Discussing nursing home rehopsitalization

Should Nursing Homes Be Rewarded or Punished for Patient Re-Hospitalization?

B. F. Skinner, father of operant conditioning – the reward and punishment theory of behavioral reinforcement – would certainly be pleased to see his life’s work applied in a massive new federal government healthcare policy experiment.

Medicare’s new carrot and stick reimbursement approach, the Skilled Nursing Facility Value-Based Purchasing Program, kicked in October 1st, the start of the fiscal year, and runs through September 30. The strategy is intended to incentivize overall improved patient care and better discharge decision-making in nursing homes. (Currently, Medicare offers full reimbursement only for the first 20 days of care and generally stops paying after 100 days, which can incline nursing homes toward premature discharge.)

The program was created by Congress in 2014 and is currently operating based on 2017 hospitalization rates.

The policy incentivizes by offering monetary rewards and penalties to 14,959 skilled nursing facilities based on how many of their patients are readmitted to the hospital within 30 days of hospital discharge. A Kaiser Health News analysis determined that nearly 11,000 nursing homes will be penalized, nearly 4,000 nursing homes will receive bonuses, while the rest won’t see any change. Medicare will redistribute a total $316 million from lesser-performing to better-performing nursing homes and expects to save an additional $211 million annually from the program. For-profit nursing homes are expected to experience more negative impacts than non-profit and government-run facilities.

Whether the rest of us non-behaviorists should be as pleased as a beaming Skinner remains an open question. Can nursing homes, from small neighborhood convalescent centers to large national chains, realistically be expected to modify their operational vectors in response to reimbursement rates, like so many of Pavlov’s dogs salivating at the sound of that now-famous ringing bell?

Certainly, fiscal conservatives and small government advocates will rejoice to see nursing homes held tangibly and materially accountable for the rates with which their patients are readmitted to the hospital. The assumption here, however, is that quality of care is the primary factor in patient re-hospitalization rates, and not, for instance, varying rates of vulnerability and severity of illness among patient populations at respective nursing homes. (e.g. A nursing home adjacent to cancer treatment or level one trauma center will have a drastically different patient-need profile than a rehab-oriented nursing home near an Olympic training center.)

Make no bones about it, this is nothing less than a throwing of life-size healthcare policy dice, a vast experiment soon to impact millions of frail and elderly individuals and those who love them. While not quite yet reduced to lab rats, nursing home patients are being subjected without their input or consent to a radical Skinner-style change. The impacts of this experiment on patient care, quality of life and mortality, not to mention healthcare costs themselves, may take years to assess.

On the upside is the possibility that hospital readmissions can and will be reduced through improved quality of nursing home care and more patient-appropriate lengths of stay, which most researchers apparently believe can happen.

On the downside is the very real possibility, expressed by concerned consumer healthcare advocates, that nursing homes may start denying admission to the most vulnerable patients, those most likely to require ongoing hospitalizations. An equally dangerous possibility is that nursing homes will hesitate to re-hospitalize patients when hospital care is legitimately needed.

Why the program is being implemented on such a large scale is difficult to grasp.

While the program certainly makes some sense and has potential merits, at least theoretically, it would be much wiser to implement this on the smallest-possible scale and then reassess to see if the larger-scale implementation is justified – and safe. The cardinal rule of healthcare is, after all, to do no harm.

In the meanwhile, unfortunately, all we can do is hope and pray that things go as well as possible for the most vulnerable amongst us.

Surely sound healthcare policy can be based on more solid underpinnings than that.