A 2018 JAMA summary of research says, "there is now independently corroborated evidence that the HRRP [hospital readmissions reduction program] was associated with increased postdischarge mortality among patients with heart failure and new evidence that the HRRP was associated with increased mortality among patients hospitalized for pneumonia. In light of these findings, it is incumbent upon Congress and CMS to initiate an expeditious reconsideration and revision of this policy."

Correlation between Low Readmissions and High Death Rates

Heidenreich et al. pubmed.gov/20650356
(2010) Journal of the American College of Cardiology, 56(5), 362-368. 

• In a study of 50,000 patients at Veterans Affairs hospitals over 5 years, "Heart failure admission rates remained constant at about 5 per 1,000 veterans. Mortality at 30 days decreased (7.1% to 5.0%, p < 0.0001), whereas rehospitalization for heart failure at 30 days increased (5.6% to 6.1%, p = 0.11)" italics added

Gorodeski, et al. pubmed.gov/20647209
(2010) New England Journal of Medicine, 363(3), 297-298.

• "A higher occurrence of readmissions after index admissions for heart failure was associated with lower risk-adjusted 30-day mortality."

American Hospital Association aha.org/research/reports/tw/11sep-tw-readmissions.pdf
(2011) Trendwatch September 2011

• "analysis using Hospital Compare data conducted by the Greater New York Hospital Association also concluded that mortality is inversely related to readmissions. (Chart 3)"

• Chart shows that states with lowest mortality, MA, CT, DC, DE, MN, NJ, IL, OH, MI, PA, all have above average readmissions, and all but two of these states are in the 70th percentile of readmissions or higher.

Krumholz et al. pubmed.gov/23403683
(2013) Journal of the American Medical Association. 2013 Feb.13; 309(6): 587–593.

• They find 17% correlation between lower readmissions and higher deaths among heart failure patients. These are the same Yale authors who develop Medicare's official readmission data:
• "The analyses included ... 4767 hospitals for HF [heart failure] ... The correlations ... [of mortality and readmission rates] were ...−0.17" for heart failure.

Gilman et al. pubmed.gov/25092831
(2014) Health Affairs, 33, no.8 (2014):1314-1322

• "safety-net hospitals were more likely than other hospitals to be penalized under the... Hospital Readmissions Reduction Program... 
• "[M]ortality outcomes in safety-net hospitals were better than those in other hospitals for patients with acute myocardial infarction, heart failure, or pneumonia. 
• "Third, the adjusted cost per Medicare discharge was virtually identical at safety-net and non-safety-net hospitals. 
• "Taken together, these results indicate that safety-net hospitals provided better health outcomes than other hospitals at a similar cost level yet were more likely to be penalized under programs that are intended to improve and reward high performance."

Higher Deaths after the Readmission Penalties Started

A 2015 CDC study found higher death rates from heart failure after the readmission penalties started. Their data cover both hospitalized and non-hospitalized patients, so they include the effect of less hospital treatment for heart failure, driven by penalties.

A 2018 JAMA study found higher death rates after the readmission penalties started, primarily in heart failure patients, and to some extent in pneumonia patients treated in hospitals. The paper's findings are strong, but the summary hides those findings: The paper says, "45-Day Postadmission Mortality... HRRP announcement was significantly associated with an increase in mortality" but the summary says, "Given the study design and the lack of significant association of
the HRRP with mortality within 45 days of admission, further research is needed." Then they refuse to say what kind of research would be more conclusive than the research so far. I asked, "Would you support removing penalties for a large random sample of hospitals for 20 years? Something else?" and they were silent.

Deaths Caused by a Program to Avoid Readmissions:

Fan et al. pubmed.gov/22586006
(2012) Annals of Internal Medicine 2012 May 15; 156(10):673-83

• 20 Veterans Affairs hospitals measured a "comprehensive care management program" for emphysema and chronic bronchitis (COPD). "Improving a patient's ability to self-monitor and manage changes"
• "data monitoring committee terminated the intervention before the trial's planned completion... There were 28 deaths from all causes in the intervention group versus 10 in the usual care group"

Minorities

Joynt et al. pubmed.gov/21325183
(2011) Journal of the American Medical Association. 2011 Feb 16;305(7):675-81

• "black patients were more likely to be readmitted after hospitalization"

Rodriguez et al. pubmed.gov/21835285
(2011) American Heart Journal. 2011 Aug;162(2):254-261.e3

• "Elderly Hispanic patients are more likely to be readmitted for HF and AMI [heart failure and heart attack] than whites"

Joynt et al. pubmed.gov/23340629
(2013) Journal of the American Medical Association. 2013 Jan 23;309(4):342-3

• "We found that large hospitals, teaching hospitals, and SNHs [safety net hospitals] are more likely to receive payment cuts under the HRRP [readmissions penalties]. It is unclear exactly why these hospitals have higher readmission rates than their smaller, nonteaching, non-SNH counterparts, but prior research suggests that differences between hospitals are likely related to both case mix (medical complexity) and socioeconomic mix of the patient population.2-3 There is less evidence that differences in readmissions are related to measured hospital quality.6"

Interviews

Dr Ashish Jha, of Harvard's School of Public Health, told PBS, "If you look at, for instance, the U.S. News [and World Report] publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted."

Dr. Sunil Kripalani, of Vanderbilt University Medical Center told Fox News, "Among patients with heart failure, hospitals that have higher readmission rates actually have lower mortality rates. So, which would we rather have -- a hospital readmission or a death?"

1. Readmission Rules

42 CFR 412.154 - Regulations for the Hospital Readmissions Reduction Program.

Medicare's summary web page and separate page of information for FY 2016

August 4, 2014 Final Rule for Fiscal Year 2015 (which starts October 2014) 

May 15, 2014 Proposal for Fiscal Year 2015 (which starts October 2014) or individual sections

• "we estimate that the reduction to a hospital's base operating DRG payment amount to account for excess readmissions of selected applicable conditions under the Hospital Readmissions Reduction Program will result in a 0.2 percent decrease in payments to hospitals for FY 2015 relative to FY 2014." Note they do not estimate dollars or numbers, as they did in 2013 below.

August 19, 2013 Final Rule for Fiscal Year 2014 (which starts October 2013) or individual sections

• "We recognize that performance-based payment programs may have the potential for unintended consequences. We are committed to monitoring the COPD measure and assessing unintended consequences over time, such as the inappropriate shifting of care, increased patient morbidity and mortality, and other negative unintended consequences for patients." (p.50650)

• "we will monitor the THA/TKA readmissions measure closely for any unintended
  consequences that may arise from implementation of this measure, and adjust the
  Hospital Readmissions Reduction Program, accordingly." (p.50664)

• "In this final rule, we estimate that 2,225 hospitals will have their base operating DRG payments reduced by their hospital-specific readmissions adjustment, resulting in a 0.2 percent decrease, or approximately $227 million, in payments to hospitals overall for FY 2014 relative to no provision." (p.51020)

May 10, 2013 Proposal for Fiscal Year 2014 (which starts October 2013) or individual sections

• "In this proposed rule, we estimate that the reduction to a hospital's base operating DRG payment amount to account for excess readmissions of selected applicable conditions under the Hospital Readmissions Reduction Program will result in a 0.2 percent decrease, or approximately −$175 million, in payments to hospitals for FY 2014." (p.27497)
• Proposal to cover knee and hip replacements (arthroplasty)
• Proposal to cover emphysema and chronic bronchitis (COPD)

August 31, 2012 Final Rule for Fiscal Year 2013 (which started October 2012) or individual sections

• "we estimate that the Hospital Readmissions Reduction Program will result in a 0.3 percent decrease, or approximately $280 million, in payments to hospitals." (p.53268)
• "We recognize that performance-based payment penalty or incentive programs may have the potential for unintended consequences. We are committed to monitoring the measures and assessing unintended consequences over time, such as the inappropriate shifting of care, increased patient morbidity and mortality, and other negative unintended consequences for patients." (p.53376)

2. Methodology for Counting Readmissions

• Their equations explain 3% of the variation (R-squared) in readmissions among heart failures (p.30), 5% for heart attacks (p.30) and pneumonia (p.29). These percents date from 2008 and have not been updated.
  
• Medicare now shows c-statistics between 0.61 and 0.66. The c-statistic has a scale of 0.5 to 1, where 0.5 means their equations do no better than chance, and 1 means their equations are perfect. "Models are typically considered reasonable when the C-statistic is higher than 0.7 and strong when C exceeds 0.8 (Hosmer & Lemeshow, 2000; Hosmer & Lemeshow, 1989)." So none of their equations is "reasonable," and they still rate hospitals with them. 

3. Medicare Budget

President, The Budget for Fiscal Year 2014, April 2013

• "The Budget encourages appropriate use of inpatient rehabilitation hospitals and adjusts SNF payments to reduce unnecessary hospital readmissions, saving almost $5 billion over 10 years." (p.38)

Dept. of Health and Human Services 2014 Budget in Brief, April 2013

• asks Congress to reduce "payments by up to three percent for SNFs with high rates of care-sensitive, preventable hospital readmissions, beginning in 2017" (p.54).
• These penalties would be based on patients starting in July 2012, so nursing homes already need to think about filtering the people they accept.

Dept. of Health and Human Services 2014 Centers for Medicare & Medicaid Services Justification of Estimates for Appropriations Committees, April(?) 2013

• "the goal of a three-year, 20% national reduction in readmissions within 30 days of hospital discharge." (p.227)

• "The Partnership for Patients [public-private partnership] has set two ambitious goals for all U.S. hospitals by the end of 2013: 1) reduce preventable all-cause harm by 40 percent, and 2) reduce hospital readmissions by 20 percent." (p.292)

Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds 2013 Annual Report, April 2013

Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds 2012 Annual Report, April 2012

Earlier Trustee Reports

Congressional Budget Office, Letter to Majority Leader, November 2009
"Estimate of Effects on Direct Spending and Revenues for Non-Coverage Provisions of the Patient Protection and Affordable Care Act By fiscal year, in billions of dollars.
...                                    2013  2014  2015  2016   2017  2018  2019  2010-2019
Hospital Readmissions    -0.1    -0.3    -1.1    -1.3    -1.3    -1.4    -1.5       -7.1
Reduction Program" (p.26)

4. Accountable Care Organizations

42 CFR Part 425 - Medicare Shared Savings Program

December 21, 2012 ACO 2013 Program Analysis Quality Performance Standards Narrative Measure Specifications

November 2, 2011 Final Rule for ACOs

2011 Pioneer ACO Request for Application

2009 Physician Group Practice Demonstration Evaluation Report (PGP)

• "The PGPs have reported implementing or enhancing a variety of care management programs that focus on improving the efficiency and quality of health care. These programs include ... end-of-life/palliative care programs" (p.6)
• "Since most of the savings are returned to the sites as performance payments, the net savings to the Medicare Trust funds in the first two years of the Demonstration were minimal when expressed as a percentage of all Target Expenditures." (pp.9, 45)

5. See also list of reports from MedPAC, a Congressional Agency

Direct URL: drugs.globe1234.com
Patients can get independent information on drugs and medical devices from sites listed farther down on this page (many track your IP address; you can check their privacy statements).

