If We Had 2020 Vision, What Would Nursing Homes Look Like?

Futurism is all the rage: worn down by the relentless drumbeat of Coronavirus hospitalizations and deaths, the mind-numbing unemployment statistics, and the unimaginable reality of parents trying to work while home-schooling their children, we are beginning to think about life-after-the-epidemic. Will movie theaters survive? Restaurants? What about orchestras and theater companies? Will doctors and researchers fly across the country and even across the ocean to attend conferences? Will anyone ever go on a cruise again? The answers to these questions have implications for how we will live our lives, for the environment, for the economy…the list goes on and on. But today’s NY Times speculates about another possible casualty of the COVID-19 outbreak, nursing homes. Battered by an acute rise in costs together with a precipitous decline in revenue as admissions fall, and shattered by their new reputation as a “petri dish for the worst pandemic in generations,” America’s nursing homes risk going under.

The US currently has roughly 15,400 nursing facilities which house 1.5 million of the oldest, frailest, most vulnerable people in the country. The Centers for Medicare and Medicaid (CMS) calls these facilities skilled nursing facilities; most of the rest of us refer to them as nursing homes. To confuse matters, the majority of these skilled nursing facilities (referred to as SNFs and pronounced “sniffs”) also provide care to another 1.5 million Medicare beneficiaries who are admitted for a short period, typically a few weeks, following an acute hospital stay. They are transferred from the acute hospital for rehabilitation or to complete a course of medical treatment prior to returning home. 

Skilled nursing facilities are paid by Medicare for short-term “post-acute care;” they are paid by Medicaid or privately, by the residents themselves, for long-term residential care. And while the subacute part of the business is profitable—according to the MedPAC (Medicare Payment Advisory Commission) “Report to Congress” just published last month, profit margins are 18 percent—the long-term residential component is not. Profit margins in the residential component are non-existent, with the latest, 2018 figures averaging negative 3 percent. Residential, long-term care SNFS were financially precarious before the COVID-19 epidemic. So, it is not surprising that they are faring especially poorly during the epidemic.

             
While the major toll, as the NY Times has reported, is the 7000 deaths among a total of 36,500 nursing home residents diagnosed with COVID-19, there has been a huge financial hit as well. One non-profit chain in Minnesota reported that the average 72-bed nursing home has been spending an extra $1922 per day on personal protective equipment for staff members and another $1500 per day for extra staff to care for residents who are in isolation or who are substituting for staff who are out sick. At the same time, revenue is down because facilities cannot fill their empty beds. Nursing homes have large fixed costs to cover salaries for staff, mortgage payments, food, and equipment. What they don’t have is much reserve. 

In light of these statistics, what will nursing homes do? What will happen to the 1.5 million Americans, who live in these facilities today? One way to imagine the future is by looking at the past. And it turns out that once before, in the not too distant past, the nursing home industry experienced a great contraction.

A funny thing happened in the late 1970s and early 1980s. Despite decades of growth of the elderly population and dire predictions about imminent shortages of nursing home beds, the demand for nursing homes fell. It fell because the baby boomers read books like “Tender Loving Greed” by Mary Adelaide (1974) and “Why Survive? Growing Old in America” by Robert Butler (1975) and concluded they didn’t ever want to go into a nursing home. Not only that, but they didn’t want to see their parents enter a nursing home. In response to the growing demand to stay at home and “age in place,” Medicare expanded its home health benefits: federal legislation in 1980 (the Omnibus Budget Reconciliation Act, known as OBRA 1980) relaxed prevailing restrictions on the ability of Medicare patients to receive nursing, physical therapy, occupational therapy, and other services in their homes. 

Then, in the mid-1980s, a new kid arrived on the block. Touted as promoting dignity and fostering independence, the new institution, which came to be called assisted living, was supposed to keep older people out of nursing homes by offering them the help they needed in the privacy of their own apartment. Between 1991 and 1999, the number of such facilities increased by 49 percent. Between 1998 and 2003, the number increased another 48 percent. Fortune Magazine reported that assisted living was a leading growth industry and that Wall Street investors were falling all over each other to get a piece of the action.

As assisted living and home care grew in popularity, the demand for nursing home care fell, relative to the population. That is, the absolute number of nursing home beds continued to increase, reflecting the growth of the older population in general and of the population over 80 in particular. But by 1980, the number of nursing home beds per person over 65 had begun to fall. A study published in 1985 projected the elderly nursing home population would rise from 1.2 million in 1980 to 1.9 million in 1995 and to 2.8 million in 2020. But here it is 2020 and the number of older people in nursing homes is back down to 1.2 million—the same level as 35 years ago.

