Healing medicare hospital recidivism: Causes and cures

American Journal of Law and Medicine

Volumn 37, Issue 1, 2011, Pages 41-80

  Marciarille, Ann Marie ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; ECONOMICS; HEALTH CARE POLICY; HEALTH CARE QUALITY; HOSPITAL; HOSPITAL DISCHARGE; HOSPITAL READMISSION; HUMAN; MEDICARE; REIMBURSEMENT; STATISTICS; UNITED STATES; UTILIZATION REVIEW;

HEALTH CARE REFORM; HOSPITALS; HUMANS; MEDICARE; PATIENT DISCHARGE; PATIENT READMISSION; QUALITY OF HEALTH CARE; REIMBURSEMENT, INCENTIVE; UNITED STATES; UTILIZATION REVIEW;

EID: 79958164834     PISSN: 00988588     EISSN: None     Source Type: Journal    
DOI: 10.1177/009885881103700102     Document Type: Review

References (254)

1. BOARDS OF IRUSTEES OF THE 1-ED. HOSPITAL INS. & FED. SUPPLEMENTARY MED. INSURANCE TRUST FUNDS, 2009 ANNUAL REPORT 2(2009), http://www.cms.gov/ ReportsTrustFunds/downloads/tr2009.pdf.
2. MEDICARE PAYMENT ADVISORY COMM'N, HEALTHCARE SPENDING AND THE MEDICARE PROGRAM 6(2010), http://www.medpac.gov/documents/JunlODataBookEntireReport.pdf.
3. Karen Tumulty & Kate Pickert, The Five Keys to Health Reform's Success: What Does It Do to Medicare?, TIME, Mar. 25, 2010, http://www.time.eom/ time/specials/packages/article/0, 28804, 1975068-1975012-1975001, 00.html.
4. JONATHAN OBERLANDER, THE POLITICAL LIFE OF MEDICARE 25(2003).
5. Id. at 31.
6. THE COMMONWEALTH FUND, WHY NOT THE BEST?: RESULTS FROM THE NATIONAL SCORECARD ON U. S. HEALTH SYSTEM PERFORMANCE, 2008, at 32, http://www. commonwealthfund. Org/-/media/Files/Publications/Fund Report/2008/Jul/Why Not the Best Results from the National Scorecard on U S Health System Performance 2008/Why-Not-the-Best-national-scorecard-2008pdf.pdf.
7. http://www.commonwealthfund.org/Content/Charts/Report/ Why-Not-the-Best-Resultsfrom-the-National-Scorecard.
8. Although there is no consistent definition of preventable Medicare readmissions, this paper offers the following working definition: a Medicare beneficiary's return to acute care within thirty days of discharge for the same or a related purpose. A Medicare beneficiary discharged after a surgical procedure who returns to a different acute care facility with a medical diagnosis of hospital acquired infection from the surgical procedure, for example, would fall within this definition. When reference is made to Medicare readmissions beyond the thirty day window, specific note is taken. One of the earliest challenges of health care reform attempts to tame preventable Medicare readmissions will be to standardize definitions.
9. Preventable acute care readmissions for Medicare beneficiaries are the symptom of the disease: the failure to integrate Part A and Part B care. This paper addresses the symptom, the disease, and possible cures.
10. Tax Equity and Fiscal Responsibility Act of 1982, 42 U. S. C. § 1395ww (2006).
11. Although there is some dispute over whether readmission rates are a better measure of quality or of outcome, there is ample reason to consider them as both.
12. Political necessity may play some role in Medicare's one size fits all design as a social insurance program.
13. Hospital readmissions are sometimes called "bounce backs" or "frequent flyers".
14. Paul Kleyman, Advocates Fight for Elder Patients' Rights, Safety, NEW AM. MEDIA (Dec. 21, 2009), http://news.newamericamedia.org/news/view-article.html? article-id=d7c97c8a8ee6eOc4c52 4a9833ba75dbc.
15. Joe Queenan's description of his alcoholic father's hospital discharge travails in CLOSING TIME: A MEMOIR is one for the ages: "The day after our trip to the funeral home, the hospital made the absurd announcement that my father was ready for discharge and could medicate himself at home until the situation deteriorated.... I responded to this lunacy by giving his doctor an earful."
16. JOE QUEENAN, CLOSING TIME: A MEMOIR 326(2009).
17. See Rohit Bhalla & Gary Kalkut, Could Medicare Readmission Policy Exacerbate Health Care System Inequity?, ANNALS INTERNAL MED. (Nov. 30, 2009), http://www.annals.org/content/early/2009/ll/19/0003-4819-152-2-201001190-00185. full;
18. Scott Harris, Discussion Grows Over Hospital Readmissions, ASS'N AM. MED. COLLS. (June 2009), https://www.aamc.org/newsroom/reporter/june09/89176/june09- readmits.html.
19. MEDICARE PAYMENT ADVISORY COMM'N, REPORT TO THE CONGRESS: PROMOTING GREATER EFFICIENCY IN MEDICARE 103 (June 2007), http://medpac.gov/documents/ Jun07-EntireReport.pdf;
20. see also Gerard F. Anderson & Earl P. Steinberg, Hospital Readmissions in the Medicare Population, 311 NEW ENG. J. MED. 1349, 1349-53(1984) (observing similarly high costs between 1974 and 1977).