This page is not about substance use disorders, but here are 2 resources

1. 800-662-4357 (HELP) is a government referral number in English and Spanish, 24/7/365. They have other languages at 877-696-6775. They say, "The service is confidential. We will not ask you for any personal information. We may ask for your zip code or other pertinent geographic information in order to track calls being routed to other offices or to accurately identify the local resources appropriate to your needs." For zip code (and phone number if it appears in their system), "We will retain the information only for as long as necessary to respond to your question." 
2. Thousands of counseling and treatment programs are listed on a map by the government. They use Google maps and Google Analytics, so Google will know that you're looking for help on that website. A private company lists its own and some other rehab centers, not clear what the criteria are. The company makes you waive class actions, but they don't require indemnification or arbitration. It has ad tracking from Google and Microsoft, so those companies will know you're looking for rehab. If that concerns you, the phone number above may be better, but if you do any web searches, major web companies and advertisers know it. 

The sources in italics below cover medical devices, like pacemakers, artificial joints, lenses, etc. as well as drugs. FDA has a search box for US recalls of medical devices, and the press has an international list. Many devices have serious problems, and experts advise finding how many patients a device was tested on, how many times your doctor has installed it, and how it can be removed if necessary, before getting it implanted.
​
GENERAL SITES ON DRUGS AND MEDICAL DEVICES:

• WorstPills.org ($15/year, cites many studies), side effects, advice and comparisons among drugs, run by Public Citizen. Besides their valuable info on each drug, they say:

1. ​​List all your drugs and supplements, and keep the list up to date [carry in your wallet or purse for emergency responders, even if you don't take any, so they know that, along with other information].
2. Ask your doctor every 6 months if you can stop or reduce any drugs.
3. When you or a family member starts a new drug, assume every new symptom is caused by the drug. Research common side effects. Most of us don't notice our own side effects, so watch for family members.
4. When a specialist orders a new drug, tell your primary care doctor's office [they need the record in case of emergency, and they may change another drug].
5. Discard unused drugs carefully [without polluting ground or water, by taking to most police stations or many private sites, or mailing needles back to the drug company].

 

• MediGuard.org (free) is the only free place which shows interactions among all drugs you take or are considering (see UpToDate below for more detail). Run by Quintiles, which uses optional information from users to identify people for clinical trials
• Medical Letter (many citations, free trial with online access for 6 weeks, $10/article, $159/year or $98 for cumulative file from 1988 to previous December or June) Reviews new drugs and compares drugs and recommendations for common diseases. Some major diseases are listed as most read. Others are searchable as "drugs for". Comparable to UpToDate, which has cheap access but not free trials. More comparisons than GuideToPharmacology. French version for Canadian drugs comes out a few weeks after English version.
• UpToDate.com ($20/week, $45/month, covers medical and surgical treatments as well as drugs, detailed, many citations), recommendations for most conditions, interactions, side effects. Many doctors go here to get complete info and training.  Or if your doctor depends on drug company presentations (see article), you can get more information here than s/he has. Comparable to Medical Letter on drugs, which has free trial, but UpToDate also covers all medical approaches, not just drugs. More comparisons than Guide to Pharmacology. For major life decisions, people can check all three.
• ​When those sources give citations, you may find free copies of academic articles through Google Scholar, or in the library of a university, hospital, or big city. A more controversial source is Sci-Hub, which stores millions of papers and accesses others as needed. It uses login codes from anonymous academics who have free access.
• AskaPatient.com (free, cites FDA), patient reviews, and FDA reports of adverse events, for over 4,000 drugs. Much easier than FDA. Ad-supported, not sponsored by drug companies.
• GuideToPharmacology.org (free, technical, many citations). Search "Ligands", which are bio-active drugs. For example if you type "statin" in the ligand search box and just wait without clicking anything, it will suggest Atorvorstatin, Lovastatin, and many more. Click on one to see chemical and clinical research about it. You can type brand names in the same search box.
• TRIPdatabase.com (free version or $40/year pro version) lets you search for primary research, or systematic reviews, or TRIP's own summaries, called "answers". Not just drugs, it covers all medical interventions, like UpToDate, which is more thorough, but not free. TRIP says drug companies "do not have any editorial say in Trip".
• MedShadow.org (free, some citations), many articles on side effects and advice, and links to patient forums

There are two big problems when doctors send prescriptions to pharmacies electronically. This is more reliable than hand-written faxes, but:

• Most doctors cannot send, and most pharmacies cannot receive, electronic cancellation orders
• If the patient does not get a copy, the patient cannot check if the pharmacy filled it correctly.

Cancellation orders are crucial to correct mistakes and cancel refills. Patients can overdose when they keep getting the old medicine after the doctor orders a new one. Only a third of prescribers and 40% of pharmacies use software certified to handle cancellations, so less than a third of cancellations can go through. "Electronic health records allow prescribers to stop a prescription, but what many physicians may not realize is that in most cases that directive is not sent to any pharmacy," even though original prescriptions are reliably sent.

Health systems like the Veterans Health Administration and Kaiser Permanente can cancel electronically, where prescriber and pharmacy are in the same organization. Otherwise only 5 pharmacy chains accept e-cancellations: 

• CVS/Caremark (which handles 23% of US prescriptions),
• ExpressScripts (12%),
• RiteAid (6%), 
• Kroger (3%),
• Wegmans (under 1%). 

Many non-chain pharmacies accept e-cancellation if they use one of 14 software systems listed with a † You can ask the pharmacy which software they use.

No other chain is certified for e-cancellation, such as Walgreens (16% of US prescriptions) and Walmart (7%). Consumer Reports unfortunately recommends Costco and Sam's Club for price (uncertified), Walgreens for its apps (uncertified), and supermarket chains for convenience (only Kroger's is certified). CR should know better.

Doctors can cancel electronically only if their software is certified under "Cancel Rx". Out of 920 systems, only 80 are marked as certified, and usually only the latest updates. If your doctor is part of a large group, you can ask the group to ensure its software gets certified and updated. Individual doctors have little control.

Automatic refills are even more dangerous. When pharmacies call patients to say, "Your prescription is ready," patients and callers do not know whether the doctor recently ordered it or it is a zombie renewal. Costco, CVS, RiteAid and Walgreens encourage patients to sign up for automatic refills, so patients at Costco and Walgreens (two which lack e-cancellations) can get undesired medicine for long periods, thinking their doctor ordered it.

Prior authorization for prescriptions is a system where an insurer tells a pharmacy that a doctor needs to send the insurer detailed information and get the insurer's approval for the prescription. Insurers tell pharmacies, not doctors or patients, when prior authorization is needed, and pharmacies say they have no obligation to tell doctors, though they have the forms and information which the doctor needs, and no one else does. A Massachusetts court says pharmacies must tell doctors, and a doctor says the entire circuitous system of prior authorization for drugs kills patients.

Dr. David Belk has clear data on wholesale (NADAC) and retail costs of generic and branded drugs (from GoodRx) and what drives the costs.

Drug stores in half the states are not allowed to volunteer to you that the cash price is less than your co-pay, but the other half of states have laws letting them tell you. You can always ask anyway.

Drugs are distributed to retail pharmacies primarily by three companies: AmerisourceBergen, Cardinal, and McKesson, which have paid small fines, relative to their revenue, for not reporting excessive deliveries of opioids.

You can find the number of drug prescriptions from each doctor and costs for Medicare patients in at least 2 places, described below. For non-Medicare prices see above.

ProPublica has Medicare Part D cost for each drug: number of prescriptions and total spending. You can get separate totals for US and each state, so you can get average cost per prescription, and for each doctor who prescribed a drug 50 or more times in 2013.

Medicare itself has more complete Part D data. The US and state summary files (bottom of the link) show for each drug: the number of beneficiaries as well as prescriptions and spending, so you can get average per beneficiary (total during a year), as well as per prescription for each drug.

Medicare's detailed files show number of days prescribed, so you can get average cost of a daily dose, as well as each doctor who prescribed a drug 11 or more times in 2013. This info is in 23 million records, without state or US summaries. However you can get good state and national estimates by opening any of their 36 spreadsheets (divided by last name of prescriber) and getting averages there. The average costs do not vary much by last name of prescriber. (Tips for working with large spreadsheets)

Some doctors and drugs typically have 30-day or 90-day prescriptions, which may be renewed all year. Their averages include the cost for each  whole long prescription (30 or 90 days). Docs & drugs with shorter prescriptions only include that lower cost. Medicare's focus seems to be on cutting total costs, not cost per dose.

ProPublica's methodology says it has "retail cost" for these prescriptions.

Medicare's fact sheet gives more detail, saying it includes,

• The total drug cost includes the ingredient cost of the medication, dispensing fees, sales tax, and any applicable administration fees. It?s based on the amounts paid by the Part D plan, Medicare beneficiary, other government subsidies, and any other third-party payers (such as employers and liability insurers). Total drug costs do not reflect any manufacturer rebates paid to Part D plan sponsors.

It does not directly include patients' monthly premiums, though on average those premiums may cover all drugs, administration, and profits.

After seeing which drugs a doctor prescribes, you can find drug safety and effectiveness from the sources at the top of the page.

 1. Hospital data

Financial data are on a separate page

Medicare has links to a "home page" for each year since 2012 (called IPPS Rule) at the bottom of the main CMS readmission page (and the bottom of the left navigation menu, which is often the only link for the coming year).

• From that home page follow the links for Tables (discussed below and on Payments page).
• There is also a link for Data Files which include the

1. Impact File (names of hospitals, size, categories),
2. Standardizing File (cost factors),
3. Wage Index File
4. Readmissions Supplemental File or Readmissions PUF (numbers of readmissions, PUF=Public Use File)

Item 4, the Readmissions file, is the source of "Number" and "Readmit Rate" for each of the 5 medical categories in our "Combined list" of all hospitals (methods). The file also shows the number of patients set aside from the data for various reasons (transfers, deaths, etc.), and the total DRG weights of readmitted patients (reflecting their costs).

Item 1, the Impact file, is the source of the price and wage adjustments in our Combined List.

Files of death rates and other quality measures for hospital and other patients. These ignore deaths of people who have been in hospice any time in the past year. (methods)

Medicare has data each year, called tables, on:

• item 1, table 1, Hospital payment bases
• item 3, table 5, Disease payment weights (DRG)
• item 5, table 6, Codes for comorbidities worsening the diseases
• item 6, table 7, Number of patients, by disease

Hospital bills for 100 most common diagnoses, each year from 2011 on.

Medicare gives away software to calculate readmission risk. It focuses attention on the frailest patients who are most likely to be readmitted in spite of better care, so are natural targets to promote hospice, comfort care and DNR, even if their condition is treatable.

Data on hospitals' use of Electronic Health Records are on a separate Medicare page.

2. Nursing Home data are on another page

3. Patient and beneficiary data

Medicare has counts for each year since 1985, more detailed in the most recent years, and interviews with a sample of beneficiaries.
File of 15,000,000 hospitalized Medicare patients ($3,700 per year, on DVD)
Medicare Advantage Plans (Part C) encounters with patients.

