Obamacare Preview? Mass. Studies Find Some Hospital Use Stays Same



Today is an Obamacare milestone: the end of the first enrollment period for new insurance plans the health care law spawned. More than 6 million previously uninsured people have signed up for private plans and 4 million more for Medicaid, The New York Times reports.

Opposition and skepticism remain, the Times says.

Yet beneath the loud debate, the law is quietly starting to change the health care landscape. In Kentucky alone, more than 350,000 people — about 8 percent of the state’s population — have signed up for coverage. Insurers and medical providers are reporting steady demand from the newly covered for health care, ranging from basic checkups to complex surgical procedures.

As that landscape changes, now seems a good time for a couple of reality-check studies from Massachusetts (yes, the state website has been messed up, but we did go through the current Obamacare stage of new enrollments years ago). They find that in certain ways — emergency room usage and readmission rates — expanded insurance coverage may not change health care, at least not immediately.

A study just out today in the medical journal BMJ finds that increasing health coverage does not quickly bring down readmissions — those unfortunate cases of patients who quickly bounce back into the hospital soon after being discharged. The hope is that having insurance and thus regular medical care will reduce those expensive readmissions. From the press release:

Boston—In a first of its kind retrospective study, Boston University School of Medicine researchers have found that providing health insurance coverage to previously uninsured people does not result in reducing 30-day readmission rates. The study, which appears in the British Medical Journal, used data on actual (versus self-reported) use of care and also found no change in racial/ethnic disparities in this outcome, despite a markedly higher baseline of uninsured among African-Americans and Hispanics in Massachusetts.

According to the researchers there are several possible explanations for their findings. For example, following health reform in Massachusetts, newly insured individuals were more able to seek medical attention after a hospital admission, which in turn may have uncovered medical problems requiring readmission. Another reason may be the inability to access a personal doctor in the state due to the primary care physician shortage, which has been well documented since 2006.

Other studies in Massachusetts have shown that access to care improved less than access to insurance, as many newly insured residents who obtained Medicaid or state subsidized private insurance still reported cost-related access barriers.

The conclusion: Expanding insurance coverage isn’t enough. Dr. Karen Lasser of the Boston University School of Medicine, the paper’s lead author, emailed that we also need to “reduce financial access barriers to care (e.g. copays), increase reimbursement rates for new insurance plans (so that more physicians accept these forms of insurance), implement medication reconciliation and patient coaching, improve disease management and coordination of care, and provide hospital based incentives to reduce use of inpatient services. Interventions could also tackle the shortage of primary care providers in MA.”

Meanwhile, another recent study, released last week, reported that, contrary to hopes that increased insurance coverage would cut expensive emergency-department use, the Massachusetts experience is that ER use slightly rose after health are reform. Continue reading

KHN: Medicare Penalizes Hospitals (Some Near You) For High Readmission Rates


Kaiser News Reports that Medicare is penalizing more than 2,000 hospitals across the nation, including in Massachusetts, for readmitting too many patients shortly after they are discharged.

“Together,” the report says. “these hospitals will forfeit about $280 million in Medicare funds over the next year as the government begins a wide-ranging push to start paying health care providers based on the quality of care they provide.”

A total of 278 hospitals nationally will lose the maximum amount allowed under the health care law: 1 percent of their base Medicare reimbursements. Several of those are top-ranked institutions, including Hackensack University Medical Center in New Jersey, North Shore University Hospital in Manhasset, N.Y. and Beth Israel Deaconess Medical Center in Boston, a teaching hospital of Harvard Medical School.

“A lot of places have put in a lot of work and not seen improvement,” said Dr. Kenneth Sands, senior vice president for quality at Beth Israel. “It is not completely understood what goes into an institution having a high readmission rate and what goes into improving” it.

Sands noted that Beth Israel, like several other hospitals with high readmission rates, also has unusually low mortality rates for its patients, which he says may reflect that the hospital does a good job at swiftly getting ailing patients back and preventing deaths…

Massachusetts General Hospital in Boston, which U.S. News last month ranked as the best hospital in the country, will lose 0.5 percent of its Medicare payments because of its readmission rates, the records show.

Twenty-Four Hospitals Face Financial Penalties For Preventable Readmissions

Hospitals face cuts in Medicaid payments for higher-than-average patient readmissions

Twenty-four hospitals across the state are facing financial penalties because their so-called “potentially preventable readmissions rates,” are too high, according to MassHealth administrators.

The penalties, slated to take effect Oct. 1, are part of the new, 2012 rate contracts between the state and the 65 hospitals who care for MassHealth patients. Hospitals deemed by the state to have too many re-admitted patients will be hit with a 2.2 percent reduction in their standard payment amount per discharge, or SPAD.

Here’s the list (from the state) of hospitals facing the financial penalty:


Children’s Blog: With ‘Frequent Flyers,’ The Doctor Must Turn Detective

Children's Hospital Boston researcher Dr. Jay Berry

Children’s Hospital Boston published a major study last month on children who are “frequent flyers,” landing often back in the hospital. It found that in a group of pediatric hospitals, about 3% of the children accounted for a whopping 19 percent of the admissions and one-quarter of inpatient expenditures.

Dry numbers, but on Vector, the ever-excellent Children’s research blog, the study’s lead author, Dr. Jay Berry, brings the numbers compellingly to life. He argues here that the findings demand action:

We could start by identifying and tracking children who are frequently readmitted. Currently, such tracking is hindered by a lack of patient accountability. Which provider is ultimately responsible for a child who’s been rehospitalized four times within the last year? The primary-care doctor in the community? The specialist? The inpatient doctor? The hospital in general?

I sometimes see finger-pointing in this situation, without a champion who steps up and takes charge of the patient and their healthcare utilization patterns. Lack of accountability for frequent-flyer children may be one of the greatest contributors to their repeated hospitalizations.

So any solution has to begin with collective accountability shared by all providers who deliver health services to a particular child: specialists, home nurses, primary care clinicians and hospital providers. Once these providers become better integrated, we can start to find the root causes of the child’s frequent readmissions.

No argument there, but I have to confess that I enjoyed even more reading an earlier post of his, describing a case of the actual medical detective work that he’s recommending.

He describes his own “first frequent flier,” and the medical mystery that needed solving: The 4-year-old boy with cerebral palsy did well in the hospital, but when he was sent home, he would start vomiting again, and end up needing to be readmitted. Once the root cause was determined, the solution was a simple one. Spoiler alert: I give it away in the following paragraph, but it is so well put I have to quote it:

We were simultaneously joyful and disheartened at this finding. Happy that we’d found a simple reason why Jim was vomiting at home, one we could alleviate by slowing down his home pump. Sad that this overlooked problem had led to a child being hospitalized four times this year.