Jordan Rau’s review of the upcoming Medicare push to make hospitals accountable for some of what happens to patients after discharge (The Washington Post, A7, July 31, 2011) is a welcome counterpoint to the current drama over debt and spending. Congress mandated a number of penalties and incentives to force a certain amount of coordination between hospitals and post-hospital providers, and Medicare is moving along in implementing them. This work will improve care and reduce costs—a real win!
However, what we don’t often acknowledge is that a very important revision in how we conceive hospital care underlies these initiatives. Once, people in the community were presumed to be reasonably healthy. We sent people with tuberculosis or mental illness into institutions, and the period very near death was short. When you were suddenly very sick or needed a planned surgery, you went to the hospital and then recuperated and were well again. That was then and this is now. Our new way of living with illnesses makes it very likely that each of us will live for a substantial period with serious chronic illness. This is especially true for the time covered by Medicare or the veterans health care system. Old age or bad luck can hand you the opportunity to live longer than our grandparents imagined possible, but with substantial limitations, illnesses, and complications.
We have not redesigned our supports and health care to accommodate these new demographics. We still think of hospitalization as the start of an episode and hospital treatment as pursuit of a “cure,” whereas mostly people now have their health conditions before hospitalization and will still have them afterwards. Hospitalization has often become the “failure mode” in self-care and outpatient care. Having hospitalization become part of the overall plan of care has become an obviously correct reform—only we are not organized to do that. Hospitals, nursing homes, home care, hospice, and doctors are all paid separately in most of Medicare. They have little reason to cooperate for efficiency, and only their dedication to patient and family well-being provides a stimulus to pursue effectiveness. They have no structure available to integrate services, monitor performance, or set priorities. Indeed, health care providers mostly have never even met those who routinely provide care to their patients before or after their spell of service.
When I served Washington, D.C., as bureau chief for cancer and chronic disease, our major safety net provider asked for a grant that would seek to inform the clinic before the patient arrived that the patient had been in the hospital—for 10 percent of the patients with one disease, coming from one hospital, to one clinic. I asked whether the city was really expected to accept a 10 percent success rate in a subset of a subset of a subset. The answer was that the event had never happened except by chance. How can that be? We spend thousands of dollars on the hospitalization and then tolerate dysfunction like this in the follow-up? No wonder one-fifth of Medicare patients are back in the hospital within a month. No wonder we outspend every other country and have no better health care.
The core of health care now is the support of persons living with chronic conditions. Building a care system that can meet this new need requires more than tinkering with some bandages. Of course hospitals have to become involved in their communities. Of course care plans need to be established, transferred with the patient into new settings, modified, monitored, and improved. Hospitals cannot count themselves out of the lives of their patients before and after their time in the hospital. The aging of Baby Boomers is sure to strain our resources and our commitment to care for one another as needed. Building a care system that the community can sustain requires thinking, planning, measuring, and paying across traditional boundaries. Getting hospitals to pay attention to discharges and to how their communities can support sick and disabled people outside of the hospital is a bare start on what we will need to do.
This piece first appeared in Kaiser Health News and published on August 8, 2011. This piece was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions.