As I listened in on the phone — I was in Boston while my siblings were sitting in a rehabilitation facility outside New York — I could feel my anger rising. A week after having a partial hip replacement, our 90-year-old mother with dementia was being talked about as if she were slowing down her own rehabilitation for some self-interested purpose.
This is wrong, I thought. My mother is scared and hurt, and she needs to be embraced by the health-care system, not run through it.
Things happen to people who live a long time — most of them not good. The second-youngest of six children of Irish immigrants and a spitfire her entire life, my mother had been in declining health.
First came the dementia, a terrible disease that slowly guts a person’s personality and awareness. With it came the inevitable slowdown in activity while sharing a tiny apartment with my brother, whose caregiving had kept her out of a nursing home. She spent much of her time in the recliner, staring at the television, sleeping and making lots of calls to my brother while he was at work.
And then one day she fell. Between a part-time home health aide and my brother, the moments when my mother was left alone had become increasingly rare. But during one of those moments, she tried to get out of her chair and tripped.
She fractured her left hip, the dreaded injury that — along with damaged knees — hits the elderly hard and eats up so many Medicare dollars, often through partial or full joint replacements.
When I got the call from my brother that he was at the emergency room with our mother, her future came clearly into focus: That day would be her last sitting in their small apartment, having some degree of independence. She was about to become dependent on a fragmented health-care system. She would traverse the modern elderly person’s trail of tears from emergency room to hospital bed to operating room to rehabilitation hospital to nursing home.
It seemed unavoidable that my mother, the fireball of my youth and adulthood, would become a passive passenger on the unpleasant train to Long-Term-Careville.
Entering the assembly line
I’ve worked in, studied and taught health care for the past 30 years, so I knew more than the rest of my family did about the maze of complexity, uncertainty and risk that my mother was entering.
Older folks, already debilitated by a significant injury, often develop a steady drip of secondary health problems in hospitals and rehabilitation facilities, such as infections and pressure sores. And the clinical interventions meant to prevent, slow or stop those morbidities often end up compromising the patients’ immune systems and set them up for something even worse down the road, such as pneumonia.
Two days after my mother was admitted to the hospital, an orthopedic surgeon we’d met only an hour before performed a partial hip replacement, inserting a prosthetic femoral head into my mother’s hip socket and anchoring the stem of that head in her femur. It was a quick and fairly straightforward procedure.
“She has pretty good bone structure for her age,” the surgeon told us after the surgery. “The operation was a success.”
Even as someone who knows health care quite well, I felt like an uneducated fool about what came next. What I found out when my mother got back to her hospital room is that with joint replacements now, you are on a quick-moving assembly line. That line whips you out of the hospital and into a rehab facility as fast as is humanly possible, and then out of the rehab facility and either back home or on to a nursing home almost as quickly.
There was also a financial incentive on the hospital’s part for this speed.
My mother had been assigned to a pilot program, created by the Centers for Medicare and Medicaid Services (CMS) as part of a “bundled payment” initiative designed to control costs, ostensibly without hurting care.
This pilot program placed hospitals at financial risk if the actual costs of joint replacement surgery and post-surgical treatment exceeded the target amount specified by CMS. Spending more than the CMS target for a hip replacement, including rehabilitation, could force the hospital to reimburse Medicare for a portion of the total costs, whereas coming in under the target might net the hospital a financial bonus.
No one told us before the surgery, or for several days afterward, that my mother would be included in this program. I found out when the hospital care manager mentioned it on the day my mother was scheduled to move to the rehab facility. If I had not peppered her with highly specific questions about rehabilitation, she might have never mentioned the bundled payment program. My brother had spoken with her several times before, but my mother’s inclusion in the program had never come up.
Learning about bundles
Had bundle-related pressures affected my mother’s post-surgery treatment and what we felt was a too-hurried effort by the hospital to get her up and moving — and into a rehab facility?
The day before the surgery, we had been told that she would be discharged no more than a couple of days later to a rehabilitation facility. The morning after her surgery, my mother was forced out of bed to sit in a chair and to try to stand. She yelled at staff members the whole time, her dementia on full display.
It sounds as though it makes sense clinically: Get them up quickly, and get them moving. But the speed with which things started happening struck my siblings and me as less than ideal.
Given the short discharge window, my brother and I had spent the morning of the surgery doing a lightning tour of a local rehab hospital that we’d selected after my own rapid-fire examination of Medicare star ratings, Nursing Home Compare data and state health inspection reports.
The hospital had recommended one, but my research suggested that a different one seemed to offer the best quality. So we chose that one. But I wondered: Had my mother’s inclusion in the bundled payment program affected the hospital’s suggestion?
More specifically, did the hospital have tacit understandings with specific rehab facilities about keeping the costs of care within a certain range? Was the hospital’s recommendation reflective of good collaboration or something more like collusion with a given facility? I can’t say whether my suspicions had much basis in reality. But my trust in that hospital and my mother’s surgeon began to wane.
