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Interview with Dr. Andrew Kramer

Hedrick Smith: We’re talking to Dr. Andrew Kramer, who is director of the Center for the Study of Aging. Let me ask you how prevalent stroke is as a disease and what it's impact is.

Andrew KramerDr. Andrew Kramer: Well there’s about 730,000 strokes per year and they are particularly prevalent in the Medicare elderly population. And it’s really a devastating disease. Not only does it have a very high mortality rate but there’s a great deal of residual secondary disability. People are unable to follow through on the activities that they were able to conduct before they had their stroke, and probably one of the most significant impacts, a lot of people end up in nursing homes subsequent to having a stroke.

Hedrick Smith: So when you study stroke and how it’s treated, what are you looking at? What are you looking for?

Dr. Andrew Kramer: I [am] very interested in the longer-term effects of stroke. What we’re really interested in is how people are living 3 months after a stroke, six months after a stroke, or even a year after the stroke, and whether they’re back in the community. I rely most heavily on issues related to where they’re living, in part because it’s such a combination of factors; a very small difference in how people can function can make a big difference in whether they can live at home.

Hedrick Smith: Are there particular policy reasons or other reasons why you’ve done these two major studies on stroke victims?

Dr. Andrew Kramer: I focused on stroke victims in part because it’s a very complicated illness to treat. [Patients] not only have physical effects after a stroke, but their speech is affected; their ability to think, their cognition is affected; their ability to swallow is affected. They can’t, they have difficulty ambulating and so it’s a, a complicated illness to treat.

Hedrick Smith: You’ve done these two major national studies. What have been your findings?

Dr. Andrew Kramer: Well, first of all we found that there’s a difference in outcomes for individuals who are treated after their stroke in an inpatient rehabilitation hospital. And because HMOs are more likely to use nursing homes for rehabilitation, we find a similar finding there where they are less likely to get individuals home than if people are in the traditional Medicare program. To give you a sense of the magnitude of the issue, if you’re in traditional Medicare you are twice as likely to be in your home a year after your stroke than if you were in an HMO because of the differences in care.

Hedrick Smith: Why is that the case? HMOs are not using as good facilities?

Dr. Andrew Kramer: Nursing home rehabilitation can be effective for many types of conditions. But as I told you before, a stroke is a very complex illness. If you look at the inpatient rehabilitation centers as we did and compare them to nursing homes, you find that there’s twice as much skilled nursing time for people in rehabilitation facilities. There’s twice as much therapy; there’s twice as much physician care; there’s three times as much specialty physician care like neurologists and physical medicine doctors. So it’s a much more intense environment for rehabilitation. And as a result, during that very crucial interval where people are trying to recover from the acute event, they have a much better improvement rate.

Hedrick Smith: Are you suggesting it costs more to treat a stroke victim the way traditional Medicare does in an acute rehabilitation center, than it does the way most HMOs are doing it, and maybe they’re doing it to save money?

Dr. Andrew Kramer: I would most certainly say that they are doing it to save money. When we went and visited the HMOs, we [found] that they thought [they] could replicate the elements of inpatient rehabilitation care at a lower cost. Unfortunately you can’t get there at a lower cost, even when you set out to do that.

Hedrick Smith: Knowing what you know from your studies, what would you do if you had a stroke and you were in the hospital?

Dr. Andrew Kramer: I would stay there and I would kick and scream and I would do everything I could to go to an inpatient rehab facility. And if for some reason I could not make that happen through the HMO, it’s probably one of those services that I would be willing to go out of the HMO, and make sure that I went to one of those settings.

Hedrick Smith: When you talk about recovery are you talking about recovering quality of life, quality of health outcome?

Dr. Andrew Kramer: First of all, I am talking about returning to my home. [It] is a measure of both function, a health outcome measure, and a measure of quality of life. There’s no doubt that people would prefer to be back in their home setting, as opposed to in a long term nursing home setting. That long-term nursing home setting also costs more over the long run because somebody has got to provide, pay for that care that requires ongoing assistance. The second thing though is the functional side. My ability to take care of myself, is [also] something that improves with inpatient rehabilitation hospital care.

Hedrick Smith: If studies like yours show that the quality outcome, quality of care, quality of life is so much better by using acute rehabilitation hospitals, why don’t HMOs do that for their Medicare patients?

Andrew KramerDr. Andrew Kramer: There are two reasons. The first reason is that it costs less to use a nursing home for rehabilitation. The second reason is I’m not sure how aware they are of what produces better outcomes.

Hedrick Smith: In other words, they’re in the health business but they’re not too sure of what actually makes a difference for people?

Dr. Andrew Kramer: There’s a lot of people that aren’t up to date on what is the most appropriate care and what yields the best outcomes and I think [that is] one of the problems. What’s going on in that situation is the HMO only has contracts and services set up to provide nursing home-level rehabilitation and does not authorize [coverage] for inpatient rehabilitation, and doesn’t understand or will not acknowledge the benefits of rehabilitation.

Hedrick Smith: Well, what you’re saying is that if HMOs are contracting for bulk medical care for hundreds and thousands of people, it may not serve the individual very well?

Dr. Andrew Kramer: I think that’s one of the problems in trying to manage care for specific conditions in the context of a very broad population with a whole array of problems, yes.

Hedrick Smith: So the patient pays by not getting as good quality?

Dr. Andrew Kramer: To some extent yes.

Hedrick Smith: Are there any other financial incentives or benefits--are there any other advantages for HMOs using nursing facilities as opposed to these hospitals?