Did nursing homes close in response to the fall in demand in the 1980s and 1990s? Some did. But many simply retooled. At just about the same time that assisted living began replacing nursing home care for many older individuals, Medicare made a dramatic change in the way hospital care was paid for, a change that would have an equally dramatic impact on nursing homes. What happened is that Congress passed legislation requiring that Medicare bill for hospital care using prospective payment. Accordingly, Medicare introduced the concept of “diagnosis related groups” in 1983, essentially paying a flat fee to hospitals for a given medical problem, say a heart attack or a broken hip, rather than reimbursing hospitals on a per diem basis. 

The implications of this payment model were immediately apparent to hospitals: since the rates assumed an average length of stay for a given diagnosis, any hospital that discharged patients sooner than the average made a profit and any hospital that discharged patients later than average sustained a loss. The incentive to discharge patients “quicker and sicker” was clear. How to do this with older patients, many of whom were weak and debilitated after their acute problem had been addressed, was less clear. 

Enter the skilled nursing facility, aka the nursing home. A little used proviso in the original 1965 Medicare legislation provided for “post-hospital extended care” in a “qualified facility having an arrangement with a hospital for the timely transfer of patients.” When acute care hospitals looked around for a place to which they could send patients (usually older patients) who were well enough to leave the hospital but not well enough to go home, they seized on this clause. Suddenly they saw nursing homes in a new light. Here were medical facilities that provided round the clock nursing care, room and board, and were accustomed to caring for older people. And those nursing homes had empty beds. 

Not only did nursing homes have empty beds but, as they soon learned, they would be reimbursed much more generously by Medicare if they used the beds for “rehabilitative” or “post-acute care” than they would be by Medicaid if they used them for long term care. On average, Medicare today pays $503 per patient per day for SNF care whereas, on average, Medicaid pays $206 per person per day for residential care.  As a result, use of the short-term skilled nursing benefit soared, going from minimal utilization in the 1980s to 2.2 million admissions in 2018, at a cost to Medicare of $28.5 billion. Not surprisingly, almost all skilled nursing facilities now accept short-term patients. A few take short-term patients only. 

So, what can this slice of history teach us about the predicament of nursing homes today? First, odds are that some nursing homes will close. Many of those that close will already have been operating at less than 100 percent capacity before the COVID-19 epidemic. Some will be temporarily bailed out by the large corporations of which they are a part, health care conglomerates that have other revenue streams. But the for-profit owners—and 70 percent of nursing homes are for-profit—will not want to borrow from Peter to pay Paul very long. They will seek to unload the failing parts of their empire as soon as possible. 

Other nursing homes will probably remake themselves. Just as their predecessors moved into the post-acute business from the strictly residential, long-term care business, today’s nursing homes may decide that the money is in the health care sector and not the residential sector. They might build on their “subacute” units—the parts of the skilled nursing facility that provide short-term care are typically physically separate from the remainder of the institution, expanding them and developing new capabilities. It would be a short leap to becoming a low-tech hospital, equipped to care for simple problems that are nonetheless too complex for patients to manage at home, such as relatively mild cases of pneumonia or kidney infections. Just as community hospitals provide some but not all of the services offered by large, tertiary care hospitals and transfer patients from one site to another if additional technologies are required, so too could skilled nursing facilities provide some but not all of the services offered by community hospitals. These new health care entities could be branded “infirmaries” or perhaps even “geriatric hospitals.” 

Acute care hospitals will in all likelihood be happy to see frail, elderly patients admitted to such facilities. They were desperate for an alternative site of care during the COVID-19 outbreak, either to house COVID-19 patients who did not require an ICU or to house hospitalized patients who had problems other than COVID-19. In the pre-COVID-19 era, they lost money on such patients because they often developed complications—falls, adverse drug reactions, acute confusion—that prolonged their hospital stay. 

What about the patients themselves? Where will they go if their nursing home goes bankrupt? After the dismal performance of the country’s nursing homes during the COVID-19 outbreak, some of which was preventable and some of which may well not have been, nursing home residents and their families will be very interested in moving to a different site of care. This will be challenging since today’s nursing home population is tremendously needy.

