Hospitals Are Making A Killing On Poorly Nourished Patients As Insolvency Of Medicare Part A Looms
July 9, 2018
admission to the hospital and not only experience more complications and hospital-acquired infections, but by conservative estimation spend an extra costly day or two in the hospital.
If nutritional assessment and corrective therapy were to be instituted upon hospital admission and reduced hospital length of stay by just 1 day, it is estimated in this report that practice would save $73 billion to Medicare Part A. That represents 24.5% of the $293 billion of Medicare funds spent on hospitalization (Part A).
This is just the estimated savings that would be achieved if nutrient deficiencies for just two vitamins – vitamins C and D, were to be corrected upon hospital admission. Further savings in billions of dollars would be anticipated for correction of other common essential nutrient deficiencies such as vitamin B1, B9 (folic acid), B12, zinc and magnesium.
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In the other direction, reduction of levels of iron by phlebotomy (blood letting) among newly hospitalized patients would predictably reduce morbidity and mortality among the many iron-overloaded patients who enter the hospital.
One authoritative study shows patients admitted to the hospital with high iron levels as evidenced by elevated iron transport protein (transferrin) have longer hospital stays (11.1 days) than patients with lower iron levels (8.4 days) and are more likely to die in the hospital compared to patients with lower ferritin levels.
Does government really want to reduce length of stay?
A problem with reports like these is that most of the time government seeks to only curb the growth of Medicare spending so as not to reduce employment or harm financial status of American hospital chains that dominate the in-patient landscape. For example, the Hospital Corporation of America, one of the largest hospital chains, advertises it has produced record financial growth over the period 2011-16.
President Trump’s proposed budget for 2019 includes $554 billion in cuts for Medicare. While seniors on Medicare fear budget cuts that would reduce levels of care, this is one measure that would reduce needless costs while increasing health. Rationing care would not be necessary.
The Federal Government may have no choice over whether to severely cut expenses for hospitalization. Medicare Part A is expected to run out of funds earlier than previously expected – by 2026. There is an urgency to put nutritional therapy into widespread practice in
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hospitals throughout America.Medicare beneficiaries in poor health account for a disproportionate share of Medicare spending. Medicare enrollment is expected to grow rapidly over the next two decades. An increasing amount of Medicare payments are being made out of the general fund. This means the Medicare Trust Fund is already partially insolvent.
Beginning in 2009, general revenue transfers became the largest single source of Medicare income.
Medicare spending was 15 percent of total federal spending in 2017, and is projected to rise to 18 percent by 2028. In 2017 Medicare Part A for hospitalization cost $293 billion.
In 2012 there were 36.5 million hospital stays in the U.S. with average length of stay of 4.5 days at an average cost of $10,400 per stay. Efforts to decrease hospital stays in order to produce more efficient use of Medicare funds has resulted in only a 0.3% (one-third of 1%) drop in hospital stay from 2003 to 2008.
It is not beyond reason to believe nutritional therapy practiced at American hospitals could meaningfully reduce length of stay to produce profound savings. At a cost of ~$2000 per day, a reduction of hospital stay by 1-day accomplished by required assessment of nutritional status upon hospital admission and provision of corrective nutritional therapy could theoretically save $73 billion.
Hospital Accreditation organizations need to enforce nutritional assessment and therapy in all U.S. hospitals. Other efforts to reduce hospital stay appear feeble compared to nutritional therapy and may produce patient harm and foster readmission.
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The high cost of malnutrition
Nationally the annual cost of disease-associated malnutrition is estimated to exceed $15.5 billion. An estimated one-third of patients are malnourished prior to being admitted to the hospital. Furthermore, another third of patients not malnourished at the time of hospital admission become malnourished during their hospital stay.
The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently proposed that “addressing disease-[associated] malnutrition in hospitalized patients should be a national goal in the United States…to improve patient outcomes by reducing morbidity, mortality, and costs… [and] to alert health care organizations on the need to provide optimal nutrition care.”
Consumption of oral nutrition supplements in hospitalized patients significantly decreases the probability for 30-day readmission, length of stay, and health care cost.
Malnutrition has been called a “skeleton in the hospital closet.” Malnutrition contributed to a myriad number of negative outcomes and readmission rates as well as poor quality of life and even mortal risks.
A survey of 243 hospitals (1500 were invited to participate, only 243 did) found almost 90% of patients were screened for malnutrition upon admission and 30% were found to be malnourished. A registered dietician ordered an oral dietary supplement 65% of the time. This practice reduced malnutrition to 14% upon discharge but less than 10% received advice or a prescription to take an oral dietary supplement.
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Malnourished patients are 1.5-5.0 times more likely to die in the hospital and twice as likely to stay longer in the hospital compared to well nourished patients.
A survey of 44.0 million inpatient hospital episodes, oral nutritional supplements were employed only 1.6% of the time and when utilized resulted in a shorter length of stay (2.3 days) from 10.9 to 8.6 days (-21%) and costs by $4734 (from $21,216 to $17,216; 21.6% savings).
