Results of a study released in the November 12, 2017 JAMA Cardiology demonstrated that lower readmission rates among hospitalized heart failure patients, a key focus of recent Medicare value-based payment efforts, were associated with increased patient mortality. In other words, patients admitted to the hospital for heart failure are being re-admitted less frequently, but dying at higher numbers. Value-based pay, as it turns out, where monetary incentives and penalties are tied to the results of various quality metrics, may cause more harm than good. More troubling still is that Medicare has made such programs the centerpiece of its payment reform efforts.
Anecdotal evidence from my practice appears to support the notion that, despite the virtual obsession with performance metrics created by value-based payment programs (or maybe because of them), patient care is suffering. Two recent hospital discharge cases are illustrative.
The first case was a patient seen in follow-up shortly after being discharged from the hospital after a coronary artery bypass graft (CABG) procedure. The patient had been discharged after a four-day post-op hospital stay. He was on a number of different medications for his blood pressure and diabetes, which was surprising, because there was no medical indication to change these medications, and the patient had been using these older generic medications for quite some time. It wasn’t clear why these medications had been changed. The patient was complaining of great difficulty urinating, which began immediately after his urinary catheter was removed on the second day after his surgery. The patient said that he had informed the hospital staff of this, but nothing had been done.
The patient’s discharge summary had not yet arrived, and the surgery took place at a distant hospital where I don’t have access to on-line information, so it was a challenge to figure out what was happening. We obtained a urine specimen to check for infection, and ordered labs to monitor kidney function. I began an antibiotic for a possible urinary infection.
The next day, both the lab results and the hospital records arrived. The labs revealed that the patient’s kidney function had markedly declined. The hospital record showed that the decline in kidney function had begun during the hospital stay.
A nurse practitioner had followed the patient during the hospital stay, and their discharge summary mentioned the worsened kidney function, but not that anything had been done to find or address the cause.
By the next day, the patient’s urinary complaints worsened. I sent him to the ER, where a catheter was again placed. His kidney function rebounded for a short period, but then worsened again, meaning that urinary retention wasn’t necessarily the cause, or the only cause, of what was going on.
I stopped his new blood pressure medication, and things did improve. Gradually, the patient has improved.
Because of what had transpired, I contacted the cardiothoracic surgeon who had performed the procedure. We both agreed that it would be of value to review the case. He was relatively new to this facility. Hearing my concerns, he was glad that I had called, and that we might use the opportunity to eliminate such things in the future.
The medication changes had occurred because the hospital’s formulary did not include the patient’s original prescriptions. But this was not noted in the patient’s medical record.
It is also customary in this hospital for nurse practitioners to provide much of the post-operative care. It is felt to be more cost effective for the cardiothoracic surgeon to perform tasks unique to his much higher level of training. Unfortunately, in this instance, these errors took place.
The surgeon also told me that while this patient had been able to stay in the hospital for four days, there had been great pressure by the utilization review team to send him home on day three. So, things were rushed.
A second case involved a patient who I saw after a two-day stay in a nearby hospital after suffering multiple injuries in a fall. I read the patient’s discharge summary prior to going into the room to see him. It was noted that he had fractures six ribs on the left side, broken the left clavicle, and had a separated left shoulder.
Immediately upon entering the patient’s room, I noted that he had a cast on his right wrist. I asked him why he had the cast. Apparently, he had a right wrist fracture which was not noted on the discharge summary.
He told me that he had been in the hospital for two days, and complained of right wrist pain and swelling the entire time, but an x-ray had only been performed at the last minute, just prior to his discharge. This had not made it to the discharge note.
The patient’s wife told me an odd story. When they arrived home, because of his obvious disabilities, she helped him to change. She noted that he still had blood on his leg from the original injury. The patient also told me that at home he had to pick gravel out of his hand. Despite being in the hospital for two days, no one had checked him or cleaned him up!
The patient also showed me an area of redness and swelling of his right thigh. He said that he complained of this during the hospital stay, but couldn’t get anyone to actually check the area.
These two cases are fairly typical in my recent experience. Doctors and nurses today deal with a long list of distractions, including unworkable EMRs, HIPAA compliance, restrictive formularies, pressure to quickly discharge patients from the hospital, and pressure to avoid expensive care, just to name a few. Added to that list now is a long list of quality-improvement programs, and increasing use of quality metrics and value-based payment strategies. As a direct result, basic patient care is suffering. No one has the time for such things.
Worsening outcomes, rather than improved care, are the natural consequence of current misguided concepts of value-based pay. Medicare should abandon such efforts before more patients die.