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bentonpena · 5 years

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What it's like to get high and eat nachos at America's first cannabis cafe

What it's like to get high and eat nachos at America's first cannabis cafe http://bit.ly/2M5wGpW

Aesthetically speaking, Lowell Cafe is like any other West Hollywood restaurant: the nachos are vegan, the outdoor patio is lined with live plant walls, and the dappled sunlight sets customers up for a perfect boomerang of them ripping a bong.

Stylized as Lowell Farms: A Cannabis Cafe but also referred to as Lowell Cafe, the restaurant is the first of its kind in the United States. Part dispensary and part eatery, guests choose from an extensive menu of pre-rolled joints, ounces of flower, vape pods, and dabs. Customers can also snack on a variety of dishes designed to compliment the inevitable munchies. It's almost like visiting a gastropub, but instead of splitting fries and sipping whatever beer's on tap, you can smoke whatever flower is in season.

"You’re entering the world of post-cannabis prohibition," the press release for the cafe promised.

When I arrived at the cafe on Tuesday afternoon, the line of walk-in hopefuls was already wrapped around the block.

All guests, regardless of whether or not they consume cannabis products on-site, must be over 21 years old. At the door, a bouncer with a tablet scanned my ID, which was added to an internal database used for cannabis purchases. After being seated, a Flower Host stopped by to give us the rundown. Instead of checking my ID when I later ordered weed, the host checked her tablet for proof of age.

Image: FREDERIC J. BROWN / AFP / Getty Images

Because regulated cannabis is a legislative nightmare, Lowell Cafe is actually two different businesses. Under California's current laws, cannabis lounges like Lowell Cafe aren't allowed to sell food or beverages, so the front patio facing the street is a basic, run-of-the-mill eatery that serves food but can't sell weed. The interior and enclosed back patio are 420-friendly areas where patrons can order food from the restaurant, buy cannabis products, and consume it. The restaurant, which serves food, beverages, and as soon as it secures its license, wine, is a separate entity from the dispensary.

Basically, as West Hollywood's community and legislative affairs manager John Leonard told Eater LA, there are "two separate businesses on two separate premises."

"Patrons in the cannabis consumption area are allowed to order food from the adjacent restaurant," he continued. "And the food from the adjacent restaurant is delivered to the consumption area."

That whole set-up made ordering both weed and food pretty confusing. Guests order from two separate servers, one for food and one for weed. Likened to a sommelier, the Flower Host — the person serving weed — explains the various products, suggests food and flower pairings, and shows you how to use the paraphernalia available to rent.

This is where the confusion comes in — since there was one server for food and a separate one for weed, figuring out who was staffing each overlapping section in the hectic restaurant seemed like a guessing game.

Choosing weed can also be a ride. Lowell Cafe's cannabis selection is packaged in an intimidating leather-bound menu similar to wine menus at fancy restaurants. The cafe is a fully stocked dispensary, and its selection includes pre-roll packs ranging from six to 14 joints per package, edibles with up to 100 milligrams of THC, and an eighth of flower. And like buying alcohol in bars or restaurants, expect a steep up-charge; eighths will cost you $55 to $65. Patrons can also bring their own weed for a "toke-age" fee of $20, like a corkage fee in a traditional restaurant.

For the most part, buying a pricey bottle of wine or an elaborate cocktail is justifiable because the party is likely to finish it before leaving. Only the strongest of stoners can finish off an eighth of weed or 14 whole joints in the recommended one and a half hours sitting at Lowell Cafe. Thanks to municipal regulations, guests can't take the leftover weed home with them, which can lead to some absurd speed hits in an effort to finish products, and will inevitably lead to wasted weed or upset guests.

Granted, it didn't seem like the Flower Hosts stopped anyone from sneaking unfinished weed into pockets as diners paid their bills before leaving.

I told our first Flower Host that I tended to stay away from THC-intense indica strains because of my tendency to cry in public when I consume them. The Flower Hosts' familiarity with cannabis varies. The first one I spoke to recommended whatever pre-roll had the highest amount of THC, but another, a former weed farmer who goes by Circa Suicide, told me that first time visitors should try to stick with low doses in case they get anxious.