According to the most recent data, 41 percent of nursing home residents are dependent in four very basic daily activities such as bathing, dressing, or feeding themselves. Another 22 percent are dependent in five or more basic daily activities. In addition, cognitive impairment is widespread in nursing homes, with 24 percent of residents diagnosed with moderate cognitive impairment and 37 percent with severe cognitive impairment—where “severe” means profound limitations in communication and mobility and total dependence on others for personal care. Nonetheless, some nursing home residents will move to assisted living complexes. These facilities, which over time have come to serve an increasingly impaired population, will need to adapt to a still needier clientele. 

Other nursing home residents will move to the surviving conventional nursing homes, where they and their relatives will apply pressure to develop models of care that are fiscally sustainable and, at the same time, focus on supporting those capabilities that remain as well as compensating for those that have been lost. 

Change is often difficult and transitional periods are often marred by missteps. But if we learn from past mistakes and if we focus on what’s best for the oldest and the frailest among us, the almost inevitable shake up in the nursing home industry just may prove to be a good thing.

The Nurse Will See You Now

           

          Articles in medical journals tend to pay scant attention to the role of nurses in treating illness—or for that matter, to the role of social workers, physical therapists, and many other clinicians. Hence, when JAMA, one of the major American general medical journals, published an article in 2002 entitled, “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” it was a bombshell. The lead author, Linda Aiken, is a nurse researcher at the University of Pennsylvania where she is a Professor of Sociology and the founding director of the Center for Health Outcomes and Policy Research. Looking at survey data from 10,000 nurses and administrative data on nearly 250,000 medical and surgical patients hospitalized in Pennsylvania in 1998-1999, she drew some dramatic conclusions: each additional patient per nurse was associated with a 7 percent increase in the likelihood of dying within 30 days of hospitalization, and each additional patient per nurse was associated with a 23 percent increase in the odds of “burnout” and a 15 percent increase in nursing job dissatisfaction. 

          Aiken's analysis, along with other smaller studies, have led to calls for an increase in the nurse to patient staffing ratios in hospitals. In light of general hospital administrative reluctance to make such increases, many nurses have demanded and some state legislatures have proposed mandatory increases in nurse to patient ratios. Massachusetts voters are being asked to vote this November on a referendum that would establish mandatory staffing ratios. To date, the only state to have instituted such a requirement is California—which passed legislation in 1999, before Aiken’s landmark study. California’s experience offers an unparalleled opportunity to ask whether mandatory ratios result in the desired improvements in quality of care and whether they produce a variety of unintended consequences. In principle, it could also shed light on whether nurse to patient ratios are particularly important for older people.

            California’s law specifies different nurse to patient ratios for intensive care units, surgical units, and medical units. Compliance was at first uneven, but gradually hospitals conformed to the requirements. Several studies have attempted to assess the outcomes. They are limited because California did not conduct a randomized, controlled experiment before passing its legislation—it did not impose mandatory minimum ratios on some hospitals and not on others. Moreover, nursing staff ratios are hardly the only factor affecting outcomes that changed in the early years of the mandate: many other federal quality improvement initiatives were undertaken to encourage hospitals to prevent pressure ulcers, falls, catheter-related infections and other major hazards of hospitalization. Hospitals have also experienced major financial pressures: the cost of hiring nurses was only one of many economic challenges. Determining cause and effect is not easy. Nearly twenty years later, what do we know?

            First and foremost, did the mandatory ratios result in improved quality of care? One of the most carefully performed studies was undertaken by the California Health Care Foundation, part of UCSF, in 2009. This report looked at pressure ulcers, pneumonia deaths, and deaths from sepsis (blood-borne infection) and were unable to find any statistically significant change after the law was implemented in 2004 (following a multi-year study period to design the regulations). Another study that focused exclusively on pressure ulcers and falls used data from CalNOC, a large nursing database for the entire state, to conclude there was no change in fall rates. They did note a paradoxical increase in pressure ulcers in patients admitted to “step-down” units, units between an ICU and a general medical or surgical floor in the acuity of their patients, after the requirement of more nurses per patient was introduced (presumably a reflection of sicker patients). A systematic review of the literature, published in the Annals of Internal Medicine in 2013, failed to find any statistically significant effect on a variety of safety measures. Of note, none of the studies I identified looked at either patient or nursing satisfaction.