21. See Stephen F. Jencks et al., Rehospitalizations Among Patients in the Medicare Fee-for-Service Program, 360 NEW ENG. J. MED. 1418, 1421(2009), http://www.nejm.org/doi/pdf/10.1056/NEJMsa0803563;
22. see also Laura Landro, Keeping Patients from Landing Back in Hospital, WALL ST. J., Dec. 12, 2007, at D1, http://online.wsj.com/article/ SBll9741713239122065.html.
23. Debra J. Lipson & Samuel Simon, Quality's New Frontier: Reducing Hospitalizations and Improving Transitions in Long-Term Care, MATHEMATICA POLICY RESEARCH (Mar. 2010), http://www.mathematica-mpr.com/publications/pdfs/health/ LTQA-brief.pdf.
24. MEDICARE PAYMENT ADVISORY COMM'N, supra note 16, at 107.
25. See, e.g., Anderson & Steinberg, supra note 16, at 1349;
26. see also Hector Bueno et al., Trends in Length of Stay and Short-Term Outcomes Among Medicare Patients Hospitalized for Heart Failure, 1993-2006, 303 JAMA 2141(2010) (studying thirteen years of Medicare readmissions data on heart failure admissions);
27. Jencks et al., supra note 17, at 1421 (examining 2004 data).
28. See Press Release, Ctrs. for Medicare & Medicaid Servs. (CMS), New Ratings for Americas Hospitals Now Available on Hospital Compare Web Site (July 9, 2009), http://www.cms.gov/apps/media/press-releases.asp (search keyword: ratings).
29. See Michael O. Leavitt & Robert Krughoff, Release of Medicare Data Could Help Reform Health-Care System, WASH. POST, Mar. 19, 2010, at A23.
30. Medicare managed care data is less accessible, though a comparison of success in avoiding unnecessary Medicare rehospitalizations between it and fee for service Medicare would be a worthy enterprise.
31. MEDICARE PAYMENT ADVISORY COMM'N, supra note 16, at 103;
32. Jencks et al., supra note 17, at 1418.
33. Jencks et al., supra note 17, at 1418.
34. Id.
35. Id.
36. Id.
37. Id.
38. Too Many Medicare Patients Dying, Returning to Hospitals Within 30 Days: Data on Hospital Compare, SENIORJOURNAL. COM (July 9, 2009), http://seniorjournal.com/NEWS/Medicare/2009/20090709-TooManyMedicare.htm.
39. Anderson & Steinberg, supra note 16, at 1349.
40. Jencks et al., supra note 17, at 1418.
41. Id.
42. Arnold M. Epstein, Editorial, Revisiting Readmissions-Changing the Incentives for Shared Accountability, 360 NEW ENG. J. MED. 1457, 1457(2009), http://www.nejm.org/doi/pdf/10.1056/NEJMe0901006.
43. Id. at 1458.
44. Betsy Schaefer Vourlekis et al., The Rise of Social Work in Public Mental Health Through Aftercare of People with Serious Mental Illness, 43 SOCIAL WORK 567, 567-68(1998).
45. See Richard M. Scheffler & Timothy T. Brown, Social Capital, Economics, and Health: New Evidence, 3 HEALTH ECON. POL'Y & L. 321(2008) (measuring social capital and discussing definitions of social capital).
46. PAUL STARR, THE SOCIAL TRANSFORMATION OF AMERICAN MEDICINE 159(1982).
47. Id. at 158.
48. Id. at 72.
49. Id. at 172.
50. JACK A. MEYER, ECON. & SOC. RESEARCH INST., SAFETYNET HOSPITALS: A VITAL RESOURCE FOR THE U. S. 8(2004), http://www.esresearch.org/publications/ NAPH-final.pdf.
51. STARR, supra note 38, at 160.
52. Id. at 158.
53. Id. at 161.
54. Pest houses or pestilence houses were popular names for quarantine hospitals, used to segregate those with small pox, cholera, tuberculosis and other diseases from the general population.
55. See, e.g., The Pest House, ST. LOUIS PARK HISTORICAL SOC'Y, http://www.slphistory.org/history/pesthouse.asp (last visited Feb. 6, 2011) (describing the history of the Minneapolis Small Pox Quarantine Hospital ("The Pest House")).
56. STARR, supra note 38, at 159.
57. See id.
58. Id. at 75.
59. John Warner, Book Review, 36 J. HIST. MED. 365, 365(1981)
60. (reviewing MORRIS J. VOGEL, THE INVENTION OF THE MODERN HOSPITAL: BOSTON, 1870-1930(1980)).
61. STARR, supra note 38, at 73.
62. Id. at 74.
63. Id.
64. See JUDITH WALZER LEAVITT, BROUGHT TO BED: CHILDBEARING IN AMERICA, 1750-1950, at 171(1986) (birth);
65. Christine K. Cassel & Beth Demel, Remembering Death: Public Policy in the USA, 94 J. ROYAL SO'Y MED. 433, 433(2001), http://jrsm.rsmjournals.eom/cgi/ reprint/94/9/433 (death).
66. STARR, supra note 38, at 75.
67. SUSAN M. SCHWEIK, THE UGLY LAWS: DISABILITY IN PUBLIC 6(2009).
68. See STARR, supra note 38, at 72.
69. SCHWEIK, supra note 56, at 89.
70. Warner, supra note 50, at 365 (focusing on hospitals in Boston).
71. STARR, supra note 38, at 161.
72. Id. at 74.
73. Peter Temin, An Economic History of American Hospitals, in HEALTH CARE IN AMERICA 75, 82 (H. E. Freeh III ed., 1988).
