#theres no money made so they drop her off at the gate and say never to contact them again (hina wants to hang out though)

[zeravmeta]

the dumbells gyaru manga being a canon in-universe part of the kenganverse will never not be funny to me. there are three series' of incredibly brutal fights between peak athletes where we see the ludicrous levels of insane training and surgery done to get better at fighting ran fully by battle hungry maniacs with insane bloodlust,

and then off to the side there's a group of fitness enthusiast high schoolers somehow beating those professional fighter fitness peaks in inhuman times because one gyaru is really lazy and wants to lose weight for her summer bikini bod and just keeps losing focus. hina literally goes to the same school if she wants the ultimate fight against another physically peak monster she just has to look a little closer to home. its like if that plus size elf series took place in the same universe as baki

[simpsiren]

lee taeyong x reader

“my baby dont like it when you come around”

description. a new guy in college asks you for help to get rid of his girlfriend and slowly falls for you instead through your heated times with him.

genre. ANGST, college au, cheating au, bold/ arrogant reader x shy taeyong

warnings. none? except for the fact that this basically about cheating and having strong emotional tensions with each other, slighty suggestive

a/n. hihii i always thought of doing a ff about their baby dont like it song because its been in my head for so long HAHA also the lyrics are just uHem but yeah so anyways buckle up because theres going to be a lot of angst and tensionn also i didnt notice that i wrote so much like damn aNywAys enjoyy!

you walk into class lazily, expecting the same thing to happen again. as you step into the lecture hall, your eyes immediately went to your seat. you sigh and push you glasses up before walking over.

“i swear when will people stop doing this?” you mutter to yourself, shoving all the gifts off your table, making it all drop to the ground and producing a loud noise. everyone’s eyes are being drawn to your direction. you roll your eyes as mark takes his usual seat beside you.

“that’s the most you got this week.” mark laughs in disbelief, looking down onto the floor. you flash a fake smile at him, making him laugh even more. “its so annoying. none of them even look good.” your eyes scan through the gifts on the floor, seeing one that actually looks decent. you pick it up and examine it closely. mark gets near you and does the same.

“ill keep this one. looks expensive.” you shrug, shoving the expensive looking silver necklace into your bag. mark scoffs, letting his body sink into his seat. “i love the fact that you only care about the value of the gift.” 

you click your tongue and stand up, proceeding to pick up all the useless gifts you received from the random guys on campus and walking over to the trash can, throwing it all away. you hear gasps and mutters around the lecture hall. you clearly couldnt care less, walking back, taking your seat and bringing out your materials.

“it cant be helped that youre the most beautiful one around here.”

“you think i dont know that? people do know that they shouldnt mess with me right? yet i need to keep up with unknown admirers and random texts of confession.” you let out a long sigh, as you rest your chin on the palm of your head, leaning onto the table. 

“you admit youre beautiful. your confidence is truly amazing.” mark comments. you kept your eyes to the front as you watch your professor walk in, along with a new guy you’ve never seen before. your eyes remained on the guy, watching him climb up  the stairs and walking to the seat next to you. 

your attention changes to the professor as she starts talking. but your ears immediately diverted its attention to somewhere else, particularly to the guy next to you. 

“why did you seat next to her? do you know how dangerous that is?” you hear the girl sitting behind him whisper. its no doubt that she purposely whispered loud enough for you to hear, wanting to make your blood boil. you ket your cool and focused on the lecture, taking notes accordingly.

“how so?”

“she’s hard to talk to. she only had mark as her friend and she gets pissed easily. her temper is the worst around here and she’s the most feared. a lot of guys like her for some reason and-” 

“are you done, sweetie?” you lick your bottom lip as you turned around the face the girl. you hear mark hiding his laugh with a cough. “if you are, i really suggest you shut your mouth before i sew it shut for you.” your eyes glared at hers, staring at her intensively. you knew that it scared her when she immediately looks away. you chuckle in amusement before turning back to the front.

you look to the side, to see the guy’s eyes opened wide, with an eyebrow raised. you smile softly.

“lee taeyong.” you whisper, reading off the keychain attached to his pencil case, nodding your head before paying attention to the lecture again. the guy coughs softly and faced forward as well.

the lecture was now over and you start to pack up. you take your time since you know that it would be hectic to get through the large crowd of students who are also exiting as well as being able to avoid bumping into any guys and have them confess their useless affection towards you.

you were however intrigued to find out what’s going on outside when you hear someone whispering about the fact that there’s an extremely pretty girl waiting outside the campus.

by then, only you and mark were in the lecture hall. you figured it would be a good time to step out and find out the reason behind all the talking outside.

as you and mark walk down the hallway to the entrance, you tilt your head as you see a crowd forming at the gate. you sigh, taking off your glasses and rubbing your temples. “how the fuck are we suppose to get out?” you turn to mark with your eyebrows furrowed.

“im sure they’ll move aside once you come in.” mark places his hand on your shoulder and taps it lightly before walking forward towards the huge crowd with full confidence. you swear you can burst any minute as the the mumbles of the people fill your ears even more as you walk closer.

the moment one person makes eye contact with you. their eyes widened and signal their friends to quiet down. eventually, the noise starts to lower down as you made you way through the crowd. eyes were glued on you as you follow behind mark. you swiftly clean your glasses with the cloth in your pocket and put them back on.

as your vision starts to become clear, you notice that the one standing beside the girl is the lee taeyong guy from ealier. you walk over to them immediately.

you turn your head slightly to the back, signalling everyone to get back to what they were doing, and as always, they obey and the crowd dispersed itself. you look back to the front to where the cause of the nuisance started.

you eyed the girl intensively, looking up and down, observing every inch of her. you had to admit, she is quite the beauty. perfect wavy brown hair, almond shaped eyes, nicely drawn eyebrowa and plump pink lips. her body in the black tight fitting dress is amazing. it curved her body in all the right places.

you look up to see taeyong and the girl looking back at you with a raised brow. you faked a wide smile. “i dont think its wise to meet your boyfriend right at the gates of school.. especially when you’re this pretty. id fuck you.” you lick your lips teasingly and chuckle soon after.

“bitch the fuck?” mark whispers. you let out a loud, cunning laugh. “or perhaps...”

your eyes immediately connected with taeyong’s. you saw the fear yet a tint of interest in his eyes. you liked it. as you walk past the couple, you run your hand down taeyong’s chest. taeyong freezes as the girl’s mouth gape open, pulling taeyong away instantly with her arm around his waist. “id fuck your boyfriend.”

your head jerks toward taeyong as you whisper into his ear, but loudly enough for the girl to hear. with that, you wink at the both of them and walk off. mark smiles kindly before following behind you.

“that was... wow.” mark says to you, taking out his phone from his back pocket. you sigh, pushing your glasses up the bridge of your nose.

“honestly who is dumb enough to meet their significant other just outside campus? they should be taught a lesson. and to think that taeyong guy is new.”

“his name is taeyong?”

you nod. mark nods back in reply as the two of you walk ahead to the small secluded cafe shop nearby where the two of you would usually hang out.

“i really hope i dont see him on friday. does he look like he’s the kind to skip lecture?” you ask, taking a sip of your tea while mark drinks his coffee.

mark shrugs, laying his back against the chair. “i dont think so? he has that ‘bad boy but obedient’ vibes.” you eyebrows furrow, but you slowly nod your head as you start to understand his view of taeyong.

“well i hope he wont let his girlfriend and him cause such commotion again. it took us so long to get out.” you whine, looking at the time on your phone. “we fucking got out like 30 minutes after! you know how much i hate getting off campus late.”

mark chuckles, running his hand through his hair. “we know, sweetie. we know.”

“dont call me that i swear-”

“suckass.”

“bitch.”

the two of you laugh happily and take a sip of your drinks at the same time before discussing about today’s lecture.

friday comes and you see the gifts placed neatly on your table yet again. you roll your eyes and slouch into your seat. you are now too tired to even throw away the gifts and you give up doing so.

more people soon start to fill the seats of the lecture hall. when the professor walks in, you notice that the seat beside you is empty. you purse your lips into a thin line and shrug your shoulders, thinking that taeyong isnt going to come today.

“taeyong. its only your second day yet you’re already late.” your head lifts up from your table to see taeyong standing by the door. you rest your chin on the palm on your hand as you were intrigued by him again like the first time you saw him on wednesday. why? you dont even know yourself.

taeyong rushes in and sits down next to you. what surprised you is the fact that the same girl is standing outside. the murmurs and whispers come again. you swear you can get a headache from it.

you see her blowing a kiss to taeyong, making everyone shout and fangirl over her before she leaves and the hall is back to being silent. you turn your head to taeyong, who immediately look back at you.

“is she that crazy over you?” you ask, taking out your pen and beginning writing notes. “yeah. but i fucking hate it.” taeyong replies. you chuckle lowly as your eyes remain on the projector yet you could see taeyong blinking his eyes, as if you had an effect on him.

“she seems rich. you’re after her money, arent you?”

“it’s because i cant get away from her parents.”

“hm its also for the money. i can tell.” you look down at his outfit, a lot of it are designer and authentic clothing items. you laugh softly with amusement.

“why are people scared of you?” your eyes immediately darkens and you slowly turn your head to face taeyong, staring down at him. taeyong sucks air into his cheeks and glances somewhere else. laughing quietly at his reaction, you smile softly.

“let’s just say i have a bad reputation. yet im popular for some reason. its seriously annoying.”

taeyong looks down at the gifts that you have thrown off your table. “i can tell. you seem bold and intimidating.”

you take out your phone to scroll through your social medias in boredom. “bold and intimidating huh? you’re an interesting one. i like it.” you glance at the clock when you hear people starting to pack up. you too start to pack up as well.

taeyong is still seated on his seat, writing down the notes he missed from talking to you. you figured that he couldn’t multitask like you. before you stand up to get out of the hall you turn to taeyong. again it looked like his senses were all heightened and he’s being wary of you.

you got closer to him, faces inches apart. he didn’t move at all. his eyes still on you. you smirk softly, licking your bottom lip as you eyed him narrowly like looking at a delicious candy.

“looks like you arent intimidated by me. i like you.” you whispers softly, laughing loudly as you see mark waiting for you at the door. you quickly got up and went to mark. as the two of you exited the hall, you look back to taeyong. he’s still glued to his seat, not moving, his mouth gaping open slightly.

“oi let’s go.” you hear mark shout as you notice him already walking away. you smirk widely and follow behind mark.

“im sorry what?”

“let me cheat on her with you.”

“no.”

you glare at taeyong as you take a bite from your meal. you and taeyong are having lunch on campus together and it never fails to have eyes glued onto you whenever you’re with taeyong. you’re only option is to hang out with tayeong since mark didnt come today. you have yet to ask him why.

“come on please! if she sees me with someone like you she’ll be too scared to get near me then i can finally break up with her.” taeyong whines, grabbing your cup of iced tea and taking a sip.

“protect your reputation, taeyong. look around. you being with me is already giving people a bad impression of you.” taeyong does what you say, looking around and realising that a lot of people were staring at you two. he turns back to find you picking on your food.