            If mandatory nurse to patient ratios did result in more face-time with patients but no demonstrable improvement in overall quality of care, might older patients nonetheless be one subgroup that did benefit?  All we can say is that many of the quality measures that were examined—pressure ulcers and falls, for example—are particularly relevant to older people. 

            What about the feared adverse consequences of imposing rigid nursing staff ratios? An analysis in Health Affairs in 2011 found no evidence that hospitals were substituting less well-qualified staff (who still meet the legal requirements) such as LPNs for registered nurses. The California Health Care Foundation did conclude that hospitals were increasingly relying on “travel nurses,” (nurses from out of state or from other countries, hired for short periods of time) and on “float nurses” to move from floor to floor to compensate for lunch breaks by the regular staff. Such changes may result in less continuity of nursing care for patients. They also showed that hospitals across the state experienced shrinking operating margins beginning in 2002, especially in the hospitals that were initially fiscally strongest. However, they emphasize that many other factors could account for this phenomenon. Hospitals of all types did comply with the law, resulting in more hours of nursing care for each patient every day:

          On balance, regulating nurse to patient staff ratios in isolation is not likely to make much of a difference in patient outcomes, nor is it likely to devastate hospitals' finances. Hospitals are complex institutions with many interrelated parts. Just because hospitals with low nurse to patient staffing ratios tend to have poorer outcomes than other hospitals does not mean that if we "fix" the ratio, care will necessarily improve. Assuring that there are enough nurses to provide good care is essential, but that step alone is unlikely to dramatically improve the hospital experience.

             

            

  

Where Do All the Dollars Go?

The editor-in-chief of one of my favorite health news sources, Kaiser Health News, recently published her first book—for over twenty years she has been a journalist at the New York Times—and it’s an important one. An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, by Elisabeth Rosenthal, is a powerful if somewhat monotonous recounting of the evils of American health care. But it only seeks to explain one weakness of contemporary American medicine, albeit an important one: it costs too much. Or, more accurately, prices are too high. As Uwe Reinhardt put it years ago, “it’s the prices, stupid.” 

Understanding the behavior of physicians, hospitals, drug companies, health insurers, and device manufacturers, as this book seeks to do, is critical if we are to change the system. The problem that they create, however, isn’t just that health care costs consumers too much; it’s also that the quality lags behind what is achievable—is evidenced by the poor standing of the US compared to other developed countries. Failing to consider both quality and cost is regrettable—we might, after all, be willing to tolerate the enrichment of drug company shareholders if what we got in return was an excellent, if pricey, product.

The litany of shenanigans by big business may be familiar to many readers, but Rosenthal's comprehensive and detailed accounting is impressive and compelling. Consider the first chapter on “the age of insurance.” The book recounts the story of how the same treatment costs orders of magnitude more--$100,000 vs $19,000 per medication infusion for a drug given monthly—when administered at NYU’s Langone Medical Center than when provided at another nearby facility. For the patient, whose treatment was covered by insurance, it didn’t much matter over the short run. But for the system as a whole, and ultimately for all patients through higher insurance premiums, it did matter. And the reason for the discrepancy is that NYU negotiated a better deal with third party payers than did the competition. What Rosenthal outlines but does not emphasize is that more powerful hospital systems and physician researchers interact with (some might say collude with) health insurance companies to produce this result. She explains that because of an arrangement with the NYU researcher who was largely responsible for creating the drug, NYU derived profit if total sales of the drug exceed a particular threshold. By negotiating a very high payment for the drug from the insurer, NYU is likely to exceed the threshold and cash in. So it’s not just the motivations of physicians, hospitals, and insurance companies acting separately that impact the health care system; it’s the way all of these forces work together that is crucial to achieving the end result.

Rosenthal presents one disturbing case after another. There’s the way hospitals and physicians game the system to assure that patients essentially have to use out-of-network providers when their insurance company will only cover in-network providers, forcing patients to shoulder what can be enormous costs. There’s the notorious “facility fee” that enables hospitals to charge insurers vastly more for a simple procedure such as injecting anti-inflammatory medication into a joint if it is done in an outpatient clinic than if it is done in a private office. What she neglects to explain is the way the system conspires to provide what is often inferior medical care to patients. Maybe this is more egregious with older patients than younger ones, and her focus is overwhelmingly people who aren’t enrolled in Medicare: either those with private insurance or no insurance at all. The facility fee example, for instance, doesn’t just mean higher costs. For a frail older person to get to a hospital clinic may mean going by car, negotiating a confusing parking garage, and walking a considerable distance from the garage to the office, none of which is so easy if you’re 85, have severe arthritis (the reason for going for the joint injection in the first place), and maybe have a little cognitive impairment to boot. The enthusiasm for high tech procedures, driven in part by the manufacturers of the devices used in the procedures, doesn’t merely drive up costs: for vulnerable, older individuals, such technological intervention may cause more harm than good. The anesthesia may result in confusion and the hospital stay in functional decline—quite apart from the effect on the cost of medical care.