74. STARR, supra note 38, at 157.
75. Bruce Vadek, Rosemary in Wonderland: A Look at American Hospitals, 3 HEALTH AFF. 233, 234(1989)
76. (reviewing ROSEMARY STEVENS, IN SICKNESS AND IN WEALTH: AMERICAN HOSPITALS IN THE 20TH CENTURY (1989)).
77. Id. at 234.
78. See STARR, supra note 38, at 159.
79. See id.
80. See id.
81. See id. at 162.
82. Id. (citing a survey of physicians in the Bronx and Manhattan).
83. INST, OF MED., FOR-PROFIT ENTERPRISE IN HEALTH CARE 32 (Bradford H. Gray ed., 1986) ("Before the 1930s, individuals in need of long-term care outside their homes were admitted to private charitable homes.").
84. Vadek, supra note 64, at 234.
85. STARR, supra note 38, at 160.
86. Id. at 178.
87. Id.
88. 2 ENCYCLOPEDIA OF CHILDREN AND CHILDHOOD: IN HISTORY AND SOCIETY 595 (Paula S. Fass ed., 2003).
89. CLIFFORD BEERS, A MIND THAT FOUND ITSELF (1st ed. 1908), available at http://www.gutenberg.org/ebooks/11962.
90. 2 ENCYCLOPEDIA OF CHILDREN AND CHILDHOOD, supra note 76, at 595.
91. NAT'L COMM. FOR MENTAL HYGIENE, HAND BOOK OF THE MENTAL HYGIENE MOVEMENT AND EXHIBIT, at 11-12(1913).
92. Id. at 20.
93. ELIZABETH KEMPER ADAMS, WOMEN PROFESSIONAL WORKERS: A STUDY MADE FOR THE WOMEN'S EDUCATIONAL AND INDUSTRIAL UNION 96(1921)
94. (quoting RICHARD C. CABOT, SOCIAL WORK: ESSAYS ON THE MEETING GROUND OF DOCTOR AND SOCIAL WORKER 19(1919)).
95. JOHN H. EHRENREICH, ALTRUISTIC IMAGINATION: A HISTORY OF SOCIAL WORK AND SOCIAL POLICY IN THE UNITED STATES 63(1985).
96. See PATRICK J. KELLY, CREATING A NATIONAL HOME: BUILDING THE VETERANS' WELFARE STATE, 1860-1900, at 2-3, 166(1997).
97. Although there is some evidence that volunteer social workers were used in this role in both the United States and Britain-Mental After Care Associations having roots back to the immediate post Civil War period in both countries-the professionalization and standardization of the role was a Progressive Era event.
98. See MATHEW THOMSON, PSYCHOLOGICAL SUBJECTS: IDENTITY, CULTURE, AND HEALTH IN TWENTIETH-CENTURY BRITAIN 192(2006).
99. Mary Cromwell Jarrett Biographical Note, FIVE COLLEGE ARCHIVES & MANUSCRIPT COLLECTIONS, http://asteria.fivecolleges.edu/findaids/sophiasmith/ mnsss30-bioghist.html (last visited Feb. 6, 2011).
100. E. E. SOUTHARD & MARY C. JARRETT, THE KINGDOM OF EVILS: PSYCHIATRIC SOCIAL WORK PRESENTED IN ONE HUNDRED CASE HISTORIES 484(1922).
101. DIANIEL J. WALKOWITZ, WORKING WITH CLASS: SOCIAL WORKERS AND THE POLITICS OF MIDDLE-CLASS IDENTITY 44(1999).
102. RICHARD C. CABOT, SOCIAL WORK: ESSAYS ON THE MEETING GROUND OF DOCTOR AND SOCIAL WORKER (1919).
103. STARR, supra note 38, at 178.
104. Margarete Arndt & Barbara Bigelow, Hospital Administration in the Early 1900s: Visions for the Future and the Reality of Daily Practice, 52 J. HEALTHCARE MGMT. 34, 35(2007).
105. A short stay is defined as thirty days or less.
106. LEIYU SHI & DOUGLAS A. SINGH, DELIVERING HEALTH CARE IN AMERICA: A SYSTEMS APPROACH 309-10 (4th ed. 2008).
107. Ardnt & Bigelow, supra note 90, at 36-37.
108. STARR, supra note 38, at 159.
109. Id. at 179.
110. Id. at 73.
111. SHI & SINGH, supra note 92, at 295.
112. STARR, supra note 38, at 207.
113. Allen C. Meadors, The United States Healthcare System and Quality of Care, in THE TEXTBOOK OF TOTAL QUALITY IN HEALTHCARE 13, 15 (A. F. Al-Assaf & June A. Schmele eds., 1993).
114. Id.
115. INST, OF MED., FOR-PROFIT ENTERPRISE IN HEALTH CARE, supra note 71, at 32.
116. Id.
117. See generally JOHN E. WENNBERG et al., DARTMOUTH INST, FOR HEALTH POLICY & CLINICAL PRACTICE, TRACKING THE CARE OF PATIENTS WITH SEVERE CHRONIC ILLNESS: THE DARTMOUTH ATLAS OF HEALTH CARE 2008, at 1-18 (Kristen K. Bronner ed., 2008) (describing recent trends in supply and demand for health care).
118. See Meadors, supra note 99, at 15 (noting that Kaiser established its first plan in 1942).
119. SHI & SINGH, supra note 92, at 295.
120. HARRY SULTZ & KRISTINE YOUNG, HEALTH CARE USA: UNDERSTANDING ITS ORGANIZATION AND DELIVERY 53 (6th ed. 2008).
121. Meadors, supra note 99, at 17.
122. Social Security Amendments of 1965, sec. 102 (a), §§ 1811-1817, Pub. L. No. 89-97, 79 Stat. 286, 291-301.
123. 42 U. S. C. § 1395y (a) (l) (A) (2006).
