Carlos Del Valle strolled out of his local bank near the Bronx Zoo on a hot summer morning last year, eager to get to City Island to spend the afternoon performing Italian pop songs at a senior center. Suddenly, he felt as though a bolt of lightning had slammed into his skull and ripped through his body. Then everything went black.
At 78, the Puerto Rican grandfather of 11 — a retired bongo player, pizzeria owner and go-to handyman for his neighbors — had suffered his fourth and most violent stroke yet.
The episode nearly killed him. It plunged Del Valle into a month-long coma at Montefiore-Einstein Hospital. It stifled his singing voice and slowed his mobility. And it might have been prevented if the Spanish-speaking entertainer had understood his doctor’s instructions several months before.
Del Valle suffered from a less tumultuous stroke in late 2010, and he was released after two days with doctors’ instructions to return for weekly blood checks. A St. Barnabas doctor tried to explain that he needed strict monitoring because his new blood thinners might cause excessive bleeding, or trigger another stroke.
But Del Valle had no idea. He had never grasped the gravity of those directions, and six months after he started taking the high-risk drug, he never went back.
Poor communication between doctors and patients is one of the key reasons Medicare patients return again and again to the city’s hospitals for expensive overnight stays, according to the Medicare Payment Advisory Commission, the independent agency that advises Congress on Medicare issues. Nearly 20 percent of Medicare patients return to U.S. hospitals within 30 days of being released, federal records show. At hospitals in Bronx County, 30-day readmission rates range from 21 to 28 percent for federally reported causes, topping both New York state and national averages.
“This is a huge social issue,” said Graham Atkinson, a health policy consultant. “It discriminates against hospitals that have the highest proportion of Medicaid patients. Those hospitals also tend to have poorer financial conditions, and so what this is going to do is further push those hospitals into diminishing their profit margins.”
Health care reform advocates have long called for driving down readmission rates as a way to pressure hospitals into giving patients the best treatment the first time around. But historically, U.S. hospitals haven’t had much financial incentive to do so.
With that in mind, a key component in the 2010 Affordable Care Act kicked in Oct. 1 that levies fees on hospitals with high patient return rates. The readmission reductions program is part of the Obama administration’s broader push to control climbing costs while improving quality of care. The policy also bundles reimbursements to hospitals per patient visits, rather than per procedures and rewards hospitals for meeting performance goals.
“This can prevent unneeded services and tests that cost Medicare money and can hurt patients,” said Kathryn Ceja, spokesperson for the Centers for Medicare and Medicaid Services in an email. “It also aims to give hospitals an incentive to coordinate care better, to prevent patients from getting sick again and coming back into the hospital.”
Del Valle’s close call illustrates one of the most common nationwide reasons patients return — communication challenges between patients and health care providers. Clinicians too often assume patients understand explanations about their conditions and follow-up care. Primary care providers too often do not communicate their patients’ needs with the hospitals that treated them.
Del Valle stumbled upon his dangerous mistake by chance, a few months before that fourth, nearly fatal stroke. He found out that a friend in his building who was a fellow stroke survivor had a similar prescription for the blood thinner warfarin, and had been making weekly visits to get his blood checked. Del Valle walked across the street from his apartment in the Belmont section of the Bronx and asked a physician who was standing outside St. Barnabas having a smoke. The doctor confirmed — no question, warfarin patients are at high risk and need weekly checks.
“Uh oh,” Del Valle recalled thinking as he rushed to visit his primary care doctor on the Grand Concourse, who was surprised Del Valle hadn’t retained the instructions from either him or the hospital. He helped Del Valle set up an appointment at the St. Barnabas clinic. This time, the doctor sent him home with a card stamped with an appointment reminder. The tests showed his blood had become dangerously thick, so the doctor adjusted his dose immediately. But the correction didn’t work fast enough, said Del Valle, who suffered his worst stroke shortly after starting the checks.
Del Valle attributed the communication gap to his muddled state of mind. The doctor had discharged him from the hospital shortly after he had just woken up from a coma triggered by a debilitating stroke.
“I wasn’t doing too well,” said Del Valle. The stroke had imparied his memory and ability to think clearly. “I got mixed up with a lot of things.”
By slapping fines ranging from $300,000 to $2 million on hospitals with high patient return rates, the Centers for Medicare and Medicaid Services expects to pressure hospitals to ramp up efforts to reduce unnecessary and preventable admissions.
But the program’s methodology for fining hospitals has triggered criticism from some health care advocates and industry professionals — even those who say they’re in favor of high readmission rate penalties. Some believe that the poorest hospitals with the least resources are the ones with the highest readmission rates, so they will be hit the hardest. And some fear the program could give hospitals a reason to turn away poorer patients in non-emergency situations.