4. Doctor and treatment data
Medicare has counts and costs for the procedures and tests billed by each doctor and other provider in 2012.

Data on doctors' use of Electronic Health Records are on a separate Medicare page.

5. Drug Use and Costs are on another page.

6. Medical Equipment

Medicare lists doctors who prescribe medical equipment and supplies, by type of equipment, showing numbers and costs, but the file is not organized by provider, so you cannot compare prices at different providers. The goal seems to be to press doctors to prescribe less, rather than help patients or doctors find the best or popular providers.

7. Other sources

Topics are also covered in the MedPAC, Data Book. June 2013

The Agency for Healthcare Research and Quality has data on costs and disease.

Medicare shows, by state or county, number of beneficiaries, as well as users and providers of ambulances, labs, home health, skilled nursing facilities, and hospices.

Comfort care means different things to different doctors, so it is important to probe its meaning. It usually means stopping curative treatment and using palliative doctors to control pain, though they have less training at that than pain doctors.

Comfort care's main justification is to provide a more enjoyable life for seriously ill patients than a life of treatment. However advocates also say it can extend life and save money. The sections below address these ideas.

There seem to be only 2 short, small, random studies of palliative care's effect on extending life. Both have almost complete overlap between the confidence intervals on length of life in palliative and control groups, which suggests little significant difference in survival.

The bigger study finds shorter life for palliative patients, and is ambiguous about its significance. The smaller, narrower study, of one disease in one hospital, claims significantly longer life for palliative patients, and only a bio-statistician can evaluate that claim.  Both studies are described below.

Medicare is pressing hospitals to limit care and promote hospice, comfort care (symptom relief or palliative care), and "do not resuscitate" (DNR) orders, so patients die at home and do not come back to the hospital. 

• In 2009 Medicare endorsed "end-of-life/palliative care programs" to cut costs and increase bonuses to doctors and hospitals.
• In 2012 a Congressional agency, MedPAC, recommended "hospice use and the presence of advance directives" to reduce rehospitalizations.
  

An unrelated study found that hiring a lay staff person to help patients with advance care planning had no effect on mortality, but cut costs and increased patient satisfaction.

Huffington Post found some hospices earning money by enrolling patients who were not ill enough.

Mercy Health Center, OK (2009). Kroch et al, "Making hospital mortality measurement more meaningful: incorporating advance directives and palliative care designations." Am J Med Qual. 2010 Jan-Feb;25(1):24-33. pubmed.gov/19966112
"Patients with care-limiting orders have higher mortality than the general in-patient population; nevertheless most DNR patients (65%) still survive the hospital stay, albeit most PC [palliative care] patients (73%) do not ... Observed mortality rates for DNR and PC patients are generally higher than those expected from patient risk factors" (p.28)

Mercy Health Center, OK (2009). Kroch et al, "Making hospital mortality measurement more meaningful: incorporating advance directives and palliative care designations." Am J Med Qual. 2010 Jan-Feb;25(1):24-33. pubmed.gov/19966112
9,100 patients from 2005-2006, analyzing hospital records retrospectively. Included 995 with DNR, of which 311 had Palliative care.
Eligible: Hospital discharges and deaths Nov.'05-Oct.'06
Location: Mercy Health Center (hospital), Oklahoma City
Findings: Death rates during the current hospital stay were abnormally high for patients who had palliative care and/or DNR orders:

Hospital    Expected...  ...(Expectation Based on Patients' Condition)
  Death        Death
   Rate          Rate
   73%           31%       Palliative care patients
   35%           16%       DNR patients

This correlational study does not show if:

1. Lack of curative treatment caused the death rates to be so much higher than expected (expected rates take into account the history of the disease and other conditions, see below)
2. Counseling and acceptance of the end (or giving up) caused the death rates to be so high
3. These palliative and DNR patients would have died sooner without those orders, or later
4. There were any reasons why so few palliative patients went home to die

 

• Mercy's other patients had lower death rates than expected (p.25, they gave no figures)
• Most palliative care patients did not get to die at home (73%)
• This hospital considers both DNR and palliative care as "care-limiting" orders (p.24). 
• They frequently assign patients to palliative care whose disease is irreversible and leading to death, though death is not necessarily expected during the hospital stay, and "maintaining the patient's comfort during the dying process is the primary objective" (p.25) 
• "[G]eneral hypothesis that DNR designation identifies otherwise unobserved risk that is revealed over time during the hospital episode" (p.30) 
• Expected death rates are calculated by the CareScience method which controls for "age, sex, race, income, relative distance traveled, principal diagnosis, comorbidity-adjusted complication risk score, defining diagnosis, cancer status, chronic disease and disease history, valid procedures, admission source, admission type, payer class, and facility type" in each of "142 different disease groupings (ie. 142 distinct regression equations)" (p.26)
• The CareScience method is fairly good at predicting which patients will die during a particular hospital stay. It explains 30% to 54% of the variation in death rates (p.30)

National Hospice and Palliative Care Organization, US (2007). Connor et al, "Comparing hospice and nonhospice patient survival among patients who die within a three-year window." (J Pain+Symptom Manage. 2007 Mar;33(3):238-46. pubmed.gov/17349493
4,493 patients from 1998-2002, analyzing Medicare records retrospectively
Eligible: Patients with CHF and cancers of lung, pancreas, prostate, colon and breast who had a major progression in their disease ("indicative date") in 1999, but not 1998, who died between 15 days and 3 years after that major progression. There are detailed criteria for each disease (see below).
Location: US patients with Medicare Part B (optional doctor coverage)
Findings: Longer life for hospice patients with lung cancer or heart failure. This correlational study does not show if:

1. Longer-lived patients had more time to think about and sign up for hospice, or
2. Giving up curative treatment helped patients live longer,  or
3. Hospice's better coordination of care helped patients live longer, or
4. Other factors caused both longer lives and more hospice, such as better doctors and hospitals, health knowledge, other health experience, etc.

Significant Differences in Survival (days):

• Lung cancer 279 vs. 240, P<.00001
• Pancreatic cancer 210 vs. 189 P=.0102

Not Significant (over .05):

• Heart failure 402 vs. 321, P=.0540
• Colon cancer 414 vs. 381 P=.0792
• Breast cancer 422 vs. 410 P=.6136
• Prostate cancer 514 vs. 510 P=.8266

Potential Biases:

1. They omitted patients whose immediate treatment or lack of it led to death in the first 15 days. A majority of these omitted short lives could be patients who chose hospice, declined treatment, and died quickly, in accordance with their wishes.
2. They omitted patients whose treatment or hospice care carried them beyond 3 years. A majority of these omitted long lives could be non-hospice patients  with successful treatment.
3. They used detailed criteria for each disease, and they note their lung cancer criteria risked getting sicker patients into the control group than into the hospice group, since survival was measured from the last date in the records when lung patients switched chemotherapy drugs. Hospice patients stopped drugs, so stopped switching, while the control group kept switching, so their last switch date would be closer to death, and survival would be shorter in the control group. Breast cancer had the same bias, but still did not show a significant difference.

Healthgrades (2013) "Hospital Report Cards™ Mortality and Complications Outcomes 2013 Methodology"
"Top Five Risk Factors by Procedure or Diagnosis ... [p.45]

• Diabetic Acidosis and Coma ... DO NOT RESUSCITATE STATUS ... [p.46]
• Heart Failure ... DO NOT RESUSCITATE STATUS ... [p.47]
• Diagnosis code V49.86 (DO NOT RESUSCITATE STATUS) ... Healthgrades included this diagnosis as a risk factor in its regression analyses for all non-surgical cohorts where mortality was the outcome being assessed. It was only considered to be a risk factor when ... present on admission. This diagnosis was statistically significant in the logistic regression model for each of these cohorts." [p.50]

Hospice (even a strategic temporary signup) can provide more home care when needed, or reduce care that patients dislike. However it can also be pushed as a way to cut costs for the hospital or medical system:

American Academy of Hospice and Palliative Medicine (2011) "When patients enroll in hospice care, their days of hospitalization might be expected to go down, thanks to hospice’s 24-hour on-call capacity ... and the shift in goals of care."

DAI Palliative Care Group (2011) "Hospices and their palliative medicine specialists have proven, several studies have shown, to be effective at reducing use of hospitals for their patients... Hospitals will likely look to post-acute care networks to assist in managing the care of at-risk (for rehospitalization) patients. Should we consider deployment of palliative care specialists (physicians and nurse practitioners) by these networks to visit patients in their homes"?

New Jersey Hospital Association (2011) "Planning for 2012-2015..:

• Reductions in hospital readmission rates and penalties... More effective use of hospice
• Accountable care organizations and bundled payment... Home health and hospice have leading roles" (p.69)

Senior Housing News (2012) "Hospitals’ reimbursements will start getting docked under healthcare reform depending on 30-day readmission rates, so communities where many residents use hospice services rather than going to a hospital could be potentially benefit. [sic]"

National Quality Forum (2012) "For both Hospice and Palliative Care... treating ... symptoms ... has the strongest evidence base and helps avoid unwanted treatments and hospital/emergency department (ED) admissions and readmissions." (p.9)

Florida Hospital Association (2013) says one method they used to reduce readmissions 15% was "Evaluating the patient’s end-of-life care wishes" (p.8)

"Bon Secours [2014] already has reduced its readmission rates, improved palliative care for terminally ill patients..."

Southern California Public Radio (2014) " 'One of the major issues that we face is really trying to enhance end-of-life care,' Cedars-Sinai's Dr. Glenn Braunstein tells KPCC... He also noted that it's partially to help cut expenses, as the last month of someone's life in particular can be tremendously expensive."

Lawyers Dubler and Sabatino (1991) "system of allocation implemented inconspicuously by private institutions and practitioners. This sort of rationing will be difficult to uncover and even more difficult to prove and prevent. It will respond to implied regulatory messages from Medicare and Medicaid; it will react to reimbursement formulas and market reward. Most worrisome, it will couch personal and institutional prejudice in the language of medical and quasiscientific criteria." p. 116, "Age-based Rationing and the Law" chapter in Binstock et al, Too old for health care? : controversies in medicine, law, economics, and ethics, Johns Hopkins University Press

Jeffrey Birnbaum, (May 12, 1997), FORTUNE Magazine

• “AARP struggles to decide which of its members to put first: those who are already retired or the growing number who are still gainfully employed…
• has subtly begun to focus more on boomers by shifting the emphasis of AARP's publications and products to its nonretired members…
• Today its finances remain robust, anchored in health insurance as well as royalty-producing businesses that range from annuities to prescription drugs…
• would countenance other curtailments, primarily payment cuts to hospitals and physicians, in order to keep Medicare's hospital trust fund afloat…
• now AARP has competition on the left from the militant, five-million-plus-member National Committee to Preserve Social Security and Medicare and from the labor-backed National Council of Senior Citizens. On the right are newer, free-market groups like 60 Plus, United Seniors, and the Seniors Coalition, all small but growing…
• AARP must transform itself into something unusual--an oldsters' lobby that serves people of a wide variety of interests and ages… Some AARP executives even talk about renaming the magazine. After all, what young-at-heart boomer wants to read something called Modern Maturity?" [renamed AARP-The Magazine]

Alliance for Aging Research (2003) "Drawing upon scores of scientific studies, this important report shows how systemic bias against the elderly hurts older patients in the U.S.--highlighting ways in which the healthcare system fails older Americans. The report cites serious short-comings in medical training and prevention screening, and outlines treatment patterns that disadvantage older patients."