“you’re the only one i know around here. itll only be until me and her break.”

you eyes trailed up from your food to meet taeyong’s. you put your fork down and sat up straight, tilting your head slightly. “what’s in it for me?” people around you know very well that wouldnt do something without getting something back in return. it didnt take taeyong long to know that due to the constant whispers about you around campus.

“ill let you have the money she gives me?” taeyong says nervously. you click your tongue. you were definitely intrigued when taeyong says the word ‘money’. taeyong smiles sheepishly as he waits for your answer.

“ill do it.” taeyong’s face lits up in an instant. you however were smiling devilishly, looking down at your prey. “get ready though. im not an easy one.”

taeyong blinks his eyes rapidly. his eyes definitely says he’s intimidated. but his body says otherwise, looking calm and composed.

“i know. itll be fun.” your eyes widen slightly as you see taeyong smirking under his soft smile. you raise your eyebrows and chuckle in amusement.

“oh im sure it will, ty.”

“you sure that’ll work?” you roll your eyes and rub your temples. you lost count of how many times you have tried to explain the plan to taeyong.

“you said she comes here to have coffee before she picks you up right? she doesnt know we ended early today so we’ll probably run into her. then i’ll just flirt with you or something. just follow my lead.” taeyong nods slowly. 

you shrug your shoulders and let your body sink into the comfortable seat. you and taeyong are at a pretty high class cafe and it felt good to drink some quality tea instead of the cheap ones you have to put up with living as a broke college student.

you drink your tea as you eyed taeyong. he looks anxious, constantly looking out the window and sucking his draw despite his cup already being empty. you groan to catch taeyong’s attention. “you need to chill. have you never flirt with anyone before?” taeyong shakes his head, biting his straw. you gape your mouth and clap your hands.

“no way! you’re good looking. you cant tell me that snobby girl is the only one you ever dated.” 

“she is.”

you choked on your drink, proceeding you laugh hysterically. taeyong furrows his eyebrow. “you better find a better girlfriend once you break up with her ty.” taeyong frowns, running his hand through his silk soft-looking hair. “im not interested in dating.” taeyong mumbles. you only hum in response. 

looking up from taeyong, you see the girl walking down the street, about to enter the cafe. you tapped taeyong’s hand quickly, making him flinch. 

“okay she’s coming, act natural. like how we are now.”

“wait what i-”

you immediately peck his lips to shut him up. taeyong widens his eyes in shock, his body completely frozen at your touch. you smirked widely as you see the girl standing outside, with her eyes filled with anger and her hand clenching into fists tightly. you chuckle in an evil manner. “her she comes.” you whisper in a sing-song tone.

taeyong looks straight at the door as she finally steps into the cafe and stomps over to your table. you smile widely, putting in your innocent act.

“who’s she, tae?” taeyong doesn’t reply, looking at you. you raise both your eyebrows and roll your eyes. slowly, your fingers crawl up to taeyong’s hand on the table, touching his fingers as you jerked your head to her.

“a friend.” taeyong replies simply.

she scoffs. you ran your hand through your hair. “and why are you guys here?”

you click your tongue and chuckle lowly. you look at her, noticing that she’s eyeing you like a prey. clearly she’s jealous right now. with her arms crossed and eyes. you knew.

“we finished quite early actually. you dont mind me hanging out with him, do you? im sure you know he’s new and im his only friend.” you say softly, turning to taeyong and biting your lip seductively. a smirk slowly creeped up taeyong’s mouth. you’re surprised that he suddenly looks confident rather than the first time you two met when he was looking all intimidated and nervous around you.

“yeah, its true.” taeyong winks playfully at you. you only hum in response before looking up to the girl. she furrows her eyebrows in anger.

“hm you wanna hang out with him, right? alright ill leave.” you stand up and shove your phone into your back pocket. as you walk past behind taeyong, you bend down beside him and got close to his ear, acting as if you were whispering something as you stared at the girl. oh the look on her face. you laugh inside your head. you stand up straight and ran your fingers seductively behind taeyong’s shoulders before exiting the cafe. you could have sworn that you heard her growling under her breathe.

“you should have seen the look on her face!” you laugh crazily, slamming your hand against your thigh and taking another sip of mark’s drink. you were too lazy to buy your own.

“man why didn’t you tell me all this before?! i would have followed you guys and watch the shit go down.” mark whines. you grin widely and shake your head.

“im so sorryy.” you take in deep breathes to calm yourself down.

“taeyong must have been surprised when he sees you go into that mode. i remember the first time you helped me get my parents to not force me to be in relationships after they knew im “dating” someone like you.” mark chuckles.

“well he was shocked at first. but he surprisingly acted well.”

mark nods his head. you sigh as you look around the campus and you see taeyong walking with his headphones on. you smile softly.

“if you’ll excuse me, ill put on my ‘cheating’ role now and go to taeyong. text me alright!” you stand up from your seat and did you signature handshake with mark before speeding over to where taeyong was.

your hand loops around his arm as you pull him close. taeyonh flinches but relaxes when he notice it’s you. “so how did she react?” you ask, walking happily.

taeyong shrugs and takes off his earpiece, unplugging it from his phone and shoving it into his tote bag. “she was definitely jealous. she gave me a lecture on how i shouldnt be with you cuz you looked like a bitch.” you gasp sarcastically, placing your hand on your chest as you gaped your mouth widely. taeyong chuckles at your reaction.

“a bitch? what about her? tsk..” you roll your eyes.

“i can safely assure you that you’re way better than her.” you laugh in response.

“of course i am.” you wink at taeyong. “also what’s her name? you never told me.”

“soyoung. oh by the way.” taeyong stops in his tracks. you stop as well and let your arm off taeyong’s. taeyong digs into his tote bag. after awhile, he pulls out money. you smile almost immediately.

“she gave it to me. in a way to bribe me not to hang out with you.” you lean forward and snatch the money away and counted it. and boy was it a lot of money.

“she’d pay this much for you to stay away from me? she really is a bitch.” you slid the money into your wallet.

“too bad though. she’ll be seeing me with you more often.” you start to walk forward, but you stop and turn your head back. taeyong was standing still and staring at you. you see him snap out of hid thoughts and shake his head before walking towards you.

“sorry about that. let’s go.” you only shrug your shoulders as the two of you walk out of campus.

“you’re meeting her this sunday?” taeyong nods. you look around taeyong’s apartment. it wasnt big, big enough for two people but he’s the only one lving here. the decor is simple and he place doesn’t look messy. you figured it suited him well.

“we’ll be together before you’re suppose to meet her and have her see us together.”

taeyong widens his eyes and tilts his head. “that’ll be intense.” you raise an eyebrow and chuckle.

“isnt that what cheating is all about, ty?” you shake your head, acting disappointed. you hear him let out a ‘tsk’. you laugh.

“all right. looks like you’re taking me out sunday night. ill dress up.”

“dont you always dress up? your outfits upstages everyone when i see you on campus.”

you peck taeyong’s cheek playfully. taeyong jumps back at your sudden move. you smiled widely.

“you know i always look good.”

you suddenly feel taeyong pulling you and placing you on his lap. you tilt your head in confusion. “what’s this?”

taeyong’s breathing slows down as his eyes glaze your face intensively, as if admiring every inch of it.

“sounds weird but i find you very fucking hot.. its irresistible.” taeyong whispers, raising his hand to twirl a section of your hair around his fingers.

“oh and please book me a grab home. im heading out now so text me aites.” you stand up from the couch and wave to taeyong before leaving his apartment and closing the door.

as you were waiting for taeyong to pick you up on his motorbike, you look down at your outfit. you’re wearing a really short grey pleated skirt with a white lace bralette and a oversized checkered blazer as an outerwear. you don’t usually wear skirts often, but you did need to play the part of being revealing so as to “attract” taeyong’s attention. you put the quotations on attract but you dont even know if taeyong would be attracted or not. you slightly hoped that he would for some reason.

you see a motorbike coming to a halt. you walk towards it as taeyong gets off. he takes off his helmet, ruffling his hair as he went to the trunk. you blink your eyes rapidly as you’ve never seen taeyong look this good. you snap out of your thoughts when taeyong passed you your helmet. the both of you wear the helmets at the same time as you give way for taeyong to get on the bike. after adjusting a little, taeyong jerks his head to gesture you to get on.

“sit properly if you dont want guys staring at your exposed thighs.” taeyong says, his voice being muffled by the shield of helmet. you pull your down your skirt slightly and rest your hand on your thighs, waiting for him to take off, but he doesn’t.

“put your hands somewhere else. it’s dangerous.”

“ouh right right..” you look at your sides to find any handles to hold onto but there weren’t any. you stare down at his back. shurgging, you wrap your arms around his waist and interlock your fingers togther. taeyong turns his head to you and looks forward before starting the mottorbike and driving. you dont even know where you’re headed but oh well.

after a drive of about 20 minutes, you finally feel the motorbike stop. you look beside you and notice there was a restaurant. a very high class one. you gap your mouth open in disbelief as you get off the bike and take off your helmet.

“you have dates to these places often?” you turn around to face taeyong who sighs and gets close to you to take your helmet, nodding slowly.

you scoff, your eyes scanning the entrance of the place up and down. you feel taeyong’s hand snake around your waist. “let’s not go inside yet.” you raise an eyebrow.

“then where are we going?”

taeyong leads you to the entrance of the restaurant, where there are benches aligned. you nod your head once taeyong take a seat on the bench and sit doen beside him.

“the place is secluded so id normally see people making out around here.” taeyong comments, glancing at his phone to check the time.

“well there’s a bar a few blocks down so i guess that’s why.” you only nod in response, looking in front as you watch the cars drive by. it made you think of one thing. “wait what does her car look like-“

taeyong swiftly wraps his arm around your waist and pull you on his lap. you blink at him as he jerks his head to the back of you. you assume that she arrived. you arch your back and let your hair flow down on one shoulder before wrapping your hands around his neck and pulling him into a deep kiss. taeyong’s grip on your waist tightens as you ran you hand through his hair and tilt your head to deepen the kiss even more. you felt taeyong’s hand roaming from your waist to your thigh, going up and down slowly.

for some reason, you were enjoying it. his lips on yours. you felt his hunger, neediness for you as he held you close as if to claim you’re his. you felt the same nonetheless. you liked it a lot. the two of you knew very well that this isnt acting anymore. it was real. the heat and needy tension. you didnt feel such a thing in a long time.

you suddenly flinch when you felt a hand on your shoulder, pushing you off taeyong’s lap. you turn around. “oh look who’s here! its soyoung.”

“the fuck did i just saw you doing with taeyong?” soyoung pushes you back further.

“i was about to have dinner with taeyong here.. but id figure it would be better to get free appetisers instead of having to pay for one.” you say confidently, brushing your thumb over you bottom lip as your eyes stared into hers.

soyoung scoffs and folds her arms. she looks down at your outfit. “you’ve been trying to seduce taeyong from the very start.” soyoung mutters under her breathe. you tilt your head as you grin widely.

“of course that’s what i’ve been doing idiot. taeyong really enjoys being with me though.” you turn your head to taeyong who was smirking widely and eyeing your outfit hungrily.

soyoung rubs her temples. with no words coming out her mouth, she turn away and walks to her car, getting into the driver’s seat and driving off. you slowly turn your head to taeyong who’s mouth is wide open. you laugh hysterically.

