HEALTH CARE/Joan Retsinas

The Poor: Gumming up the Healthcare Bureaucracy

The poor! What an expensive nuisance! They crowd our jails, panhandle, shoplift from discount stores, cost taxpayers millions in subsidies. Now they are gumming up our healthcare bureaucracy.

Ploughing through reams of data, the bureaucrats-of-health spotted miscreant patients who boomerang in and out of hospitals. For a few specific diagnoses (heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, elective hip and knee replacement), the “normal” curve points to an “expected” recovery, translating into hospital-days. But some patients, once discharged, return too soon – the data-mark for “too soon” is 30 days. Statistically, they shouldn’t. They should recuperate at home. Since the federal government, via Medicare, pays for these hospital stays, the bureaucrats charged with safeguarding taxpayer money look askance at “outliers” who gobble up too much of the budget.

Bureaucrats blame the miscreant hospitals. The hospitals are doing something wrong. They must be. Taking diagnosis, age, gender – whatever the bureaucrats fed into the algorithm — into account, the statistics are clear: at some hospitals, too many patients, once discharged, are returning. Since every day spent in a hospital costs taxpayers money, the government understandably wants to shorten the length of stay (encouraged by DRG payment schemes), while shutting the door on re-admissions. (Admittedly, the two incentives don’t dovetail. Presumably a too-rapid discharge might encourage an early re-admission.)

The government recognized the hospital as the key fulcrum. The best way to nudge hospitals into changing their modus operandi: money. Under the fairest, most rational rules of engagement, laggard hospitals should pay a penalty for boomerang patients. In the short run, hospitals will suffer; but, in the long run – a Keynesian optimism – hospitals will speed patients out the door, with safeguards to keep them out. And, given iatrogenic possibilities in hospitals, which sometimes seem incubi of infections, patients will do better at home.

Overall, the money-strategy, aka Hospital Readmissions Reduction Program, launched in 2012, has worked. Hospitals, faced with penalties, are paying attention: fewer patients are boomeranging back within 30 days. Last year Medicare “penalized’ half of the nation’s hospitals (2,592), but fines for most were minor.

Some hospitals, though, have challenged the formula. They want to add a new factoid to the algorithm: poverty. All patients may have the same diagnosis. Damaged hearts, lungs, and knees look the same on MRIs, EKGs, lab tests. Yet, biology aside, poorer people may lack safe homes they can return to; they may lack caregiving family to bring meals, change sheets, oversee medications; they may lack transportation to medical appointments. In short, as discharge planners recognize, poor patients face a different post-recovery world than their wealthier counterparts; and some hospitals serve a great many poor patients.

The hospitals’ campaign to include poverty will probably prevail. It should. The patients’ lives won’t demonstrably improve, but at least the hospitals that care for them won’t sink into the red. Congressmen Patrick Tiberi, R-Ohio, and Jim McDermott, D-Wash, introduced a bill to add “socioeconomic status” to the formula.

The larger reality, though, is the invisibility of poverty. We know about the widening gap – thank you, Thomas Piketty. We know about the nation’s multi-millionaires. Look at our political candidates – their wealth could rescue our cities on the cusp of bankruptcy. Add the wealth of their major campaign contributors, and we might rebuild our crumbling bridges. We know about the sinking middle class – their ire has fueled a nativist backlash that has buoyed Donald Trump. But we don’t hear much from the people who live a paycheck from insolvency, in hock to payday lenders, stuck in dreadful apartments in dangerous neighborhoods.

The poor exist. Welfare “reform,” followed by Temporary Assistance for Needy Families, saved governmental budgets; but when the government “ended welfare as we know it,” it didn’t end poverty. Today 3 million children live on household incomes of $2 a day. Even housing subsidies have grown scarce: some housing authorities have closed their waiting lists – the lists were too long, the supply too short.

In this campaign season, don’t expect candidates to plead for people stuck on the bottom of Horatio Alger’s ladder. Why should they? After all, the poor don’t figure into the “outrage-of-the-moment” internet headlines. They don’t skew pollsters’ numbers. They don’t smile in photo-ops. They matter only when they are costing hospitals money.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, August 1, 2016

Populist.com