A 2007 study at Ohio State, Duke and other hospitals found that doctors and nurses "overestimate the risk of death," so they may limit care even among patients who have low risk of readmission and death.

Brown Professor Ackerman (2012) Doctors " 'keep a portion of the savings.' This arrangement obviously provides a financial incentive to withhold expensive life-prolonging treatment from Medicare patients whose quality of life is deemed low... Whose life is it, anyway? This slogan is conventionally used to support the right to die. It applies just as much to a sick old person who wants to stay alive. Such a person deserves better than to have well-schooled manipulators coax his family into signing his death warrant."

Neurologist Robert Weinmann (2012) "The days of searching out rare and unusual diseases to care for are over: these unfortunates will be obliged to find  whatever comfort is available under the nearest bus... Quietly, with as little fanfare as possible, physicians and hospitals will be encouraged to avoid the sickest, oldest, and most complicated patients."

Gastroenterologist Michael Kirsch (2013) "This is but a single example of how the medical profession is being forced to game the system to comply with a punitive financial penalty system that is poorly disguised as a medical quality initiative."

Cardiologist Walton-Shirley (2013) "palliative care has been birthed, ... of patients labeled as "frequent fliers" at high risk for budget-busting bounce-backs... a small part of me that worries that patients who need readmission will be held captive at home or in palliative-care programs or even become ensnared in a hospice-type situation when in fact there might have been help for them"

Medicare also researches how hospices spend Medicare's money: spending is higher early in a patient's participation in hospice, and just before death.

Patients can learn some of the differences between pain doctors and palliative doctors by reading the topics included in exams for board certifications. The following are summaries, with more details of each topic in the links given.

The Board Certification for "Pain Management" devotes far more time to assessment and treatment of pain, both drug and non-drug, and a little more time to psychological issues. The Palliative and Hospice subspecialty devotes more time to communication and death. Both devote similar time to legal and ethical issues.

Major telehealth companies include American Well, Doctor on Demand, and MDLive. If you want a consultation by telephone or skype, the rules and insurance coverage are constantly changing, so ask. Veterans hospitals have permission for any VA doctor to treat any VA patient, regardless of state licensing rules. Insurance and Medicaid may cover telehealth. Medicare has decided to do so too from 2019 on.

​All states now allow doctors to see patients by telehealth even from the first appointment, if they have the right license, but distant doctors refer too rarely to other local specialists, since they don't know them, so patients need to ask.

​​Between 1% and 6% of doctors refuse insurance and/or charge concierge subscriptions starting at $600 per adult per year and $120 per child, or more typically $1,500 per adult. 10% of Texas doctors do not take insurance, and instead charge for each office visit, starting at $50 per visit.

Industry sources include Concierge Medicine Today, Direct Primary Care Journal, and Direct Primary Care Coalition.

A Commonwealth Fund study gives examples of what to watch for in deciding if an app is safe to use. FDA has some legal guidance on apps and an overview.

Some apps will call a doctor to visit you at home, or you can use lists here to find doctors who visit homes and assisted living, and call them directly to build a relationship with the same doctor over time.

There are many health apps (some say over 100,000, others say over 1,000) competing to offer personalized service.  A commercial site with practicing doctors on its staff reviews many apps. The reviews are often specific and helpful. They also include articles written by or for advertisers. Each reviewer must tell the editors about potential conflicts of interest, and the editors decide what to reveal to the public.

Some computer systems go through your symptoms and tell you possible diagnoses. 19 systems ranged from 5% to 50% "right" on a 2014 test of 45 vignettes (sets of symptoms, 18 computer systems and one paper system), published in 2015. "Right" means the single diagnosis which the authors of the vignettes expected. No one checked if the other diagnoses offered were also fully consistent with the symptoms given, or perhaps even more consistent.

A long list of other systems use the same algorithms and would have had the same results. Many nurse help telephone lines use the same algorithms and would have about the same results, except when accuracy is changed by the nurses' own judgment.

When the systems were asked for the 3 most likely diagnoses, they included the "right" diagnosis as one of these 3 from 29% to 71% of the time, depending on system. Researchers at Harvard and 3 Boston Hospitals did the test. In 2016 they tested 234 doctors, who identified the "right" diagnosis 72% of the time and got it in their top 3 possibilities 84% of the time. Researchers did not report the range of accuracy from doctor to doctor, as they did for computer systems, but success did not vary much by level of training (intern, resident, attending doctor).

A study found poor quality in dermatology consultations based on sending photos through the internet. A RAND study of claims said that pharyngitis patients went out to get strep tests after 3% of Teladoc consults, compared to getting them (usually in the same visit) after 50% of office visits. RAND said bronchitis patients got (inappropriate) antibiotics after 83% of Teladoc consults, compared to 72% of office visits. Since the study was based on claims, it is not clear how many patients were told to get a strep test or antibiotic, and did not bother to go out and do so. 

​Amazon and Google are expected to expand into health care.

Referral sites generally give you no choice of provider, and you know which one they selected only after paying the referral fee. If you have time to search the Specialists tab above, you can find the experience and cost of different providers and negotiate directly.

Referral services may give local or distant referrals.

ZendyHealth refers you to a local provider based on how much you want to pay ($49 referral fee). They cover only a few procedures, primarily imaging, tests, counseling, dental extractions or implants, cosmetic procedures. For these and other procedures they also refer you for a free consultation. More details are on the Costs page.

PinnacleCare charges $650 to set up a consultation with a specialist and transfer medical records. 

GrandRounds.com (formerly ConsultingMD.com) refers patients to local or distant doctors for initial care or second opinions and transfers medical records to them. They charge $200 to arrange an initial office visit with a local doctor in the "top" 3% or 10% of local doctors, or $7,500 for a remote expert opinion from a doctor in the "top" 0.1%. They also charge $7,500 for "STAT," an emergency telephone consult with the best doctor they can find at short notice.

• The first time you use their services they need time to collect your health records from your doctors and hospitals, and (with your permission) provide them to the doctors they refer you to. They do not say whether your health records are encrypted while stored in their offices. 
• They offer their telephone consult ("STAT") 24/7, but don't say how many hours it may take to find a relevant expert. They're ambiguous whether the expert talks to the patient/family or the treating doctor. If you cite both those links to them, you can insist they talk to both.
• The emergency STAT service is expensive, and is based on the idea that Grand Rounds has pre-identified doctors willing to consult by phone, which you would have trouble finding in an emergency. Dr. Kussin recommends that when you know what health conditions you have, make an annual appointment with a top specialist for a checkup, so you can call him/her as an existing patient in any emergency (p.206).
• The non-emergency $7,500 expert opinion seems aimed at big spenders. They warn you that the expert will not have "information that would be obtained by examining you in person and observing your physical condition." Without spending that much you can identify the top national experts in the Specialists tab above, and in your $20 subscription to UpToDate, call for an appointment, and go see them in person. 
• Their $200 fee to recommend and set up a local office visit is reasonable. You pay them to research doctors and transfer records instead of doing it yourself. You and your insurance will still have to pay for the visit itself. 
• A problem with Grand Rounds is that the terms of service require you to pay their legal bills for any problems which arise: "You agree to indemnify, defend and hold the Company and its directors, officers, employees, agents and contractors harmless from and against any and all claims, damages, losses, costs (including without limitation reasonable attorneys’ fees) or other expenses that arise directly or indirectly out of or from (i) your breach of any provision of these Terms, or (ii) your activities in connection with this Site." They don't provide any examples, but perhaps this would protect them if they misuse your information.
• Grand Rounds does not reveal its algorithm to identify top doctors, but says it includes: "Institution (is the physician associated with a top-quality one?), Training (where did the physician study?), Research (does the physician publish in his or her area of study?), Reputation (what do the physician’s peers think?)" Another page adds, "procedure volumes; and clinical outcomes." Another page says that the doctors' "success rates are well above national averages and that they follow state-of-the-art care practices." They say these top 10% doctors have "15% lower hospital readmission rates. 30% – 40% lower mortality rates, 20% – 25% lower complication rates, but again no information on how these differences were found, over what time frame, comparability of patients, etc. They describe their service as doing some of the same analysis this website describes, on procedure volumes, doctors rating other doctors, and researchers. They simplify the process, while hiding the details. 

PinnacleCare and Private Health Management help wealthy clients navigate the health-care system, for $16,000 per year or more, plus the cost of care. 

Many hospitals offer amenity rooms, typically on a separate floor, with extra service and space for an extra $250 to $2,500 per night. They often say the medical care is the same, but facilities for doctors and nurses are also presumably less crowded and more comfortable on these floors, so care could be better. If someone knows of a list, or effective way to search for them, please email it.

nytimes.com/2012/01/22/nyregion/chefs-butlers-and-marble-baths-not-your-average-hospital-room.html
parents.com/pregnancy/giving-birth/labor-and-delivery/labor-and-delivery-most-luxurious-birthing-suites
enherts-tr.nhs.uk/patients-visitors/our-services/maternity/amenity-rooms/
money.cnn.com/2014/10/02/luxury/luxury-hospital-suites/
articles.sun-sentinel.com/2012-02-26/health/fl-hk-hospital-luxury-suite-20120226_1_hospitals-offer-south-florida-hospital-community-hospitals
utsandiego.com/uniontrib/20050904/news_1n4hospital.html  (associated press)
therichest.com/luxury/the-10-most-luxurious-hospital-rooms-in-the-world
nydailynews.com/new-york/class-ward-lenox-hill-hospital-article-1.1186213 Nurse overwork on non-luxury floor
denverpost.com/news/ci_7746964  Claims a profit
dujour.com/lifestyle/luxury-hospital-accommodations/  They comment, "unclear whether hospitals are actually turning a profit from this enterprise. What they are doing, however, is cultivating future donors"

Direct Payments which doctors get from major medical companies (Medicare's site) and drug companies (ProPublica's site) show which doctors have strong bonds with the companies. Patients need to decide if these affect their care. The sites do not reveal profits from doctors' own businesses. Consumer Reports says that when a doctor orders X-rays or other scans, "ask whether he is financially affiliated with" the radiology clinic, since "studies have found that physicians who own scanners or are part owners of radiology clinics use imaging substantially more than others." 

The Journal of the American Medical Association (JAMA) May 2 2017 summarizes a lot of research on how payments from drug and equipment companies affect doctors' decisions, usually sub-consciously.  Where policies change or payments stop or start, average prescribing practices then change. Public Citizen has a less detailed November 2017 update.

Nurses also get payments and meals from drug companies, but only Massachusetts tracks these payments.