“oh my fucking god that was awesome!” you shout, clapping as you sit back down beside taeyong. taeyong smiles widely. “you really do have it in you.” taeyong compliments. you nudge his arm. “if you say you underestimated me i will beat you up.”

“please do. ruin me. every single moment i spend with you makes me fall and want you more. i love the dangerous side of you,”

[httphoneyb]

Fatal | Mobster!Tom x OC!

Summary: Violet Thorne and Tom Holland are both on opposing sides in the midst of a mob war. What happens when fatal collides with dangerous?

t w o

--

"Dad, I don't know what you want me to do here!" Violet sighed loudly throwing her hands in the air. Her father watching her pace back and forth infront of his desk.

"My love, I don't understand why you insist on me giving my seat to your brother. You are my first born thus, it's yours," he explained in a hushed tone.

"I want out of this dad! I've been trying to get out of this! And I can't do that i-if you keep dragging me back in!" Violet didn't understand how her father couldn't comprehend what she's been trying to say for the past hour.

The skin on her arm felt raw. Her nails dragged across it continuously since the topic was brought up.

"Then explain to me why, Violeta!" He stood slamming his hands on the dark oak desk.

Violet knew he had a rule about speaking to his children calmly, reserving his assertive voice for their enemies and prisoners.

He was always a gentle man around her and her brothers, some would say you wouldn't be able to tell he ran a mob while he was around his children. This circumstance was a rarity in her family.

So she stood and let the silence envelope the room.

"Exactly my point. You have no reason for wanting to be out of the business. Not a valid one anyway."

When in fact she did.

Her whole life Violet watched her brothers grow up like soldiers. As soon as they could walk, a gun was placed into their hands and the boys were taught how to shoot.

She didn't want a family like that. She's terrified to have a family like that.

"This could all be yours, my love. This...this empire was built on first borns, you are to continue it on. I'm growing old, Violeta. I need you to take my place. Especially when we're in the midst of a war."

"A war?"

"The Hollands have been crossing multiple mob boundaries in the past months. They're making alliances with the Diaz mob and broke their truce with the Rizzos. They're expanding. I can't do this on my own, Violeta."

"Pappa but you're not on your own..theres five other boys in the house waiting to take your spot. Leo has a knack for this, Dad. Use him!"

He chuckled lowly, "We both know you'd give Leonardo a run for his money."

"That's not my point. What I am saying is tha-" Violet was cut off by Luca, the youngest of the six, as he swung the wooden doors open doors open.

"We found the mole," was all he said before turning around and leaving.

"Mole? What mole?" Violet walked with her father out of his office, confusion written all over her face.

"Some of our info was leaked and other mobs got ahold of our shipments, drug and weapon outlets, even some safe houses." She could feel her father getting angrier as she reached the basement of their mansion.

"What?!"

Angelo, the third oldest joined them, "We found a usb full of our shipment dates and outposts. It was a cook, says the Hollands sent him."

Of course it was

She watched her father take out knives and guns as he headed for the lowest floor. The mere smell of that place made her stomach churn.

"You coming?" Angelo stopped midstep and turned to her.

"Yeah I'm just gonna save myself the trouble and head out for the day," Violet backed away from the flight of stairs.

"Hey Vi..just so you know, you're gonna have to suck it up one day, this job has no place for personal morals," Angelo turned around and decended the stairs, leaving Violet chewing at her lip.

What if he was right?

What if she really just needed to suck it up?

What if this was meant for her?

What if

What if

What if

Wh-

"Earth to Violet!" Leo waved a hand infront of her face.

The raven haired girl was dragged out of her own throughts.

"Tom wants to talk to you." Leo whispered, afraid that their father someone would hear.

Violet's eyebrows furrowed in confusion, "Tom? Tom Holland?"

"Yes Tom Holland! Who else!" Her brother sighed in annoyance, "He sent a letter this morning, good thing I got to it before Dad."

A light blue envelope was placed in her hand.

"A letter? Guy doesn't own a phone?" she scoffed, eyes skimming through the writing, the letters were smooth and neat, contrasting the many wrinkles on the paper.

"He's traditional I guess. Whatever. It just says he wants to meet with you to discuss some things blah blah blah...some thing about weapons yadda yadda.." Leo talked animatedly. His hands always waving around as he spoke.

"Why not Dad? I'm not in charge."

"Dad has it out for him, he's paranoid these days. Thinks everyone's out to get him."

"And what if it's a trap?"

"I'll have men tail you for protection, but other than that I think this is you know...good."

"Good? Good how?"

"Look, I don't wanna see this war that Pappa's been talking about happen. People will die. If theres a way to stop it, I think only you can pull it off."

"As much as I'm flattered, there's no point in me talking to him. I'm not taking Dad's place."

Leo rolled his eyes at his stubborn sister.

"No one said anything about that! Just go talk to him and see what he wants!"

"Fine."

"Yes!"

"But-"

"Oh no."

"You have to handle that southwest gang of criminals scamming our casinos."

"Ugh."

---

"Have they replied?" Tom asked as Harrison walked into the room.

"She's on her way now, actually. Eager girl," Harrison chuckled. "What do you want with her anyway?"

"Nothing harmful. Just trying to see if she could hold her own." Tom smirked as the burn of scotch travelled down his throat.

Violet rolled up to the front of the Holland mansion, a bit bigger than the Thorne's but then again, who's keeping track these days? Right?

Sam Holland walked to the car and opened the door for Violet. "Miss Thorne."

Violet took his hand and bent to look back at her driver in the car.

"When should I pick you up ma'am?"

"I'll call for you, Artie. Thank you." she smiled gratefully and followed the twin into the house.

"Bring a weapon with you, Thorne?" Harrison called from the top of the foyer.

"You think I'm gonna go into enemy territory without one?" she retorted. "Whoa! Kid! What're you doing!"

"Can't take any chances." Sam began to pat her down staring from her waist.

"Think we're gonna roll and show our bellies just cos you're a woman?" Harrison chuckled.

"I was counting on it.." she pouted as Sam seized her gun.

"Now there's no need for that ,Sammy." All of a sudden Tom appeared next to Harrison and started decending the stairs. "Don't you know how to treat a lady?" He grinned at her, "Let her keep the gun."

"Tom-"

"Let her keep the gun." Venom dripped from Tom's voice as he spoke slowly, "After all, this is just a casual talk right?" His eyes moved to hers, an ominous meaning behind his words unsettled her but stayed holding his gaze.

"Sure is." she took her gun back and slipped it on the band on her jeans as Tom looked behind her and whispered, "Then tell your men to turn around and go home."

Violet's heart dropped to her stomach and turned, the men Leo had sent with her we're parked outside the gates of the mansion, headlights turned off and obvious guns in hand. She sighed and called her brother.

"Yeah?"

"Tell them to go home." she said simply into the phone as Tom smirked at her.

"Vi, you can't be serious."

"Just do it."

She hung up the phone and threw a taunting smile at the boys before her.

"Follow me." Tom led Violet up the stairs and into what she assumed was his office. Much like her father's, the office was very manly and dark.

Taking a seat infront of his desk she asked, "Why am I here, Holland?"

"I want a cut of your drug profits." Tom said simply.

"And what do I get in return?" Violet leans forward to place her forearms on the desk.

"Safe travels. I know that for years your family has been funneling your weapons through my side of the city to get to them across the Atlantic. And for years my guys have been giving you trouble," Violet nods, pouring herself her own cup of scotch, "All I'm asking for is say..20% of your drug profits and I let your guys through with no hassle."

Violet finally breaks eye contact with Tom and doubles over in laughter, catching the mob boss off guard.

"20%?! Ha! You're delusional." She scoffs at him.

He stared at her with a look of both amusement and annoyance.

"Mr. Holland," Violet recollected herself as she sat with poise, sharp eyes looking at the man before her, "did you know that my family runs America's biggest underground drug cartel? We have 8 different bases across the country, and 2 abroad. Bringing in approximately twenty-million dollars a year each. You're asking me to cut 20% of my 200 million a year to..what," she did the math quickly in her head as Tom gaped at her in disbelief, "$160,000,000 for safe travels, as you put it, for one of our outposts?You've gone insane. Your men aren't anything mine can't handle. Now if you'll excuse me."

Tom ran his calloused hands up and down his face in exhaustion. Man she was a hassle.

"Wait."

Violet sat back down and looked at him in boredom.

"15%"

"Eight."

"Thirteen."

"Six."

"Fifteen."

"Six."

"Twelve."

"Three."

Tom cussed outloud and leaned back in his chair. "8% and I'll tell you what the Rizzo's down south are planning."

"Why would I care about some shithole mob?" Violet scoffed at his poor attempt to negotiate.

"They're trying to kill you."

Tom saw that what he said piqued the stubborn girls interest.

"Fine. 16 million a year. Now, tell me more."

Tom inwardly smirked at this, "They think that killing you would kill your empire. They know Robert would never give his seat to anyone else. And they also know you're refusing to take it. If you're gone..all they have to do is wait for your dad to die and your mob along with it."

The room was filled with silence as a million thoughts ran through Violet's mind.

"Huh," she chuckled.

She's laughing? Why would she be laughing at the fact someone's trying to kill her? Tom thought to himself.

"Guess that's just another thing on my list," she got up and slid her coat on, "enjoy your sixteen million, Holland."

"Pleasure doing business with you, Violet." The pair shook hands before Violet said, "Buy your share under a different name, my dad would never sell to a Holland."

"Will do," Tom walked her to the front door, "And for the record..I wouldn't mind you being the business, Violet. You'd be a worthy opponent." Tom complimented her genuinely.

Violet only looked back at him, winking she said, "You bet your sweet ass I'd be."

Tom chuckled as the click of her heels faded and Harrison was at his side.

"So...?"

"Ferocious that one.. smart too." Tom had a sly smile decorating his face.

"But I've got her right where I want her."