124. MARK R. CHASSIN, OFFICE OF TECH. ASSESSMENT, HEALTH TECHNOLOGY CASE STUDY 24: VARIATIONS IN HOSPITAL LENGTH OF STAY: THEIR RELATIONSHIP TO HEALTH OUTCOMES 9-10(1983), available at http://www.fas.org/ota/reports/8329.pdf.
125. MEDICARE PAYMENT ADVISORY COMM'N, REPORT TO THE CONGRESS: MEDICARE PAYMENT POLICY 46(2005), http://www.medpac.gov/documents/Mar05-EntireReport.pdf.
126. Tax Equity and Fiscal Responsibility Act of 1982, 42 U. S. C. § 1395ww (2006).
127. See Rick Mayes, The Origins, Development, and Passage of Medicare's Revolutionary Prospective Payment System, 62 J. HIST. MED. & ALLIED SCI. 21, 44(2007) (discussing "New Jersey's experiment with DRGs" which began in 1980).
128. OBERLANDER, supra note 4, at 126.
129. Id. at 123.
130. Discharge Planning, 42 C. F. R. § 482.43(2006).
131. The use of proprietary software to manage acute care hospital discharge planning is a story that deserves to be told. This is both because the software combines the functions of utilization management and discharge planning and because its very use shapes the nature of discharge planning.
132. See A. Jacqueline Mitus, The Birth of Inter Qual: Evidence-Based Decision Support Criteria that Helped Change Healthcare, 13 PROF. CASE MGMT. 228, 228-30(2008).
133. At least one attempt has been made to develop a predictive score to identify a patient's risk of discharge to a post-acute care facility in order to jump start hospital discharge planning in the U. K.
134. See Martine Louis Simonet et al., A Predictive Score to Identify Hospitalized Patients' Risk of Discharge to a Post-Acute Care Facility, 8 BMC HEALTH SERVS. RES., no. 154, July 22, 2008, http://www.biomedcentral.eom/l472- 6963/8/l54.
135. CMS, Hospital Discharge Appeal Notices, http://www.cms.gov/BNI/l2- HospitalDischargeAppealNotices.asp (last updated Oct. 12, 2010) (click "Important Message from Medicare" and "Detailed Notice of Discharge" links for templates). The Notice of Discharge and Medicare Appeal Rights is sometimes referred to as the NODMAR document. A revised NODMAR document will be in use as of April, 2011.
136. Id.
137. 42 C. F. R. § 412.42 (c) (3) (2006).
138. CMS advises its Medicare Advantage partners to explain the term "medically necessary" to Medicare beneficiaries as follows: Medically Necessary means services or supplies that: are proper and needed for the diagnosis or treatment of a medical condition, are provided for the diagnosis, direct care, and treatment of a medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of a member or doctor. CMS, MEDICARE ADVANTAGE COMPLIANCE TRAINING 151(2009), http://www.iceforhealth.org/podcast/20080407-Resources.pdf.
139. 42 C. F. R. § 422.620 (d) (2006).
140. Quality Improvement Organizations, most often third party vendors, represent the first line of appeal for Medicare beneficiaries appealing hospital discharge decisions and denials of Medicare funded services. 42 C. F. R. § 412.42 (c) (2) - (4) (2006).
141. 42 C. F. R. § 413.13 (a) (2009) (defining customary charges as "the regular rates that providers charge both beneficiaries and other paying patients").
142. Different, longer time limits may apply if the beneficiary is no longer in acute care. 42 C. F. R. § 405. 1205 (c) (2) (2007).
143. Testimony on Medicare Appeals Processes: Hearing Before the Subcomm. on Health of the H. Comm. on Ways & Means, 105th Cong. (1998) (statement of Michael M. Hash, Deputy Administrator, Health Care Financing Administration, U. S. Department of Health and Human Services), http://www.hhs.gov/asl/testify/ t980423a.html.
144. Eleanor Bader et al., Medicare Consumer Rights: Appealing a Denial of Coverage, 104 AM. J. NURSING 70, 70(2004).
145. Wendy Johnson, Qui tarn: 15-Bed Hospital Agrees to $846, 000 Whistleblower Settlement, FIERCE HEALTHFINANCE (Jan. 6, 2010), http://www.fiercehealthfinance.com/story/qui-tam-15-bed-hospital-agrees-846-000- whistleblower-settlement/2010-01-06.
146. See, e.g., N. J. ADMIN. CODE § 8:43G-2.12(2008);
147. N. M. CODE R. § 7-7-2.18K (2004).
148. THE JOINT COMM'N, HELPING YOU CHOOSE THE HOSPITAL FOR YOU 2(2010), http://www.jointcommission. 0rg/assets/l/l8/HYC-Hospital.pdf.
149. Id. at 1.
150. NCQA is a private, non-profit organization that accredits health plans. About NCQA, NAT'L COMM. FOR QUALITY ASSURANCE, http://www.ncqa.org/tabid/675/ Default.aspx (last visited Jan. 26, 2011).
151. News Release, Nat'l Comm. for Quality Assurance, New NCQA Standards Promote Wellness, Preventions; 56 Health Plans Schedule Surveys (Aug. 1, 2005), http://www.ncqa.org/tabid/273/Default.aspx.
