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One Medicare program pays nearly $1 billion to treat heart failure in Pennsylvania

Morning Call - 8/7/2018

Aug. 07--More than two-thirds of heart failure patients have to return to the hospital after their initial hospitalization, racking up hundreds of millions in Medicare costs, according to a state report Tuesday.

Heart failure care cost one Medicare program nearly $1 billion in Pennsylvania in one year, according to an analysis of federal data from 2014-2015 by the Pennsylvania Health Care Cost Containment Council. About $500 million went to hospitalizations, making heart failure a costly and preventable problem, according to the agency.

"Understanding the various health care needs of heart failure patients, along with the cost of that care, provides opportunities to evaluate how that care is delivered, improve coordination of care, and examine different payment models," said Joe Martin, PHC4's executive director, in a statement. "Looking at episodes of care is a step forward in understanding the patient's experience," Martin added.

About 5.7 million Americans live with heart failure, a condition in which the heart isn't pumping blood to meet the body's needs, according to the American Heart Association. Because a weak heart can't pump blood efficiently, blood is slow to return to the heart and causes fluid to build up. Tissues also swell with water because there isn't enough blood for the kidney, which filters fluids.

In Lehigh County, 10 people are hospitalized for heart failure for every 1,000 people enrolled in the Medicare fee-for-service program, according to the agency analysis. In Northampton, the rate is 13.3 people. Both figures are higher than the state average of 9.5 people.

Because heart failure is more common among the elderly and poor, the rates can vary based on the demographics of a region, health experts said. The Medicare program enrollees are just a fraction of the Pennsylvanians suffering from heart failure.

Commercial insurers, Medicaid and Medicare's managed care program -- which pays hospitals a lump sum to treat health conditions -- are also major payers for heart failure treatment. The fee-for-service payment model, which tracks each service as a charge, allows researchers to see where patients are racking up expenses in their treatment.

Readmissions make up the biggest share of the expenses, followed by initial hospital visit, skilled nursing, primary care, outpatient services, prescription drugs, home health services, hospice services and medical equipment.

Hospitalizations can be avoided by managing heart failure through medication, low-salt diet and doctor's visits, said Dr. Ronald S. Freudenberger, the physician in chief of Lehigh Valley Health Network'sHeart Institute. However, there isn't a commonly accessible tool to monitor fluid buildup in the body, except to monitor body weight, he said. Fluid overload is one of the major reasons that people have to be admitted to the hospital.

"They can accumulate fluids without symptoms, until one day they have severe symptoms" he said. "What we need in this field is a gas gauge, like in a car, to check how much fluid people have accumulated."

Many patients with heart failure also suffer from other health conditions, such as chronic obstructive pulmonary disease and high blood pressure, which makes readmissions common, said Dr. Abhishek Singh, an advanced heart failure physician at St. Luke's Cardiology Associates.

Patients from low-income communities face even more challenges to managing heart failure, he said.

"Patients sometimes don't have access to medication, transportation or health care literacy," he said. "We try to address those things in the hospital."

But ideally, these issues could be tackled before patients need to be admitted to the hospital, Martin said.

"Given that nearly half of the costs are for inpatient care, it suggests there is room for improvement on the management side," he said.

Bhuang@mcall.com

610-820-6745

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