---

taglist:

@scuzmunkie

[libidomechanica]

Kissd off played with graces

To sword, and would till take they saw they are  douce a saint release: or when  old my heare: adieu ye Wood a future,  or what is the complain, such  a past she long to be waiting  injunctions, he ink below  my your fire in search reign monastic  the mused him at a lamp-light and  low, because original  shape of Judges of though alleadgd  God half as sometimes mature of  the bantling dallying sweeps that glitterne,  and blood close whole to prey and  my Muse, and when itself a  miracle; and silent art that love, have  it lovely July, or money,  drawn ; but now despise. I am to  the blossom, then his boot, and what  is but this Foot amiss. Seeking eyes, maud  to move they said, “Sweet and rumbled the  can claims, quiet—sank into  a sorts, might should or rested  hand—just weedy locked from they deepe and  insolent his radiance (our  round my ioyfull mazed he knowst, modest, to  bed thus matron boild; there despises frenne.  Bring generable to keeper… . Come the  drops above ate affects name,” when  to see, I never you? I marvel the  onward they dont known; we both more so full  of Paradise or truth vain! Lie on  the show what he spare in me say loves  flight, howe he would only one unworthy tottring;  thought I am done. That run intents,  dales “twill mountains blunder grew, for what  crack to the scorn, but this wont to  and look but to enter  and grow mankind, or elemen, and  sight; today I division I thou art  or found all is wished promised the  green, call with the restore; with  Molieres light, and truth, and  by then, stood like to the short time corne,  and an hour in russet, south,  I fear, plaiting and quaint, old with  the fain path worke eternall his lust, fair  they behote him loiter and all we have  seen treach. ” From a level, nor judge at not  like: behind no guide, ask whatever  mount my find on me sounded as a  sad to hide thee seen the mirror  and ingots like a grant quite English,  she asked, she hath some fly, with  his laye, a globe marrying, eyes conspicuous  draw near. No more sads sportion by natures  change with the unplumbd, salt over  years bless tract of Julia, and what— and was they notes, that right, I  promptings which rhyme. Or sea, over ye  the fair; and to such a  long silently wise curious to Sleep break.  And skies, the woe of such a  kiss and round in honour, madam, calld, a  fool is it never she noble name at  first I sparrows death, and every  shock, ere about  thirty-three pace, is  perhaps; but Sorrow will, a sort of  The pours afloating at the blue description  of this were danged love, I  woke doe nothing to the knee, had  love-knot iaelous transitory is every  day; I knew what no long that  were nigh to plucks the men say)  but hope I had to his chains of  life, into this won behold.  Hearkenst thy might now she weak of all; also  calld off the mothers hand, as put the  Gothic, such and plate throught when  with Brocade of the duchess  condition? On stood calm and came  the gates, that is a brief momental  silver lowing strange of chaste, where, or  odds, it now grey sigh pars past and modestly  the new emotion  the pure, with Damaske rocks: upon  and proved in his comes they were  at breast a future down overthrowe. She might  she pool, and fall as the king,  for corne between us, who doth  say, for my far about thy to  you see, Make the excusd, were the  laughing, he still. doe bath, and even as  the wept, and sang of the  power give him he skies. —Swith rival by inheritance  laughing Ignorance, not to  know he heart would call to catch and soever  yet locks, pride! Be not his abuse,  To see how of a passion into  fill the ghast, lovely hearded;  neither, made monastic vows answered  poor. S knew twas I grandame Elisa,  Queen, but one, “Ay me, Ill her  naked to record of  her dead despair is endowed to  sit into her, as from  all: which much like thou shalt not. Thou canst thought ’‘t  is care: my Life, where a several  sexe doth Lover, a torrent on  a stayed so dirty mock mid she innkeepe: als  or than if I have her limbs whirl  frost, that I have the giant, Arac:   Arac:  Aracs arrows in theres  Longman Anthea, Heros to learn there.’”

[kappasigmalife]

Eternal Purgatory: Chp 6 Theres Something about Robby

Eternal Purgatory: Chp 6 Theres something about Robby

 Chris wakes up cuddled to Brendan in bed looking at his phone getting blown up by paul, asking for breakfast. Looking at the clock he sees its 2pm and rolls his eyes saying hes gotta meet up with his friends, given its Saturday and everyone wants to go to the movies seeing the jigsaw marathon. Brendan kisses chris’s forehead telling him he wishes he was coming with. Chris nuzzles up to his furry little cub and tells him hes always welcome to join, the more the merrier, so long as no one bothers to ask for money. Brendan looks at him and smiles, accepting the invite. Paul calls chris telling him to get here and feed him.

“Apologies my sweet prince, but the animals need tending too.” Brendan laughs as he smacks chris’s ass as he gets up to dress for the day

“what can I say I love what I see.” Chris raises his eyebrow and tells him of course he does considering the amount of fun they had last night and waking up to those gorgeous brown eyes. Brendan begins blushing as chris gets another text of paul needing food.

“yeah ill text you when we pick you up okay.” Chris leaves and kisses Brendan leaving him smiling and getting dressed. Getting home, chris looks around and slowly enters the living room with helen waiting for him with coffee.

“afternoon slut, how was your little rendezvous with brendan.” Chris embarrassed looks at her stupidly blushing like mad.

It was nothing, we gamed all night and got too drunk so I stayed over, nothing really happened.” Paul from the other room

“BULLSHIT!!!, I saw it all from his console.” Chris jaw drops and looks at paul as he comes into the room with one of his gfs by his side. Shocked and appalled chris looks at paul and questions what he means.

“what do you mean you saw, were you watching us?” “Oh no, everyone was watching you, all 10000 subscribers on pornhub, you guys were phenomenal .

Chris grows red in the face and races to his bedroom calling Brendan. On the phone chris is apologizing hoping that he would undersand he didn’t know what happened and that paul shouldn’t of recorded them. Although shocked Brendan reminds chris it didn’t mattera s he was amazing and that the comments prove that the same.

“I never knew you could go 5 hours baby, I loved how slow you took it, like it was from a movie and you were reading me like a book. Asking me if I was in pain or if I wanted it softer, you made me feel loved.” Chris blushes smiling

“I just wanted to make sure you were comfortable with what was going on, no sense of having once sided pleasure.” Paul comes in giving chris a check, written for 500 and tells him that’s his share of the profits and theres more where that came from everytime they fuck, considering many people enjoy the slow porn and actual romance. Chris just glares at paul and thinks of how much money can be made by just making love to the same person every night and grins like a moron.

“Save your load asshole, we got customers for tonight, now lets go catch the movie.” Robby cuddles with helen on the couch and reminds her how amazing being in her arms makes him feel strong. Helen reminds him that they are just starting to date but it seems like they knew each other for a long time.  the group cram into the SUV and blast metal on the way to brendans who sits in the front and paul just smirks as he says his a great performer.

“shut up I didn’t know the camera was there!!!!!”

“yeah but the moaning and begging for more sure was prevalent.” Chris ducts under his shirt embarrassed and mentions that at least they got a commission off the video. Paul tells chris that the money is to be split between the two of them as they are sharing a salary. Robby asks about why he and helen weren’t recorded and paul tells him it’s a performance issue.

“what do you mean by performance issue?”

“people wanna see a hour long movie, not a 4 minute trailer.” Chris starts laughing and looks at helen and soon shuts up.

“im laughing at my own sister in disappointing sex, god I deserve to be in hell, oh wait I live with satan already.” Paul looks at chris and smiles through the rear view mirror

“and you wouldn’t change a damn thing.” “I hate it when your right, I wouldn’t change you at all, youd be too boring.” The group get to the theater and immediately get the marathon tickets and head to the middle rows with robby getting a shit load of snacks and gorging as chris and Brendan nuzzle to the movie starting. As the scares getting deeper in the movie, Brendan jumps and buries his head in chris’s chest.

“protect me, im scared.” “its okay cubby, your in safe hands.” Chris looks at paul whos smiling at the murders and looks around as everyone else is afraid.

“are we the only ones not affected by this movie series, I just love the story, but everyone just cringes at the gore, I find it appealing and exciting how he kills next using traps.” Paul nods in agreement and looks over as helen cuddles to robby, not even flinching.

“yeah you watch this while your alive, then as a dead person you don’t get much on the matter.” Chris thinks and agrees.

“yeah come to think of it, I never been scared about these movies, ive seen them since they first came out.”

Paul nods

“same here.” Brendan puts a thumbs up and asks for chris to tell him when its over.

Everyone looks at robby, watching the movie and eating his pretzel bites as everyone waits for his reaction.

Chris whispers to robby asking when he saw the movies.

“oh I don’t remember, not much to say, love the gore and mayhem.” Helen looks at robby, then asks him what his favorite anime growing up was, only to get a shrug and ignoring the situation. As the movie lets out the group look and see robby just walking to the car the rest still dumbfounded by his reaction. Chris decides to see whats up and asks robby what his parents were like when he was alive.

“eh I don’t really know, no one remembers their childhood.” “okay, I remember every time my father treated me like garbage and how my mom turned to the bottle just to cope, you obviously got something hiding in there.” “well I just don’t know, never really concerned myself with the meaning of existence.” Brendan goes over as chris drops his jaw.

“babe, you okay?”

“I don’t know if I should be pissed, jealous, or confused, im currently all three.” Paul walks over telling chris to get in before he leaves without him. Chris jumps in the back with Brendan and looks as robby stares blankly out the window.

“you ever wonder how far the world goes, like beyond our reach are the stars and through that, vast amounts of nothing, like a fantasy world undiscovered.”

The group get to the house where chris decides to take a break from the pressing matter of robbys psyche and goes to take a nap, with Brendan joining him. While getting up late in the evening to grab some late night snacks, chris goes to the living room to robby watching angel beats crying.

“yeah that anime was sad bro, but its just anime, not like your really in purgatory…. Never mind.” “no its not that, the characters all remember where they came from, you guys did too, but I don’t, all I know is my name and barely anything else, almost like im in a drugged state.” “hey bro its okay, no need to feel off about it, you will figure it all out over time.” Robby goes on to talk about he doesn’t even have a spectral power yet and everyone else including chris has their developing while he remains a ghost.

“I know its rough man, but you need to relax, youll figure things out as time passes, were basically here for centuries.” As chris glows his hands to calm robby down, he begins emitting a glow from his eyes creating a bright flash knocking him out. chris disappears and fall unconscious. A half hour later chris wakes up on a marble floor and finds himself in an entryway of a castle only not to find anyone around. As he lingers around, he looks at the hall behind him expand to hundreds of doors and goes to look, seeing a chain attached to him leading back to the front gate labeled exit. Chris finds a wooden door with a golden knob with the image of a rat on it. When he opens it shows a currently aged robby looking at a rat by his dining hall and calls it “sir whiskers”, while a bunch of frat guys laugh at him. The door reminiscent of smelling like lavender leads to a meadow where robby is shown hiking, getting bitten by a snake. Chris finds a chained door with no handle with a warning on the front labeled (NO ENTRY). Hearing crying, chris backs away and follows his chain back to the entrance that has been left partially opened. Looking back the halls appear black and slowly residing away as if withering, hearing chains, chris runs through the open gate in the front and leads to a massive light shining before him and appears outside of the castel and back home. Going back to bed, Brendan asks what took him so long and Chris replies with a friend who needed him. Chris gets up once more and brings robby to helens, and tells her that she should really be thankful for all he is.

“there's something about him hidden deep in his mind, but forcing your way in is devils work.”

Helen becomes confused and asks what chris means, chris points to his watch.

“3am sis, no way were doing that.”

[writingguide003-blog]

Would that all journeys were on foot: writers on the joy of walking

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Would that all journeys were on foot: writers on the joy of walking

Will Self on London, Fran Lebowitz on New York, Helen Garner on Melbourne and other writers love letters to urban pedestrianism

For Walking the City week exploring all aspects of urban walking, good and bad writers tell us where they walk and why.

Will Self watches the world go by at Charing Cross in London; Fran Lebowitz finds areas of midtown New York off-limits because Donald Trump lives there; Helen Garner says her quotidian route through her Melbourne suburb is not beautiful or meaningful to anyone but her.

These and other writers have shared their love letters to urban walking. And were eager to hear yours. You can send your routes, views and reflections to us using this form, or on social media with the hashtag #GuardianWalking.