Like Atkinson, the American Hospital Association and Association of American Medical Colleges fault the formula behind the readmission penalties for not considering a hospital’s socioeconomic factors. Federal regulators counter that such adjustments could create a lower standard of quality at poorer hospitals that wouldn’t be fair to those populations.
Low-income and immigrant patients tend to have higher readmission rates because they don’t have access to the caregivers and support systems that wealthier patients do, Association of American Medical Colleges spokesperson Jennifer Faerberg said. She argued the penalties also don’t take into account various unrelated readmissions — such as a heart failure patient returning for a traumatic head injury — and she pointed out that in some cases, hospitals reporting some of the higher readmission rates also boast surprisingly low mortality rates. “If you’re continuing to be readmitted,” Faerberg said, “then we’re keeping you alive.”
Others believe the penalties will help usher in a new focus on “value over volume” that’s long overdue.
“It is the right thing to do,” said Dr. Jitendra Barmecha, vice president of medical informatics at St. Barnabas in the Bronx. “If you look at the current health system, it is based on volume. The more admissions you do, the more tests you do, the more you get paid. The future is based on value, based on quality.”
The fines may help bring out of control health costs into line at the same time. “There are real disconnects in what should be continuity of care,” said David Gould, senior vice president of the United Hospital Fund, a nonprofit organization that studies ways to improve health care in New York. “We want to help hospitals understand what they could do differently in terms of preparing patients for discharge.”
Successful interventions have the potential to generate major cost savings to both insurance companies and taxpayers.
Readmitted Medicare patients in the U.S. rack up an estimated $15 billion to $17.5 billion annually. In New York State, readmissions cost taxpayers $3.7 billion in 2008, with Medicare patients making up 60 percent of the tab, the New York State Health Foundation reports. New York ranked last out of all 50 states on the nonprofit Commonwealth Fund’s 2009 scorecard for avoidable hospital use and costs.
The new penalties are capped this year at no more than 1 percent of each hospital’s Medicare reimbursements, and are set to increase to 2 percent in October 2013 and cap at 3 percent in 2014. More than 2,200 U.S. hospitals are expected to be fined an estimated average of $125,000 each in the coming fiscal year. For St. Barnabas, the fine may amount to $136,000, or 0.35 percent of the hospital’s total inpatient Medicare fee-for-service revenue in 2013, the Healthcare Association of New York State estimates.
“It’s not as punitive as it sounds,” Gould said. “But the financial risk has got folks’ attention. It enables them to think differently, that there really is a business proposition in doing this.”
Knowing the penalties were coming, St. Barnabas joined with Bronx Lebanon and Montefiore hospitals and EmblemHealth and Healthfirst health plans in 2009 to form the Bronx Collaborative, an initiative aiming to reduce readmissions within 60 days throughout the Bronx.
“All payers are looking at readmissions more closely,” Barmecha said, “especially as the financial landscape changes in the future, with more and more patients coming into health plans.”
The Bronx Collaborative aims to improve a patient’s case management, and has focused on increased follow-up phone calls and home visits. It represents an effort to coordinate plans across different types of health care facilities and players, from the insurance company to the pharmacy — even though some of those other players aren’t facing the revenue reductions confronting hospitals.
“It’s a community experiment and at this point the whole penalty is being put on the hospital,” Faerberg said. “And while they are a major driver and certainly can do work to improve on what they have control over, they don’t have control over the whole continuum.”
Montefiore Medical Center, which runs four hospitals and more than 100 medical offices, is in a unique position to coordinate the care for some 500,000 Bronx residents within its vast network. The network’s care management company has also teamed with its geriatric division and nursing facilities to organize more in-person meetings with older patients, spokeswoman Anne McDarby said. Montefiore is working on developing a predictive modeling tool to better understand what drives preventable readmissions and identify at-risk patients while they’re still hospitalized.
The Medicare penalties initially target three types of conditions: heart attack, heart failure and pneumonia. The punitive program is expected to branch out to more causes in coming years, including joint replacement, heart bypass, stenting and stroke treatment.
Through $70,000 in grants from the United Hospital Fund, St. Barnabas launched a program to study its most frequently readmitted patients throughout 2011 and implement solutions to curbing readmissions in 2012 and 2013.
But St. Barnabas administrators decided not to limit their study to the types of Medicare patients targeted in the fines. The idea was to get a handle on the highest local repeat patients, and then implement changes that would ultimately benefit every patient admitted. None of the federal markers matched the top three reasons patients returned to St. Barnabas. Instead, local returners tended to have diabetes with complications, substance abuse problems and infections.
Researchers interviewed 30 of the most readmitted patients, reviewed their charts and talked with their primary care doctors. Though the sample size was small, some of the findings were stunning and bucked common assumptions, Barmecha said.
The assumption was, for instance, that patients who used the hospital most frequently lacked insurance. But all of the patients in the study were covered. Further, 80 percent had primary care physicians, even though in the majority of cases, nobody at the hospital had contacted the primary care doctors during the patient’s stay or discharge. Half had been readmitted within seven days of their first hospital stay.
