Post CES reflection on role of technology and Alzheimer's.
Boston, mid-May, 2016
Hospitals say don't come back -- but do they mean it? Apparently hospitals needed the current push from the government to figure out a way to keep patients, especially the elderly, from being re-admitted within 30 days of their departure. So now many hospitals are on the case, working their way through individual pilot programs designed the way they see fit, one pilot program at a time. In an article whimsically titled 'Don't Come Back, Hospitals Say,' today's WSJ offered up Boston University's 'Louise', a 'virtual discharge advocate' wheeled up to bedside (aka a software app) to offer discharge instructions to patients (post hospital regimens, including lists of meds) as they ready to leave the hospital. BU's Project RED (Re-Engineered Discharge) converts into a packet of materials that offer up a medication dosage package and instructions.
Why are hospitals so interested now? Money, of course. Medicare will reduce reimbursements in 2012 to hospitals who re-admit patients within 30 days. Nationwide, a number of 'Project REDs' became eligible for funding as part of a $500 million Medicare grant program to reduce re-admissions to hospitals of the 1 in 20 elderly who return within 30 days. Actual nurse discharge advocates are assigned in many hospitals at time of admission -- educating patients on their diagnosis, follow-up appointments and medication plans -- and tracking re-admission reduction goals of 10%. One executive offered up one barrier to wider efforts for avoiding re-admission avoidance programs -- spending "a significant amount of money that isn't reimbursable." Let's think about that. Is the coffee shop staffer reimbursable? The flower shop clerk? The TV sets and the set repairman? Bill processing staff? Hospitals have been bundling costs together into the overhead of care since their opening day, so I'm really not buying that excuse. But Medicare believes it to be so, and is granting them money to 'reengineer' discharge.
So Medicare is a cross-hospital program that does not dictate practice. How sad, however, that every hospital has to read about the other hospitals' initiatives in the WSJ after they have implemented their own unique program. Some involve 'transition coaches' who call the patient up, some even involving pharmacists making house calls to home-bound patients. At the end of the pilot period and when the new reimbursement limitations kick in, all the autonomous pilot administrators will decide what has worked for them and what doesn't -- none 'forced' to deploy anyone else's best practice. Meanwhile, despite the use of Louise and the printouts, no actual tech deployed in the home was mentioned as part of the 'Don't Come Back' programs. No chronic disease monitor of any type, not even an automated voice response system. Nothing for congestive heart failure, heart attack, and pneumonia -- the most common re-admission diagnoses. And hospitals are focused only on the 30-day period, after all. Presumably after the 30 day period is up and your stay is once again reimbursable, you are welcomed back into your role, which after all, is to keep the hospital beds full and utilization of fixed resources fully committed (see FastStats from CDC for 2010 utilization).
'Technology when you want it, people when you don't -- or vice versa'? Meanwhile, Dr. Joseph Kvedar's recent cHealth blog post pondered the trend in other industries, starting with insurance of offering technology first, people as a follow-up exception when you need more help -- examples like online reservations, ATM machines, pumping gas, etc. He tried to imagine an approach like that for heatlhcare, and research confirms that people actually prefer getting their discharge instructions from a virtual discharge advocate -- because they can ask the same questions over and over. He believes that the 'technology when you want it, people when you don't' concept should apply to healthcare -- and he quotes Steve Jobs on what market research was done before the iPad was developed: "None, it isn't the consumer's job to know what they want." (Of course, so far, Apple has done well with that strategy -- but history is littered with failures of forgetting to ask the customer before spending fortunes on development -- some of those were Apple's.) Dr. Kvedar then charges cHealth (c is for 'Connected') entrepreneurs to make the experience of technology so compelling that people will choose tech over people when it makes sense.
What's wrong with these pictures? The problem? Your money and mine, one way or another, is threaded throughout. Surely you have enjoyed an information-rich conversation with the billing checkout person in a doctor's office about what the experience 'costs': ('full price is X, presumably billed to the insurance company, but you have a deductable and in that case it is Y, and then because you have insurance, it dictates that we charge you with the following: n(X-Y). But of course, for your diagnostic code, 3 months of follow up visits are included for 'free' in that charge.' Get it? Of course not -- this is not a consumer decision-making industry with a published price list and we aren't buying iPads that we didn't know we needed. What the consumer prefers with healthcare, to contradict Dr. Kvedar, is to be appropriately cared for and ideally monitored after we receive the care to make sure we're still okay and in compliance with a regimen thought through to keep us well. Nobody said that this monitoring must come from a real person -- and we didn't say we preferred it. How would we know? Why hasn't insistence on telehealth monitoring post discharge become standard practice? That monitoring could start with an automated phone call system -- press 1 if the swelling is the same as it was yesterday and could proceed to 'please step on the scale and come back to the phone to report your weight'. Or 'have you forgotten to take your meds today?'
What hospitals and doctors prefer -- continuity of revenue and income. Perhaps you read the article recently about doctors' preference for higher-paying subspecialties versus primary care. Perhaps you heard the NPR story about the physical therapist who refuse to take insurance because the reimbursement is too low to be worth the paperwork. Now add the reliance on Medicare to fund pilots targetting a reduction in 30-day re-admissions. In fact, costs as they relate to reimbursement drive a practitioner's behavior. That is why technology deployment is so half-hearted and partially-deployed throughout the health-related industries -- and why only when reimbursement is interrupted, too much of a hassle, or when demand exceeds supply, meaning that it is not available when you need or want it, does technology of any type cautiously dribble its way into health care processes. But what the consumer needs, maybe, is less hassle (aka more technology). What we all need are lower costs and adequate access -- which may mean that reimbursement is reduced for utilization of fixed infrastructure and increased for methods that match method to need. And that need may mean we, and especially the older adults who use so much of that fixed infrastructure, should instead be monitored at home over time, contacted based on out-of-bounds conditions, offered consultations via e-mail, phone, video, or other tech-enablement. At that point, we know that hospitals really mean it when they say 'Don't Come Back'.