Unintended Consequences

Anyone who has flown on a commercial airline recently knows this story.  You show up for your flight and are offered a choice: you can either pay an extra $25 to check your bags or try to pack all your vacation items into a rollerboard and schlep it on the plane with you.

It didn’t use to be this way, of course.  A couple of years ago an enterprising executive at one of the airlines decided that a clever way to enhance the company’s bottom line would be to charge customers for something that had previously been included in the price of a ticket.  Soon, nearly every airline jumped on board and the money started rolling in—the industry brought in an additional $3.4 billion in 2010 alone by simply putting a price tag on something that used to be free.  No major revolts occurred, and now everyone loves a system that has become a reliable source of new revenue.

Everyone, of course, except passengers.  And flight attendants.  And TSA personnel.  And baggage handlers.

Those of you who fly frequently know exactly what happens.  Passengers try to cram all their belongings into smaller bags that are advertised to easily slide into the overhead bin, provided that "easily slide" is defined as "cram into tiny crevice using jackhammer."  This results in more bags carried onto the plane, longer security lines, less overhead space, slower boarding times, more gate checking, and less efficient airplane turnaround.  One flight attendant I recently chatted with called it a "very trying situation" (actually, I made up that quote—her real words weren’t fit for a wholesome family blog like this one).

But it’s more money for the industry and that’s what is important even if customer satisfaction plummets.  There are, however, a couple of airlines that recognize the customer aggravation as an unhealthy consequence and have advertised—with great success—the fact that people can still fly on their planes without forking over more to store their bags in the belly of the plane.

Air travel is not the only industry where unintended consequences arise.  A new law meant to save Medicare dollars may result in some outcomes that are neither desired nor anticipated.

For patients of Medicare age about one in five hospital stays are readmissions for a short list of chronic—and expensive—medical conditions (such as heart failure and pneumonia), amounting to a price tag of more than $17 billion in 2008 alone.  Built into the Affordable Care Act is a plan to "help hospitals smooth transitions for patients and reward hospitals that are successful in reducing avoidable readmissions" with the idea that this alone will save up to $12 billion yearly.

The way Medicare plans to "help hospitals" is to simply not foot the bill for any patient who comes back to the hospital within 30 days of being discharged, a policy set to take effect this October.   For example, if a patient is admitted for an exacerbation of congestive heart failure (CHF), is discharged after therapy, but is readmitted 29 days later, the hospital will end up picking up the tab for all costs incurred.

This, as you can imagine, is very powerful incentive for hospitals to cut down on the rate of repeat admissions for chronic diseases.  A recent story in the Omaha World-Herald highlights the dilemma by citing statistics from some of our area hospitals:

The Nebraska Medical Center performed poorly in a national study comparing academic medical center readmissions from 2004 to 2009. The center's readmissions among Medicare patients over a 30-day period increased to 19.4 percent in 2009 from 14.8 percent in 2004.  Creighton University Medical Center's readmission rate dropped during that period from 18.6 percent to 18.1 percent. The University of Iowa's dropped from 19.1 percent to 18.2 percent.

Hospitals are understandably anxious.  They have complete control over the diet and medication compliance of hospitalized patients, but once people are out the door there’s nothing to keep them from trashing their new prescriptions and heading out to Julio’s Mexican Cantina.  To safeguard against this, hospital administrators are beginning to implement systems designed to keep recently discharged patients healthy.  Patient education during the hospitalization has improved, home nursing is used more frequently to keep tabs on patients in the first few weeks, and outpatient heart failure clinics are playing more of a role in treating early symptoms before they blossom into serious problems.  At Alegent we are agressively using these strategies—with quite good success—along with very early cardiology appointments (within just a couple of days) to make sure that the treatment plan continues when the patient is back home.

This all sounds good, right?  On the whole, I agree.  I’m happy to be part of a system that is doing its best to keep people as healthy as possible.  But wait until the full program is implemented and I believe we’ll start seeing the unintended consequences I mentioned.

Hospitals will naturally want to do everything in their power to avoid a hospital stay that Medicare refuses to fund.  The first natural step to avoid readmissions is to simply not discharge patients from the hospital.  As it stands, we do our best to get patients back to their homes as quickly as possible in order to limit cost and the chance for hospital-related complications (mostly infections).  My bet is that this will change.  We’ll be hanging on to the sickest of patients longer just so we don’t risk their premature return.  The average length of stay for CHF and emphysema will rise, as will the rate of hospital-acquired infections and other problems.

We’ll also see emergency departments doing their darndest to keep the returning chronically ill patient from actually obtaining an overnight bed in the hospital.  Some enterprising facilities will no doubt create units in the ER dedicated to a "23-hour" admission (of sorts) that allow doctors to provide treatment to CHF recidivists while still classifying them as outpatients.

Finally, the use of rehabilitation and transitional facilities will balloon (good news if you’ve invested in these lately).  We’ll be so paranoid about sending chronically ill patients home that we’ll insist they be transferred to some type of intermediate care facility until they get out of the 30-day window.  These types of rehab centers provide great care, but may be overkill for many of the patients who would have done just as well at home.  The additional cost of mandatory transitional care for a high percentage of patients might easily surpass the savings gained by refusing to fund the hospital stays of those few who require readmission.

The way I see it, this whole Medicare strategy is both good and bad.  We needed a bit of a kick in the pants to get us to provide better transition care for chronically ill patients after they leave the hospital.  Improvements in outpatient education, therapy, and communication are certainly a useful byproduct.

That said, I can see ways that patient care can inadvertently be compromised.  We’ll know soon.  Hopefully the net effect will result in healthier people without the unintended consequences of lengthier hospitalizations, increased use of transitional care, and more facility-acquired infections.