152. Both CMS and the Agency for Health Care Research and Quality located in HHS (AHRQ) are developing measures to target avoidable hospitalizations, and not just avoidable readmissions. See generally DEBRA J. LIPSON & Samuel Simon, MATHEMATICA POLICY RESEARCH, QUALITY'S NEW FRONTIER: REDUCING HOSPITALIZATIONS AND IMPROVING TRANSITIONS IN LONG-TERM CARE 4(2010), http://www.mathematicampr. com/publications/pdfs/health/LTQA-brief.pdf.
153. Thomas Bodenheimer, Coordinating Care-A Perilous Journey Through the Health Care System, 358 NEW ENG. J. MED. 1064, 1068(2008).
154. See generally Sunil Kripalani et al., Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists, 2 J. HOSP. MED. 314(2007), http://onlinelibrary.wiley.com/doi/l0.1002/jhm.228/pdf (Patients are vulnerable after discharge, so hospitalists should assist patients "through appropriate discharge planning and effective communication with patients, their family members, and outpatient physicians.").
155. See Brenda L. Plassman et al., Prevalence of Cognitive Impairment Without Dementia in the United States, 148 ANNALS INTERNAL MED. 427, 433(2008), http://annals.org/content/l48/6/427.full.pdf+html.
156. It is possible, however, that volunteer coaches may be of some assistance. These services are, however, exclusively hospital and clinic based.
157. See Joseph Bernstein, Topics in Medical Economics: Health Care Rationing, 88 J. BONE & JOINT SURGERY 2527, 2530(2006).
158. This phenomenon, sometimes called "the woodwork effect", can produce the perverse conclusion that if a government service is too popular, no government will be able to offer it.
159. Mary D. Naylor et al., Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders: A Randomized Clinical Trial, 7 JAMA 613, 618(1999), http://jama.amaassn.org/content/28l/7/6l3.full.pdf+html.
160. See Mary D. Naylor, Director, NewCourtland Ctr. for Transitions & Health, Presentation at the National Health Policy Forum: The Transitional Care Model for Older Adults 11 (Apr. 3, 2009), http://www.nhpf.org/library/handouts/ Naylor.slides-04-03-09.pdf.
161. Reed Ableson, Hospitals Pay for Cutting Costly Readmissions, N. Y. TIMES, May 9, 2009, at B1.
162. Id.
163. Id.
164. Boston Medical Center Hospital was created in 1996 by the merger of Boston City Hospital and Boston University Medical Center Hospital. It has the largest twenty-four-hour Level I trauma center in New England and an emergency department with more than 132, 000 visits in 2010. Facts, BOSTON MED. CTR., http://www.bmc.org/Documents/BMC-Facts-2010.pdf (last updated Nov. 15, 2010).
165. Boston Medical Center is the largest safety net hospital in New England. Id.
166. Brian W. Jack et al., A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial, 150 ANNALS INTERNAL MED. 178, 178(2009).
167. Id. at 178-80.
168. Id. at 182 (Increased access to primary care may be a key driver of hospital readmission reduction.).
169. For a similar study conducted at Veterans Affairs Medical Centers, see Morris Weinerger et al., Does Increased Access to Primary Care Reduce Hospital Readmissions?, 334 NEW ENG. J. MED. 1441(1996).
170. Jack et al., supra note 148, at 182. The central role of the pharmacist at the care crossroads for these patients is a further embellishment of the enhanced role assigned to pharmacists for certain Medicare beneficiaries under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. No. 108-173, 117 Stat. 2066. Medication therapy management programs, administered by Medicare advantage drug plans, are funded by CMS for certain Medicare beneficiaries, targeting those with multiple chronic diseases, multiple chronic medications, and particularly high Part D Drug Costs. Daniel R. Touchette et al., Survey of Medication Therapy Management Programs Under Medicare Part D, 46 J. AM. PHARMACISTS ASS'N 683, 684(2006).
171. See Jack et al., supra note 148, at 184.
172. See Paul Heaton & Eric Helland, Does Treatment Respond to Reimbursement Rates? Evidence from Trauma Care 2-4 (RAND Inst, for Civil Justice Working Paper Series, Document No. WR-648-ICJ, 2009), http://www.rand.org/pubs/ working-papers/2009/RAND-WR648.pdf.
173. See Robert Pear, Long-Term Fix is Elusive in Medicare Payments, N. Y. TIMES, July 13, 2008, at A18 (quoting Gail R. Wilensky, Administrator for CMS under George H. W. Bush, describing Medicare's physician payment system as "hands down the most broken part of Medicare").
174. See CMS, QIO FACT SHEET: MEDICARE QIOS AND CARE TRANSITIONS (2009), http://caretransitions.tmf.org/CareTransitionsOverview/tabid/1130/Default.aspx (click "Medicare Fact Sheet") (last visited Feb. 6, 2010) http://caretransitions.tmf.org/CareTransitionsOverview/tabid/H30/Default.aspx.
175. "The following QIOs serve as Care Transitions leaders throughout the country: Quality Partners of Rhode Island; IPRO Inc. (in New York);
176. Quality Insights of Pennsylvania; Healthcare Quality Strategies Inc. (in New Jersey);
177. Georgia Medical Care Foundation Inc.; FMQAI (in Florida); AQAF (in Alabama);
178. Health Care Excel (in Indiana);
179. MPRO (in Michigan);
180. CIMRO of Nebraska; Louisiana Health Care Review;
181. Colorado Foundation for Medical Care;
182. TMF Health Quality Institute (in Texas);
183. and Qualis Health (in Washington)." Press Release, CMS, Medicare Announces Sites for Pilot Program to Improve Quality as Patients Move Across Care Settings (Apr. 13, 2009), http://www.cms.gov/apps/media/press-releases.asp (search keyword: medicare announces sites).