My friend Rebecca and I ended up splitting a pre-roll sativa joint called Kushberry Cheesecake, a 21.88 percent THC joint that cost $20. (A similarly fruity sativa pre-roll with a similar THC content, for reference, goes for about $10 through marijuana delivery services. Many dispensaries in Los Angeles will also toss in a pre-roll for free with the purchase of an eighth.) The menu described it as "Invigorating, Active" and it yielded the kind of high that makes the world more visually interesting while still letting you think clearly. It's also the kind of body high that motivates you to demolish a plate of vegan nachos at an alarming, but almost admirable pace.

I was worried that once I started smoking, I'd be overwhelmed by the cafe. I've visited Amsterdam's coffeeshops before, and while most of my experiences were lovely, I have felt suffocated by the smoky air, dim lighting, and crowded spaces. I can get pretty paranoid when I smoke weed that contains just THC and no CBD, but I felt at peace lazily passing off that joint. At times, the tightly packed tables were a touch claustrophobic and a particularly lengthy cover of Fleetwood Mac's Dreams felt like it was four decibels too loud, but the "Invigorating, Active" part of this high never felt overbearing. The air inside wasn't excessively smoky, either, thanks to the cafe's ventilation system.

"I would bring my parents here, I would bring my partners here," Circa Suicide said as I snacked on what may have been the best burger I've eaten in L.A. (That might have been the weed deciding that, though.) "I would even bring my coworkers here. It's a really nice, neutral vibe."

Circa Suicide added that since not everyone does well getting high in such an overstimulating environment, she recommends not smoking at all if you're anxious about being anxious. If you do decide to partake, take it slow.

"Take one hit, put it out, give it ten minutes," she said, explaining how first-time smokers should try it out in a public setting like Lowell Cafe. "You can always go back in for one more. If you're feeling weird, we're here to bring water and talk to you."

At times, the Flower Hosts seemed more like well-meaning parental units checking on an after school hang than typical budtenders. When the couple next to Rebecca and I fell into a couch lock, punctuated by bursts of giggles, a Flower Host stopped by and offered them bottled water. When I put out the last of the joint in the Lowell Farms-branded ashtray, a food server asked if I wanted any other munchies-quelling snacks off the menu. Circa Suicide recommended pairing the ice cream sundae with a Banana OG pre-roll before leaving to teach a first-time smoker how to roll a joint.

Image: Frederic J. BROWN / AFP / getty images

Overall, the first public American cannabis cafe didn't exceed high expectations, but that's more the fault of regulatory confusion than poor planning. On one hand, Lowell Cafe is just a public place to smoke weed. On the other, it's also pioneering the way American culture approaches consuming cannabis in public. Considering the exhaustive list of limitations Lowell Cafe had to work with — separating businesses, a ban on serving cannabis-infused food, and state laws forbidding the sale of alcohol and cannabis on the same premise — Lowell Cafe managed to pull off an impressive blend of bar culture and weed.

But regulating weed like alcohol also holds back the cannabis industry. Laws that work for alcohol, like not allowing patrons to bring home extra product, don't make sense when applied to weed. That, though, is in the hands of municipal governments to reform.

Lowell Cafe's social impact is complicated as well. Paying for overpriced weed and taking the afternoon off to get baked is an immense privilege. As L.A. Taco noted earlier this year, greater Los Angeles' booming marijuana industry is promising, but it leaves convicted felons with non-violent drug charges behind. People of color have been, and still are disproportionately incarcerated for it. Part of the application process to secure a spot as one of eight approved cannabis consumption lounges involved taking "social equity" into account, which includes prison reform and minority inclusion. In its FAQ, Lowell Cafe says it gives "special employment consideration" to recently pardoned, non-violent cannabis offenders. But like L.A. Taco says, "being given priority to work minimum wage or low paying jobs at the bottom of a billion-dollar business feels like too-little-too-late."

I left Lowell Cafe satiated by delicious food and gently toasted, not quite baked enough to want to take a walk. Over 750 people visited during its opening day, according to a Lowell Cafe spokesperson. While it wasn't revolutionary, smoking on a lively outdoor patio certainly beat the "prohibition"-era experience of hotboxing a friend's grandpa's car and messily ordering pizza. And it's paving the way for the not only West Hollywood's cannabis consumption lounges, but the many sure to pop up as legalized states figure out how to regulate it.

Lowell Cafe sits at the awkward crossroad of legalized weed and clumsy regulation — the marijuana industry is moving forward, but the government can't keep up. At least the food is good while the rest of us wait.