Drug companies also have constant access to doctors and give them biased information. A 2012 summary found (emphasis in the original):

• 61% of physicians reported that their own behavior was immune to influence by industry, but only 16% thought that other physicians’ behavior was equally secure
• sometimes the suggestion that such influence exists can be infuriating to them
• The frequency of meetings with pharmaceutical representatives varied across specialties, ranging from two per month for anesthesiologists to 16 per month for family practitioners
• representatives presented only selected, usually positive, information about their products
• In one of the few studies of specific [training] content, 11% of statements in formal lunch presentations by pharmaceutical representatives were found to be inaccurate, all favorable toward the promoted drug, yet only 26% of medical residents attending those presentations recalled hearing any false statement. All statements about competing drugs were accurate, but none favorable
• research supported by industry is more likely to report positive results—3.6 times as likely, according to one meta-analysis
• One study of industry-sponsored review articles and Cochrane [academic] reviews on the same medications found that all of the former recommended the drug in question whereas none of the latter did

• 85% of [US medical students] who thought that accepting a small gift or lunch was inappropriate reported accepting them anyway. This may be partially explained by the fact that 93% of the students had been asked or required by a faculty member to attend a sponsored lunch
•  In one survey of internal medicine residents, 100% of those who thought interactions with industry were inappropriate accepted at least a lunch or a pen
• In a random sample of physicians in six specialties in the United States, 94% reported some relationship with industry (18). Eighty-three percent reported receiving food or beverages in the workplace; 78% received samples
• Clinicians often describe the role of samples as helping those who cannot afford medications to receive treatment... Physicians themselves report that samples influence them to prescribe drugs that differ from their preferred choices (32). Although the initial reason may be to avoid cost to the patient, most samples are of the newest and most expensive medications, which patients may not be able to afford after their samples run out. Further, the side effects of newer medications are usually less well established

Doctors see frail old people, and sometimes assume they have few remaining days left, and comfort is most important. However at every age we have 8 or more months left, and up to 112 we have over a year of life expectancy left. Those with good minds may want to enjoy that time. With each additional year we live, our life expectancy extends by 9 or 10 months, and with good care and luck we keep living. The data are prepared by the Social Security Administration.
 
CDC has instructions to doctors on filling out death certificates, but there are weaknesses, especially for the minority of patients who die without a recent doctor visit.

Average Years of Life Remaining, by Age, US Population, 2014

Doctors use many versions of the Charlson Comorbidity Index to estimate life expectancy for patients, depending on their age and illnesses (comorbidities). Many versions are little better than chance in predicting life expectancy.

The C statistic is an estimate, from a research project on particular patients, how often an index is more accurate than chance. Values range from 0.50 (no better than chance) to 1.00 (always right). C statistics for different groups of patients are in supplementary tables 1-4 of Yurkovich et al. (2015) Journal of Clinical Epidemiology. v.68(1):3–14. "A systematic review identifies valid comorbidity indices derived from administrative health data." Details of how big the errors are may be found in the original studies, listed by Yurkovich et al.

An older study is Sharabiani et al. (2012 Dec) Medical Care. v.50(12):1109-18. "Systematic review of comorbidity indices for administrative data." . doi: 10.1097/MLR.0b013e31825f64d0 pubmed.gov/22929993

US life expectancy overall, and specifically for people over 65 was improving steadily until around 2011. Since then it has been flat (Bloomberg, and CDC p.116, table 15).

Starting in 2013, US hospitals are treating fewer patients for heart failure, and US death rates from heart failure are rising. Starting at the end of 2012, Medicare began penalizing hospitals for heart failure patients who were re-hospitalized (readmitted) within 30 days. Hospitals cannot always prevent readmissions, so the most effective way to avoid penalties has been to cut the number of Medicare patients they admit for heart failure.
 
Hospitals treated 60,000 fewer patients for heart failure in mid 2012-mid 2015, than in mid 2008-mid 2011, or 20,000 fewer patients during a year, compared to four years ago, before the penalties.
(Source, column CZ of: globe1234.org/hospitals1216.xls)

CDC says in the US:

• Death rates from heart failure fell every year from 2000 to 2012,
• Death rates from heart failure rose in 2013 and 2014.
• Source: cdc.gov/nchs/data/databriefs/db231.pdf, CDC instructions on defining causes of death: cdc.gov/nchs/data/misc/hb_cod.pdf

The higher death rates in 2013 and 2014 mean 7,200 and 9,600 more people died from heart failure in these years than would have died if the 2012 death rate had continued.
 
The term "heart failure" is also called "congestive heart failure" or cardiomyopathy. It refers to weak pumping because of muscle deterioration, stiffness, leaking valves, etc. It is not the same as a heart attack or heart stopping.
 
These are the latest figures which cover hospitalized and non-hospitalized patients, but many other studies of hospitalized patients also find that hospitals which had fewer readmissions had more deaths, especially among heart failure patients.
(Source: globe1234.info/medicare/category/research)
 
Medicare said in August 2012, "We are committed to monitoring the measures and assessing unintended consequences over time, such as the inappropriate shifting of care, increased patient morbidity and mortality, and other negative unintended consequences for patients." (p.53376) They have not reported any of these monitoring results in 4 years.
(Source: federalregister.gov/d/2012-19079/p-1799)
 
The penalties apply to patients treated under Medicare Part B. Hospitals which face the readmission penalties now admit 5% fewer Part B patients for heart failure, even though the total number of seniors covered by Part B increased 12% in the same period.
 
Readmission penalties give hospitals incentives to treat fewer seniors. Medicare even gives hospitals an online tool to predict readmission risk for each potential patient.
 
Hospitals can avoid penalties by any mix of the following:

• Avoid admitting the sickest Medicare patients with heart failure ("There's not much we can do for you. Hospitals are dangerous. You're better off at home.")
• Treat as many as possible of the least sick outside of hospitals
• Change diagnosis to "hypervolemia," too much water in the blood, which is not penalized, but risky if caught
• Improve subsequent care for those admitted, to reduce readmissions

It is easier to give less care than to improve it, though hospitals certainly are doing both. And what we see is that death rates have started to rise.
 
The following hospitals had the biggest drops in heart failure patients admitted, comparing the most recent 3-year period to the 3 years before penalties:
 
St Vincent's Medical Center Riverside, Jacksonville, FL, -871 patients
Northwest Community Hospital 1, Arlington Heights, IL, -779 patients
Baptist Medical Center, San Antonio, TX, -724
Community Medical Center, Toms River, NJ, -570
St Luke's Hospital Bethlehem, PA, -543
King's Daughters' Medical Center, Ashland, KY, -536
Beaumont Hospital - Dearborn, MI, -517
Hackensack University Medical Center, NJ, -504
Vassar Brothers Medical Center, Poughkeepsie, NY, -454 patients
 
On the other hand these hospitals may have unique reasons for their changes, and the real story may be among all the other hospitals with smaller drops in heart failure patients. Changes at all hospitals are in a spreadsheet (in column CZ; changes in Part B enrollment are in column DL):
globe1234.org/hospitals1216.xls
 
I counted hospital admissions in July 2012-June 2015, compared to July 2008-June 2011. These are the newest and oldest comparable data available. Medicare released the older data in a comparable form in May 2013. It released the newer data in August 2016.

Hospitals face readmission penalties when they treat Medicare patients for heart failure. Each hospital pays a penalty if more of their heart failure patients than the US average need another hospital stay within a month. So hospitals know they have a 50% chance of a penalty, since about half the hospitals will have readmission rates above average each year. 

Meanwhile for heart attacks, admissions fell 1.3% in the same time period, even though Part B beneficiaries increased 12%. I haven't found death rates from heart attacks, and it seems that all survivors who reach a hospital would be admitted. Have heart attack rates really dropped 13%? Are more people dying before they reach a hospital? Or is something else driving down hospital admissions for heart attacks?
 
For pneumonia, which is the other of the three original readmission penalties, a 2018 JAMA study found higher deaths within 30 days after the readmission penalties started, though no significant change in deaths within 45 days.

​In the pneumonia data we have to compare 3 year periods ending June 2014 and June 2011, since Medicare expanded the pneumonia categories counted in later periods. Pneumonia admissions fell 4% over that period, while the number of Part B beneficiaries rose 9%. Death rates oscillate each year but were on a downward trend from 1999-2012. It looks as if the trend may not have continued in 2013 and 2014, though it is hard to tell.
statista.com/statistics/184574/deaths-by-influenza-and-pneumonia-in-the-us-since-1950
cdc.gov/nchs/data/health_policy/influenza-and-pneumonia-deaths-2008-2015.pdf
 
Readmission penalties are large. Hospitals get $6,000 for treating a Medicare heart failure patient, but pay a $27,000 penalty for each readmission within 30 days, above the national average rate. For other conditions penalties range from $25,000 to $239,000 per readmission above the national average rate. So every hospital tries to be below the average, driving the average down and the risk of penalties up every year. There are also minimal adjustments for the mix of patients each hospital serves. Penalties total $469 million this year.

There are newer penalties for re-hospitalizing patients after coronary bypasses. The penalty is $188,000 for each one above the national average rate; penalties began October 2017. Penalties after elective hip and knee replacements are $239,000 and began October 2014. The penalty calculations are written into the Affordable Care Act. It is too early to see if the number of people treated has fallen, but the  American College of Surgeons warned Medicare that treatment would be cut: "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue."
(Source: regulations.gov/contentStreamer?documentId=CMS-2013-0084-0090&attachmentNumber=1&disposition=attachment&contentType=pdf)
  
In 67 metro areas, Medicare has a second way to discourage hip and knee replacements, especially for the frailest patients who may need them most: the hospital must pay nearly all medical expenses for 90 days after the hospital stay, though it has no control over these costs. Fewer hip and knee replacements and fewer coronary bypasses, when Medicare patients need them, condemn seniors to reduced activity and faster decline.
(Source: globe1234.info/medicare/publiccomment)
 
For heart attacks and coronary bypasses, Medicare plans the same approach of making hospitals pay 90 days of medical costs, starting July 2017, in 98 metro areas.
federalregister.gov/d/2016-17733/p-3
federalregister.gov/d/2016-17733/p-753

Another page explains some arithmetic behind the readmission penalty calculations, which give hospitals a strong incentive to serve fewer patients.

Hospitals have cut admissions for the diagnoses which face readmission penalties. Most publicity has been about cutting the readmission rate, which they have also done, but that just shifts penalties to other hospitals without cutting the total paid across the US. Especially for large hospital chains, they gain nothing from lower penalties at one hospital if that raises penalties at their other hospitals.

The only way hospitals overall can reduce the national total of penalties they pay is by treating fewer patients. The arithmetic behind this statement is explained here.

The national total of penalties mathematically equals the penalty per excess readmission, times the number of excess readmissions. Excess means above the national average readmission rate.

A. Example of One Hospital

Consider a hospital with a patient mix similar to the national average (adjustments for patient mix are small, so most hospitals end up like the national average). Suppose this hospital admits 500 patients for one of the treatments subject to readmission penalties.