My daily walk loops me back on my lifecycle

The Royal Vauxhall Tavern, one of Londons most celebrated LGBTQI pubs, is on Will Selfs walk from home, in Stockwell, to Soho Photograph: Rob Holley/PA

Will Self in London

In the early 1900s, 90% of journeys fewer than six miles were taken on foot. Would that they still were! Between being online and being on a bus or a train, we all too often lose our sense of properly being where we are: walking sets that right, as with each footstep we plant, were revivified by our perceptions of this genuinely firma terra.

I walk in London a great deal, and always have. In my teenage years and my 20s, I mainly walked because I was skint. But with age and some emolument has come walking for health; physical and more importantly mental. My favourite walk is a workaday one, from my home in Stockwell where I both live and work to Soho, in yet more central London, where I socialise and shop.

There are several possible routes: the grandstanding one takes me past the Vauxhall Tavern, south Londons most celebrated gay pub, and its near neighbour, the MI6 building; then along the Thames embankment, past the Houses of Parliament, and up Whitehall to Trafalgar Square, before I work my way through the backstreets around Leicester Square and enter Soho. But should I want to avoid busy streets, and the phalanxes of tourists battling it out against the three-card-monte scam merchants on Westminster Bridge, I can cross at Vauxhall instead, and make my way through the Arts and Crafts blocks of flats behind Tate Britain (built as social housing, but now luxury flats many of which are used as pied–terres by our lordly legislators), then along Marsham Street through the back of Parliament Square, along Horseguards, and via King Georges steps, up to Lower Regent Street and Piccadilly.

Listen, I know it seems an insult to detail all these storied landmarks as my mere way-stations en route to buy some stationery, or have a coffee with a friend. But in my defence despite the depredations of neoliberalism, and its sequel: the complete commoditisation of urban space it remains the case that London is a very big city indeed. If you know your way around it (or are prepared to get lost), you can always find a vista thats been overlooked, or an under-recognised corner of a familiar neighbourhood. Theres this and theres the delight of true flnerie: the ambulatory pursuit of chance encounters, overheard aperus, and those little unrepeatable vignettes that constitute the never-ending drama of urban life.

It was Dr Johnson who remarked that if you were to stand by the Charing Cross for long enough, youd see the entire world go by. My regular walk can take me past this spot which feels to me like some strange sort of still point, around which that processing world does indeed revolve. But then that could be because I was born in the old Charing Cross hospital, a few yards away which means that even my quotidian pedestrianism loops me back in to my own lifecycle.

Trumps even made walking worse

Fran Lebowitz once spotted Cary Grant on Madison Avenue in Manhattan. Photograph: Alamy Stock Photo

Fran Lebowitz in New York

Ive never taken a walk just to walk. People who drive everywhere take a walk, but for me its a form of transportation. I like to walk because, first of all, youre in control. I could tell you exactly how long it will take you to get from one point in New York to another because Ive walked it a million times. This is not something you say of the subway. It could take you 10 minutes, or it could take you an hour, or you may never get there.

Walking used to be a kind of pleasure, but it is really an enormous effort to make your way around town on foot. The bicycles everywhere, the tourists everywhere, some tourists on bicycles the worst possible combination. I feel like Im in The Exorcist, my head twirling around to see what way theyre coming from. The cyclists are in general quite smug, with that expression on their face like I am saving the planet. I always think: No, I am. They didnt have to manufacture me in a factory. When I wear out, theyre not going to throw me away in a pile of metal and plastic.

The tourists obviously come from places where no one walks anywhere. They dont think of the sidewalk as a road for humans. Though they may annoy me all humans annoy me people who live and work here are always in a rush to get where theyre going, because they have to get to work to make enough money to be able to afford their apartment. They dont stand in the middle of the sidewalk on their phones.

I do not have a phone so when everyone started looking at their phones all the time, I could not believe that everyone was abdicating the observation of New York and giving the whole city to me. I am always saying to people: did you notice that building? And they say no, because no one looks up except me. To me, its like winning a lottery. They just handed me the city. Im the official noticer.

Of course Trump has made everything in the world worse, including being a pedestrian. Because he lives right on Fifth Avenue there is a big part of midtown you cant even go down anymore. Now its Trumps area. If he is there, or his wife is there, you cant walk on that block. Ive had numerous fights with cops about this. A cop once told me: You cannot walk on this block. I said: I am walking on this block. I almost got arrested, she was so angry at me.

Most of my memories of walking stand out for being unpleasant. But there was one day in the seventies, back when New York was mostly filled with New Yorkers. I was walking up Madison Avenue and I noticed that the people walking towards me were kind of stopped. It was just very odd. Of course Madison Avenue is very fancy, especially then I had never seen people behaving like this.

There, coming towards me, was Cary Grant, in a white linen suit, with his white linen hair. He was emanating white. There are a million celebrities in New York. One thing you must never do is look at them, especially not on Madison Avenue. I had never seen New Yorkers stop like that. As told to Elle Hunt

Putting litter in the bin makes a lucky day

Terrace houses in the suburb of Flemington, Melbourne. Photograph: Alamy

Helen Garner in Melbourne

I walk this exact route through my Melbourne suburb of Flemington every morning. Its not beautiful or meaningful to anyone but me.

I barge out my front gate, under plane trees in which magpies sometimes warble. I cross the railway bridge, turn east at the house with the huge fig tree, then north again, past the brick garage and its inexplicably prolific gardenia bush. Nothing much to report till I reach the witchs house with the iron lace veranda and the hedge of dark pink rose bushes that no ones pruned for years. Every day I think their disgraceful neglect of those roses entitles me to pinch some on my way back. But I know I wont because my walk is a circle and I wont pass them again till tomorrow.

I cut through the booze warehouse car park and dash across the big road to the Bikram yoga school, then dive into the street with the weird antique shop on the corner. Good houses in a row, big wide Californian bungalows. Here, where the street drops downhill to the hockey fields and the concreted creek bed, I once saw a fox go strolling home at dawn. Another day a horrible man cursed me out and kicked my dog in the ribs.

Where the shared pedestrian and cycle track runs alongside the freeway wall I turn south again and pick up speed. Riders heading for the city zoom up behind me with sharp little warning chimes, and gusts of air as they pass. Im breathing hard and feeling powerful. Here comes the old Chinese couple, the dead-faced woman and the husband with his desperate smile. A tradesman in hi-vis stands in the middle of the football oval, reaches for the sky and bows three times.

At the primary school I turn right and tackle the steepest hill. Halfway up, panting, nearly home, I cop the first lemony whiffs of my reward: pittosporum blossom. Its perfume floats between the houses from an invisible tree.

If I can scoop up that McDonalds rubbish from the playground gate and shove it into the bin without breaking stride, Ill have earned myself a lucky day. All this, with its seasonal variations, takes up 40 minutes of what remains of my life, in my undistinguished and beloved suburb.

Walking is transgressive in carmaggedon

People crossing the street in Santa Monica, LA Photograph: Anna Bryukhanova/Getty Images

Rory Carroll in Los Angeles

One of the great joys of my years in Los Angeles was being able to leave my car at home and walk to a cafe, a supermarket, the library, the beach. In the worlds car capital this could seem a transgressive act, putting one foot in front of the other. This, after all, is a sprawling metropolis where sidewalks often dont exist, where everyone obsesses about exit ramps and parking and where traffic jams get nicknamed carmageddon.

But in Santa Monica, a small city wedged between Malibu and Venice, walking was not only feasible, it was pleasurable and an efficient way to get around. My morning routine included wheeling my toddler from our home on Montana Avenue to her daycare at the YMCA on Sixth Street, a one mile, 15-minute stroll past low-rise homes, stores, offices and cafes.

Sunshine, wide pavements, pedestrian-friendly crossings it was bliss. We were on nodding terms with some joggers and dog-walkers, listened to birdsong, paused to collect pebbles, monitored Fourth of July bunting giving way to Halloween pumpkins, then Christmas trees. I learned the timing of the traffic lights on Wilshire Boulevard, a busy thoroughfare, with precision, knowing when to stroll, to trot, to gallop, my daughter strapped into her stroller shouting faster.

During the long, hot summers and autumns I had one grumble: palm trees. Great for postcards, useless for shade.

Theres zen-like triumph in battling the elements

Pedestrians shield themselves from the wind and rain with umbrellas as they cross a road during a storm in Wellington. Photograph: Phil Noble / Reuters

Ashleigh Young in Wellington

Visitors praise Wellington for its compactness. Its so compact! The word is said with a sort of chefs kiss.It is convenient to be able to walk everywhere, but thats also why, sometimes, I dont want to walk everywhere. Everyone else will also be walking everywhere. Wellington is a relatively young city but its history of unwanted social encounters is richly layered.

I was once walking on Wellingtons beautiful south coast, along a long footpath empty but for an old housemate of mine with whom Id badly fallen out years earlier. We walked towards each other on that path by the sea, as though in chilling slow motion and after approximately 100 years, we passed. It felt like an outtake of Blue Planet.

To succeed as a walker in Wellington, you must embrace the turbulence both social and, infamously, weather-related. When it rains, youll want to rip out the slippery cobblestones of death in the central city; on gale-force days, youll want to campaign to have the city rebuilt underground.

The biggest problem I have to contend with when walking is truly my own annoyance. A sudden hail-studded gale blowing open my jacket Im indignant. Slow walkers on a tiny footpath and theres nowhere to pass my spleens swelling. A 4WD mounting the pavement so that it can pass an oncoming car on a narrow road Im Larry David in Paris. Ive internalised the citys melodramatic tendencies.

But then youll be stumping along in a gale and suddenly the silvery harbour is winking through trees. Or a native wood pigeon is perched on a powerline, its chest puffed out like a doughnut. Even the overhead wires for trolley buses that used to crisscross the skyline lent the streets a punk beauty. Wellington is full of these postcard moments, and you see more of them when youre on foot.

Sometimes, if youve been here long enough, when you look into the contorted faces of other pedestrians as theyre lashed by rain, you can just about see a kind of zen-like triumph.

Well-behaved women do not walk at night

View of a bus shelter at night in New Delhi, India. Photograph: Pradeep Gaur/Mint/Getty Images

Priya Alika Elias in Delhi

In Delhi, the female pedestrian is a rare bird. For one thing, its too hot most of the year (Delhi summers are notorious for wilting the most hardened traveller). For another, there are too many men, jostling and crowding each other, busying themselves with Typical Male Activities. Once twilight falls, whos left on the streets but the male cigarette-vendor, the male chaiwalla? Men stake out their territory while women remain quietly at home, making dinner for their families.

And yet I enjoy walking in Delhi. I make it a point to buy my own groceries from the store near my home. I walk in Old Delhi for an hour and reward myself with kebabs that I have to eat standing up in a crowded restaurant. In Lodi Gardens, where it is cooler, I watch peacocks in silhouette against the tomb of Sikandar Lodi. There are clandestine lovers cuddling in the bushes, and I stifle a smile in India, lovers are always on a quest for privacy.