Alas, the fixes the author proposes, the part of the book devoted to taking "health care back" from big business, aren’t going to fix the system. She calls for creative insurance plan design, for example plans that cover “essential” treatment fully and levy co-pays for “semi-elective” treatment. That’s much like what the ACA does when it requires full coverage for preventive services such as a screening colonoscopy, but allows the same colonoscopy to be billed in full (if the patient has a high deductible health plan) if the procedure is ordered to remove a cancerous polyp. Maybe that’s a good idea, although it leads to some bizarre incentives—better to get that polyp removed at the end of the plan year, when you might already have burned through your deductible, than at the beginning of the year, when the growth might be more curable; better to say nothing to your doctor about the blood you’ve noticed in your stools and just have a “screening test” than to mention the blood and undergo the procedure to treat a “disease.” But whether or not “benefit redesign” is a good idea—and one of the last major benefit redesign ideas wasn't so thrilling, it was those very high deductible health plans that are conquering the market—it’s not going to help patients now. Even the suggestions that could, in principle, help right away, such as “demanding price transparency” when getting an MRI, are a bit pie-in-the sky. You’re in the doctor’s office and s/he wants you to get a scan right away. You’re supposed to get a list of 5 centers that do MRIs and compare their prices? Really? What about quality? What about accessibility of the image to your physician? What about transportation to these other sites?

An American Sickness goes a long way to uncovering the workings of the health system and for that it is to be lauded. It is extensively and for the most part carefully researched, though there are errors. Rosenthal says pharmacists should be able to prescribe birth control pills because they all have PhDs and shouldn’t just be relegated to counting pills. Maybe they should be able to prescribe birth control pills, but most pharmacists have a BPharm (a bachelor’s degree), not a PhD. She says the website GoodRx allows comparison of prices for prescription drugs only for Medicare patients. Maybe that was once true, but it is no longer. But read this book for the insight it may give you on how the design of the system affects outcomes. We will need to build on that scaffolding to investigate the full range of systemic consequences—for quality as well as cost of health care, and to engage in meaningful reform.

-->

Falling Down on the Job

In the sixties, physicians routinely prescribed bed rest for patients who had suffered a heart attack. Then along came the recognition that bed rest led to clot formation in the lower extremities, clots that sometimes broke off and traveled to the lungs, causing potentially life-threatening pulmonary emboli. Bed rest also led to deconditioning—when patients finally were allowed to get up, they found they were often weak and wobbly. And so bed rest was out and early mobilization was in. But now, concurrent with a vigorous attempt to prevent falls among older hospitalized patients, bed rest is back in—and with more complications than ever, as reported in a thoughtful article in JAMA Internal Medicine last week.

In 2008, in response to the observation that “injurious falls” were responsible for increased hospital costs and were clearly bad for patients, the Centers for Medicare and Medicaid Services introduced a program incentivizing hospitals to prevent falls. Currently, a fall resulting in significant injury (such as a fracture) is one of eight hospital-acquired conditions that collectively determine whether hospitals will be penalized for poor performance. To address the CMS initiative, hospitals introduced a variety of techniques designed to keep older patients from falling such as bed alarms and “fall risk” signs on the door. According to Growdon and colleagues, the result has been a “national epidemic of immobility among hospitalized older adults.”

Paradoxically, the means used by hospitals to prevent falls don’t work. Bed (and chair) alarms are ineffective—which is not entirely surprising, as by the time a nurse responds to the buzzer indicating the patient has gotten out of bed (or chair), the person is probably already on the floor. Even a multi-prong study from Australia using a variety of different approaches simultaneously was unsuccessful.

But all those bed alarms and signs on the door do achieve something, and that’s to keep patients at bed rest. And just as bed rest was bad for heart attack patients in the sixties, it’s bad for older patients today. Bed rest promotes the development of confusion (delirium) and worsens mobility, so when patients finally do get out of bed, either late in their hospital stay or after they get home, they are more likely to fall.

