To understand how the health-care system sometimes fails patients and often wastes money, consider the case of a South Florida nursing-home patient who developed a cough and slight fever.
“The nurse notifies the doctor, who doesn’t get much information and says, ‘Send her to the emergency room,'” recounts Joseph Ouslander, associate dean for geriatric programs at Florida Atlantic University. “She has tests in the emergency room, some of which are falsely positive, and is admitted unnecessarily to the hospital, where she gets acute confusion and breaks her hip.
“It happens every day: An episode that could have cost Medicare a couple hundred bucks turns into one that costs closer to $20,000. So you are creating human misery, and you’re spending money.”
Striving to avoid such calamities, Ouslander and other health-care leaders in Florida are developing innovative methods to care for many patients in the comfort of their homes or in nursing homes instead of sending them on costly and risky trips to the hospital.
An FAU program trains nurses and advises thousands of nursing homes across the country about ways to detect problems and treat patients without always resorting to the emergency room. Farther north, Orlando Health is using physician interventions, “tele-medicine” and even old-fashioned house calls to keep people out of hospitals.
These Florida initiatives are tackling one of the biggest problems facing Congress and the nation: how to provide quality care at lower cost without raising taxes or cutting benefits.
They are unfolding just as Congress and the Obama administration are looking for ways to restrain health costs that threaten to overwhelm government programs such as Medicare and Medicaid during a time of huge deficits.
U.S. Sen. Bill Nelson, D-Fla., new chairman of the Senate Committee on Aging, points to more efficient methods such as these as an alternative to proposals in Congress that would cut costs by privatizing Medicare through a voucher-like insurance system.
“Reducing hospital readmissions will not only save the Medicare program billions, it will save beneficiaries from potential infection and further out-of-pocket expense,” Nelson said at a recent committee hearing.
A long-running controversy over Medicare will heat up this week when House Budget Chairman Paul Ryan, R-Wis., unveils his latest budget framework. He is expected to revive a plan that would give Americans now 54 and younger fixed “premium support” money to buy private insurance once they become eligible for Medicare rather than provide open-ended coverage as now.
Ryan and fellow Republicans note that Medicare’s Part A hospital coverage is projected to run short of money by 2024 unless Congress cuts costs.
Nelson’s Aging Committee is exploring other options, including more reliance on home health care and moving away from the traditional fee-for-service system that rewards doctors for the number of procedures ordered.
More efficient delivery of health care would save $2 trillion over 10 years — $1 trillion of it spent by the federal government, including $761 billion by Medicare — according to The Commonwealth Fund, a respected research group, which presented its findings to the Aging Committee.
Nelson plans to raise these findings and point to a range of cost-cutting options in the coming budget debate while trying to fend off voucher-like proposals that would reduce Medicare benefits.
One example is a program developed by Ouslander at FAU called INTERACT, which already is used in nursing homes here and abroad and soon will be adapted for patients at home and in assisted-living communities.
“We have a great opportunity now to improve care for a growing number of people who are going to live until extreme age, prevent complications and unnecessary expenditures,” Ouslander said. “We’re saving billions of dollars and giving better care.”
The program trains nurses to better detect health problems, communicate with doctors and treat patients in some cases without sending them to hospitals. Ouslander also encourages more end-of-life care at patient homes or hospice centers.
An INTERACT pilot project at 25 nursing homes in Florida, Massachusetts and New York cut the rate of hospital admissions by 17 percent, FAU reported.
Orlando Health, meanwhile, is exploring ways to keep patients from returning to the hospital, spurred in part by being penalized under the Affordable Care Act for a relatively high hospital-readmission rate.
Patients now leave Orlando Health hospitals with a 30-day supply of medicine and a follow-up doctor’s appointment within five to seven days. Patients also get advice about diet and medication and are asked about financial needs.
“Somebody who doesn’t have enough money may be taking a half dose of blood-pressure medicine that puts them back in the hospital,” said David Sylvester, who oversees post-acute services at Orlando Health. “Or a patient may think a can of soup is a healthy meal but wakes up the next morning after gaining 3 pounds because of all the sodium in the soup and goes back into congestive heart failure.”
An experimental program at Orlando Health allows patients to stay at home, push a button on a control box, stand on a scale and send information such as weight and blood pressure to a nursing station miles away to detect early signs of heart failure. And a House Calls program that sends doctors into homes is serving about 200 patents a year.
The result: a 15 percent reduction in hospital readmissions during the past two years, Sylvester said.
Starting in June, Orlando Health plans to add a “hospital at home” service in which home-health nurses and patients consult with doctors via videoconference to devise treatment plans without a trip to the hospital.
“People are more comfortable, their loved ones are around, and it’s much less expensive because you don’t have the capital costs of a hospital,” Sylvester said.
“The demand will continue to grow,” he predicted. “We as baby boomers have a little higher expectation for our health care, and I think we will continue to focus on having people treated in the least restrictive, most cost effective, safe environment.”