A European analysis reports cost savings of 12.2% for standardized oral nutritional therapy with concomitant reduction in mortality, complications and reduced hospital stay (~2 days).
A review of 19 studies involving long-term care homes showed oral nutritional supplements, when employed for 3 months or more, accounted for less than 5% of the total cost for care and reduced hospitalization by 16.5%.
In another study, the estimated cost of treatment for a patient at nutritional risk was 20% higher than the average cost of treating the same disease in a patient without nutritional risk.
Evidence for correction of malnutrition among hospitalized patients
The evidence for nutritional therapy among hospitalized patients is compelling. This report is confined to the impact restoration of just two key vitamins, vitamins C and D, would have upon hospital length of stay and consequent reduction in morbidity and mortality.
Hospitalization and specific nutrients: vitamin C
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A study conducted at a hospital in Australia found 76.5% of patients had low vitamin C blood levels and was associated with two days longer hospital stay.
In another study of critically ill patients, one-third exhibited low vitamin C levels (below 23 micromole per liter of blood sample) and another third were frankly vitamin C deficient (below 11 micromole per blood sample). Among patients with sepsis, a life-threatening condition characterized by an over-responsive immune system, was twice as prevalent among vitamin C deficient patients. This was despite receiving recommended intravenous or oral vitamin C therapy.
A review of studies involving vitamin C levels among patients hospitalized for heart surgery found reduced length of stay in (by ~1-day) and a significant reduced risk for atrial fibrillation following surgery (atrial fibrillation is when the top chambers of the heart flutter) with vitamin C therapy.
While there is scientific debate over whether vitamin C therapy reduces atrial fibrillation among patients hospitalized for heart surgery, a review of all published studies up to 2016 concludes vitamin C treatment more than halves the risk for post-surgical atrial fibrillation. Other similar meta-analyses come to the same conclusion.
One study found cardiac patients who received 2 grams (2000 milligrams) of vitamin C intravenously immediately prior to surgery followed by 1 gram (1000 mg) for the first 4 postoperative days, reduced hospital stay by ~2 days compared to patients who received an inactive placebo pill.
A study of severely injured trauma patients found 7-days of antioxidant therapy (vitamin C, E and selenium) reduced the risk for death by 68%.
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Hospitalization and specific nutrients: vitamin D
A study conducted at a hospital in France revealed patients with low vitamin D levels (less than 50 nanomole per blood sample) were more likely to spend more days in the hospital and patients with high vitamin D blood levels (15.2 days versus 12.1 days). Another study found similar results among hospitalized patients with low vitamin D levels.
Yet another study conducted in France shows that hospitalized males with vitamin D deficiency were 3.7 times more likely to have longer hospital stays.
One study shows hospitalized patients with adequate vitamin D blood levels experience a shorter length of stay in the hospital (11 days compared to 14 days).
Another telling study conducted at a hospital in France found, among all factors analyzed, only vitamin D blood levels were associated with in-hospital death. Patients with high vitamin D levels were less likely to die in the hospital.
Other nutrient deficiencies
While this report is confined to the impact of supplementation of just two vitamins upon hospitalization, there are many other evidences that supplementation with other nutrients can produce similar health benefits and cost savings. For example:
- Among patients undergoing open-heart cardiac bypass surgery, the incidence of post-operative atrial fibrillation was cut in half (from 35% to 16%) when patients received intravenous magnesium.
- Heart failure is a common reason for hospitalization. A deficiency of vitamin B1 (thiamin) is known to induce heart failure. In one published study, 33% of heart failure patients were vitamin B1 deficient compared to 12% among hospitalized patients without heart failure. The prevalence of thiamine deficiency ranges from 21% to 98% of patients hospitalized for heart failure.
The tragedy of all this is worsened by the use of prescription drugs that deplete essential nutrients, a problem that is largely ignored by modern medicine.
Physicians are not adequately trained in nutritional therapy in medical school and are rewarded financially (a drug consult fee) for prescribing drugs, not vitamin pills. Physicians typically look down their nose at patients who take vitamin pills. There is an anti-vitamin crusade within modern medicine that suggests patients are being intentionally gamed for more disease to treat via nutrient deprivation.
Standardized dose of supplemental nutrients provided upon hospital admission may be practical but may also result in ineffective dosage. Advocates of vitamin prophylaxis and therapy will surely hear of the risk of kidney stones associated with vitamin C and hyper-calcification with use of vitamin D. Yet recent studies shows no risk for kidney stones with intravenous vitamin C therapy or oral vitamin C and it takes an implausible dose of ~1 million units of vitamin D to produce hyper-calcification. Physicians safely inject 300,000 units of vitamin D in older women for wintertime bone protection without side effects.
Another irony is that patients who arrive at the hospital for planned admissions routinely have their vitamin pills taken away from them.
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