I decided I needed to read up on the CMS bundled payment program for joint replacements. Online I found an item from the Federal Register that was more than 280 pages long with 48 pages of “frequently asked questions” describing the program to health-care providers. For patients and families, I found an oversimplified set of statements on the CMS website, including many still unproven assertions that bundled payment produces better care for patients.
The information I found made my head hurt. It felt as if my mother’s care trajectory had been reduced to thousands of hard-to-understand words online. And I was someone trained to explain health-care issues for others.
I tried not to laugh out loud at the grand-sounding but vague statements about “coordinated patient-centered care,” the benefits of hospitals and providers “working together more closely to coordinate their care,” and how bundling created incentives to “work together to deliver more effective and efficient care.”
I know enough about health care to understand that these sentiments do not translate well in the siloed, hypercompetitive, slim-profit-margin system of care delivery that we have today.
Not working for her
What we saw during the first week my mother was in the rehabilitation facility made me feel as if the “bundle” was, in fact, working against her. Given her dementia-impaired reasoning, getting her up and walking and doing the many things required by rehab was going to be difficult and was going to take time.
Yet my siblings and I were told initially that participation in the bundled program generally meant five days of Medicare-covered rehabilitation for a partial hip replacement. Every time I spoke with the rehabilitation facility staff members in that first week, I could feel that this bundled payment program and its short discharge window were on their minds.
“You know your mother is part of a care bundle,” a nurse on my mother’s floor mentioned to me one day. In separate instances, the physical therapist and the social worker in charge of my mom’s health-care team mentioned that to me as well.
I also learned that the rehabilitation facility was in constant communication with the care manager at the hospital that had discharged my mother. This could have been just good post-surgical care. But the cynic in me also wondered whether the rehabilitation facility, to ensure future referrals from the hospital, was also hoping to show that it could make the bundle a financial success, through highly efficient service delivery.
It soon became clear that my mother could not be discharged in five days; her response to physical therapy was slow. A little more than a week into my mom’s stay, my siblings and I had a meeting with my mother’s health-care team at the rehab facility, with me participating by phone from Boston.
Your mother wasn’t progressing, the team members said. At times, she refused to cooperate in her rehabilitation; the facility was about to report to the hospital and Medicare that they had reached the limit of rehabilitation progress. That would trigger her transition to a “private pay” patient, ending Medicare Part A coverage and saddling her with $400 a day of expense just to have a bed at the facility. (Any additional rehabilitation she required would cost extra.)
The meeting got heated in a hurry. “You have to realize my mother has dementia and has to be treated differently — are you taking that into account?” I asked. We pressed the team on the fact that my mother’s dementia and other secondary morbidities, such as chronic knee pain, were probably slowing down her physical therapy progress compared with that of a typical patient.
“I can’t believe we have to state what should be obvious,” I said.
I repeatedly brought up the financial pressures of the bundled payment program. I wanted everyone to know that we knew about it, a subtle (maybe not so subtle, in hindsight) form of shaming that might get them to think like advocates for my mother.
For 45 minutes, this back-and-forth continued between the dry, clinical analysis from the care team and the emotional, frustrated pleas from my brother and me. This was nothing like what the CMS website talked about. After the call, I left my office, feeling sick to my stomach, and went outside to clear my head. I felt increasingly powerless to help my mother.
An unrealistic policy
For years I’ve believed and taught my students that fee-for-service medicine was a wasteful, dysfunctional way to reimburse providers for health care. Maybe it still is. But I now think that the supposed antidote — value-based reimbursement, which includes bundled payment plans — makes little sense and is equally dysfunctional, at least from the patient’s perspective. It can create a massive conflict of interest within a system that is neither coordinated nor collaborative, and facilitate gaming among the different institutions that are still very much concerned with profit.
Ironically, my mother is still in that same rehab facility, though now in a long-term-care bed that Medicare is not paying for.
Her staying put is out of necessity because the facility is close to where my brother and sister live, allowing them to visit her every day, and it had an available long-term-care bed when we needed it. There is no way she could function back in the apartment; she rarely gets out of her wheelchair, and her dementia grows worse.
In the end, Medicare covered her rehabilitation for five weeks, because of meaningful setbacks in her health and, I believe, because we pushed back hard in that meeting.
I credit the rehabilitation facility with justifying to both the hospital and Medicare a need to cover her care longer than the predicted period. But I wonder whether they have learned a hard lesson that they will apply in less patient-friendly ways to another person,particularly if bundled payments are our future.
Hoff is a professor of management, health-care systems and health policy at Northeastern University in Boston and the author of the forthcoming "Next in Line: Lowered Care Expectations in the Age of Retail- and Value-Based Health." This article was excerpted from Health Affairs and can be read in full at www.healthaffairs.org.