consequences.
“We’re always worried the bad nursing homes are going to get the message, ‘Don’t send anyone to the hospital,’” says Tony Chicotel, a staff attorney at the California Advocates for Nursing Home Reform.
I recall the grief our whole family shared as my father-in-law gradually descended into Alzheimer’s over the course of several years. At a certain point, his wife could no longer handle him at home and social workers helped her get him settled in a nearby nursing home. I never had a chance to visit him there, so I can’t say if the facility was a “good” or “bad” one, but two weeks later his heart gave out while he was asleep. Despite all his struggles, I’ll always think of him as one of the lucky ones.