A Fate Worse than Death

“A fate worse than death.” How many times have we heard the term? What could be worse than death? We all have our opinion.

When William Gibbon used the term in his History of the Decline and Fall of the Roman Empirehe was using it as a euphemism for the “involuntary loss of a woman’s honor.”  In the quarter millennium since his epic work, many have appropriated the term for their purposes. Famously, Kurt Vonnegut, in his address “Fates Worse than Death” acerbically pondered if there are truly any fates worse than death. But I digress… 

It seems we finally have a formal, government sanctioned definition for a fate truly worse than death. We can even quantify exactly how bad such a fate is when compared to death. Aren’t these grand times?

Tom Baker, of Doctor Who fame, once said “I think quite often a fate worse than death is life - for lots of people.” (Mr. Baker portrayed the fourth doctor, if you are wondering.)  Fortunately, the Center for Medicare and Medicaid Services has stepped in to provide clarity here, and they support Mr. Baker’s definition wholeheartedly. Life is indeed worse than death, or at least when it comes to Medicare reimbursement.

Do you consider it worse to be readmitted to a hospital, or to die?

A physician colleague of mine once opined that she thought the ideal patient outcome, in Medicare’s view, was for a patient to achieve Medicare eligibility, then promptly die without ever utilizing any Medicare resources. Now it appears that view is documented, to some degree, through scientific study in a peer reviewed journal. To the CMS, readmission to a hospital (in other words, living) is worse than dying.

In a study published in JAMA Cardiology, physicians at the University of Michigan and the Ann Arbor Veterans Administration Medical Center noted an amazing paradox in health care reimbursement by Medicare. In the study, the authors identified two cohorts. In one group, hospitals had a higher readmission rate. These hospitals were punished with financial penalties because of the increased rate of readmission.  These penalties were levied even though these hospitals kept more patients alive than expected.

That is right – more people lived than would be expected based on the disease groups being studied, yet the CMS punished the hospital. 

Compare this to a second group of hospitals, where there were low readmission rates.  In this group, more patients died within a month of leaving the hospital. The hospitals in this group were penalized less because they did not have as many readmissions.  How much less? More than ten times less. This degree of difference essentially makes it a reward to have the patient die rather than be readmitted. 

In a Reuters report, Dr Scott Hummel, one of the study’s authors states “You could argue that from the individual patient’s perspective, mortality should be weighted much higher than readmission.” I will hazard a guess that most of the survivors would agree. I will also go out on a limb and report that many, if not most, deceased Medicare beneficiaries would agree.  (It is Halloween, so I will report back if I get new information tonight.)

This compensation practice may perplex all but the most dedicated Vonnegut fans. The hospitals that do the best job keeping patients with significant illnesses alive are penalized for keeping them alive, while those that let them die are, essentially, rewarded.

No one argues that we want more efficient care. We waste untold amounts of money in the health care sector.  We should all realize that readmission may mean the hospital could have done a better job the first time around. It might  also mean their patient was sicker.  We also recognize that not all who died could have been saved had they been readmitted.  Some patients were destined to die despite all best efforts.  Likewise, some might have lived had they been readmitted.  There are many variables to consider. We should not rely solely on some one-sized fits all algorithm that shifts the focus from the patient and places excess value on the bottom line.

Let us start by admitting that living is not necessarily a fate worse than death.


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