Growdon, a resident in internal medicine at a major Boston teaching hospital, and his colleagues at a VA Hospital in Florida and at Hebrew Senior Life, a teaching nursing home, are rightfully indignant. They advocate promoting mobility rather than penalizing falls, arguing that “although hospital falls can lead to harm, treating them as ‘never events’ has led to over implementation of measures with little efficacy for falls [prevention] yet profound contribution to immobility.” They are, no doubt, correct. But why? Why should an incentive program based on outcomes lead to the adoption of a strategy that does not lead to the desired outcome?

If CMS had used a process measure, if it had offered extra payments to hospitals that introduced fall prevention programs, I wouldn't have been surprised that it resulted in hospitals adopting programs for the sake of having something, regardless of efficacy. But instead it opted to penalize hospitals for performing poorly, which should by rights have led to hospitals choosing to take steps that made a difference. What is it about the culture of hospitals or the leadership of hospital CEOs or the knowledge base of physicians and nurses that lets them make such irrational choices?

I wish I knew the answer. In the meantime, perhaps CMS would do well to offer carrots rather than sticks, and to be specific about the kind of carrots that it likes the most. If programs that promote mobility work, directives to get patients out of bed early and to consult physical therapy—both to prevent falls and to maintain function—then it’s those specific programs it should endorse and pay for.

--> -->

The Emperor Has No Clothes

I’ve been studying Medicare’s new Hospital Compare website. Lots of people have complained about this particular ranking, which gives only 102 hospitals in the country five stars, some of them fairly obscure institutions. I’ve argued in the past that rankings are often misleading, that institutions try to game the system, and that they are often based on measuring the wrong things. But I was curious about how Boston area hospitals, hospitals that I’m familiar with, actually performed. I was particularly interested in how they compared to other hospitals in the country in those domains that Medicare chose to examine. The bottom line is that they didn’t do very well.

Not a single hospital earned five stars. The only major teaching hospital to earn four stars was Massachusetts General Hospital (MGH). And I was curious about its weaknesses: CMS reports two, in readmissions rates and in the timeliness of care. Now I’ve suggested that there may be an irreducible minimum readmission rate—the frailest, sickest patients are going to get sick again, no matter what kind of care they get either in the hospital or after they return home. The only way they aren’t going to be readmitted is if they are offered, and agree to, care exclusively at home (for example, home hospice). And unless we provide more ways that the frailest and sickest can get care at home (aside from hospice, for which not all will be eligible and not all those who are eligible will elect), and unless we discuss their goals of care and how best to achieve them, they are going to return to the hospital when they get sick again. Which they will. But it’s nonetheless striking that MGH—and every single other major teaching hospital in Boston—did worse than the national average in readmissions. That's not a problem with hitting an irreducible minimum. That's a problem achieving the achievable.

MGH’s other Achilles heel, timeliness of care, was also a problem for all the other leading Boston hospitals. Both these deficiencies suggest that the hospitals are not doing a good job of working with primary care doctors and community agencies to coordinate care, to make sure that whatever needs to get done is in fact done. That's a problem for geriatric care.

The other two principal teaching hospitals of Harvard Medical School, the Beth Israel Deaconess Medical Center (BIDMC) and the Brigham and Women’s Hospital (BWH), only managed to get three stars each. In addition to problems with readmissions and timeliness of care, they had assorted other difficulties. BIDMC’s “effectiveness” was on par with the national average, but no better. It did not demonstrate the efficient use of medical imaging. And BWH was below the national average in effectiveness and in safety. That’s disturbing.

The major teaching hospital of Boston University, the Boston Medical Center, also got three stars. It was the only large hospital that did worse than the national average in the domain of the "patient's experience," or how patients rated their stay. The principal teaching hospital of Tufts University, New England Medical Center, only got two stars, with problems in safety, readmissions, timeliness of care, and the efficient use of imaging. Not very impressive.

Two community hospitals, Faulkner and Newton Wellesley (both in the Partners orbit, the hospital system that owns MGH and BWH) got four stars. This result is a bit perplexing as Newton Wellesley, for example, was actually at (not above) the national average in safety, readmission, effectiveness of care and efficient use of imaging, and below the national average in timeliness. Evidently a bunch of B’s and only one C is deemed worse than a bunch of A’s and two C’s. The process of lumping all these measures together to get one final grade seems to me to lead to a misleading conclusion.