Tech via Mashable! http://bit.ly/2nGI2sr October 3, 2019 at 10:42AM

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cristoph00cdc · 6 years

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Justin Trudeau in conversation with Paul Wells: Maclean's Live

i am told in Malaysia - i am nothing - so they denied me all medicine- all care - while telling me - that all this will kill me - then Canada closed the doors on me - by saying i was not Canadian enough etc. i cant leave as i am too weak - hemorrhaging- dying -

HISTORY OF LEPTOSPIROSIS INJURY FROM COCO-BAY MALAYSIA https://youtu.be/AYpTDYtbUEM https://youtu.be/6aY90OyWqUU

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https://youtu.be/_SZobVbastw https://youtu.be/3XhhF_1hcjg https://thebookof25.wordpress.com/2017/06/06/a-morte-pela-viral-persistente-leptospirose-humana-na-malasia/ https://thebookof25.wordpress.com/2017/03/19/the-return-of-the-plague-cocobay-port-dickson-malaysia/ https://youtu.be/ewRlP5SzbYU http://campaign.mcdonalds.com.hk/en/promotions/evm/ https://youtu.be/evO9T14E4Bc https://youtu.be/GAJrN7uBrlc https://youtu.be/MYFc69caOJ4 https://thebookof25.wordpress.com/2017/05/29/death-by-viral-persistent-human-leptospirosis-in-malaysia-gofundme-comdeath-by-persistent-leptosporisis/ https://www.gofundme.com/death-by-persistent-leptosporisis https://igg.me/at/dm8tpfdQs5Q https://youtu.be/pcJf3xL2iT0 https://youtu.be/GXA3KwCLhLM THE BOOK OF 25 - THE HORROR OF PHL https://patient.info/doctor/leptospirosis-weils-disease http://www.leptospirosis.org/medical/phl.php http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0076549 https://www.cdc.gov/leptospirosis/symptoms/ https://www.pressreader.com/malaysia/new-straits-times/20170218/281741269180169

http://newsinfo.inquirer.net/790079/malaysia-warns-of-leptospirosis-risk-at-natural-water-spots http://www.medicalnewstoday.com/articles/246829.php

https://youtu.be/GfVqNbjtf_k

https://www.linkedin.com/pulse/i-have-leptospirosis-i-am-dying-cristoph-de-caermichael?published=t

https://youtu.be/euGRa8fIvuc

Organ failure, internal hemorrhaging, and death can result if the bacterium infects the liver, kidneys, and other major organs. Care should be taken to differentiate between PHL as detailed here, which is a long-term but essentially transient condition, and the Human persistent leptospirosis where the subject has it for life if not treated – it goes to Weil Disease – and then Blood Cancer – but this is Murder.

THE BOOK OF 25 - THE HORROR OF PHL https://patient.info/doctor/leptospirosis-weils-disease http://www.leptospirosis.org/medical/phl.php http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0076549 https://www.cdc.gov/leptospirosis/symptoms/ https://www.pressreader.com/malaysia/new-straits-times/20170218/281741269180169

http://newsinfo.inquirer.net/790079/malaysia-warns-of-leptospirosis-risk-at-natural-water-spots http://www.medicalnewstoday.com/articles/246829.php

https://youtu.be/GfVqNbjtf_k https://youtu.be/euGRa8fIvuc

With all the garbage here of why this occurred and that there is no assistance.. Due to the Malaysians themselves – and the incomprehensible reality – of incompetence and outright insanity of the Malays as a collective. A very corrupt - very dangerous people -the country should be closed. As for Canada - trudeau is such a delinquent - its not only corruption its insanity.

This is..an international incident- meaning the ,minute I say or write that this leads to my death – OMG – and that I can’t leave – as ………………….