If the hospital readmits 125 patients, it has a 25% readmission rate.

Suppose the national readmission rate is 20%. At this hospital that national rate would have meant 100 readmissions expected.

The hospital has 25 excess readmissions (= 125 ~ 100).

Since readmission rates are fairly well spread above and below the average, close to half of patients are in hospitals with below-average readmission rates, and half are in hospitals with above-average readmission rates. The latter thus have excess readmissions and pay penalties on them. These hospitals face choices described below,

B. Cutting Admissions Cuts the Penalty, for Any or All Hospitals

Suppose the example hospital cuts admissions 4% without changing its 25% readmission rate:

When a hospital cuts admissions (from 500 to 480) while keeping a similar readmission rate (25%) in that smaller pool of admissions, it reduces four important counts:

• admissions (to 480),
• readmissions (to 120 = 25% of 480),
• expected readmissions (to 96, which is 20% of 480), and
• excess readmissions (to 24, which is 120 ~ 96).

Thus they reduce their excess admissions from 25 to 24, cutting their own penalties and the national total of penalties.

If all hospitals cut admissions similarly, they all cut their penalties, even when their readmission rates do not fall.

Data show hospitals have reduced admissions for heart failure, heart attack and pneumonia, and thus reduced the total national penalties.

C. Cutting Readmissions in the Same Way at All Hospitals Leaves All Penalties the Same

Suppose all hospitals, on average, cut readmissions four percent (from 20% to 19.2%) without cutting admissions. They get no benefit, because the penalty per excess readmission goes up; it is controlled by another formula:

The penalty per excess readmission equals the cost of initial treatment divided by the national readmission rate (MedPac June'13 p.99).

For example suppose the initial treatment averages $6,000. A national readmission rate of 20% means a penalty of $6,000 / 0.2 = $30,000. But when the national readmission rate drops to 19.2%, the penalty becomes $6,000 / 0.192 = $31,250.

Suppose the hospital in the example above cuts readmissions 4% (same as the nation) from 125 to 120, without cutting admissions. Now it faces expected readmissions of 96 (= 500 x .192), and has 24 excess readmissions. Its penalty was $750,000 (= 25 x $30,000), and still is $750,000 (= 24 x $31,250).

When admissions stay the same and the national readmission rate goes down, the penalty per excess readmission goes up, and every hospital which manages to cut at the same rate as the nation keeps the same penalty.

D. Cutting Readmissions at Some Hospitals Shifts the Penalty

Hospitals shift the penalty to other hospitals when they cut readmissions. Suppose a hospital cuts its readmission rate by 4% instead of cutting admissions:

If other hospitals on average don't cut their readmission rates, so the national average stays at 20%, the example hospital's expected readmissions do not change (100 = 500 x 20%). The hospital's total readmissions fall from 125 to 120, so excess readmissions drop from 25 to 20, and the hospital's penalty drops 20%.

Now think nationally, where many hospitals cut readmissions. Think of a million patients with 200,000 readmissions (20%).

• (a) 500,000 patients were at hospitals with readmissions below average, and
• (b) 500,000 were at hospitals with readmissions above average. 
• 300,000 each of groups (a) and (b) are at hospitals which cut their readmission rates by an average of 1% of admissions (such as from 25% to 24% of admissions at a particular hospital, or or 19% to 18%), so 6,000 admissions are no longer readmitted.
• 200,000 patients remain at hospitals with excess readmissions which on average make no change in their excess readmissions (some rise a little, some fall a little)
• Hospitals in group (b) which cut readmissions (call them "cutters") saved penalties on 3,000 excess readmissions
• National readmission rate will drop by 6,000 or 0.6% of the million admissions, from 200,000 to 194,000, which is from 20% to 19.4%
• All hospitals face an expected readmission rate which has dropped by 0.6 percentage points (readmissions as percent of admissions at each hospital)
• 500,000 patients at hospitals with readmissions above average (including cutter hospitals) face a lower cutoff for excess readmissions. The cutoff used to be 20% or 100,000, now it is 19.4% or 97,000, which adds 3,000 new excess readmissions, 1,800 at the cutter hospitals, 1,200 at the non-cutter hospitals
• Cutter hospitals cut their net excess readmissions by 1,200, not 3,000
• Penalty per excess readmission will rise from $30,000 to $30,928 (= $6,000 / .194)
• Cutter hospitals pay the higher penalty on all their other excess readmissions. If their 300,000 patients averaged 21% readmissions, which are now down to 20% readmissions, they had excess readmissions 21% ~ 20% = 3,000, and now have 20% ~ 19.4% = 1,800. So penalties dropped by $34 million, from $90 million to $56 million
• If the 200,000 patients at non-cutter hospitals also averaged 21% readmissions, they had excess 21% ~ 20% = 2,000 and now have 21% ~ 19.4% = 3,200, so penalties rose by $39 million, from $60 million to $99 million
• An unknown number of the 500,000 patients are at hospitals with readmissions between 19.4% and 20% which now also have excess readmissions and pay penalties.

Cutting readmissions at some hospitals reduces their penalties, and shifts the penalties to hospitals which did not reduce readmissions as much. Whether the shifting is exact depends on the detailed distribution of readmission rates among the hospitals

E. Other Approaches Do Not Cut the National Total of Penalties

The penalty and national total of penalties could theoretically be reduced by cutting the cost of initial treatment, but Medicare already cuts it as much as they think they can.

Arithmetically the only other way to reduce the national total of penalties is to narrow the dispersion of hospitals below the national rate: raising readmissions in hospitals below the national average. This lets more readmissions be in low hospitals than high hospitals. This does not cause the low-rate hospitals a penalty, and it cuts the number of excess readmissions for high-rate hospitals. No one advocates this or is working on it, and hospitals could not count on it as a strategy.

F. Formulas

US Total =
(penalty per excess readmission) x (number of excess readmissions)

Which is:
(initial payment / readmission rate) x (number of excess readmissions)

Which is:
(initial payment / [total readmissions / total admissions] ) x (number of excess readmissions)

Which is:
(initial payment x total admissions / total readmissions) x (number of excess readmissions)

So US Total =
(initial payment) x (total admissions) x (number of excess readmissions / total readmissions)

The last parenthesis, excess over total readmissions, reflects the dispersion of readmission rates. For example a ratio of 0.04 means the average penalized hospital has 4% more readmissions than the national average.

The ratio of excess over total readmissions has risen for pneumonia and dropped for heart conditions:
2012-15    2008-11
4.06%        3.91%        Pneumonia
3.27%        3.70%        Heart Failure
2.94%        4.07%        Heart Attacks
4.77%                           Hip & Knee Replacements
3.58%                           COPD
3.39%                           Coronary Bypasses

G. Graphs of Heart Failure

The third graph, below, shows excess readmissions. They are the readmissions above the national average rate, between the dark blue and light blue lines in the graph. As discussed at the end of section F, the national total of readmission penalties depends on the ratio of excess to total readmissions. This ratio can be brought down by bringing every hospital's rate closer to the average, as shown with the red dashes. This would mean raising readmission rates at hospitals with below-average rates, which is implausible.

A more plausible alternative of reducing all readmission rates at all hospitals does move down the dark blue and light blue lines, and does not change the ratio of excess to total readmissions, so it does not reduce the national total of readmission penalties.

In the readmissions spreadsheet the dollar penalties for each diagnosis, at each hospital, are estimated by multiplying the number of excess readmissions at each hospital, times the US average penalty adjusted for the local cost level. The US average includes the "Base Operating DRG Payment Amount = Wage-adjusted DRG operating amount + new technology payment, if applicable". DRG stands for Diagnostic Related Groups.

Formal readmissions penalty rules are at 42 CFR 412.152 and 154.

The number of excess readmissions at each hospital, for each diagnosis, derives from two numbers in Medicare's "Readmissions Supplemental File" for the current year:

1. Medicare provides the ratio of each hospital's own readmission rate, to the national readmission rate (adjusted for patient mix): (readmit@hosp/admit@hosp) / (readmit@US/admit@US)
   
2. The readmissions spreadsheet subtracts one from that ratio to get just the excess readmission rate at each hospital (still as fraction of national readmission rate): (excess@hosp/admit@hosp) / (readmit@US/admit@US)
3. The spreadsheet then multiplies by the national readmission rate (readmit@US/admit@US), to get the hospital's own excess readmission rate:  (excess@hosp/admit@hosp)
4. The spreadsheet then multiplies by the number of admissions at the hospital (also provided by Medicare, in the same file) to get the number of excess readmissions at the hospital: (excess@hosp)

Medicare's full payment calculation is described in the Payments section. For the local cost level at each hospital, the readmissions spreadsheet calculates a weighted average of 2 numbers, which Medicare provides in the "Impact File" for the current year:

1. Wage index for labor-related share of operations
2. Cost of living factor for nonlabor share of operations (1 except in Alaska and Hawaii)

Besides dollar estimates described above, the readmissions spreadsheet also shows penalties as a percent of hospital revenue for each of the 6 diagnoses affected. Section F below explains how this is estimated.

In the financial spreadsheet the total readmission penalty at each hospital is Medicare's Readmissions Adjustment Factor times each hospital's "wage-adjusted DRG operating payment plus any applicable new technology add-on... [including] adjustment for transfers" (42 CFR 412.152), same base as VBP, with a different adjustment factor. Subtotals for the 5 diagnoses are based on the national cost of treatment and each hospital's excess readmissions, as shown in the readmissions spreadsheet.

The dollar amounts of VBP penalties and bonuses in the financial spreadsheet are estimated by multiplying a VBP Adjustment Factor times Medicare's "wage-adjusted DRG operating payment plus any applicable new technology add-on... [including] adjustment for transfers" (42 CFR 412.160, DRG means Diagnostic Related Groups). Medicare's public financial statements do not separate DRG into operating and capital, so the spreadsheet finds what percent is operating at each hospital, generally 93%.

Medicare provides the Adjustment Factors in .zip files, and calculates them from several measures (pdf item 25). The percent adjustments are scaled so the worst penalty is no more than 1.5% in FY 2015, 1.75% in 2016, 2% in 2017+, and the total bonuses equal the total penalties. After Medicare's correction, the actual range in 2015 was from a 1.24% penalty to a 2.09% bonus.

Formal VBP rules are at 42 CFR 412.160 to 167.

This "Value Based Purchasing" applies to hospitals, and is not the same as the "Value-Based Payment Modifier" also called "Value Modifier," which applies to doctors and doctor groups.

Electronic health records are problematic, since they have enabled vast breaches of medical privacy for 30,000,000 patients. Great systems are rare, though ideally they would show key information clearly in the way that each clinician needs it. Bad systems are not read by clinicians, are full of errors, generate erroneous prescriptions, and interrupt doctors when listening to patients. (Thoughtful article on referrals and funny video.) Electronic records often send prescriptions to pharmacies electronically, but far fewer can send a cancellation order to correct a mistake or cancel refills. Only a third of prescribers and 40% of pharmacies use software certified to handle cancellations, so only about 13% of cancellations can be expected to go through. Pharmacies often generate refills automatically, so patients can get undesired medicine for long periods, thinking their doctor ordered it.