So I still don’t think it’s reasonable to conclude very much from the conglomeration that goes into coming up with a single rating. But I do think that observing that every single hospital in the Boston area was below the national average in at least one area and most of them, including the most prestigious institutions, were below the national average in several, is sobering. The areas Medicare chose to focus on are important for quality. There is no good reason for Boston institutions to have more difficulty with any of these measures than the national average. Boston, shape up!

The most interesting article I came upon this past week dealing with an issue of great importance to older people wasn’t in JAMA or the New England Journal of Medicine and it wasn’t a report from the Institute of Medicine or from the Henry J. Kaiser Foundation. It was in the Wall Street Journal.

The article reported that beginning April 1, Medicare is embarking on a brave new experiment: it is “bundling” payment for patients getting a knee or hip replaced. MedPAC, the independent, agency that advises Congress on how to improve Medicare, has long advocated reforming the way Medicare pays for surgical procedures. And the CMS Innovation Center has funded a variety of projects testing the ability of bundling payments to improve care. But now, for the first time, proposals and theories affecting nearly half a million patients are being put into practice.

Actually, it’s not half a million patients right away. Only hospitals in the 67 metropolitan areas randomly selected by CMS will be affected—New York and Los Angeles won the lottery—hospitals that perform about one-third of all hip and knee replacement surgeries in Medicare enrollees. And calling the new payment mechanism “bundling” isn’t entirely accurate either: Medicare isn’t giving out a single lump sum for all aspects of care and telling orthopedists, hospitals, radiologists, and rehab facilities to divide it up however they see fit. What it’s doing instead is to pay everyone the way they usually do—hospitals get a single DRG (diagnosis-related group) payment, SNFs get paid a prospectively determined amount each day the patient is in the SNF, and physicians are paid on a fee-for-service basis. But if the total amount that Medicare ends up distributing over a 90-day period exceeds a target figure, the hospital has to pay back the excess. And if the total amount is less than the target, the hospital gets the difference. In short, rather than truly sharing the risk—or, from a clinical perspective, the responsibility—for care, the burden of ensuring that everyone provides optimal care rests solely on the hospital.

Now I think it’s a good idea for hospitals, rehabs, and doctors to work together—and for that matter, physical therapists and free-standing labs and radiology units as well—but I’m not convinced that placing the responsibility exclusively at the hospital’s doorstep is wise. It’s essentially the same approach taken by Medicare to the problem of hospital readmissions—of patients being discharged, only to come back to the same hospital, sometimes for the same problem, in less than a month. Medicare has instituted a system of penalties to hospitals whose readmission rates exceed a given threshold. As a result, the majority of hospitals were penalized for their readmission rates in 2015, some losing as much as 3 percent of their Medicare reimbursement. In a number of states, including New York and Massachusetts, three-quarters or more of the hospitals were hit with penalties.

The problem in both cases, the readmissions and payment for joint replacement surgery, is twofold: hospitals do not have control over all aspects of the patients care, and sometimes things go wrong that couldn’t have been prevented, no matter how much control the hospital exercised. Many Medicare enrollees are very old and very frail—these patients are likely to get sick again even if they are discharged from the hospital with follow-up arranged and their medications reviewed and a nurse visit scheduled the day after they get home, all the ingredients of a good “transitional care plan.” These same patients are likely to benefit from a stay in a skilled nursing facility or a rehabilitation hospital after they’ve had a joint replaced, strategies that cost more than sending them home with a few visits by a physical therapist and a nurse or a printout of exercises to do at home.

In the case of the new bundled payments for orthopedic procedures, the hospitals might respond by making sure that their patients only go to the very best skilled nursing facilities where they manage to restore them to perfect functioning in a matter of days or else go directly home, where they get the very best Visiting Nurse service that supplies the very best physical therapist who likewise can restore them to perfect functioning after just a few visits. But I worry that the hospitals might try to cherry pick patients—only accepting for surgery those people who are eighty-going-on-sixty and will do just fine at home with no services at all. I worry that hospitals will despair of their ability to control anything that goes on in a nursing home or home health agency and will opt instead to buy them up, leading to further consolidation within the hospital industry—and bigger isn’t always better for patients. And I worry that in the unlikely event that the system works, that care improves and costs go down, hospitals will have simply robbed Peter to pay Paul: they will achieve improvements in the domain of hip and knee surgery at the expense of care in the arena of abdominal surgery or stroke care.