Most of all, I enjoy walking at night, down the zigzag lanes of Hauz Khas Village or Green Park. I walk in whatever I like, refusing to defer to the convention that women dress modestly. Yes, there are male eyes on me, staring at my crop top. Often men are astonished a

Read more: http://www.theguardian.com/us

[verykimmy]

My First 4 Months Doing Uber

So I mostly created this tonight because I've seen all of the horrible things being said about Uber drivers during the strike yesterday and wanted to say my piece. I started doing Ubereats 4 months ago. I was excited to have a job, I still am. 7 years ago I was hit hard with chronic illness that stripped everything from me. I worked in music for 15 long years, eventually starting a record label, and up until 3 years ago was content in my field of choice. My health got terrible along with doctors putting me on a host of meds, and I had to leave the business. The stress was swinging me into pain flare ups. My engagement also ended around the same time. My heart broken, I was out on my own, in bad health with no one to turn to and no one would give me a job because of my health and I couldn't get disability as sick as I am because I live in the state of Georgia and they didnt expand Medicaid.

I was super excited when I found Ubereats. I qualified barely with my 1999 car and it would allow me to make my own schedule so if i had a flare up and had to be home in pain, no one would fire me. It also made enough money to pull me out of the hole that my engagement ending and medical bills had put me in. I started driving, very happy to get to meet people and make money in the city i loved and lived in 25 years, Atlanta. So, every day i would get up, drive the hour and a half there because there are no jobs in my country town and no one would give me one anyway with my health.

At first it was awesome. I was like "Wow, I can make great money driving and picking up and dropping off food", and I couldn't be happier. I was having to pull overnight 12 hour shifts after I realized there was no money like I needed on day shifts, which was fine, I adjusted. The overnight helped me because pain is bad for me at night and gives me insomnia, so early mornings are hard for me. Then, after about 3 weeks I started realizing the bad to the job.

Late nights customers are requested to come down in bad areas, and you cant avoid those areas, because if you turn down too many orders you get messages saying you've cancelled too much. You get order after order way across Atlanta on the bad sides of town and you either have to take them or not make money. It ended up being not so bad until I had to deliver to an area known for drug dealing and violence. I was scared to death. I messaged the customer to please come down for her food (she only had a few steps), and she came charging out to my car, ripped the food from my hand and twisted my hand screaming for me to get out of my car so she could kick my white cunt ass. I booked it away from there, called support and they just said call the police. That was it....just call the police. Where was my company I was working long painful hours for?

After that the area scared me, but I had to do my job. I started noticing on late late weekend nights, customers would order and not put gate codes, apartment numbers and not answer us or just not answer in general. I couldn't tell if they were passing out, falling asleep or if it was some scam to get money or food somehow the next day. I strongly feel that they place big expensive orders, dont answer, we have to cancel after calls, texts, putting the timer on, knocking and even calling support, and they call back the next day getting free food or money they never spent. I still feel that way.

The problem? When that happens, we get an email the next business day saying we committed fraud. If you cover yourself calling support etc, the customer gets mad and submits fake reviews. One late Sunday night I was working and it happened a few times, and I received an alert that my account was frozen and could get no more orders. Someone reported I was in a wreck I was never in and they wanted pictures. It was a busy night and was costing me, but I complied. I pulled to a lit gas station, took pics of my car and sent them over with an explanation that I'd had a few bad customers in a bad area. Instead of letting me go back to work, I had to drive the long ride home having only made gas money and lost $250 in pay after it took 2 days to straighten out. The same thing happened a month later when someone reported I was drinking and driving although I dont drink. Another $250 loss. I started to realize that the company I was so excited about didnt care about me.

Over and over these things would happen. Crazy things. 2 months ago my little sister went into the ICU dying and I missed a month of work, the weekend back, I was struggling to make enough to catch up bills I got behind on. That Monday, I received an alert my fast pay was taken away, that I had committed fraud stealing food. It was after a long weekend of overnight driving and I had so many people not bother to answer the door. For us, no fast pay means no gas money through the night. With gas at $3.19 a gallon in Atlanta, me doing 12 hour shifts and living so far away, it rendered me jobless. I had to spend 2 weeks begging for my job, sending over screen shot after screen shot of it happening to hundreds of drivers. Obviously something isnt right. Obviously if its happening so much to so many drivers something is going on. I lost $2000, the money to fix my car that 4 months of driving put 34,000 miles on. An old 1999 Mercedes, an expensive fix.

After 2 weeks they finally let me go back to work only to find out that pay was reduced, promotions taken away and gas went higher. I was in debt, had lost money and my car was now breaking down. It finally stopped running this week. I'm penniless, carless and Uber just says tough, not our problem. I'm back stuck in the country with health issues, no doctors, cant go do my job and will only make barely over gas if I could. Theres so much more....illegal restaurants in people's homes, guns in our faces, being called names, no help from support that barely understands us, but that's been my last 4 months so far.

[lostandbrokenshell]

Darkest Before Dawn Part 6

Farcry 5 fanfic. Rated M for Mature language and sexual reference. No pairing or plans for smutt.

“So how did get in contact with the whitetails end up as tea with Jacob again?” Whitehorse asked exhausted

“Well you see to make sure the kids could get here safely, the dep here sacrificed herself to the peggies.” Sharky said with a nod. “They wouldn’t hurt her and there was only a couple of them. Hurk and i then brought the kids back here and waited for you to get back from your thing.”

“And it was coffee, let me tell you it was terrible coffee. It also ended up with me being drugged. So not the most ideal outcome, but i found and returned a deputy. So not a complete loss.” You say as you steal some of Sharkys jerky.

“Jacob made the coffee. Hes not much kitchen talented.” Pratt said “He still put you through the trials. But yours was different than everyone elses.”

“Different how?” Whitehorse asked.

“I only seen a couple... But even a couple of Jacobs peggies said it was different. Its usually all ‘Cull the heard’ ‘Kill the weak’ and rook’s, wasnt. I don’t know what it was, but it wasn’t what they normally are.”

“I don’t even remember.” You say as you shake your head. “Was having terrible coffee one second, waking up in peggie VIP solitary confinement the next.” You look around and jail at everything going and back to the Sheriff. “I think they will expect me to come here after busting out Pratt. I should go back into Johns region and make some noise there take the heat off of here.”

“I call shotgun!” Sharky yelled jumping up.

“Awe man.” Hurk groaned.

“Your right, this place might be more of a target now. Alright, go make some noise over there.” Whitehorse said with a nod.

“Thanks rook. I owe you one.” Pratt said with a nod.

“Buy me a beer when we’re in Canada. And its even.” You say with a smile.

“I hear canadian beer is thick like maple syrup.” Sharky said as you all head to the door

“That is definitely true.” You say “Most six packs come with a mini maple syrup bottle.”

“Awe man! That’s brilliant so you always have some for pancakes the next morning!” Hurk said excitedly.

“Most people are to hungover to make pancakes and suffer with the lesser cousin, frozen eggos.”

“Yeah, I usually eat that for breakfast after a kick ass party to” Sharky said as he hoped into the passenger side “Any ideas on where you want to go next?”

“Im stuck between ‘Thats fucking stupid’ and ‘How stupid are you’ ideas.” You reply as you start the truck.

“Im a personal fan of ‘How stupid are you.’ Ones” Hurk said from the back

“Ah! That one is, break into Johns house! And look for cult plans and that kind of things.” You say overly optimistically.

“Whats the ‘Thats fucking stupid’ plan?” Sharky asked looking at you with curiosity.

“Dress up like peggies, get into Johns vault and get out with Hudson. The get out part, is a little holey on the how details of the ‘how to’ part.”

“Wow, that really is. A fucking stupid idea dep.” Sharky said with great surprise. “At this point Jacob has probably shared your photo so everyone will know who you are and what you look like. Thats a very bad idea.”

“I agree which is why its in that category. I dont have much more for ideas, so im open to suggestions right now.”

“Lets do the house thing!” Hurk said excitedly from the back.

“Well, it’s probably got gaurds an stuff. I doubt he would leave it unguarded so I would need you two to make noise and draw them away. I will radio when i got stuff, or nothing.”

“What if you get caught or something?” Sharky asked

“Im golden, you know im safe, i will give three long clicks on the radio. Go wait at the spread eagle i will eventually give the slip to the peggies.” You say optimistically.

“You get caught, i give you one week to bust out or im busting you out.” Sharky said sternly.

“That is fair enough. I also have no clue where John lives so, im going to need directions at this point.”

“The Seed Ranch is that way, past Falls end.” Sharky said pointing to an upcoming road. “Hurk and I could start blowing shit up at the end of the air strip while you skidaddle on up the road to the house.”

“Theres an air strip? Does he keep planes there?” You ask excitedly

“Uh, i think so.” Sharky replied slightly confused.

“New plan! If there’s a plane, i take the plane! Theres another airfield right? Close by?”

“Yea the Rye’s airfield is up from the ranch” Hurk said.

“Sweet deal boys! We got our selves a plan! And hopefully a plane.”

You three sat at the end of the airstrip “You sure about this?” Sharky asked you nodded. “Alright then dep, we give you a five minute head start then we start blowing shit up to draw them away.” You flash a thumbs up and start running down the road hugging the busshes, crouching after a bit you heard a big explosion behing you followed by loud yelling from Hurk and Sharky. You start to move slightly slower and hug lower to the ground, ready to drop to the ground for cover at a moments notice. You could see the commotion up ahead, the peggies where scrambling to get things together. Head lights flared up and you drop and start army crawling in the ditch. When you heard the vehicles close you stop and wait for them to pass before you pop your head up. You couldn’t see anyone else coming so you go back to crouching and keep heading to the house. There was only a couple peggies left at the house, they didn’t seem to concerned about the commotion at the end of the road. They also were terrible gaurds a simple rock thrown in the opposite direction drew them in like blood in the water for a shark.

“Wow.” You say as you look walk in. The fireplace took you by surprise, the whole place was so beautiful. You start looking around and pick a random door to go through. It had model planes, some hanging from the ceiling others on stands throughout the room. They where all so beautiful and displayed with care. Did he build them?

“It keeps me busy in my down time.” Startled you turn around John was standing in the door way watching you. “I missed you JoJo. I looked for you. Spent lots of money on private investigators trying to find you. When you popped back up on radar i was hoping you would come sooner.”

“You should ask for your money back from the P.I’s, I’ve pretty much been in the same spot in Canada the whole time. But i missed you to, John. I missed all of you. I..” you pause “I remember you use to cry on my birthday. Something about being older and it should be your birthday first.” John looked slightly surprised you brought that up. “I think it was more about about for a month and a half we are the same age.” He got a small smile. “I, don’t know why i never came back until now. Maybe i was scared? I cant be sure on the answer honestly. I can be sure on whats going on right now. John this is not the way.” You grab on to your radio one click “Im going to put my radio down.” Two click John nodded and you put it on a table three click.

“You belong with your family JoJo. We missed you, we looked for you, we waited for you.” He put his hands up and turned around waving to everything. “This isn’t just mine, its ours, its our family’s. Edens gate, is ours, its our family what we are doing.” He took looked you in your eyes. “These people need saving, they just don’t know it. Its coming, and we will be ready.”

[kristinsimmons]

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

The youngest of six children, Mrs. C was born with many embedded disadvantages. Being born black in a poor West Philadelphia neighborhood in the 1960s is a story that too often writes itself with a bad ending.  But Mrs. C avoided the usual pitfalls that derail young women in the neighborhood early. No drugs. No alcohol. No teenage pregnancies. Finished high school. Mrs. C. worked for the hospital as a unit clerk, had her own place, health benefits, and even a retirement plan.

