The mandate that everyone has health insurance is the foundation of the Affordable Care Act. But a lesser-known provision of the law helps ensure that if people end up in the hospital, they'll get good care.
Under the ACA, the government now bases Medicare payments to hospitals in part on the quality of care they provide, not just the number of procedures they perform.
Wisconsin hospitals have been faring well under the new system, including Froedtert Hospital in Wauwatosa, where 29-year-old Maryiam sits in a dimly-lit patient room, picking at her breakfast.
Maryiam has sickle cell disease, which causes red blood cells to become sickle shaped and get stuck inside blood vessels. This restricts oxygen flow throughout the body, resulting in organ damage, and intense pain.
“It’s basically all over. Like, my knee’s been hurting really bad, and my head and my back and stuff,” Maryiam says.
Dr. Joshua Field is medical director of the Adult Sickle Cell Clinic at Froedtert and the Medical College of Wisconsin. The clinic opened in 2011 to serve as a medical home for people with sickle cell disease. It’s one way Froedtert is working to improve patient care. Field says prior to the clinic, sickle cell patients would become so ill, they’d end up in the emergency room every few weeks to get pain meds or blood transfusions.
“Really, what you’re doing is you’re putting out the fire that day. You can do that for a day and it’s fine. But if you start doing that over years and years, what you have is usually a lot of health care issues that just aren’t at all being addressed and you have a person that is getting sicker and sicker and developing more and more morbidities,” Field says.
Field says the clinic’s approach is to stay ahead of the disease. Make sure people have the right medications, and take them. Schedule blood transfusions. Even arrange transportation, if the patient needs it.
“It’s basically allowed them to be at home, be with their families and really have an opportunity to live a more successful life without depending upon the hospital and the emergency department,” he says.
Wisconsin a Leader
“Wisconsin hospitals have been working on improvement for a long time,” says Kelly Court, chief quality officer at the Wisconsin Hospital Association.
She says hospital executives recognized quality wasn’t as high as it should be, and wanted to do better for patients.
“They keep the patient at the front of their mind and when we all focus on the needs of the patients, then the improvement work follows,” Court says.
The association recently issued a report on changes dozens of hospitals here have made. For example, some have cut down on the number of babies delivered early for convenience sake. Infants born before 39 gestational weeks face a greater risk of complications.
Court says one of the most noteworthy findings overall is a 22-percent drop in the number of people readmitted to the hospital following an in-patient stay. She estimates the change has reduced health care costs in Wisconsin by $34 million.
“The hospitals are recognizing that to improve re-admissions they have to start working with patients in ways they haven’t worked with them before so that patients understand in a better way how to take their medications, how to do their follow up work,” she says.
Court says while Wisconsin hospitals have been working to improve care for some time, the Affordable Care Act adds urgency. Under the law, Medicare no longer just pays for the procedure. Rather, it gives hospitals incentive payments or penalties based on their performance on quality measures, such as patient satisfaction and death rates.
“We focus a lot on outcomes of care, and the value-based purchasing program is starting to pay more attention to outcomes. All of those things working together contribute to Wisconsin’s relatively high performance in these national programs,” Court says.
Wisconsin hospitals rank third best in the nation for average incentive payments versus penalties.
Preparing for New Standards
In coming years, Medicare’s new payment model will expand to include even more quality measures. One number the federal government will monitor is the rate of bloodstream infections patients suffer, from the lines hospitals use to administer medication or fluids. Up to half the critically ill patients who get those infections and not proper treatment, die.
“And that is our transplant patients, our patients that are in the ICU, our oncology patients,” says Nathan Ledeboer, medical director of microbiology and molecular diagnostics at Froedtert and the Medical College of Wisconsin.
He says the typical way to test for an infection involves taking a blood sample, incubating it, and doing a stain to look for bacteria.
“The problem is, historically, that’s taken up to three days, which leaves our physicians in a great degree of quandary,” he says.
Ledeboer says without test results, doctors don’t know how to treat the infection. So, he’s helped create a faster test that uses DNA to identify the bacteria and determine how to treat it, rather than waiting for a culture to grow.
“And the really cool thing is, we can do that about 50 hours faster,” Ledeboer says.
Ledeboer says speedier diagnoses mean fewer days patients are on antibiotics and in the hospital, and fewer deaths resulting from bloodstream infections.
The improvements should help Wisconsin hospitals maximize their Medicare payments. But there are also efforts underway here to make hospital care safer and more efficient overall – not just for Medicare patients.
For example, Columbia St. Mary’s on Milwaukee’s east side has begun refusing to deliver babies early when there’s no medical necessity. Infants born early are more likely to end up in the ICU.
Dr. Paul Burstein is an OB-GYN at the hospital. He says it’s also working to better manage a birth complication called shoulder dystocia. That’s where a baby’s head is delivered, but the shoulders get stuck.
“And the natural impulse without training would be potentially to just pull harder which just makes it worse and injures the baby,” Burstein says.
The staff has been using simulation to learn proper techniques, including a full-sized mannequin named “Noelle.” She’s lying on a hospital bed with a swaddled baby, also a dummy, tucked under her arm. Noelle can simulate a normal delivery and a range of complications.
Burstein taps at an iPad in the room, signaling Noelle to shout out, “The baby’s coming…my water broke!”
Burstein says staff rushes in to attend to Noelle and then afterward, examines what went well and what did not.
“It’s led to decreasing the time it takes to do certain important interventions where if there’s a delay, then harm can come to either mother and/or infant,” he says.
Still Room for Improvement
“Wisconsin ranks fourth in the nation in terms of the quality of health care that people in the state receive every day,” says Dr. Jeff Brady, director of the center for quality improvement and patient safety within the U.S. Agency for Healthcare Research and Quality.
He says while Wisconsin is leading a trend toward improved care, there’s still work to do.
Both Froedtert Hospital and Columbia St. Mary’s score at or better than national rates for most quality measures Medicare tracks, but lag on a few.
Froedtert performs worse than the national rate for readmission and complications after hip or knee surgery. Columbia St. Mary’s performed lower in timely removal of catheters after surgery, and the number of patients given a flu shot.
Brady says overall, the country needs to improve communication among health care providers, such as doctor’s offices, nursing homes and hospitals.
“So that patients understand what they need to do to get better and stay that way,” he says.
Officials also say the rates of falls and bedsores in hospitals across the country are still too high. And Brady says the U.S. must better serve low-income and minority groups. He says right now, blacks and Hispanics have less access to healthcare and lower quality care, than whites.