The Big Lie, part 2

From "rest and recuperate" to "quicker and sicker"

In the Big Lie, we talked about the fact that while many older adults go to a skilled nursing facility (SNF, or “sniff”) after they are hospitalized, few are informed about the implications of these choices. However, we didn’t talk about some of the powerful, invisible forces that push older adults along this path. In other words, you might have been wondering: why on earth do so many older adults leaving the hospital go to a nursing facility after discharge? Knowing about these forces is also critical as you and your family members consider what the future might look like for an older adult, and we want to help you to use them to your advantage.

If you spent time in a hospital prior to the 1980s, you might remember wards full of people recovering from illness or surgery. Adults would stay for three weeks after a heart attack, a week after having a baby, and a week after minor surgery like a hernia repair. Most patients felt well by the time they were discharged – if anything, they wanted to get out a day or two earlier.

Photo by National Library of Medicine on Unsplash

Now the most common complaint I hear from my patients is that we’re talking about discharge too soon. “Discharge planning starts on day 1!” is a proud motto of many hospital care teams. But patients say they haven’t had enough time to recover and still feel sick! One older adult told me, “you know, you used to stay in the hospital until you got better. Now, they just send you to rehab.”

Today, heart attack patients only stay on my inpatient roster for 2 or 3 days. Most mothers are discharged within one day of an uncomplicated delivery of a new baby. Now you don’t even get admitted to the hospital after having a hernia repaired! Hip and knee replacements are increasingly outpatient surgeries; patients go back home after a few hours in the recovery area.

What gives?

There are invisible forces that dictate the kind of hospital care we receive. These forces are particularly powerful in the care of older adults, who often struggle to be effective advocates for themselves in the hospital for good reason – they are sick! We can’t see these invisible forces, but we certainly can feel them. When my wife’s grandmother Gigi was being discharged from the hospital - despite not being able to get out of bed - we felt these effects. If you or your loved one is about to be discharged from the hospital, and you need to find help at home on very short notice, only to be faced with a long waitlist, you feel these effects.

Our hope is that by showing you what’s behind the curtain, you can become more effective advocates and navigators. Becoming savvy about these powerful unseen forces will empower you to address them head-on, and use them to ensure your care is the best it can be. In contrast, those who remain ignorant of them are pushed along well-worn pathways and spend their time in reactive mode, feeling like victims. My Mom and I think that most people need both a good doctor and an effective advocate just to ensure hospital and post-hospital care is safe and makes sense. After bruising interactions with the health care system, we have both become far less shy about intervening, earning my mom the moniker “Advo-Kate!”

To understand how The Big Lie became a common refrain, it’s important to know how hospitals are paid. Prior to 1983, hospitals received a payment for every day a patient spent in the hospital. This seemed like good policy – it certainly cost the hospital money every day a patient was there. However, it also incentivized hospitals to keep their beds full, so they could charge the maximum amount. This in turn caused a crisis of insolvency in the Medicare program (a common theme we’ll return to) as the number of hospital beds, hospitalizations, and hospital length of stays increased. Facing this crisis, Medicare changed to a single lump-sum payment for an entire hospitalization in 1983, no matter how long the patient stayed in the hospital, basing that payment on the diagnosis the patient was hospitalized for.

The Centers for Medicare and Medicaid Services (CMS) are leaders in trying to achieve higher-value health care through changing payment structures. The rest of the nation follows their lead. But making good policy is hard! Changing to a single payment was very successful in controlling hospital costs, arresting their meteoric rise. It also completely reversed hospital incentives.

Before, the hospital made more money if patients stayed longer, resulting in very long lengths of stay. After the change from daily payment to lump sums, an earlier hospital discharge opened up two different avenues for hospitals and health systems to increase their revenues. First, if patients were discharged sooner, hospitals got to keep more of the lump-sum payment since they didn’t have to spend money on additional days of care. Second, it meant a bed opened up earlier for another lump sum payment. If a hospital could turn a single 6-day stay into two 3-day stays in the same bed, it could double the payments it received, while keeping costs similar.

Again, this seems like sound fiscal policy on its face. We shouldn’t be encouraging hospitals to keep patients in the hospital who don’t need to be there. However, it resulted in two major unintended consequences.

First, Medicare anticipated hospitals might try to “game” the system by admitting patients who weren’t very sick, and were almost guaranteed to have a shorter hospital stay than a generally sicker patient with the same reason for admission. When Medicare made the change to a single payment, it also made it clear it would only pay for hospital admissions for patients that were “sick enough” to require hospital-level care. This makes sense - nobody wants to be admitted to the hospital if they don’t have to be, and most of us would prefer to be cared for in our home environment.

This change to lump-sum hospital payments set into motion a revolution in how “sick” you need to be to be admitted to the hospital. We were forced to consider a question that still reverberates today: what kind of care really requires the hospital?

When I started my medical career in the early 2000s, I saw a lot of older adults with pneumonia who needed a day or two of antibiotics and were able to return home. These were rewarding patients to care for, since they nearly always got better quickly.

These patients are no longer admitted to the hospital. When I am on the hospital wards these days, most of my patients have 10 or more different diagnoses, a host of subspecialists, and more than 20 medications prescribed to be taken on a daily basis. Our standards of what is “normal” on the hospital wards has dramatically changed as a result. When I started my training, adults needing more than 6 liters per minute of oxygen (indicating serious lung or heart problems) were cared for in the Intensive Care Unit (ICU). Now, I routinely have patients receiving 50 liters of “high-flow” oxygen on the regular medical wards. My aunt who has lung disease uses 10 liters of oxygen per minute in her own home!