“We were very surprised that these patients, in spite of having primary care physicians, were getting readmitted again,” Barmecha said. “The thinking was, ‘Maybe they shouldn’t have been admitted in the first place.’”
The hospital is now rolling out a new data system that alerts clinicians when a returning patient arrives at the hospital, and enforcing a more stringent process for readmitting patients who might be better off getting care in a clinic or at a primary care office. For patients faced with waiting weeks for an appointment with their primary care physicians, the hospital will work to find them a spot at a St. Barnabas-run clinic or ambulatory unit. Extra attention will be placed on getting in touch with a patient’s assigned primary care provider before a patient leaves the hospital.
After cleaning up the readmissions process, the next big focus is on patient education before patient discharge. Just as Del Valle didn’t understand his doctor’s orders, the St. Barnabas study showed rampant inconsistencies between what doctors thought they had told patients and what patients actually understood.
“Lying in a hospital bed is never a great place to learn about anything,” Gould said.
Later this month, St. Barnabas plans to open a new patient discharge lounge, a lobby area specifically designed to educate up to about 10 patients on their way out of the hospital about their conditions, follow-up plans and medication lists. This extra layer of instruction aims to reinforce anything patients and their caregivers may have missed. A specific curriculum will be rolled out to help diabetes patients control blood sugar levels.
In the St. Barnabas emergency room, Dr. Ernest Patti, senior attending physician, has been teaching classes for patients with congestive heart failure. He walks patients and caregivers through practical ways to exercise more and eat less salt, including offering new culturally friendly recipes to try at home.
Dr. Eric Gayle, who oversees five Bronx health centers as regional director for the Institute for Family Health, welcomes improvements at each hospital, but he stressed that it’s critical for hospitals to do a better job communicating with community-based clinics, primary care providers and specialists. It can be especially tough to get access to patient information when a primary care office and a hospital aren’t in the same network. His office has a strong line of communication with Montefiore hospitals, for example, but not with St. Barnabas.
“What’s missing so far is the hospital piece, where you can engage the hospital or the emergency room when the patient presents to get some coordination with what’s happening with the patient and whether or not you can prevent an admission,” Gayle said. “I see the hospitals doing it but they’re doing it better in their own primary care networks. They can do that much better.”
When hospitals and clinics have communication gaps, the results are under-informed doctors, duplicate tests and medication management mix-ups — either patients taking the drugs improperly, or doctors unknowingly prescribing duplicate or conflicting drugs.
Just as too weak a blood thinner caused Del Valle to have dizzy spells and risk another stroke, too much diabetes medication can trigger fainting or seizures and too much of a drug to control blood pressure can be fatal.
“There are so many potential hazards to not being able to reconcile medications across hospitals and the primary care physicians,” Gayle said. “It’s remarkable that we’re able to avert or avoid or minimize disasters.”
In the St. Barnabas study, 40 percent of the most frequently readmitted patients had been taking more than 10 medications, and most of the drugs were classified as “high-risk.”
“If anybody is on more than 10 medications,” Barmecha said, “you are bound to make some sort of error.”
As he returned home from the corner pharmacy on a recent afternoon, Del Valle parked his aluminum walker, sat down at his kitchen table and started sorting his bottles of prescription pills stored above the refrigerator in a square-shaped Easter egg basket — all 17 of them. He set several aside that his doctor advised he could eliminate, along with a few others he needed for occasional pain. Seven bottles and an inhaler remained in his daily regimen, some taken every eight hours, some taken once at breakfast and some before bed.
For the most part, Del Valle said he feels he has his pill-swallowing routine down pat, but he’s pretty sure there have been times when he got distracted by a phone call and missed or doubled a dose. He said he keeps in weekly contact with his home health care aide and primary care doctor about any side effects he’s feeling, and his doctor will often adjust his regimen accordingly.
He’s especially careful these days. He watches what he eats. He knows he’s not supposed to get too excited or angry, so he plays his Italian tunes to soothe him.
He misses some of his favorite activities. He used to belt out eclectic ballads in nightclubs and restaurants and lead eager crowds in the waltz and mambo. Now, he often stammers while speaking and has trouble pronouncing familiar words. “Sometimes people think I’m drinking or something,” he said. “My brain doesn’t come out with the words.” For years he’s made a splash roller-skating down Southern Boulevard in the annual Halloween parade, with a trail of children gliding behind him, but he decided to skip it this year.
“I have to just take it easy,” Del Valle said. “I just can’t take a chance. I’m afraid to be out there on the street. I don’t want to fool around.”
He reached into his wallet to pull out a small folded card stamped with the dates of his upcoming blood level checks. He makes sure he never misses those Monday appointments.
“Like I told my daughter,” Del Valle said, “God doesn’t want me up there yet.”