Finding electronic records for a patient is hard, since most names and birth dates are common. Other items like address, phone number, and insurance number can change. All items can have typos. Addresses can be abbreviated many different ways. Some people do not want to give their Social Security numbers, which can have typos too. In the last 100 years, there are only 36,500 unique birth dates. Some names are more common than that, and even names held by just a few thousand people can have common birth dates, since some names were common in some years. Medical systems try to avoid matching you to anyone else's records, so they may not match you to your own records if there is any ambiguity. Study by Pew.

When people compare hospitals and doctors, and "control for the differences among patients," the risk adjustment is pitifully poor.

Since risk adjustment is ineffective, hospitals can improve their results by denying care to the patients with the worst conditions (“We can’t help you…”), giving the hospital a better “success” rate. Attention to outcome measures leads to denial of care to the sickest.
​

• “the most assiduous work on risk adjustment has produced tools of only moderate power. The prospects for solving this problem with improved risk adjustment are not promising.[4],[5]” http://medicaring.org/2014/12/16/protecting-hospitals/
• “You can’t get all the right variables on the page” said Berwick, former Medicare Administrator. ​https://jamanetwork.com/journals/jama/fullarticle/2673607

As a very professional and problematic example, Medicare’s adjustment of health condition (HCC) is poor. It explains only 2% to 12% of the total variation actually caused by patient mix (p.65 table 3-22, “r-squared” of version 21).
http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/downloads/evaluation_risk_adj_model_2011.pdf
​
Medicare’s adjustment of patient mix for readmission penalties is also poor. For example, their equations explain 3% of the variation in readmissions among heart failures (p.30), 5% for heart attacks (p.30) and pneumonia (p.29). These percents date from 2008 and have not been updated.
http://www.globe1234.info/medicare/category/medicare-texts
Medicare now shows c-statistics between 0.61 and 0.66 for readmission penalties,
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&cid=1219069855841
 The c-statistic has a scale of 0.5 to 1, where 0.5 means their equations do no better than chance, and 1 means their equations are perfect. So some equations are little better than chance, and they still rate hospitals with them. “Models are typically considered reasonable when the C-statistic is higher than 0.7 and strong when C exceeds 0.8”
http://mchp-appserv.cpe.umanitoba.ca/viewDefinition.php?definitionID=104234
​so none of their equations is “reasonable,” and they still charge hospitals hundreds of millions of dollars of penalties with them each year, driving hospitals to reduce admissions among the sickest.
​
The Society of Thoracic Surgeons (STS) has its own risk adjustment.

• https://publicreporting.sts.org/chsd-risk-model
• https://www.sts.org/sites/default/files/documents/Shahian-2018-Risk-Model-Part-1-of-2.pdf
• https://www.sts.org/sites/default/files/documents/Shahian-%202018%20Risk%20Model-Part%202%20of%202.pdf 
• https://ars.els-cdn.com/content/image/1-s2.0-S0003497518303710-mmc1.docx has c-statistics

They give “c-statistics” ranging from 0.616 to 0.826, so some of their equations are not "reasonable," and are little better than chance, but they use them to compare hospitals.

A reader wanted to know when updates happen, so I will try to list them here, starting July 25, 2014.

​2019 Jan 13 - updated estimate of mental changes after CPR from better source
​2019 Jan 5 - added 4-page pamphlet on DNR choices and 2018 research on deaths from readmission penalties
​2018 Dec 17 - updated CPR and DNR page with clearer explanations
2018 Dec 6 - added description of CPR and more detail on its organ donation possibilities
2018 Dec 1 - added options for advance directives
2018 Nov 27 - noted that able-bodied people under-estimate quality of life of people with disabilities, and life in a coma.
2018 Oct 29 - added treatment links to drugs page. Updated advance directive form and CPR info.
2018 Oct 5 - added note about 2019 readmission penalties. Updated information on VA hospital quality.
2018 Oct 2 - moved Coma explanations to a new section. Updated AMA guidance on patient-doctor negotiations about end of life care
2018 Sep 12 - updated data and graph on CPR and DNR
2018 Sep 9 - added comparison of ways to let medics reach your emergency information instantly online.
2018 Sep 8 - added deadly results of measuring medical outcomes in Veterans Affairs Medical Centers
2018 Aug 13 - added non-Medicare cost data for drugs and office visits.
2018 Aug 8 - added new guidelines for coma prognosis and videos to page on medical representatives
2018 Aug 1 - updated penalties on nursing homes for sending patients to hospitals too often
2018 Jul 27 - added links on telehealth, nursing home data, and Medicare Advantage data on encounters with beneficiaries
2018 Jul 6 - added links on Medicare premiums and FDA regulation of software apps.
2018 Jun 20 - added to advance directives page: report on Gosport hospital overprescribing painkillers, causing deaths of 456-656 patients, and added to drugs page: complexities of prior authorization
2018 Jun 14 - updated data on specialists 2012-2016
2018 Jun 3 - updated medical travel
​2018 Mar 5 - Added pills advice and international comparisons
​2017 Nov 7 - Added life expectancy adjustments for health status
​2017 Sept 21 - Updated maps
2017 July 14 - Added 2015 map and spreadsheet of appointment lengths for general doctors
2017 June 19 - Added 2015 list of specialist doctors
2017 May 25 - Added Conflict of Interest to doctor ratings page
2017 May 23 - Updated FOIA page and spreadsheet of all agency processing times
2017 May 10 - Updated ACO public information, waivers, odds of a bonus for cutting patient care.
2017 Apr 27 - Added Medical Letter to Drugs page and Eye issues to Specialists page
2017 Apr 15 - FOIA results, response times, fees, settlement negotiations
2017 Mar 10 - Added detail on problems with e-cancellation in Drugs page 
2017 Feb 27 - Rearranged Specialists page, highlighting and expanding Step C - Other Information for Choosing Doctors
​2017 Jan 30 - Wider text, more on costs and referrals
2016 Dec 22 - added header about use of cookies, and noted that federal retirees' price matching to Medicare excludes hospital outpatient charges
2016 Dec 8 - added sites on FOIAs
2016 Nov 23 - estimated 8,000 heart failure deaths per year, caused by readmission penalties
2016 Nov 3 - rearranged penalty calculations and hospital quality. Added NICHE levels of geriatric care
2016 Oct 21 - updated readmission penalties to FY2017, with bypass operations for the first time. Added detail on Healthgrades data about hospitals and doctors
2016 Sep 27 - noted BCBS of NC costs on Specialists page
2016 Sep 18 - new format to name medical representative and noting organ donation.
2016 Sep 7 - updated codes for medical procedures with 2014 costs and volume
2016 Aug 30 - gave links to search for hospitals with the most experience in each procedure
2016 Aug 26 - put specialists on a new page, and re-wrote it with instructions for using Medicare's interactive site to search for specialists.
2016 Aug 23 - corrected patient strategies to note how hard it is to drop Medicare Part A.
2016 Aug 22 - lists of independent doctors and nursing home organizations
2016 Jul 8 - 2012-2014 data on 683,000 doctors & others, to find those who give long appointments & treat you in multiple settings
2016 Jun 10 - Signs and letters written by Medicare, telling patients about ACOs
2016 Apr 2 - Doctor's incomes, hours, satisfaction, discipline
2016 Jan 6 - More info on Drugs
2015 Nov 30 - Renamed Advance Directive Form to emphasize Medical Representative, and updated CPR statistics with success outside hospitals.
2015 Nov 17 - Improved labels in financial data, and added Google sheet of doctors' office hours.
2015 Oct 22 - Improved labels in office hours data, and gave numbers of new patient appointments instead of the ratio between later and new appointments.
2015 Oct 16 - Updated Hospitals.xls+Penalty.xls with minor price changes issued Oct.5. Also corrected total US penalties to exclude Maryland, which is exempt from penalties. Removed blank columns, since sorting is sometimes blocked by blank columns. Reformatted advance directive pdf. Clarified definition of 1st visit with a patient.
2015 Oct 3-6 - Linked to better file to find doctors' phone numbers. Described California's ratings of hospitals. Stressed agent in advance directive. Expanded Excel instructions. Noted new data on types of patients seen by each doctor.
2015 Sep 30 - Added links on selecting medical representative; changed background photos
2015 Sep 2 - Better labels for Doctors, dropped diabetes education (30') to stay under 200 MB
2015 Aug 22 - Clarified doctor files & advance directives; added a Creative Commons license
2015 Aug 9 - Added data on hospitals cutting treatment.
2015 Aug 6 - Slightly better sort of Doctors, added longer patient education, better labels of countries
2015 Aug 5 - Updated readmission penalties to October 2016
2015 July 25-31 - Compiled ratings of doctors on one page 
2015 July 1-9 - Added length+number of appointments for 636,000 generalist doctors. Updated data on 230,000 specialists. Better advance directives.
2015 Jun 12 - Simplified example of advance directives 
2015 Apr 25 - Added percent readmitted for various causes
2015 Apr 7 - Added state totals for each penalty
2015 Mar 20-23 - Added penalties, address, latitude + longitude to Hospital financial statements. Fixed omission of last character of amounts. Expanded description of penalties.
2015 Mar 14 - Added name, address, phone & hospital chain to Hospital financial statements
2015 Mar 4 - Re-ordered columns, and added web links in spreadsheets of doctors
2015 Mar 3 - Added spreadsheets of Hospital financial statements, and highest-volume 25 doctors for each procedure
2015 Mar 2 - Added note on how high-volume doctors get their start
2015 Jan 15-Feb 22 - Article on Advance Directives
2015 Jan 23-26 - Reduced readmission penalty estimates, to omit capital and other costs which are not subject to penalties, and use Medicare's October updates.
2015 Jan 7-14 - Split off sections about unnecessary care, knees, legal searches & patient reviews
2014 Dec 31 - Published article on selecting doctors by experience & other measures
2014 Dec 30 - Updated ACO list with 89 new groups starting in 1/1/2015
2014 Dec 18 - Corrected in my files, errors which Medicare had in 650 doctors' state or zip code.
2014 Dec 1-12 - Added research on doctors' experience
2014 Nov 29 - Added maps of doctors' experience
2014 Nov 26 - Added more complete files on doctors' experience

2014 Sep 8 - Added input on 2015 Dietary Guidelines
2014 Sep 2-5 - Added comments on Medicare ACO rules, an option to create nutrition graphs in USDA file of nutrients, and more comparisons of protein sources, in site & USDA file.
2014 Aug 22 - Re-sorted USDA file of nutrients, added nutrition labels for protein alternatives
2014 Aug 18 - Added Calories in the nutrition labels proposed in the salt section, and identified almond milk with less sodium than average
2014 Aug 7 - Updated readmission rates and penalties with data from p.756 of Medicare's final rule, instead of p.1495. Both tables have the same title and have slightly different numbers. Medicare says p.756 applies to readmissions penalties.
2014 Aug 6 - Added the idea of clearer Explanations of Benefits, as a cost-saving alternative
2014 Aug 4 - Updated readmissions with data released by Medicare today
2014 July 27 - Listed doctors' experience on home page, with files on the Northeast and elsewhere
2014 July 25 - Adjusted readmission penalties at each hospital, for variations in local costs

Medicare is trying to cut the cost of serving dialysis patients by paying dialysis centers and kidney doctors for cutting costs, even if the patients die.