Certain life habits, however, carry a heavy price. George Burns, the comedian never pictured without a cigar who died past his hundredth birthday, may have been immune to the effects of tobacco.  Mrs. C was not. She started smoking when she was 16. She doesn’t recall why. Her dad smoking didn’t help perhaps. Nausea racked her body after that first drag. It eased up after. Too bad.

That measly cigarette became the great addiction of her life. Day by day, the exquisitely thin membranes of the lungs that mediate gas exchange were destroyed. By the time the disease manifests with shortness of breath and bluish tinged lips, it’s too late. Short of the very few who qualify for a lung transplant, the efforts of doctors at this point are for mitigation rather than cure.

Complicating things further, in Mrs. C’s case, the normally low pressure vascular circuit of her lungs became a high pressure circuit that places ever increasing demands on the normally thin-muscled right ventricle of the heart.  This jeopardizes the ability of her heart to handle changes in blood volume.

A little extra fluid and the right side of the heart ends up causing unbearable swelling in her legs.  A little dehydration and severe disabling dizziness on standing ensues. Adding to that that her tenuous lung function decompensates with the slightest respiratory infection, that chronic steroid treatment to decrease her wheezing suppresses her immune system, and that the young man down the street helpfully drops off Newports at her home for a few extra dollars, and it’s easy to see why the hospital is her second home.

The most recent admission to the hospital was for kidney failure related to taking too much fluid off with diuretics. What was to be a short stay for gentle hydration turned into a longer stay when a pneumonia complicated the matters (though a trip to the intensive care unit and a ventilator was barely but fortunately avoided).  She was treated by the pulmonology team and sent home on a lower dose of diuretics.

The situation I am now confronting puts me in a quandary.  Her edema and weight are up markedly just a few days after returning home.  Could her fluid overload be because her kidneys are shutting down? Or does she just need more aggressive diuresis?

Should I guess? Knowing her present renal function would be helpful. But even if the Theranos lab I could appeal to for help wasn’t fictional, I would have to get her to my office everyday or every other day while adjusting her diuretic dose.

And so it comes to be that, days removed from a hospital admission, I’m sending her back to the hospital to be readmitted.  According to some, this is not supposed to happen.

A policy on readmission

In 2008, the commission that advises Medicare – the Medicare Payment Advisory Commission (MEDPAC), issued a report that focused on hospital readmissions.

The focus on hospital readmissions had been of great interest to the health policy community for some time. At the core of this interest lies the belief that hospitals and physicians are incentivized to treat patients rather than prevent admissions.

The MEDPAC report wanted to discourage readmissions like Mrs. C’s.  And so it wasn’t a terrible surprise that, rolled into the 2010 Affordable Care Act, was a section called the Hospital Readmission Reduction Program (HRRP) which created a system for Medicare to penalize hospitals with ‘high’ readmission rates.  The program was rolled out in 2013.

At first, the program seemed to work like a charm.  Hospitals significantly ramped up their efforts at care coordination.  Teams of nurses and aids were assembled to make sure patients would get their medications as prescribed upon discharge and to check on patients once they got home.

Hospital readmission rates suddenly dropped and Medicare started saving money.  A staggering 81% of all hospitals suffered penalties in 2018, which translates to ~$500 million or 0.3% of total Medicare payments to hospitals.

A complex analysis

But there’s more to this too good to be true story.

The HRRP penalty schemes are risk-adjusted based on administrative claims data. Risk-adjustment is a statistical procedure to take into account the diversity in complexity and severity of disease among patients so they can be compared.

Physicians know that risk-adjusted claims data are of dubious value because they themselves are often the reluctant data entry clerk in the byzantine scheme that starts with adding diagnostic items to the medical chart and ends with generating a coded billing claim for Medicare.  Needless to say, there’s a huge potential disconnect between what a claim attempts to convey and the actual condition of a given patient.

Yet another major problem is that the risk-adjustment employed by the HRRP does not take socioeconomic status into account, when that is arguably the single biggest driver of poor outcomes and of hospital readmissions.  The creators of the HRRP program seem to believe that a hospital located in poor area shouldn’t get a break for having high readmission rates, perhaps because they believe that hospital systems in general should be mindful of health inequities and address “care gaps” (differences in care provided to poor vs. affluent patients)  in their neighborhoods no matter what.

Finally, the initial out of the gate benchmark for readmission rates on which the HRRP would adjudicate the need for a penalty was a national average.  In such a scheme, a Johns Hopkins Hospital serving inner city Baltimore could be pitted against a regional hospital in rural Montana with an entirely different patient demographics.  This made the regional hospital in Montana very happy.

Gaming the metrics

Regardless of these technical considerations, it is an adage of social science that any metric will be gamed, and healthcare is unfortunately not immune to that law.

One tool increasingly used by hospitals to comply with Medicare payments rules is to admit patients to short stay units, under so-called “observation status.”  Another is to put pressure on emergency departments to avoid readmitting certain types of patients.

So, instead of primarily functioning as a triage operation where sick patients would be turned over to the care of the cardiologist in the hospital, the ER has been increasingly housing and managing heart failure patients to save the hospital money.

But the ER physician or the hospitalist supervising the short stay unit and who just meet a patient in the setting of an acute illness are poorly equipped to know which heart failure patient to discharge after a diuretic dose and which to keep for advanced heart failure therapies.

Source: MedPAC’s June 2018 Report (http://bit.ly/2CXD0fJ)

Nowadays, the cardiologist is increasingly insulated from those decisions.  I have personally experienced with alarming frequency instances where I learn only after the fact that a complex patient of mine has been treated for heart failure in the ED.

And my experience seems to be shared by many of my cardiology colleagues, especially among cardiologists who work in academic centers that are most affected by the policy.  Luckily, some of them are also clinician-scientists that can do more than just whine to colleagues about the new policy.  They can also study its outcomes.

What do the outcomes data show?

In a pivotal study, a group of cardiologists (Gupta et al.) saw that the drop in readmissions that followed the introduction of HRRP was unfortunately accompanied by a reversal in the decade long downward trend in heart failure mortality. This reversal suggested a serious potential harm from the policy.

But the possibility of harm was quickly challenged by another group of researchers led by one of the biggest names in health policy: Harlan Krumholz, a cardiologist who directs the influential Center for Outcomes Research and Evaluation at Yale University.

The Krumholz group analyzed millions of Medicare claims data from 2007 to 2016.  They also found that mortality for heart failure patients increased, but concluded that no causal link between decreasing readmission and increased mortality could be established.

Krumholz at al. noted that mortality rates for heart failure started climbing before the HRRP program was announced and they noted no inflection point in mortality rates with the policy announcement in 2010.  The evidence for their claim is highlighted in the table below:

As can be seen in the boxed row, Krumholz’ team concludes that the increasing mortality slope post-HRRP is no different from that pre-HRRP because the change did not reach statistical significance at the obligatory and arbitrary P<0.05 level.  The actual P-value was 0.11 and the confidence interval for the positive increase in mortality slope of 0.006 is (-.002 to .015).  Even poor students of epistemology would be loathe to conclude this result excludes a signal of harm.  It seems entirely plausible that, with all the limitations of the data set in question, mortality may in fact have accelerated after the institution of the HRRP.  Yet Krumholz insists that no signal of harm is to be considered.

But this did not stop another group of cardiologists (Wadhera et al.) from adding their contribution to the HRRP literature. Using the same data-set that the Krumholz group used — Medicare claims data — these researchers found once again that accelerating mortality coincided with the announcement of the HRRP.  More troubling, they also demonstrated that mortality rose primarily among patients not readmitted to the hospital.

A messy science

Admittedly this whole business of analysis is incredibly messy, with a number of moving parts.

My brief summary doesn’t do justice to a variety of maneuvers taken by the various groups to account for many of the limitations inherent in this type of study. Two of the competing analyses (Krumholz, Wadhera) used Medicare claims data while the other (Gupta) used a more limited voluntary registry.

During the time period in question, there were also other policy changes such as the introduction of new hospital billing codes (MS-DRG) that sought to adjust hospital payment rates to patient complexity. Better patient coding meant higher reimbursement from Medicare.  Armies of “documenters” were then employed by hospitals to capture more revenue.

This means that the claims data gathered by the researchers might look significantly different from one time period to the next even if the patients themselves were ostensibly the same. As the readmission rate is risk-adjusted, it is eminently plausible and likely that systematically upcoding patient risk could actually have been the primary driver of the drop in hospital readmission rate.

The other program playing a confounding role is the Recovery Audit Contractor (RAC) program begun in 2010 to reduce payments for inappropriate hospital admissions. Hospitals responded to denials for inpatient admissions by expanding ‘observation status’ stays. Which was the biggest driver for expanded observation stays? RAC or the HRRP? Once again an exact attribution is impossible.

Denying the obvious?

Despite the messiness of the data and the variety of analytic methods used, a consistent and uncontested observation remains: Heart failure mortality has increased in the last decade. The question being hotly contested is Why?

Oddly, Dr. Krumholz is steadfast in denying the possibility that the policy may have caused harm, even though the independent and contradictory conclusions from the other research groups at least raises a reasonable doubt.  And Dr. Krumholz has been quick to cast shade on research that does not conform to his conclusion.

By tweet he appears to ask for a level of detail his own papers lack, and he questions the legitimacy of another group’s data-set, all the while resisting any calls to put the program on hold despite the paucity of evidence showing benefit, the signal for harm, and perhaps most importantly, the concern of clinicians who see a mechanism for harm.

Greatly admire @rwyeh and his group…appreciate his focus on readmission &public policy. For such high-profile article, really need more info about statistical weighting. Methods should be sufficient so others can reproduce results. Can’t do that here. Look forward to more info.

— Harlan Krumholz (@hmkyale) December 21, 2018

Can you account for why the registry you used had, on average, such a small number of patients per site. Did you determine how many patients coded with heart failure by CMS were in the Registry? Just curious about the selection. It may not explain your results…but is a question. https://t.co/WSvJAN8Jjd

— Harlan Krumholz (@hmkyale) June 2, 2018

Dr. Krumholz also places much weight on an independent analysis carried out by MEDPAC which concluded there was no link between policy and the uptick in mortality. This particular conclusion rests heavily on the assertion that heart failure patients in 2016 were much sicker than patients in 2010. Recall that this coincides with a period of more intensive coding over the same time frame, so it is impossible to say this with any confidence.

The MEDPAC conclusion also relies on an analysis that finds no correlation between hospital level readmission and mortality rates.

While technically true, that conclusion overlooks that a large number of hospitals exhibited reduced readmission rates and increased mortality. Perhaps MEDPAC feels that patients dying at low readmit/high mortality hospitals should be mollified by the knowledge that somewhere there’s a low-readmit/low mortality hospital to balance things out?

That Krumholz and MEDPAC display such certainty about the direction of the signal they observe, and take pains to discount other possibilities seems strange and suggests that pre-existing biases may be at work. What might those biases be?

Conflicts of interest: You get what you pay for

In a world where heads roll for undisclosed personal financial conflicts of interest, it is remarkable that the current dispute, while full of scintillating exchanges about “propensity weighting” and other arcane points of statistics, does not reference any other potential conflicts at work that might affect the conclusions being reached.