Rat fever here or Leptospirosis has only been seen as humans interacting with rat urine in water. I had the rat urine / feces in the blanket – desiccated dried and fed on by Bed bugs - parasites and mold. When I saw the blanket at 3am – I thought it was a beige tweed – wool blend - the fuzz was the mold – and as it was so late – and my bedding had not dried – I used it. All the realization was after the fact and washing the blanket - the water turned crimson not red but crimson – and the turds floated to the surface. I did not know it was turds – I thought menses blood clots – thought human – not rat – it was only in march I physically saw the red rat shit and realised I was in extreme danger. That it was the plague. (4) This mode of infection is closer to the plague. It was the fleas that bit the humans – in my case it’s the Bedbugs and parasites – and mold. that transmitted the lepto- via 3 different modes of venom..all create deadly infection. The infection is fierce – there are no antibiotics strong enough for this – I am on so many and after 1 month of these pox – and hives etc.. I’m in agony. I have now had the infection for 4 months – the first infection lasted about a month – it had fewer bites per se – about 50.. and I had to fight to get rid of them. Then I noticed I was still getting the hives – and the itching but they were fewer – then my heart went crazy – I had noticed – there was pain and a pretty strange heartbeat - but it the heart got worse. So after I had the heart confirmed – the pox was I think was dormant at that time – so that is now March. I was still very weak and trying to figure what to do. I moved to the new place – and then a massive pox attack in April – it came on – so fast and my entire body broke out – my back – my legs – my arm – my head – about 200-300 of them – as you have seen. Agony It was during April and the new outbreak and the intensity of the outbreak – which it was then understand that it is persistent human leptospirosis and no one could treat it. No here and not in Canada – I would have to be quarantined and guinea pigged on in Canada – here – they are waiting for me to die. I did the turmeric – and now the hives are subsiding – some are disappearing from my legs – like magic – but it’s a lot of work – I had 20 showers yesterday - applying all kinds of ointments – mixing turmeric with oils and rubbing it in – all this to try and fight it. My sheets and pillows are yellow – the turmeric – though I bathed – and scrubbed it off – still lingered. How do I explain all this to an mp and say – well – under the circumstances - ? https://youtu.be/RBhVyabqdAc https://youtu.be/Cz0MRO_JIoQ https ://youtu.be/80DTZGvebN4 https://youtu.be/EQ4RJZiGSQQ

B-13A-08, CAPE NAUTICA VILLAS, PD WORLD MARINA RESORT, BATU 6, JALAN PANTAI, 71050 PORT DICKSON, NEGERI SEMBILAN

I M J Boland 283 Beckett Cres, Fonthill ON, L0S1E4 CANADA (905) 892-8383

G. BOLAND 210-895 Maple Avenue Burlington, on, Canada L7S 2H7 https://youtu.be/OpB2AjeMq64 https://youtu.be/_RLB1UTySGU https://youtu.be/KSOweFN76l0 Hospital Kuala Lumpur 50586 Jalan Pahang Wilayah Persekutuan Kuala Lumpur. Tel No: 03-26155555 | Fax: 03-26989845 | Email: [email protected] [email protected] https://thebookof25.wordpress.com/2015/06/01/cannabis-wisdom-as-per-vancouvers-ted-smith/ https://thebookof25.wordpress.com/2015/06/01/marijuana-it-all-goes-up-in-420-smoke-anyway-but-canada-is-still-a-huffin-and-a-puffin-to-make-it-legal/

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C:\Users\Cristoph-Dell\Pictures\Exported videos\POS MALAYSIA CORRUPT_Small.mp4 https://youtu.be/eoGLeaBSciM https://www.pinterest.ca/marinasct/mariano-fortuny/?lp=true

Justine Trudeau House of Commons Ottawa, ON K1A 0A6 [email protected] https://www.change.org/p/human-rights-campaign-free-a-canadian-trapped-in-malaysia

Dr. Lawson Baird Address: 2190 York Ave, Vancouver, BC V6J 3X1, Canada +1 604-733-9110

URGENT REPORT TO THE PRIME MINISTER OF MALAYSIA - PLEASE STOP MY DEATH IN MALAYSIA DATED JUNE 17 2018

https://www.facebook.com/TunDrMahathir/ [email protected] Dr. Mahathir bin Mohamad @TunDrMahathir Mahathir Bin Mohamad Office of The Prime Minister of Malaysia Main Block, Perdana Putra Building Federal Government Administrative Centre 62502, Putrajaya MALAYSIA https://youtu.be/Xmulc2YN4uY

C:\Users\Cristoph-Dell\Pictures\Exported videos\lawd have mercy_Small.mp4

Address No. 1, Jalan P8H Precinct 8, Putrajaya 62250 Malaysia Tel: +603 8885 8900 Fax: +603 8889 1166 Email: [email protected]

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Constituency Office Dr. Hedy Fry MP hedyfry.ca Community 106 - 1030 Denman Street, Vancouver, BC, Canada 604-666-0135

HEDY -FRY - LOVES FAKE NEWS https://www.theglobeandmail.com/news/national/cross-burning-furor-hits-liberal/article4145631/

AN EXCERPT OF DR.FRY'S CUNNING - DECEIPT-RIDICULE OF HER OFFICE & PRIVLEDGE

"We can just go to British Columbia in Prince George, where crosses are being burned on lawns as we speak," she said to mark International Day for the Elimination of Racism.

