Hospitals increasingly try to keep patients away to save money

Asked about his health issues, Anthony Tramonte of New Castle, Del., says, “Do you have about an hour?”

It's no wonder: The former postal worker, 72, is on dialysis, has diabetes, heart disease, high blood pressure and eye problems. He's been hospitalized three times for heart failure in the last few years and was blind for awhile due to his diabetes.

Tramonte's wife of 50 years, Phyllis, is his fulltime caregiver, but she’s got help in high places - the Christiana Care health system near their home. There, pharmacist Kelly Ann Steeves is his "care coordinator" after Tramonte is hospitalized to make sure he gets all the medical and social support he needs to avoid a return visit. A monitor checks his heart beat and notifies his doctor if it's irregular, which Phyllis says has saved his life twice.

"I sleep easier knowing he's got that care," she says.

Tramonte is one of about 75,000 patients in a Christiana program called Care Link that’s funded by a variety of federal grants through the Centers for Medicare and Medicaid Services. Patients have care coordinators such as Steeves who link them with a nurse, pharmacist and social worker. Similar projects around the U.S. are federally funded and share the goal of keeping people healthy and out of the hospital, at least for preventable reasons.

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Under the Affordable Care Act, hospitals now get penalized when Medicare patients are re-admitted within 30 days of a visit, but there are a host of other ways they get rewarded when they keep people healthy. Some are funded through CMS' innovation center, such as a reimbursement plan that gives hospitals a set amount for, say, a knee replacement. They get more if they treat the patient for less and lose money if it costs more.

The ACA also prompted hospitals and doctors to work together in what are known as "accountable care organizations" that share in any savings they bring to the Medicare system.

As the fate of the ACA — and CMS' Center for Medicare and Medicaid Innovation — becomes increasingly uncertain, Christiana CEO Janice Nevin says she’s apprehensive about what will happen to the funding. But she’s convinced it's still the best way to practice health care.

"We're used to dealing with lots of change and certainly the uncertainty now is a challenge," says Nevin. "But all of the work we are currently doing is work we need to be doing to (stay) focused on health and affordability."

The money has sure helped, though.

Christiana has seen a 20% drop in patients being readmitted after 30 days as part of its overall "bundled" payment plan for heart failure. For hip and knee replacement, readmissions are down 25% 30 days after they are released.

"Without the funding we got through CMMI, it's hard to imagine we’d be in the position we’re in today," says Nevin. "I would strongly urge that we keep the commitment to CMMI (because) you have to innovate to learn."

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In South Carolina, Greenville Health System's accountable care organization, MyHealth First Network, includes more than 2,000 providers across 11 counties. In 2015, the first year the network was part of a Medicare program that allowed it to share savings, it generated more than $17 million in savings and improved the care for nearly 60,000 Medicare patients, says Greenville spokeswoman Karen Potter. The hospital got about $8 million of that back.

Less than 20% of these doctor-hospital groups achieve savings in the first year.

Christiana and Greenville are among the hospitals - still in a minority - participating so much in “population health."

Even before the ACA, CMS was trying to reform how doctors and hospitals were paid in an attempt to emphasize quality over quantity, says health care consultant Rita Numerof. The law helped accelerate it, however.

"Most organizations don’t change unless they have to," says Numerof. "This is a mechanism to get real change in health care outcomes."

Population health overdue

Population health, which can involve a set number of patients in an area or with a certain condition, is "long overdue in this country," says Leah Binder, CEO of the Leapfrog Group, which rates hospitals on quality and safety.

Binder, whose group was started by employers and insurers hoping to bring health costs down, says the changes in how hospitals are paid drive the focus and she hopes it will accelerate in the Trump administration. The push, she says, "forced hospitals to think about what happens after patients are discharged."

"What ties this all together is the laser focus on the well being of the patient," says Binder, a former hospital administrator. "Even though that sounds like the most obvious thing in the world, that has never been business as usual in healthcare."

In a typical hospital, the 5% of patients with multiple chronic conditions make up about 50% of the cost, says Nevin.

Health IT company Caradigm helps hospitals figure out who their highest cost patients are and what will help those people most.

Often, it's a matter of figuring out why they keep going to the emergency room and may be as simple as the fact that they don't have a primary care doctor, says Corinne Stroum, who heads program management for healthcare analytics at Caradigm. These patients are health care's "super utilizers," she notes.

"You want to catch that before it becomes a concern," says Stroum.

A host of chronic conditions

Few have more chronic conditions than Anthony Tramonte. He developed Type 2 diabetes while in his 20s and it "attacked all of his organs," says Phyllis.  After spending 36 years working for the U.S. Postal Service, he started working for the armored car company Brinks and retired five years ago. It hasn't exactly been peaceful, but it's been better than it would have been without his care team, the couple says.

Christiana helps Phyllis "put things into order," she says. After hospitalizations, nurses come to their house to take his vital signs and let the doctor know if "something was out of whack," she adds. They make sure he's eating and taking his medications correctly given his conditions.

"If someone goes in for breathing issues and their inhaler is changed, if they leave the hospital and don't make that change, it's all for nothing," says Steeves.

These developments will lead many patients to be hearing more from their doctors and hospitals.

"It’s a fine line" how much contact is too much, acknowledges Caradigm CEO Neal Singh.

You can't be "constantly following up and nagging" patients or they'll tune you out altogether, he says.

Some can see a clear benefit.

Mandy Cutting, a registered nurse at the Greenville Health System in South Carolina, was working with patient Thomas Keffer, who has diabetes. Even though Keffer's doctor wanted to put him on insulin, he was reluctant because of the cost. So Cutting convinced the doctor to take him off some of his highest cost medications so he could afford the insulin. Thanks to the insulin, his health improved enough to allow him to come up another medication, says Greenville spokeswoman Potter.

It can be too much for some patients. Binder says the last straw for her with a former insurer was when they kept reminding her to get a mammogram every year while in her 40s. She knew federal guidelines recommended them for her age every two years and, given the possibility of alarming false positives, she didn't want to go more often. She told them to make a note of that.

"I felt like my privacy was being invaded," she says.

Done properly, however, Binder says payment reform programs that keep people current healthy "are very exciting."

Nevin agrees.

Population health increasingly will help hospitals save or make more money by keeping people healthy, which "creates this opportunity for the patients."

"But it's also an opportunity for the physicians because for many of us, that’s why we got into health care," she says.