NEW YORK CITY—During her 9½ years as director of nursing at Bellevue Hospital's emergency department, Susanne Greenblatt came to know many of its regulars on a first-name basis.
“The one yesterday? He comes in every day,” said Greenblatt, now associate executive director for case management at NYC Health & Hospitals/Bellevue, as it is officially called. The patient, a homeless man and substance abuser, had recently been hospitalized for several days for a brain injury. After initially refusing to go to a nursing home, he had returned to Bellevue a day earlier, having finally changed his mind.
His decision represented a bittersweet victory. Bellevue is a safety net hospital, the kind charged with taking care of everyone no matter how poor or sick. Such hospitals tend to see disproportionate numbers of patients who are homeless, uninsured or simply sicker because they can't afford regular medical care.
As a result, safety net hospitals say, they are handicapped in not only healing these patients, but in keeping them from returning to the hospital after the initial discharge.
“How are you going to convince somebody who's homeless to take their medication, and know what time it is?” Greenblatt asked. “You have to be very innovative.”
The challenges of treating poorer, sicker patients are indeed spurring ingenuity at some safety net hospitals, but they are also driving a fiery dispute in healthcare, tied to government reimbursements and quality metrics for hospitals. Should these hospitals be held responsible if their patients, often lacking a stable place to live, often without money for medicines, bounce in and out of the hospital?
How this question gets resolved will have huge financial implications, since factoring the social determinants of health into Medicare's Hospital Readmissions Reduction Program could lower the penalties many face under the program.
Advocates for safety net hospitals say the penalties unfairly punish them. The CMS, which has long insisted its methodology is fair, has finally agreed to revisit the question.
Yet not every safety net hospital is suffering under the program. At Bellevue—a storied hospital along the East River just below midtown Manhattan—hospital officials have been able to make significant strides in reducing its readmission penalties in recent years. A deeper dive into its approach outlines the contours of this complex, simmering debate, even as it reveals significant variability in the penalties' impact from hospital to hospital.