Later that day, Ms. Fry clarified her comments, saying that cross-burnings had occurred in the past. "I know of this because I was contacted immediately that these incidents occurred by the mayor of Prince George," she said. Prince George Mayor Colin Kinsley says he never told Ms. Fry such a thing and that there are no confirmed reports of cross-burnings in the city.

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tminor09 · 7 years

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Life is a Hustle...Find multiple

I admire all of the hustlers out in the world whatever it is as long as it isn’t robbing. But I’m not even going to mention the drug dealers, prostitutes, etc. I’m only speaking on the legal hustlers. This is the positive side of social media. Sure some of them get annoying, but they are trying to get their business out. From people making food plates and selling them out of their houses to the women doing hair. The handy men, the artist, life is a hustle, find multiple. One of my best friends is a personal trainer, his main job is at the YMCA, but he also trains part time at D1 sports, he coached at Davis HS, and he goes to people’s homes and trains athletes. That’s hustling. It was this woman that I went on a date with, she was the one that I took to brunch very bright woman, just didn’t want kids, but she has a bachelors in psychology and works at a psychiatric hospital in protective services, but she also taught herself to paint and she sells art on the side, mainly to friends right now, but that’s hustling. My brother n law is a DPS officer he builds model cars mainly police cars and sells them. Sends them all over the country and I tell you those white folks love those. He said people on the outside may think it’s kiddish, but back at their old house, those model cars paid all of the utility bills alone. Plus his normal income and my sisters income, that got them their new house. That’s hustling. Last one, my dad, he didn’t do much besides work on cars, but he did that on the side, especially race cars. He loved cars, but back in my younger years he use to street race betting money, that was his other hustle besides doing work on the side, he had a 1968 Camaro. I remember hitting back streets finding a empty road and the guys unloading and racing before the cops came. If not on the street then on the track, but he would bet money. My sister and I didn’t have to grow up struggling because sometimes he would bring home like 10,000 in two weeks 5k a Sunday. That’s hustling. I thought on this. I have many talents, but I never really utilized multiple at one time. I just thought of things ,such as drawing, as a hobby. When people use to ask me for tattoo designs I would do them for free because I loved to draw. Well not anymore. Millionaires are made off of ambition, what are you willing to do to make it. It’s a tattoo parlor right across the street from my place and I was thinking about getting more tattoos since it’s been awhile. It then made me think back to the older days. For the people who never knew, The summer before my freshman year in college, I was a tattoo apprentice. I always drew my own tattoo designs so when I came to the shop they were fascinated by them. They finally asked if I wanted to hang around and learn to do tattoos. Back then I was going pretty much every weekend I had money saved, getting more work done that’s why I have 27 tattoos now. It was pretty much a black and Hispanic shop, 420 Tattoos off of 249 on the Northside. J-Boy was my tat guy. They use to have me doing crazy stuff like going to the 99 cents store in a diaper to buy green soap. I couldn’t say anything either I just had to do it. We were rolling laughing too. But anyways J-Boy got locked up and I pretty much stopped going after awhile and I got a job at Walmart until college started. Just today I was on amazon and I thought about it again. I want to teach myself to tattoo, starting off as a hobby, but through hard work, I’ll do them in my apartment. I already know how to keep things sterile. I saw a tattoo kit plus practice skin and everything else that I need, I’m going to order it. It’ll make for a good hobby. Also, I know I’m not a master chef or anything, but it’s actually fun trying and mastering these vegetarian meals. Making things like vegetarian Gumbo, vegetarian burgers, etc. I bet I could make and sell plates if I really put my mind to it. Anything to make a little side change. Add that to detailing cars, small body repairs, changing bumpers, lights, even spark plugs and things of that nature right in my garage. I’m also thinking about painting on canvas. It’ll all be worth it and fun. As my closest friends know, i don’t like to openly talk about it, as my sister says, “the more you talk about your goals, the more chances you have for people to pray against you because they don’t want to see you progress. All prayer isn’t good prayer.” So I’ll just say I’m trying to continue my education. When that time comes around, I’ll have to live off of loans. Whether I have a family or not, I wouldn’t want to live strictly off of loans. That’s how this all came to mind. Make as much as you can, utilize your talents, and hustle that’s how you make it in life.