184. See CMS, QIO FACT SHEET, supra note 155, http://caretransitions.tmf.org/ CareTransitionsOverview/tabid/ll30/Default.aspx.
185. See A. BOUTWELL ET AL., INST, FOR HEALTHCARE IMPROVEMENT, STATE ACTION ON AVOIDABLE REHOSPITALIZATIONS (STAAR) INITIATIVE: APPLYING EARLY EVIDENCE AND EXPERIENCE IN FRONT-LINE PROCESS IMPROVEMENTS TO DEVELOP A STATE-BASED STRATEGY 44(2009), http://ah.cms-plus.com/files/STAAR-State-Based-Strategy.pdf.
186. William C. Nugent, Editorial, In Health Care, Geography is Destiny, 120 J. THORACIC & CARDIOVASCULAR SURGERY 976(2000).
187. See U. S. GOV'T ACCOUNTABILITY OFFICE, GAO-09-802, REP. TO THE CHAIRMAN, SUBCOMM. ON HEALTH, COMM. ON WAYS & MEANS, H. R., MEDICARE: PER CAPITA METHOD CAN BE USED TO PROFILE PHYSICIANS AND PROVIDE FEEDBACK ON RESOURCE USE 9-20(2009), http://www.gao.gov/new.items/d09802.pdf.
188. See MEDICARE PAYMENT ADVISORY COMM'N, REPORT TO THE CONGRESS: REFORMING THE DELIVERY SYSTEM 82(2008), http://www.medpac.gov/documents/jun08- entirereport.pdf.
189. Id. at 84.
190. See, e.g., Lisa M. Schwartz et al., How Do Elderly Patients Decide Where to Go for Major Surgery?: Telephone Interview Survey, BRIT. MED. J., Sept. 28, 2005, at 1, http://www.bmj.com/content/33l/7520/821.full.pdf (Only ten percent of responding Medicare beneficiaries "seriously considered" going to another hospital for elective surgery, and only eleven percent sought information to compare hospitals.);
191. Chad T. Wilson et al., Choosing Where to Have Major Surgery: Who Makes the Decision?, 142 ARCHIVES SURGERY 242, 242(2007) ("Thirty-one percent of [Medicare] patients said their physician was the main decision maker about where the patient would have [elective] surgery.").
192. See HANYS QUALITY INST., UNDERSTANDING PUBLICLY REPORTED HOSPITAL QUALITY MEASURES: INITIAL STEPS TOWARD ALIGNMENT, STANDARDIZATION, AND VALUE 7(2007), http://www.hanys.org/publications/upload/hanys-quality-report-card.pdf.
193. See MICHAEL TRISOLINI et al., MEDICARE PHYSICIAN GROUP PRACTICES: INNOVATIONS IN QUALITY AND EFFICIENCY 27(2006), http://www.commonwealthfund.org/ usr-doc/971-Trisolini-Medicare-physician-group-prac tices-i.pdf.
194. See Mark Murray et al., Improving Timely Access to Primary Care: Case Studies of the Advanced Access Model, 289 JAMA 1042, 1045(2003);
195. Mark Murray & Donald M. Berwick, Reply to Letter to the Editor, Advanced-Access Scheduling in Primary Care, 290 JAMA 332, 333(2003).
196. See MASS. MED. SOC'Y, PHYSICIAN WORKFORCE STUDY 102(2008) (In Massachusetts, patient wait times for a primary care office visit average eighteen days for an existing patient and twenty-nine days for a new patient.), http://www.massmed.org/AM/Template.cfm?Section=Home6&TEMPLATE=/CM/ContentDi splay.cfm&CONTENTID=23l66.
197. See NEW ENGLAND HEALTH CARE INST., REMAKING PRIMARY CARE: FROM CRISIS TO OPPORTUNITY 3, 5(2009), http://www.nehi.net/publications/40/remaking-primary- care-from-crisis-to-opportunity.
198. See Manya F. Newton et al., Uninsured Adults Presenting to US Emergency Departments, 300 JAMA 1914, 1920(2008).
199. See Joanne Kenen, Revolving-Door Patients Illustrate Health System Flaws, KAISER HEALTH NEWS, June 30, 2009, http://www.kaiserhealthnews.org/Stories/ 2009/June/30/frequent.aspx (describing patient monitoring and education programs that address readmissions). Acute care providers are increasingly disclosing hospital risks to patients as part of their 360-degree attempt to avoid never events.
200. See, e.g., ALLEN TECHNOLOGIES, INC., KNOCKING DOWN NEVER EVENTS: EMPOWERING AND EDUCATING OUR PATIENTS (2010), http://www.allentek.com/ whitepapers/Never Event.pdf.
201. See Eric A. Coleman et al., Reducing Emergency Visits in Older Adults With Chronic Illness: A Randomized, Controlled Trial of Group Visits, 4 EFFECTIVE CLINICAL PRACTICE 49, 54-56(2001).
202. See RANDALL BROWN, THE PROMISE OF CARE COORDINATION: MODELS THAT DECREASE HOSPITALIZATIONS AND IMPROVE OUTCOMES FOR MEDICARE BENEFICIARIES WITH CHRONIC ILLNESSES 4-5(2009), http://www.socialworkleadership.org/nsw/Brown-Executive- Summary.pdf.