Dr. Andrew Kramer: Yes, there’s a very important one and that is the way the payment is now set. An HMO would receive more funding if an individual was residing in a nursing home. [So] there’s a very strong incentive to put people in nursing homes.

Hedrick Smith: Tell me in some detail what’s the difference between the kind of care a stroke victim would get in an acute rehabilitation hospital as compared with a nursing facility?

Dr. Andrew Kramer: In an inpatient rehabilitation hospital they receive twice as many service hours from a skilled nurse. They receive twice as much therapy, physical therapy, occupational therapy and speech therapy. They receive twice as many physician visits on an ongoing basis, three times as many visits from a consulting physician, like a neurologist. Ninety percent of the people in a rehabilitation hospital in our study were seen by a physical medicine or rehabilitation doctor, a physiatrist. So across the board there are major differences in the intensity and the amount of care people receive.

Hedrick Smith: Do you see any difference between the kind of care provided by HMOs?

Dr. Andrew Kramer: There is a great deal of variation and that variation is a result of the nursing homes that they will send people to. You get a few nursing homes that are trying to become as close to rehabilitation hospitals as they can and they have a rehabilitation unit providing many of the types of services that are in a rehabilitation hospital. But many nursing homes, most of them in fact, do not have that strong rehabilitation orientation and the strong types of, of rehabilitation programs with those services. And so if you are admitted to one of those settings you are much less likely to get the type of care that is required.

Hedrick Smith: If a patient gets into an argument with an HMO over where to be treated and it takes several days to get that straightened out, is that critical time for the patient?

Dr. Andrew Kramer: I think days can make a big difference and more importantly it’s hard to reverse these kinds of changes, even over weeks.

Hedrick Smith: Do you think HMOs are unhappy if their stroke victims or sick patients wind up by leaving the program and going back to traditional Medicare or are they financially better off if the sick patients leave?

Dr. Andrew Kramer: From the perspective of the HMO you’re better off if you don’t have people that require multiple services over a long period of time, so yes, it serves them financially.

Hedrick Smith: If I understand you right, you’re saying there’s a financial incentive say goodbye to sick patients?

Dr. Andrew Kramer: Yes, not only is there an incentive to not encourage sicker patients to remain, but also to not have elaborate programs to take care of the very, very sick that would attract the sickest patients.

Hedrick Smith: So don’t have too generous a benefit structure or you might attract the sick?

Dr. Andrew Kramer: The way it’s set up now, yes. That’s the case.

Hedrick Smith: What an irony that we have health plans and a health system which is designed to serve the sick but which basically don’t want, doesn’t want the sick to come around.

Dr. Andrew Kramer: Well, it’s very strange that we have a health care system that encourages you to take care of the healthiest individuals and discourages you from taking care of those who have the greatest illness. And that is why HMOs have the best programs for the healthiest individuals. To draw very healthy members.

Hedrick Smith: So what you’re saying is that in traditional Medicare, compared with HMOs, patients are getting much more care and much higher quality care?

Dr. Andrew Kramer: They are. They’re getting more care from more skilled professionals. In settings that are oriented towards rehabilitation and towards the outcomes that we’ve been talking about as being important.

Hedrick Smith: For the patients is there actually a pay-off in the quality of the outcome for them and their quality of life afterward?

Dr. Andrew Kramer: There are some very big pay-offs. Even if you look at the very short term effect. During the period while they’re in the facility, we found that people improved much more if they went to an inpatient rehabilitation hospital than if they went to a nursing home. Over the much longer run that’s 6 months or a year they were then much more likely to be in their home, or in some other similar home setting, as opposed to a nursing home setting.

Hedrick Smith: If they were in an HMO program that used nursing homes, were they more likely to wind up back in the nursing home?

Dr. Andrew Kramer: Yes, individuals who had been in the community were two times more likely to be in a nursing home at 6 months or twelve months after their stroke. They were not only getting more care but they were getting care from more skilled professionals.

Hedrick Smith: Now, you’ve talked about the amount of time with nurses, the amount of time with doctors, the amount of time with specialist doctors, and so forth. Why is that so important to the patient?

Dr. Andrew Kramer: Because stroke affects so many different aspects of somebody’s health, you need individuals who are highly skilled in stroke care. You need psychologists to help deal with issues related to depression that is often associated with stroke. You need neurologists to deal with the neurological problems that might affect eyes and your ability to move and, and sensory abilities. You need physiatrists or rehabilitation doctors to examine the disabilities in motor skills. So you need skilled nurses. You need physical therapists. You need occupational therapists to help you and develop adaptive equipment so that you can return to your home. You need speech therapists. It’s a very complicated team and they have to function as a team. And they have to be there on a very regular basis and without that it’s hard to have optimal outcomes.

Hedrick Smith: Is it fair for two different categories of stroke victims, one treated in traditional Medicare and others treated by an HMO to get a totally different quality of treatment?

Dr. Andrew Kramer: It is certainly not fair to have two different levels of care for people in two different systems with the same illness like stroke.

Hedrick Smith: So how do we do that, how do we get the standards that you say are necessary?

Andrew KramerDr. Andrew Kramer: We have to begin to develop disease-specific standards for some of these problems. Typically the way it is now is [that] across the board rehabilitation ought to be provided in certain settings. Well, that’s not the case. Rehabilitation in some settings is appropriate for some diseases but for stroke the standard ought to be [that] rehabilitation is expected in the inpatient hospital.

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