I do think that older patients benefit from coordinated care. They win if their orthopedists at the hospital talk to the attending physician at the skilled nursing facility. They win if the details of their hospital stay are available electronically to the staff at the rehab facility. They win if hospitals, SNFs, and home care agencies work together. Let’s hope that Medicare’s experiment achieves that result.

The Sound of Music

From a mathematical perspective, adding and subtracting are equivalent:  with addition, you perform an operation on two positive numbers; with substraction, you perform the same operation on one positive and one negative number. In medicine, by contrast, addition and subtraction couldn’t be more different. Introducing another drug or another procedure is considerably easier than discontinuing a long-standing practice, even when there is mounting evidence that the practice is not beneficial, perhaps even harmful. One way to wean patients and doctors from an established treatment is to substitute a different, more effective or safer treatment. It’s a lot easier to change behavior if you can offer a new, improved treatment rather than just asking people to forgo something that they believe must be helping them. So clinicians ought to be very enthusiastic about the strong evidence supporting the use of music to aid in postoperative recovery, as shown in a systematic review and meta-analysis recent published in the British journal, the Lancet.

Taking all available studies of the utility of music into consideration, the authors conclude that playing music before and/or after an operation decreases the amount of pain medication patients take, it decreases their degree of pain, and it lessens their anxiety. That means opioid medications, currently in the news because of the epidemic of overdose deaths from these drugs, can be given in lower doses, for shorter periods of time, or potentially not at all. Ditto for anti-anxiety medications, which have been associated with increased confusion, increased falls, and other problems in older people.

This is a rare instance where we should go ahead and change the way we practice medicine without demanding additional studies, better studies, or more definitive studies. Here's an intervention that has no disadvantages that I can think of, it's cheap, and there's even moderately persuasive evidence that it is effective. Not only that, but playing music for patients doesn't mean we have to stop doing what we're currently doing, only that we should do a little less of it. 

If we don't introduce music into surgical units and recovery rooms (parenthetically, I'd like to see a study of the effect of classical music on surgical performance in the operating room--my guess is that it would calm the doctors as well as the patients), that will say a great deal about what we value in medicine today. It will suggest that what drives the diffusion of medical care is not so much evidence as advertising. There are, after all, no medical device manufacturers or pharmaceutical companies that will promote and market classical CDs and portable CD players to hospitals. I can't say I'm very optimistic, but I hope we will do the right thing.

Til Death Do Us Part

Why did this image go viral? In case you haven’t seen it before, it depicts a couple who were admitted to separate rooms in a Georgia hospital. Thanks to the wisdom of the nursing staff—and some bending of the rules—they were reunited. I think the photo struck a chord because it captures the important reality that what matters most as we get older—and perhaps at any age—is relationships.

We devote an inordinate amount of effort when we are younger to being “successful,” which we tend to define in terms of fame and fortune. And then, when we retire, we focus on living longer, on diet and exercise, on health and on experiences. But what so clearly mattered most to the couple in this photo is each other. Yes, the oxygen flowing through the plastic tubing is important. Yes, the intravenous catheter (not visible in the photo but I’m reasonably sure it was there) was useful for delivering potentially life-prolonging medication. But what makes life meaningful above all is our connections to others.

Lisa Berkman, a prominent social epidemiologist, has found compelling evidence that social networks—our links to our community—even affect our physical health. They influence whether we get a heart attack or stroke in the first place and how we fare if we get one. They affect our propensity to develop cognitive impairment and how well we cope if dementia strikes. But perhaps George Vaillant said it best when summarizing his book, Triumphs of Experience: the Men of the Harvard GrantStudy. This ambitious, longitudinal project followed 268 men who graduated from Harvard in the 1940s with a series of in-depth interviews over the course of their lives. Of course, generalizing rom these privileged Americans, all male and all born in one era, to the rest of us is risky. But despite their talents and their opportunities, these men had their share of alcoholism, of poverty, of suffering, and of disease. The inescapable conclusion that Vaillant reached  was, as he put it himself: “It was a history of warm, intimate relationships—and the ability to foster them in maturity—that predicted flourishing in all aspects of these men’s lives.” And that's the message conveyed by the photo of the two nonagenarians in their hospital johnnies, holding hands.