Photo by Samuel Ramos on Unsplash

Hospitals faced a moment of financial reckoning. They had to admit much sicker patients, but still had the same lump-sum incentive to keep their length of stay as short as possible. In addition, new policies meant they faced financial penalties if patients were readmitted to the hospital from home within 30 days of discharge. How could they both admit sicker patients and discharge them more quickly? It seemed impossible. Families didn’t have the skills to deliver the high level of care that might be required after just a day or two in the hospital (wound care, antibiotics through an IV, feeding tubes). Many older adults also needed help getting up and around safely at all times of day and night.

The solution, and the voltage drop

The solution was to use the only other structure in our health care system that was staffed 24/7 and widely available: nursing homes, also called skilled nursing facilities (or SNFs – pronounced “sniffs”). The resultant change in nursing home use in the US has been astounding. When we did the math in a research paper, we found that there were 1.2 million more stays in SNFs after hospital discharge in 2010 than there were in 1996 – even after accounting for more expected nursing home admissions due to the aging of the US population. That’s nearly 3400 additional SNF admissions per day in 2010. Currently, one in five Medicare enrollees goes to a SNF after hospital discharge.

We were even more concerned in our research when we found the age group with the largest decrease in hospital length of stay were people age 80 or older. If this seems odd to you, it should: how could the oldest (and presumably most frail) adults - who might need the most time for rest and recuperation - be having the most drastic decrease in hospitalization length? It’s because the majority of this group now goes to “rehab” (SNF) following their shortened hospital stay.

But nursing homes weren’t designed to be hospital step-down units, and there was no additional investment to help them adapt. They now serve a function for which they were not designed, as an accident of changes in how hospitals were paid. Consider how different the care is for the same patient on their day of hospital discharge and SNF admission. In the hospital, they had their vital signs taken every four hours day or night, were seen by physician teams multiple times a day, and shared a nurse with at most 4 other patients. When they arrive in the SNF, they will have their vital signs taken once a day, will be seen by a physician once a week, and will share a nurse with up to 30 other older adults. This is a gigantic “voltage drop” in the intensity of care. For most long-term care nursing home residents, a lower intensity is perfectly appropriate – they are living there long-term (why it’s a nursing “home”). Now, the dual nature of nursing homes as hospital step-down units and long-term residential facilities means strikingly different patient populations and needs, but in the same physical space with the same number and skill level of staff.

Can’t nursing facilities just refuse to keep admitting sicker patients?

Why don’t SNFs refuse to serve this unintended purpose, and tell the hospital to keep their patients until they are much better? From a SNF perspective, this is a Faustian bargain. It’s financially attractive for SNFs to admit sick patients from the hospital because the daily rate Medicare pays for “rehab” is much higher than the rate they are paid to care for long-term nursing home residents (usually by Medicaid). SNFs balance on the razor edge in terms of their profit margin. The government’s main body that advises Medicare reports the average profit margin of SNFs in 2021 was -1.4% (a loss of 1.4%). Admitting more post-hospital patients can be the difference between keeping the doors open or closing.

However, the incentives that led to “quicker and sicker” hospital discharges means the cohort of people going to SNF are some of the sickest, most functionally and cognitively impaired older adults in our health care system. It’s hard to meet those needs on a negative profit margin. It’s no wonder so many older adults fail to recover significantly during their SNF stay.

Harnessing these forces

Now that these invisible forces are revealed, how can you use this to advocate and navigate?

First, you should know a patient has to consent (in writing) to be transferred to a SNF. Hospitals can’t discharge older adults against their will – in fact, you can appeal a discharge decision. This doesn’t mean it’s reasonable to expect to stay in the hospital for weeks and weeks, but it does mean if you think a hospital discharge is unsafe, you have options to halt the process. In particular, since hospitals are penalized for readmissions, it’s very effective to mention that you think an older adult will “come right back” to the hospital if discharged in their current state!

Second, I’ve learned that the dynamic course of older adults in the hospital often stands in sharp contrast to the thinking of the inpatient team, which can be fixed. When my research team asked a bedside nurse to describe why a particular patient ended up in SNF, she described it this way,

“First he [the patient] as going to go home with home care. Then, he was going to go to a SNF. Then, he had a choking event and had a real tight abdomen and they were thinking imminent death was near. But then he started looking and feeling way better, and so he could probably benefit maybe from some therapy.”

Let’s unpack this a little. The same patient was going to go home, to SNF, was going to die, and then looked terrific across 4 hospital days. While we hope to avoid near-death events in the hospital, this story is otherwise typical in my experience. A hospital stay is rarely a linear path to recovery in the older adults. Rather, it’s characterized by large day-to-day and even hour-to-hour differences in how well older adults are functioning and feeling. However, since “discharge planning begins on day 1,” inpatient teams are often evaluating older adults when they look the worst, and concluding a SNF discharge is the right choice very early in the stay. I often think if we just kept some older adults one more day in the hospital, they’d be able to go home, rather than to SNF – a choice they prefer and is cost-saving to the system. You can help challenge the inertia that sets in and encourage the inpatient teams to re-evaluate whether they really think SNF is the right choice – or whether another day might allow this older adult to return home.

Third, it won’t come as a surprise that SNFs that do the most post-hospital care are also the best at it. In addition to using the overall star rating in nursing home compare, I’d click on the “staffing” and “quality measures” sections. You’ll want a SNF that has above-average nurse staffing to handle the sick patients coming from the hospital, and one that performs particularly well on the “short-term” quality measures. I hope that future iterations of Nursing Home Compare will include a measure of how much post-hospital care a particular SNF provides.

In the big picture, we hope - with your new insider knowledge - that you feel the same way we do: the way that older adults receive care in and after the hospital is an accident of health policies, rather than the creation of an intentional system designed to meet their needs. Armed with insider information and using our collective imagination and advocacy, we can do better.