Cardiovascular Readmissions in Dallas County Hospitals

Thank you for taking the time to read about and address the health issues that are prevalent in the 30th District as mentioned in my previous memo. I would be happy to provide additional details and evidence on the rates of readmission to Dallas hospitals for cardiovascular-related health issues. I would like to use health statistics and data from our friends in France to compare their health care system and lower rates of readmissions for cardiovascular-related health issues, despite the fact that there are many similarities in demographics and disparities to the United States. It is my belief that this information will be crucial to persuading the 30th District Congressional Committee to take action to reduce these costly readmissions.

The French health care system is a good one to compare to the United States because their health care system is revolutionary in many ways, as well as are similarities in demographics and culture that can provide insight into this issue. The main and likely obvious difference between France’s and the United States’ health care, however, is that the French health care system is nationalized and accessible to all of its citizens.

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To begin, it is important to first understand the basics of the French culture, government, and population. France is a representative democracy located in Western Europe with a population of 65.1 mil. people as of 2019 and territories throughout the world (Staff, 2019). France is estimated to be primarily Caucasian, with less than 10 percent of residents being African American or Asian (Staff, 2019). Almost 30 percent of newborns in 2010 had at least one parent who was not a French native (Staff, 2019). There are many immigrants in France and has been estimated that close to half of the French population has immigrant ancestors (Staff, 2019). France has a high rate of non-religious identifying persons (39%), as well as Christians (51%) and Muslims (8%) due to immigration from Islamic nations (Staff, 2019).

France has the sixth largest economy in the world with a GDP of $2.8 trillion, and per capita GDP of $38,400, but the third highest debt of any country in the world, at 97% of the nation’s GDP (Staff, 2019). The unemployment rate is 8 percent, lower than the United States’ unemployment rate of 3% (Staff, 2019).

Although the health care system in France is not perfect, it was ranked number 1 in the world according to the World Health Organization in the year 2000, making it impressive and worth analyzing (Rodwin, 2003). That same year, the United States ranked number 37 in terms of quality and cost. Over the past 19 years, France has remained at the top of the list when compared to other countries. The country of France spends much less on healthcare compared to the United States, yet their health outcomes are much more positive. There are twice as many infant and maternal deaths in the United States as there are in France (Rodwin, 2013). The rate of readmission to hospitals for individuals ages 65 or older in France is only 14.7%, when in the United States that number climbs to 20% (Morabito, 2019). This can be widely attributed to a more effective and widespread access to primary care, in addition to individuals being able to afford longer hospital stays (Morabito, 2019). Furthermore, being able to receive preventative health care from an early age adds over 4 years of life expectancy to the French citizens when compared to that of the United States population (Morabito, 2019).

Originally passed in 1928, the French national health care system was implemented to cover salaried workers making a low wage. In 1945, France expanded their national healthcare system as we know it today, social security, to combat the increase of health care costs post World War 2 for all of their citizens, regardless of socioeconomic status (Morabito, 2019). Since 2000, any residents of France for more than 3 months are now eligible for health care (Rodwin, 2003). The people of France still have many choices of physicians and facilities and are not bound to limitations by the government, and physicians are able to practice with freedom in providing the best treatment necessary.

The French healthcare system is financed by the French government, but is not run by the French government. On average, the government funds up to 80 % of health care costs, with the remaining balance being the patient’s responsibility (Morabito, 2019). French citizens pay high income taxes to fund their social security health care system, but Americans will still pay more out of pocket costs and premiums when it comes time to utilize health care services (Morabito, 2019). As described by Paul Dutton, a historian from Northern Arizona University, payments from French income tax are funneled to quasi-public insurance funds who negotiate fees for the patients, while the government continues to negotiate hospital fees (Dutton, 2016). The French are able to, and often encouraged to take advantage of private insurance through employers to supplement what coverage the government does not provide. Last year, the American government spent double on health care per capita than the French government, with an average of $10,000 per capita (Morabito, 2019). A portion of the cost reduction in France is at the expense of the physicians, who make about half of what American doctors make per year, but this is offset by the extremely low cost of medical school tuition and malpractice insurance when compared to the United States (Morabito, 2019).

Coverage is extensive in France, with little to no wait for elective procedures and no discrimination of pre-existing conditions (Shapiro, 2008). In fact, the more ill you are, the more coverage you receive. Severe illnesses like cancer are prioritized and patients are not limited to a narrow choice of drugs (Shapiro, 2008). Coverage spans from hospital and outpatient care, to drugs, assisted living, dental, vision, and alternative spa care (Rodwin, 2003). Quasi-public organizations determine coverage and reimbursements (Rodwin, 2003).

Support and opposition of this healthcare system ultimately comes down to the fiscal effects. Supporters of this health care system are those who believed funding would not be impacted. Opponents are concerned that there are complications with coordinating care and that annual income for specialists is declining.

Currently, reformation is being discussed, specifically to improve management and financial organization within the healthcare system, such as with the Public Health Policy and Health Insurance Reform Act that give priority to the state and parliament. Fee for service incentives are also being implemented to entice physicians to practice their medicine in areas of the country that need it most.