203. See id. at 3.
204. See Cheryl L. Shigaki et al., Nurse Partners in Chronic Illness Care: Patients' Perceptions and Their Implications for Nursing Leadership, 34 NIURSING ADMIN. Q. 130(2010) (In a primary care setting, patients with chronic conditions appreciate their nurses' role in care management.).
205. BROWN, supra note 172, at 3.
206. Health care provider angst over professional responsibility concerns raised by early hospital discharge is longstanding but unresolved. Philip J. Boyle, Is Business Incompatible with Health Care?, 27 J. CHIROPRACTIC 24, 29-30(1990);
207. cf. Wickline v. California, 192 Cal. App. 3d 1630, 1635-42(1986) (incorporating premature Medicaid hospital discharge concerns into claims against the health care payor).
208. As part of the ongoing implementation of section 5001 (c) of the Deficit Reduction Act of 2005, CMS has addressed the prevalence of certain hospital-acquired conditions through a reimbursement disincentive structure built into the Inpatient Prospective Payment System final rules for fiscal years 2008 and 2009. The HACs covered under the fiscal year 2009 provision include the following: object left in patient during surgery, air embolism, blood incompatibility, catheter-associated urinary tract infection, pressure ulcers, vascular-catheterassociated infection, surgical site infection (specifically mediastinitis after coronary artery bypass graft surgery), hospital-acquired injury due to external causes (fractures, dislocations, intracranial injury, crushing injury, burns, and other unspecified effects), surgical site infections following certain orthopedic procedures and bariatric surgery for obesity, manifestations of poor blood sugar control, such as diabetic ketoacidosis and hypoglycemic coma, and deep vein thrombosis or pulmonary embolism associated with total knee and hip replacement procedures. The list of HACs found above includes seven never events which will not be reimbursed. Never events comprising falls, burns, and electric shock are grouped as one HAC. Preventable Hospital-Acquired Conditions (HACs), 73 Fed. Reg. 48, 471, 48, 471-74 (Aug. 19, 2008).
209. As of January 2009, CMS further clarified the limits of Medicare reimbursement for services related to never events.
210. See CMS, pub. no. 100-02, MEDICARE BENEFIT POLICY MANUAL, ch. 1 §§ 10, 180(2010), http://www.cms.gov/Manuals/IOM/ (click publication 00-02);
211. id. ch. 16 § 120.
212. See NAT'L QUALITY FORUM, SERIOUS REPORTABLE EVENTS IN HEALTHCARE 2006 Update (2007), http://www.qualityforum.org/Publications/2007/03/Serious- Reportable-Events-in-Healthc are-2006-Update.aspx.
213. Not-for-profit hospitals are exempt from federal taxation under section 501 (c) (3) of the Internal Revenue Code. The IRS's Hospital Compliance Project, begun in 2006 to study not-for-profit hospitals and community benefit, has collected some of the most comprehensive data on not-for-profit hospitals' activities, governance, expenditures, and executive compensation practices. This project elaborates on the data on not-for-profit hospitals ordinarily filed with the IRS on Form 990, Schedule H, each year.
214. IRS, IRS EXEMPT ORGANIZATIONS HOSPITAL COMPLIANCE PROJECT FINAL REPORT 147-151(2009), http://www.irs.gov/ch arities/charitable/article/0.id=203109, 00.html.
215. See Ben Furnas & Peter Harbage, The Cost Shift from the Uninsured, CTR. FOR AM. PROGRESS ACTION FUND (Mar. 24, 2009), http://www. americanprogressaction.org/issues/2009/03/pdf/cost-shift.pdf;
216. Glen Whitman, Hazards of the Individual Health Care Mandate, 29 CATO POL'Y REP., Sept.-Oct. 2007, at 1, 1, http://www.cato.org/pubs/policy-report/ v29n5/cpr29n5.pdf.
217. CMS has decided to dedicate fiscal year 2010 to an evaluation of the HAC program's impact. CMS, Medicare Adds Quality Measures for Reporting by Acute Care Hospitals for Inpatient Stays in FY 2010 (July 31, 2009), http://www.cms.gov/apps/media/fact-sheets.asp (search keyword: quality measures).
218. Mary Agnes Carey, Ways to Change How Medicare Pays for Hospital Care, THE COMMONWEALTH FUND (Nov. 26, 2007), http://www.commonwealthfund.org/Content/ Newsletters/Washington-Health-Policy-in-Review/2007/Dec/Washington-Health- Policy-Week-in-Review-December-3~2007/Waysto-Change-How-Medicare-Pays-for- Hospital-Care.aspx.
219. Id.
220. ADAM SINGER ET AL., THE PHOENIX GROUP, HOSPITALISTS MEETING THE CHALLENGE OF PATIENT SATISFACTION 2(2008), http://www.phoenixgroupwhitepaper.com/docs/ Hospitalists-Meeting-Challengel00108.pdf.
221. Id. at 3.
222. Cross-health system data on the effectiveness of hospitalists in reducing acute care hospital recidivism is scant. The Phoenix Group, a trade association of hospitalists in the United States, offers one of the few voices on health care policy from the perspective of a hospitalist. Phoenix Group estimates a full 30% of hospitalists in the United States are affiliated with their organization.
223. Id. at 1.
224. Thomas H. Lee, Pay for Performance, Version 2.0?, 357 NEW ENG. J. MED. 531, 531(2007).
225. Id.
226. Francois de Brantes, et al., Should Health Care Come with a Warranty?, 28 HEALTH AFF. w678, w680(2009), http://content.healthaffairs. Org/cgi/content/abstract/28/4/w678;
227. Ronald A. Paulus et al., Continuous Innovation in Health Care: Implications of the Geisinger Experience, 27 HEALTH AFF. 1235, 1242(2008).
