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updated: 9/29/2013 6:30 AM

Obamacare incentives slow hospitals' revolving door

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Obamacare has already transformed Esther Redd's health, like that of thousands of other Americans.

Redd had been admitted to Mount Sinai Hospital in New York seven times over six months, spending 24 days there for conditions ranging from kidney failure to high blood pressure and diabetes. Each time she was released, Redd would later miss doctor's appointments and skip medications only to wind up back in the emergency room for basic care.

"I was living on the edge," said Redd, a 53-year-old from Harlem. "I wasn't used to going to the doctor."

Then Redd, like more than 600 other Mount Sinai patients over the past three years, was singled out as a high-risk patient and assigned to one of 27 social workers focused on keeping patients out of the hospital. Mount Sinai created the program after the Affordable Care Act set up an incentive system to provide hospitals extra money for keeping people healthy, and penalize them for having too many patients readmitted too soon.

Mount Sinai said the program reduced admissions 43 percent and cut emergency room visits 54 percent during a test run from September 2010 to May 2012. The decision to target high-risk patients is estimated to have saved $1.6 million in medical costs over a six-month period, the hospital said.

In Redd's case, she said the program may have saved her life. Since May, when she started working with a hospital social worker, she has been admitted to Mount Sinai just once, is regularly going to dialysis and on the waiting list for a new kidney.

Health Experiment

Mount Sinai's program is part of a nationwide effort on the part of hospitals to improve their patients' health and bolster their bottom lines under new programs created by the health law. Some 250 medical centers and doctors groups are now paid by Medicare based on the cost of caring for a patient, rather than fees for procedures, tests and office visits. The government expects to save as much as $1.9 billion from 2012 to 2015 through so-called accountable-care programs. And the law also penalizes hospitals with excessive patent readmissions within 30 days of their going home.

"This is not just one more of those 1990s' initiatives around cost containment, this is really a trend around changing the way you deliver care," said Karoline Hilu, a senior director at the Advisory Board, a Washington-based health care consulting firm that works with hospitals. "This is going to be what hospitals need to do to survive in this current era of health care."

At Mount Sinai, administrators begin each morning by making a list of those patients most likely to hurt the hospital's bottom line. Using a multimillion-dollar computer system and complex algorithms, they score how likely each patient in the hospital is to be readmitted based on a rage of factors, such as medical history and recent admissions.

Social workers

Those scores go to a group of social workers who make contact with the patients determined to be most at risk. A social worker then spends 75 minutes meeting with each patient, trying to tease out issues that may result in a round-trip back to the hospital.

"We are looking for the underlying reason that people are coming back to the hospital," said Maria Basso Lipani, program director for Mount Sinai's Preventable Admissions Care Team. "We really will do anything and everything."

Redd, who has a 13-year-old daughter, made it on the list in May and was assigned to Derrick Williams, the social worker charged with helping her improve her health over the next 35 days -- and stay out of the hospital.

When Redd first become ill last year, she didn't have a primary care doctor and bounced between emergency rooms trying to figure out what was causing her vomiting, pain and a sudden gain of 50 pounds.

Painful existence

Her legs were so swollen with fluid she couldn't walk or put her clothes on, she said. She spent most of her time sleeping and struggled to care for her daughter. When doctors at Mount Sinai finally diagnosed her with kidney failure they told her she needed dialysis treatments, which made her continue to feel ill and sparked return trips to the hospital's emergency room.

"I used to feel like I wasn't going to wake up the next morning," she said during an interview after finishing one of her four-hour-long dialysis treatments that she now does three times a week. "I felt so bad. The only time I felt good was when I was sleeping."

Williams first met Redd at her hospital bed where they talked for more than an hour about her health, family and home life. Williams soon found a primary care doctor for Redd, a simple yet effective way of keeping patients away from the emergency room, where Redd had been three times in six months.

Doctor search

Mount Sinai has a special program for its most at-risk patients to enable them to get easy access to a regular doctor or nurse practitioner, which many low-income patients struggle to find. Now, Redd has someone to call, day or night, who can help her determine if she's having a true emergency and, if not, schedule her for a checkup within a day or two.

Next, Williams had to make sure Redd showed up at her appointments. He'd wake up before sunrise to meet her at 6 a.m. on Manhattan's Upper East Side for her three weekly dialysis treatments and to go with her to doctor's appointments. Williams also helped enroll Redd in a mental-health program for her depression and arranged a delivery of free meals suited for her medical conditions.

The work with Redd was as much about boosting her morale as it was provided health services, Williams said during an interview in August while accompanying her to her dialysis treatment.

"Having to come here three times a week and already having depression issues, having to raise a young child, having cardiac issues, side effects from medications, that's a lot," Williams said. "I would try to tell Esther, 'you are my hero.'"

Doing more

Like Williams, the other social workers often go beyond the usual service for their patients. In one case, a social worker went to the Department of Motor Vehicles to lobby on a patient's behalf for a driver's license -- a piece of identification needed to get health insurance. In another case, a social worker arranged to get mold removed from a patient's apartment to help with a respiratory condition.

Support also comes in less-tangible ways, like helping patients feel comfortable talking to their doctors and asking questions, or giving them confidence that they can improve their health.

"Physicians are trained to look at the patient in their physicians' lens, we look at the whole picture," Williams said. "With Esther, I looked at her body issues, her mental-health issues, her social issues and made sure I was looking at all of them."

Early success

While the work isn't cheap or easy, Mount Sinai said the efforts are worth it. Based on the initial results, the hospital received a five-year grant from the federal government to pay for 20 social workers focused on patients in Medicare, the U.S. government's health plan for the elderly and disabled. In addition, insurer HealthFirst pays for three social workers to help keep its members healthy, and the hospital pays for four more to target patients with Medicaid and private insurance.

Hospitals with a high number of readmissions within 30 days can lose as much as 1 percent of their Medicare payout for fiscal 2013 and 3 percent in 2015.

While not all hospitals are investing as heavily in keeping patients healthy as Mount Sinai, Hilu said almost every hospital she works with has a program to prevent readmissions.

"This is going to keep coming, it is only just beginning and it is going to be increasing," Hilu said.

For Redd, the program has helped her take control of her health as she waits for a kidney transplant. Without the intervention, she said she would probably be dead or dying. Now, she's planning a party to celebrate the day she is able to go off dialysis, a party where Williams will be a guest of honor.

"I wasn't realizing that the only way I would get better was if I treated myself better and he showed me that I needed to do this." Redd said. "He is a good man. He helped me a lot."

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