While the Healthy People 2020 goal for stroke and cardiovascular related deaths is at 34.8 per 100,000 people, Dallas county has a death rate of over 50 per 100,000 people (Healthy North Texas, 2019). Statistics in North Texas have shown that heart diseases are the chief cause of hospital readmissions and that ethnicity plays a part as well, as racial health disparities make African Americans more likely to suffer from cardiovascular related hospital admissions (Sharma, 2015). These cardiovascular related deaths are higher in Dallas than the nation’s average, and readmissions must be prevented.

The American Heart Association recently implemented a pilot program for heart failure patients called Rises Above Heart Failure, and will be implementing its early testing and training efforts for medical professionals in three different Dallas hospitals (AHA, 2019). Although the AHA is making headway with cardiac readmissions through this program, there is more that can be done to ensure readmissions are reduced, and we can see that by looking at the French healthcare system.

Two French programs whose frameworks could really aid the United States in reducing cardiac hospital readmissions are the Carte Vitale and by widely implementing Enhanced Recovery After Surgery (ERAS) protocol and increasing funding for the existing ERAS programs in the U.S. (McConnell, 2018). Administrative costs are 3 times less expensive in France than the United States, and this can be explained by the French using the Carte Vitale health care card to streamline their health care facility visits (Morabito, 2019). This card can be swiped by health care providers and contain health and financial information for the patient without having to waste time and money tracking down this health information through multiple EHR systems or referring physicians (Morabito, 2019). Furthermore, cross platform EHR systems like Carte Vitale can be used to determine and flag potential patients that are susceptible to readmission, like patients that have recently suffered cardiac arrest (Baillie, 2013).

The ERAS protocol has been proven successful in France and across Europe, and includes practices such as: “medical optimization, patient education, minimization of invasive procedures, multimodal opioid-sparing analgesia, preemptive mitigation of complications and early mobilization” (McConnell, 2018). The ERAS-cardiac program has been described as “an example of value-based care applied to a specific surgical specialty with goals, including improved patient and staff satisfaction, earlier recovery, reduced costs, and a reduction in opioid use' (McConnell, 2018). The United States has been limited on collecting data with their use of ERAS protocol, and apprehensive about implementing this protocol widely, even though studies have shown that the cost of implementing ERAS protocol greatly outweigh the cost of hospital readmissions (Stone, 2016).

As Democratic dominance is on the horizon for Texas in the upcoming election, we have faith that our policy recommendations will be heard and implemented with support from influential politicians like you, Congresswoman Johnson.

To ensure successful interventions, especially for implementing ERAS protocol, we will need support from physicians and hospital stakeholders as well. Support can be gained by showing these leaders the results that ERAS does reduce readmissions and therefore reduces hospital overhead costs and reflects a healthier community.

As we understand the increase of cardiac readmissions in Dallas hospitals, we can observe and learn from the trial and error of our French friends to implement national health care policies to reduce this issue. We urge the 30th District to consider incorporating ERAS protocols into Dallas hospitals to reduce readmissions and implement more centralized EHR systems similar to the Carte Vitale to flag high risk patients that slip through the cracks.

References

1. AHA. (2019). The American Heart Association Launches Pilot Program to Reduce Hospital Readmissions for Heart Failure Patients. Retrieved June 30, 2019, from https://newsroom.heart.org/news/the-american-heart-association-launches-pilot-program-to-reduce-hospital-readmissions-for-heart-failure-patients
2. Baillie, C. A., VanZandbergen, C., Tait, G., Hanish, A., Leas, B., French, B., … Umscheid, C. A. (2013). The readmission risk flag: using the electronic health record to automatically identify patients at risk for 30-day readmission. Journal of hospital medicine, 8(12), 689–695. doi:10.1002/jhm.2106
3. Dallas News. (2019). With Trump at the top of the ticket, Republicans, Democrats prepare for epic 2020 Texas fight. Retrieved July 13, 2019, from https://www.dallasnews.com/news/elections-2020/2019/07/05/trump-top-ticket-republicans-democrats-prepare-epic-2020-texas-fight
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8. Morabito, C. (2019). France's health-care system was ranked as the world's best-Here's how it compares with the US'. Retrieved July 13, 2019, from https://www.cnbc.com/2019/05/17/france-versus-the-united-states-how-the-two-nations-health-care-systems-compare.html
9. Rodwin V. G. (2003). The health care system under French national health insurance: lessons for health reform in the United States. American journal of public health, 93(1), 31–37. doi:10.2105/ajph.93.1.31
10. Rodwin, V. (2013). The french health care system. World Hospitals and Health Services - Universal Health Coverage (UHC): Making Progress towards the 2030 Targets, 51, 1st ser. Retrieved July 13, 2019, from https://wagner.nyu.edu/files/faculty/publications/French.health.system.03.2018 (1).pdf.
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12. Sharma, S. (2015). Readmissions in North Texas: A Comprehensive Overview of Statistics, Demographics, and Charges to Identify Disparities 2013-2015. Retrieved from https://dfwhcfoundation.org/wp-content/uploads/2017/10/White-Paper_Final-_Oct_2017.pdf
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