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.
One reason for his frequent returns, he says, is that he often can’t afford the medications his doctor prescribes, “so I have to do without.” Another is that he fears exercising outside because of neighborhood violence.
Hospitals with frequent instances of patients returning for potentially avoidable readmissions face new Medicare penalties, and hospitals serving large numbers of poor patients are expected to be disproportionately affected. Ralph Rust's decade-long struggle to stay out of hospitals shows the complex factors that cause patients to be readmitted frequently.
Medicare is preparing to penalize hospitals with frequent potentially avoidable readmissions, which by one estimate costs 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 that served the most 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 such well-known medical centers as NewYork-Presbyterian Hospital and Mount Sinai Medical Center, both 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, where, a government study reported last year, readmission rates are higher than in most parts of the country.
Even at places such as Washington Hospital Center, which Medicare says has average readmission rates, physicians contend with large numbers of poorer patients who have both chronic congestive heart failure and 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.
“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 about how to take care of themselves.