~TayMinor

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omcik-blog · 7 years

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New Post has been published on OmCik

New Post has been published on http://omcik.com/this-aca-rule-keeps-you-out-of-the-hospital-and-saves-billions-will-it-survive/

This ACA rule keeps you out of the hospital and saves billions. Will it survive?

The ACA hospital readmissions penalty program is supposed to punish hospitals with an unusually high percentage of patients who keep coming back with serious medical problems. (Photo: Thinkstock)

(Bloomberg) — The Republican replacement for the Affordable Care Act, now fighting its way through Congress, removes the individual insurance mandate at the heart of Obamacare and phases out the Medicaid expansion that accounts for millions of the newly insured.

One piece it appears to have spared, so far: the Medicare Hospital Readmission Reduction Program.

Related: Medicare penalizes hospitals for readmission rates

It’s not a household name. But HRRP has been quietly improving the quality of health care—while saving the federal government billions of dollars—by penalizing hospitals that have too many readmissions within 30 days of patient discharge. Since its implementation in 2013, readmissions for targeted conditions are down, according to multiple studies. The savings come because the penalties are imposed as Medicare reimbursement cuts and because the program leads to fewer visits for Medicare to reimburse in the first place.

The philosophy behind the program is that when patients come back to the hospital, it’s not only costly; it also represents a failure of some kind by the health care provider. By paying hospitals for each subsequent but avoidable treatment, the thinking goes, you’re rewarding the shortcomings.

So the program penalizes eligible hospitals with readmission rates for Medicare patients higher than the national average, if those patients were initially admitted for specific, listed ailments and they returned to the hospital for any reason within the following 30 days. Hospitals that don’t measure up can lose as much as 3 percent of their Medicare payments, a significant hit to many of them.

“Before [the ACA], hospitals got paid for readmissions” of Medicare patients, said Robert Yeh, director of the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center in Boston and an associate professor of medicine at Harvard Medical School. HRRP turned the tables and appears to be changing how hospitals operate.

Will HRRP survive the battle in Congress? Speaker of the House Paul Ryan’s office didn’t reply to emailed questions about how it would be treated in the new legislation, and the draft bill released this week doesn’t address the issue. For now, some of Obamacare’s fiercest foes don’t seem intent on eliminating the program. Americans for Tax Reform and the Club for Growth, both of which have pushed for ACA’s repeal, declined to comment on it.

The Heritage Foundation even offered mild praise, though it said it doesn’t take an official position on the program. “In general, it has been somewhat successful in that it has reduced hospital readmissions,” said John O’Shea, a senior fellow for health policy at the foundation.

Related: Witness: Provider pay distorts health market

That might not sound like a ringing endorsement, until you consider how the organization describes the Affordable Care Act as a whole: a “proven policy failure,” “a welfare program,” and a law made of “hopelessly complex and unworkable subsidy schemes, boondoggle bailouts, and collapsing co-ops.”

While hospital readmission rates were already in decline, they began to fall faster in April 2010, after the ACA was passed and even before it was implemented, according to a study published in the New England Journal of Medicine in February 2016. The decline for targeted conditions was steeper than for nontargeted conditions, further suggesting that the ACA was the cause. From October 2012 to May 2015, readmission rates continued to decline, but less quickly.

“Presumably, hospitals made substantial changes during the implementation period but could not sustain such a high rate of reductions in the long term,” the authors of the study wrote.

Yeh’s team conducted a study, published in the Annals of Internal Medicine in December, that set out to answer another question: Were the hospitals with the worst performance under the program also the ones caring for the most socioeconomically disadvantaged populations—and therefore the ones that could afford the penalties the least? “There was even a concern that financially penalizing these hospitals would be just the opposite of what you needed to do,” Yeh said. Instead, his study found that the worst-performing hospitals were improving the most.