91% of dialysis patients do not participate in Accountable Care Organizations, which have their own incentives to cut costs, so Medicare is trying to set up groups just for kidney patients. These are called End Stage Renal Disease seamless care organizations (ESCO). Dialysis patients are "1.3% of the Medicare population and accounted for an estimated 7.5% of Medicare spending, totaling over $20 billion in 2010."

ESCOs will receive 50%-75% of Medicare's savings on dialysis patients, compared to baseline costs. "Members must place their fiduciary duty to the ESCO before the interests of any ESCO participant" (Medicare's explanatory slides p.39)

They have 23 quality measures, one of which is the death rate. Medicare has not yet announced the weight to be given each measure, but judging by weighting for Accountable Care quality measures, no one measure will have much weight, including the mortality rate, so ESCOs can meet quality standards without minimizing deaths. Since a death stops all costs, the financial rewards for death are large.

Each "beneficiary’s first visit to a given dialysis facility during a particular period will prospectively match that beneficiary to the dialysis facility, and by extension the ESCO, for the upcoming performance year" (Request for Applications-RFA p.12). So a patient can avoid the incentives by changing to another dialysis facility, not part of the same ESCO. An email from Dr. Alefiyah Mesiwala, Medicare's leader for the program, says, "Once a beneficiary is seen by an ESCO facility, they are then matched for the life of the entire model unless the beneficiary dies, has a transplant, or becomes ineligible as stated in the RFA. Once a beneficiary is aligned to a facility, even if that beneficiary visits multiple facilities or providers in a given performance year, all costs associated with that beneficiary will be attributed to the ESCO facility the beneficiary was initially matched to per the matching rules outlined in the RFA" (5/5/2014).

The "first visit" rule gives an incentive for dialysis centers to be unable to find space for high risk patients (old or with multiple sicknesses), so they go to another ESCO at least for the first visit.

When patients find themselves in an ESCO, patients can avoid the cost-cutting incentives by finding a dialysis center which is not part of the same ESCO, and using doctors who are also not part of that ESCO. These other centers and doctors will not face the conflict of interest of being rewarded for cutting costs, so patients are more able to trust their recommendations and treatment decisions.

Dialysis companies and researchers doubt the ESCOs will be successful.

These topics are on a separate page.

(The "comments" link above does not send to Medicare; it just puts comment on this page.)

2015

Medicare wants comments by September 8 on fining hospitals in a quarter of metro areas, if their patients who get knee or hip replacements have total Medicare costs above average. "Total" includes costs far beyond the joint replacement, since it includes continuing treatment of pre-existing chronic conditions, like diabetes, dialysis, AIDS, etc. (here, here, and here).

This is rationing by denial of costs: patients with chronic diseases would continue to have above-average costs even after perfect joint replacements, which hospitals cannot afford. So they will hear, "You are not a good candidate for joint replacement." Yet these chronically ill patients especially need the improved mobility and ability to exercise that a joint replacement can provide. Medicare acknowledges that hospitals will try to reduce costs as part of this program, which is why they exclude their favorite technologies, "We do not believe it would be appropriate for the CCJR model to potentially hamper beneficiaries' access to new technologies."

The Center for Healthcare Quality and Payment Reform has a good analysis. Patients with above-average Medicare expenses would be able to avoid the lack of local treatment by going outside their area, reminiscent of the days when divorce or abortion were legal in some states, and people traveled to get them. The adopted final program lists the areas covered in a table. As usual Medicare excludes Maryland, where Medicare has its headquarters and many Medicare family members and retirees live. This time they exclude Washington, DC too. They cover New York City and much of New Jersey, so patients will need to go upstate, or to Connecticut or Long Island. They cover Los Angeles and Orange counties, so patients will need to go to Ventura, Santa Barbara, Riverside, San Bernardino or San Diego. It will be interesting if orthopedists get hospital privileges in those outer counties, to treat their higher-cost patients.

However hospitals and doctors will not be able to tell sicker patients that they might easily get treated in another county, since Medicare will monitor and penalize their efforts to shift care. Patients will have to find out on their own, while lacking mobility because of the poor joint.

"An unintended consequence of a payment model such as (this) may be the 'cherry-picking' of low risk patients," according to a February article written by Drs. Alexandra Page and Mary O'Connor, posted on the  website of the American Academy of Orthopaedic Surgeons. "Health systems and surgeons will be subject to financial incentives to avoid patients at higher risk of complications and hence, more expensive care." The two doctors are being polite to call it "unintended." Medicare has been warned about cherry-picking repeatedly, so it is clearly Medicare's goal.

2014

You can read comments on new incentives for Accountable Care Organizations to reduce care, which were due September 2, 2014, including mine. 

At the same time the Center for Healthcare Quality and Payment Reform provided substantial and critical comments on other aspects of hospital payments which can hurt patients.

You can read comments on hospital payments which were due June 30, 2014, including mine. 

 2013

The public submitted comments to Medicare's 2013 rules by June 25, 2013, and you can read them, including mine.

The American College of Surgeons commented to Medicare that doctors and hospitals do reduce care when they respond to readmission penalties and other incentives:

• "penalizing hospitals that care for the highest acuity Medicare patients and the potential that these hospitals will decrease their care for such patients, thereby creating an access issue."
• "catheter is removed as soon as possible in order to comply with the measure, resulting in complications"
• "incentives to limit access to care to such high risk patients [with resistant infections]"
• "discourage the early diagnosis of PE or DVT [clots]... encourage the use of overly aggressive anticoagulation immediately after surgery."
• "decrease in care of patients with small bowel obstruction"

80 Members of the House of Representatives have co-sponsored bill HR 4188, which redefines readmissions to omit "transplants, end-stage renal disease, burns, trauma, psychosis, or substance abuse." This change protects those patients, but half the hospitals will still be above the national average, pay large penalties, and have incentives to deny care to fragile elderly outside these protected classes.

Please support a better fix: ask Congress to change HR 4188 to redefine "excess readmission" in1886(q)(4)(C)(ii) rather than "readmission" in 1886(q)(5)(E). This technical difference means the national average would not change, and the narrower definition of "excess readmission" means far fewer hospitals would be above that national average and face penalties.

4 Senators have introduced a bill to adjust readmissions for income, education, and poverty rate of the patients or neighborhood of the hospital, so hospitals which serve poor or poorly educated patients are not penalized.

Globe1234 is aimed at diligent patients looking for doctors, and trying to understand incentives in the healthcare system.

It's also aimed at primary care physicians looking to find details about specialists' practice, when deciding where to refer patients having various conditions.

The site covers specialist doctors, generalist doctors, privacy, end-of-life planning, salt as a nutritional and practical issue, hospitals' financial position, government penalties and incentives. It has a large amount of information on Medicare, because of Medicare's pervasive influence on care.

The site editor is Paul Burke, an independent researcher who has managed and analyzed data for HUD, Congress' Office of Technology Assessment and the UN Development Program.

He is not financed by Medicare or the healthcare industry. There are links to some books with helpful information, but they do not generate fees for the site.

His career has focused on analysis of data.

• He has consulted for the UN Development Program on issues in education, development, the environment, economics, poverty, gender, and government spending.
• He chaired the committee on member surveys of a health care cooperative with 100,000 members in the 1980s.
• He has led seminars at the University of California-Berkeley, Columbia University, Fordham University, Venezuela's National Council on Human Resources, and the International Labor Statistics Center of the US Department of Labor.
• He was President of the Jefferson County (WV) Planning Commission.
• For HUD he designed and analyzed national surveys. He did research on planning, counseling, subsidized and free-market housing.
• As a sworn Census agent, he analyzed data about individuals on the Census Bureau's head office mainframe.
• He has an undergraduate degree in Mathematics, and a Master's degree in Interdisciplinary Urban Studies, both from Brown University.
• He also has a website on election security, VoteWell.net

Paul Burke
PO Box 1320
Shepherdstown, WV 25443
Burke@Globe1234.com
The designated agent for any notice under 17USC512(c)(3)(A), claiming copyright infringement, is the same person and address, also at CopyrightNotice@Lang1234.com, 304-876-2227

Readmission Penalties:
2015 August 10 - Hospitals Treat Fewer Seniors when Medicare Charges Penalties
2014 August 6 - Hospitals Fined $529 Million, or here
2014 May 30 - Readmission Penalties Put Burdens on Hospitals, or here
          Coverage by Bloomberg BNA
2013 August 14 - Size of Readmission Penalties, or here
          Coverage by EHRIntelligence, Orthopedics This Week

Accountable Care Organizations:
2014 July 15 - Medicare Plans to Penalize Hospital Use, or here
2014 February 12 - Medicare Pays Doctors To Cut Treatment

Comments on 2015 Diet Guidelines

I try to make this site clear for young and old. I realize there is a long way to go.
For readers who need to analyze the statistics here, there are suggestions in the page on Excel, including links for statistics at the bottom of that page.

Here are some thoughtful articles on presenting information.

• CMS Toolkit Part 9, "if your written material is for older adults"
• HHS Health Promotion,tips for websites
• NIH MedlinePlus Health Literacy issues
  
• NIH, "Making Your Printed Health Materials Senior Friendly"
• Institute of Medicine, "A Prescription to End Confusion"

These articles have good suggestions, but their figures on adults' health literacy are too low. Adults are probably more literate than they say. Their numbers come from an unreliable 2003 voluntary study of people 16 and older, with only 60% response in households, and no nursing homes. They did not pay or reward participants, so there was no incentive to complete the long survey or try hard on long reading assignments. They started with 35 pages of sensitive questions on language, health, income, welfare, work, voting, parenting, etc. Then they tested people's reading ability for 45 more minutes.

They published only 4 of the ability questions. The 4 questions have big flaws, as is  typical  in Education Department surveys. Health issues are indeed hard, but this survey did not measure well. They said:

1. 74% answered correctly question N110101 on why finding one's blood pressure is hard*
2. 64% answered correctly question C080201 by finding a small warning in a medicine label. However the real-world problem isn't finding this warning when you're told to look, the problem is taking time to look, and then remembering all the warnings.
3. 60% answered "correctly" question C080101 aboutwhat time to take a medicine which must be 2 hours after lunch. The question said when lunch started, not when it ended, so the right answer depends on how long you think lunch takes.
4. 40% answered correctly question N110201 by calculating the Black death rate from the White rate and the ratio of the rates*

* The 74% and 40% questions required reading a brochure on Blacks dying from high blood pressure, with data from the 1960s. No surprise that 26% of adults didn't have time or interest to pore over a brochure about death so long ago, and 60% didn't calculate a Black death rate. The second column of the brochure says "The only way you can be sure is to have the doctor check your blood pressure." Why do they think home machines, or nurses, who usually take it, are not good enough? Why would people keep reading a brochure with such suspect advice?

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