Happy New Year and welcome to a once-in-a-decade opportunity to promote the growth of Medical Family Therapy. On January 1, new Medicare rules for hospital payments took effect and are a veritable game-changer.
In the past, if a 70-year-old man was admitted to a hospital with, say, a COPD exacerbation, he'd be pumped full of steroids and given breathing treatments for 3 days and then sent home; the hospital would be paid by Medicare for those 3 days of intensive care. If, once home, the guy started smoking heavily again and then suffered another COPD exacerbation a week later, he'd be readmitted to the hospital—jocularly called a "bounce-back”--and the hospital would again be paid by Medicare for another 3 days of care. The guy could keep going in and out of the hospital and the hospital could keep reaping the profits from its ultimately futile treatments for up to 100 days a year that the gentleman was hospitalized.
No longer. Under the new regulations, hospitals will not be paid by Medicare for patient re-admissions within 30 days of hospital discharge. That means the hospital will be paid for the first admission for our 70-year-old smoker but for none of the re-admissions thereafter if the guy bounces back too quickly. In other words, hospitals will have to eat the cost of the care it provides—the steroids, the breathing treatments, the food, the linens, etc.--during those bounce-backs. Medicare will no longer incentivize hospitals to provide inadequate care that doesn't keep patients out of hospitals.
This has spooked hospital administrators. Nearly every VP of Clinical Integration in the country is now scrambling to find ways to decrease hospital bounce-backs and thereby save their institutions money. They are looking at "care transitions”—i.e., how to make sure patients follow up with their primary care doctors, get the proper medications, and receive necessary home-based services. They are also turning their attention to something we know is obvious—the conditions in patients' home environments that affect their health.
Here's MedFT's golden opportunity. We have the know-how and techniques to understand the impact that patients' family members have, for example, on treatment compliance and to foster good health habits to keep patients ensconced at home.
For instance, please take a look at this presentation by Carol Levine, MA, a MacArthur Award-winning ethicist, director of the Families and Health Care Project of the United Hospital Fund of New York, and a major figure in the family caregiving movement (as well as a former CFHA conference plenary speaker)-- http://www.uhfnyc.org/publications/880807?tr=y&auid=10030107. The presentation, given during October 2011 at the National Health Policy Forum in Washington, DC, has a simple premise: If we better support all family caregivers in their work with chronically ill patients, then they will keep those patients from being re-hospitalied.
Then consider combining this approach with that of the "hot spotter” or "super-utilizer” emphasis propoundeded by Jeff Brenner, MD, a family physician and plenary speaker at the CFHA Philadelphia conference in 2011. Dr. Brenner has been highly successful using data to identify those patients within Camden, NJ who have the highest health cost expenditures and then lowering their hospital and emergency room usage by providing them with team-based primary care instead. For an eloquent description of Dr. Brenner's work, see this New Yorker magazine profile--http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande
At the Crozer-Keystone Health System in suburban Philadelphia where I work, we are now trying to decrease hospital bounce-backs by using a "super-utilizer” approach that focuses on family factors. For example, we identified a brittle diabetic man who was hospitalized 20 times in 12 months for diabetic complications, creating hospital bills in excess of $500,000. What simple method worked to decrease his rate of hospital re-admissions? We engaged the man's wife and convinced her to provide greater supervision for his diabetic regimen. To cite another example, a middle-aged, somaticizing woman who was frequently hospitalized for syncope ran up hospital and ER bills of over $700,000 over a 5-year period. What changed this pattern for her? We engaged her husband to help us convince the patient that her symptoms were more stress-related than neurologically based.
Money always talks. Under the new Medicare rules, hospitals will quickly get out of the revolving-door, bounce-back business. Working effectively with patients' families will be the key. We hold that key.
Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and the author of the book, The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. He is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springrfield, PA and has had adjunct faculty positions with the Temple University School of Medicine, University of Pennsylvania School of Nursing and the Institute for Clinical Psychology of Widener University. He is on the board of directors of the Collaborative Family Healthcare Association. He lives with his wife and two children in Swarthmore, PA and maintains a website—www.emotionalsurvivalguide.com.