A Heritage Foundation fellow has some mild praise for the readmissions reduction program. (Photo: Thinkstock)

Positives, negatives and fixes

HRRP spells government savings in two ways. The penalties amount to Medicare dollars the government gets to keep in its coffers, which totaled $420 million in 2016 and are estimated to hit $528 million in 2017, according to an analysis by the Kaiser Family Foundation, with the increase mostly due to the expanding list of covered medical conditions. (While 78 percent of eligible hospitals received some kind of penalty, the average penalty was only 0.61 percent.) Then there are the savings achieved simply by providing better care the first time around.

From 2013 to 2019, the federal government will have saved $7.1 billion from the readmissions program alone, according to the Congressional Budget Office’s 2010 estimate.

Hospitals are using different approaches to avoid penalties. At Massachusetts General Hospital, the focus has been on identifying high-risk patients when they are admitted and taking extra steps to make sure they get the care they need after they leave. Ryan Thompson, a primary-care physician at Mass General, calls it a “holistic approach,” which begins with a word search to review medical records and identify factors that often put people at higher risk.

“It’s often not clinical factors,” Thompson said, listing transportation issues and food and housing insecurity as indicators that the person is likely to be readmitted. “Those elements are sometimes not in structured data but in notes in medical records. The natural-language query identifies them.” The No. 1 indicator of a future readmission, he said, is a past one.

The hospital has put in place new resources to help these patients, he said. An appointment scheduler works with the patient to find nearby clinicians and make sure they have transportation to reach them. Instead of just handing them a phone number, the staffer will help plan the logistics of the appointment. Mass General is working with pharmacists to make sure as many patients as possible leave with their medications in hand and an understanding of how to take them. A nurse practitioner is available to them after discharge as well, even making the trip to their homes, if necessary.

All this has required new investment, Thompson said, but for a hospital that has more patients than beds, it’s money well spent. “We only want patients to come back who need to be here,” he said.

HRRP has its flaws. One of the most commonly cited concerns is that, even as they’ve been improving, hospitals serving lower socioeconomic populations are still penalized too often, said Cristina Boccuti, an associate director of the program on Medicare policy at the Henry J. Kaiser Family Foundation.

“Since the HRRP’s inception, hospitals caring for the poorest patients have been significantly more likely to receive penalties,” the American Hospital Association told the Subcommittee on Health, of the House’s Committee on Ways and Means, in September. “The current HRRP failed to recognize that community factors outside the control of the hospital—such as the availability of primary care, mental health services, physical therapy, easy access to medications and appropriate food, and other rehabilitative services—significantly influence the likelihood of a patient’s health improving after discharge from the hospital or whether readmission may be necessary.”

Both Thompson and Leo McCall, chief executive officer of Neshoba County General Hospital-Nursing Home in Philadelphia, Miss., echoed this sentiment.

“It’s virtually impossible to change how people behave in their homes,” McCall said. “Some people just don’t care, and we get penalized for that segment of the population. That’s just not fair.”

In December, the Obama administration tried to fix this problem with the passage of the 21st Century Cures Act. It requires, beginning in 2019, that the penalty calculations account for the socioeconomic status of the hospitals’ Medicare patients. Hospitals will then be divided into peer groups based on shares of low-income patients, identified by Medicaid eligibility. It’s a start, Boccuti said.

“It’s one way of identifying low-income patient populations, but some hospitals in some states may find it doesn’t adequately identify their economically disadvantaged patients,” she said.

There’s also the problem of using the national average rather than fixed targets, which creates a “moving goal post” by which hospitals are graded on a curve instead of on their own merits, Boccuti said. “It’s possible that hospitals can improve but still face penalties,” she said. Mass General and Neshoba County General, for example, have both been penalized despite their efforts.

Nor are readmissions the only metric that matters, Thompson said. “We want to make sure we’re actually keeping our eye on the ball, which is to keep patients alive,” he said. “It could be that readmission is a good thing when it comes to that. The goal for a readmission score should never be zero.”

He called HRRP “terrific for patients,” even if it feels like a chore sometimes, and McCall said it helped his hospital “move from the old concept of you do it, you get paid for it, regardless of what the outcome is.”

O’Shea, of the Heritage Foundation, said the Cures Act “was a fairly thoughtful way” of keeping hospitals from getting penalties based on socioeconomic conditions.

And HRRP seems to align with some of the GOP’s stated hopes for a replacement plan.

“Right now, it’s not a point of focus for the ACA changes,” Boccuti said. “It does carry the goals of improving care, lowering costs, and adding value to what Medicare pays for.”

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