228. Francois de Brantes et al., Building a Bridge from Fragmentation to Accountability-The Prometheus Payment Model, 361 NEW ENG. J. MED. 1033, 1033(2009).
229. de Brantes et al., supra note 190, at w682.
230. Id. at w 686.
231. Denise Grady, Facing End-of-Life Talks, Doctors Choose to Wait, N. Y. TIMES, Jan. 11, 2010, at D1, available at http://www.nytimes.com/2010/0l/l2/ health/l2seco.html.
232. ELLEN-MARIE WHELAN & JUDY FEDER, CTR. FOR AM. PROGRESS, PAYMENT REFORM TO IMPROVE HEALTH CARE: WAYS TO MOVE FORWARD 16(2009), http://www.americanprogress.org/issues/2009/06/health-payment-reform.html.
233. CHRISTINE E. EIBNER ET AL., RAND CORP., CONTROLLING HEALTH CARE SPENDING IN MASSACHUSETTS: AN ANALYSIS OF OPTIONS 12-13(2009), http://www.mass.gOv/ Eeohhs2/docs/dhcfp/r/pubs/09/control-health-care-spending-rand-08-07-O9.pdf.
234. JOSEPH ANTOS ET AL., ENGELBERG CTR. FOR HEALTH CARE REFORM, BENDING THE CURVE: EFFECTIVE STEPS TO ADDRESS LONG-TERM HEALTH CARE SPENDING GROWTH 3(2009), http://www.brookings.edu/reports/2009/0901-btc.aspx.
235. WHELAN & FEDER, supra note 195, at 18.
236. Id.
237. Daniel Esquibel, Shift in Medicare Pay Policies Could Hit Safety Net Facilities, CAL. HEALTHLINE (Jan. 27, 2010), http://www.californiahealthline. org/road-to-reform/2010/shiftin-medicare-pay-policies-could-hit-safety-net- facilities.aspx.
238. S. FIN. COMM., 111TH CONG., REPORT ON TRANSFORMING THE HEALTH CARE DELIVERY SYSTEM: PROPOSALS TO IMPROVE PATIENT CARE AND REDUCE HEALTH CARE COSTS 13-16 (Comm. Print 2009).
239. Id. at 14-15.
240. Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, § 3023, 42 U. S. C. § 1395CC-4(2010).
241. Id.
242. Id. § 3025, 42 U. S. C. § 1395ww.
243. Robert Berenson, Implementing Health Care Reform-Why Medicare Matters, 363 NEW ENG. J. MED. 101, 103(2010).
244. DAVID BLUMENTHAL & JAMES A. MORONE, THE HEART OF POWER: HEALTH AND POLITICS IN THE OVAL OFFICE 201(2009).
245. See Duke Helfand, Healthcare Providers Experiment with Lump-Sum Pricing, L. A. TIMES, Apr. 24, 2010, http://articles.latimes.com/2010/apr/24/business/la- fi-healthcare - costs-20100424.
246. See Robert E. Mechanic & Stuart H. Altman, Payment Reform Options: Episode Payment Is a Good Place to Start, 28 HEALTH AFF. w262(2009), http://content.healtharffairs. Org/cgi/content/abstract/28/2/w262.
247. Prospect Medical Holdings, Inc., for example, disclosed in its July 8, 2009 8-K SEC disclosure that adoption of proposed bundled payments for Medicare beneficiaries would negatively affect its bottom line. Prospect Med. Holdings, Inc., Annual Report (Form 8-K), at 13 (July 8, 2009), available at www.secinfo.com/dllMXs.sl9Ea.9.htm.
248. See U. S. GOV'T ACCOUNTABILITY OFFICE, GAO/HEHS 96-16, REPORT TO THE CHAIRMAN, SPECIAL COMMITTEE ON AGING, U. S. SENATE, MEDICARE: HOME HEALTH UTILIZATION EXPANDS WHILE PROGRAM CONTROLS DETERIORATE 9-10(1996).
249. See Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, §§ 3022, 3129, 10307.
250. 2U See James Conway et al., Is California Ripe for Global Payment, ACOs?, CAL. HEALTHLINE, Feb. 16, 2010, http://www.californiahealthline.org/think-tank/ 2010/iscalifornia-ripe-for-global-payment-acos.aspx.
251. BARBARA GAGE et al., RTI INTERNATIONAL, EXAMINING POST ACUTE CARE RELATIONSHIPS IN AN INTEGRATED HOSPITAL SYSTEM 1-2(2009), http://aspe.hhs.gov/ health/reports/09/pacihs/index.shtml.
252. See Jeffrey R. Binder, Will Reimbursement Policies Create an Access Crisis?, AAOS Now, July 2008, http://www.aaos.org/news/aaosnow/jul08/youraaos4. asp.
253. AARP Testimony Before the Senate Finance Committee on Reforming America's Health Care Delivery System, AARP, Apr. 21, 2009, http://www.aarp.org/ politicssociety/government-elections/info-01-2009/senatetestimonty0421.html.
254. S. FIN. COMM., 111TH CONG., REPORT ON TRANSFORMING THE HEALTH CARE DELIVERY SYSTEM: PROPOSALS TO IMPROVE PATIENT CARE AND REDUCE HEALTH CARE COSTS 10-11 (Comm. Print 2009).