Medicare’s decision to start the HRRP program didn’t come in a vacuum. It was inspired by years of research from Dr. Krumholz himself, who suggested that preventing admissions should be a goal for any policy that would aim to move the system from one paying for “volume” to one paying for “value.”

As far back as 2003, Krumholz held the view that:

“Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues.”

If Krumholz’s unfavorable and crudely simplistic view of the operations and motivations of hospitals (and of the still relatively independent physicians staffing those hospitals) informs his position on health policy, it stands to reason that serious blinders would prevent him from seeing any evidence of harm in a particular policy that promotes the same view.

But that’s not all.  Krumholz’s group at Yale received grants from CMS under the auspices of the Measure and Instrument Development and Support (MIDS) program to study and produce the metrics and instruments needed to devise the readmission measures.

The MIDS program supports the “development and use of clinical quality measures which remains a critical healthcare priority and the tool of choice for improving quality of care at the national, community and facility levels” and it allocates $1.6 billion dollars to this purpose.

Thanks to a bipartisan act of Congress, a helpful little website, usaspending.gov, provides contract level detail about payments made to the Krumholz’s group from the MIDS program.  Those payments can be seen in the table below:

The numbers are staggering. I know little about how to interpret these data about federal contracts, but it sure appears that the Yale-New Haven Health Service group led by Krumholz has received $144 million dollars since 2008.

Yet the only clue to these payments in Krumholz’ published analyses of the HRRP program comes in one disclosure sentence in a footnote, as seen here:

It seems to me that the disclosure is hardly proportional to the amount of funding that his group receives and understates the inherent pressures it must be under to demonstrate that the policy did not actually result in higher mortality.

And recall that MEDPAC’s “independent” analysis that also rejected a policy-mortality link came from the organization that recommended the policy to begin with.  The bottom line is this: There’s a tremendous amount of face to lose and a massive source of institutional funding at risk if the policy is found to be harmful.

It now becomes more clear why, in the following tweets, Dr. Krumholz feels that only he can say anything definitive about readmission rates and mortality:

Um, @JAMA_current, even the authors say they cannot say their findings are causal… "but whether this finding is a result of the policy requires further research.” Why do you promote the paper as proving harm? Need to treat twitter like you do any of your Editorial comments. pic.twitter.com/xugasHvPWY

— Harlan Krumholz (@hmkyale) December 26, 2018

6/Hospitals that have improved their readmission rates tended to improve their mortality rates. Published in @JAMA_current… https://t.co/R7FXLwTMPp

— Harlan Krumholz (@hmkyale) December 22, 2018

A diversity of biases

Biases are ubiquitous.  When I was a cardiologist-in-training, spending hours on the hospital consult service for a fixed salary, I vividly recall looking for ways to avoid doing any work I considered unimportant or banal: The minor cardiac enzyme leak in a patient with a widespread infection; The extra heartbeats on the ECG that the ER physician didn’t like the look of; etc.  “Are you sure you need an official consult?”  “The chances we’re going to recommend doing anything about a small enzyme leak in an 80-year-old with a severe lung infection are very low… “ I was even successful sometimes.

Contrast these comments to my demeanor in private practice where I am acutely aware that my income relies on such consults: “I just need the patients name or room number…” “I’ll take care of it!…” “I can put in the orders if you’d like!”

But there are other biases and incentives that motivate human beings, apart from personal financial incentives. Do they pale relative to the financial ones as is so often claimed? How does one begin to quantify them?

When it comes to the HRRP policy, no individual person’s bank account ballooned every time a patient didn’t get admitted. And yet this is a story of ideological bias that drove the design of policy and now claims ‘success’ for its own program.  The HRRP saga is illustrative of the importance of non-financial bias and of the dangers of blinding ourselves to that bias.

The story also highlights the downsides of tweaking healthcare systems that were built to deliver more care.

Clearly, I personally have a direct financial conflict of interest to provide more care. Since I haven’t talked anyone out of a consult in 8 years, I’m probably guilty of participating in a system that detractors appropriately criticize for promoting overuse of healthcare.

But the problem is that some of those consults I was trying to avoid as a fellow ended up really needing a cardiologist. There was the 55-year-old Cambodian woman admitted to the medical intensive care unit with pneumonia who went into atrial fibrillation. I recall rolling my eyes and thinking that the ICU could certainly handle this without a cardiologist. It turned out she didn’t have a pneumonia. It was pulmonary edema from heart failure related to undiagnosed rheumatic mitral valve disease. She had been in the wrong unit. She needed diuresis, heart rate control, and eventual surgery to replace her valve, not antibiotics. Less isn’t always more.

Attempt to reduce inappropriate hospital admissions? Get ready to pay a price.  To contradict Dr. Krumholz, it is entirely probable that we are underestimating the upside of our current system when we contemplate changing the status quo.

We are underestimating the downside of our current system when we contemplate change. We need to take some risks to do better. #abimf2013

— Harlan Krumholz (@hmkyale) August 5, 2013

Final Thoughts

Ironically, the HRRP quagmire offers a number of clarifying lessons.

Empiricism in social policy is a subjective enterprise. The often parroted conclusion is that cold, hard, unbiased evidence trumps the biased, unmeasurable judgment of clinicians. Yet, frequently, real world data-sets are complex, the choice of analytic paths can be highly variable, and the instruments to measure success are often imperfect. As it relates to HRRP, which analysis should we trust? The choice requires faith. And if the currency here is faith, perhaps the concern of clinicians at the bedside has more value than advertised.

Metrics won’t save us. The narrative of metrics is an appealing one that promises hard and objective accountability. The problem comes when the metric (readmission) becomes disconnected from outcomes that actually matter (death). False and blind prophets are good descriptors for those who claim to be unable to see without metrics. The fools in this enterprise are easy to identify as those who think the answers lie with ever better metrics.

Conflicts of interest: Going beyond the simple narrative.  Focusing on biases induced by personal financial interests is a mistake. Personal enrichment is just one bias in a sea of conflicts. In the healthcare context, financial disclosures—while clarifying in themselves—may simply give cover to other, more perverse biases, unless those other biases are equally disclosed.  It requires diligence to ascertain the impact, and direction of bias.  Rarely do we get the opportunity to observe the direction of bias in policy research.  In the case of the HRRP, the presence of bias was made evident because research groups with opposing biases (clinician-scientists versus policy wonks) have reached conclusions that would be expected on the basis of those pre-existing biases.  How often is the problem of such bias examined in the design, implementation, and analysis of health policy?

Beware of technocrats with all the answers.  I am reasonably sure that if practicing clinicians would have been asked to devise a rule to reduce heart failure readmissions for the whole population they would have refused. It seems too challenging a task to get right.  Even if clinicians can be induced to participate in the design of such a policy, most would readily acknowledge the likelihood that it could harm some patients. It requires a special type of hubris to design a policy and refuse to acknowledge its potential for harm. Unfortunately, hubris within a public health community that believes only they can give us a better health system is more feature than bug.

As for Mrs. C, she has been home for 16 days. All fingers on both hands are currently crossed.

Anish Koka is a cardiologist in private practice in Philadelphia.  He can be followed on Twitter @anish_koka. This post originally appeared here on The Accad & Koka Report. 

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag published first on https://wittooth.tumblr.com/

[kristinsimmons]

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

The youngest of six children, Mrs. C was born with many embedded disadvantages. Being born black in a poor West Philadelphia neighborhood in the 1960s is a story that too often writes itself with a bad ending.  But Mrs. C avoided the usual pitfalls that derail young women in the neighborhood early. No drugs. No alcohol. No teenage pregnancies. Finished high school. Mrs. C. worked for the hospital as a unit clerk, had her own place, health benefits, and even a retirement plan.

Certain life habits, however, carry a heavy price. George Burns, the comedian never pictured without a cigar who died past his hundredth birthday, may have been immune to the effects of tobacco.  Mrs. C was not. She started smoking when she was 16. She doesn’t recall why. Her dad smoking didn’t help perhaps. Nausea racked her body after that first drag. It eased up after. Too bad.

That measly cigarette became the great addiction of her life. Day by day, the exquisitely thin membranes of the lungs that mediate gas exchange were destroyed. By the time the disease manifests with shortness of breath and bluish tinged lips, it’s too late. Short of the very few who qualify for a lung transplant, the efforts of doctors at this point are for mitigation rather than cure.

Complicating things further, in Mrs. C’s case, the normally low pressure vascular circuit of her lungs became a high pressure circuit that places ever increasing demands on the normally thin-muscled right ventricle of the heart.  This jeopardizes the ability of her heart to handle changes in blood volume.

A little extra fluid and the right side of the heart ends up causing unbearable swelling in her legs.  A little dehydration and severe disabling dizziness on standing ensues. Adding to that that her tenuous lung function decompensates with the slightest respiratory infection, that chronic steroid treatment to decrease her wheezing suppresses her immune system, and that the young man down the street helpfully drops off Newports at her home for a few extra dollars, and it’s easy to see why the hospital is her second home.

The most recent admission to the hospital was for kidney failure related to taking too much fluid off with diuretics. What was to be a short stay for gentle hydration turned into a longer stay when a pneumonia complicated the matters (though a trip to the intensive care unit and a ventilator was barely but fortunately avoided).  She was treated by the pulmonology team and sent home on a lower dose of diuretics.

The situation I am now confronting puts me in a quandary.  Her edema and weight are up markedly just a few days after returning home.  Could her fluid overload be because her kidneys are shutting down? Or does she just need more aggressive diuresis?

Should I guess? Knowing her present renal function would be helpful. But even if the Theranos lab I could appeal to for help wasn’t fictional, I would have to get her to my office everyday or every other day while adjusting her diuretic dose.

And so it comes to be that, days removed from a hospital admission, I’m sending her back to the hospital to be readmitted.  According to some, this is not supposed to happen.

A policy on readmission

In 2008, the commission that advises Medicare – the Medicare Payment Advisory Commission (MEDPAC), issued a report that focused on hospital readmissions.

The focus on hospital readmissions had been of great interest to the health policy community for some time. At the core of this interest lies the belief that hospitals and physicians are incentivized to treat patients rather than prevent admissions.

The MEDPAC report wanted to discourage readmissions like Mrs. C’s.  And so it wasn’t a terrible surprise that, rolled into the 2010 Affordable Care Act, was a section called the Hospital Readmission Reduction Program (HRRP) which created a system for Medicare to penalize hospitals with ‘high’ readmission rates.  The program was rolled out in 2013.

At first, the program seemed to work like a charm.  Hospitals significantly ramped up their efforts at care coordination.  Teams of nurses and aids were assembled to make sure patients would get their medications as prescribed upon discharge and to check on patients once they got home.

Hospital readmission rates suddenly dropped and Medicare started saving money.  A staggering 81% of all hospitals suffered penalties in 2018, which translates to ~$500 million or 0.3% of total Medicare payments to hospitals.

A complex analysis

But there’s more to this too good to be true story.

The HRRP penalty schemes are risk-adjusted based on administrative claims data. Risk-adjustment is a statistical procedure to take into account the diversity in complexity and severity of disease among patients so they can be compared.

Physicians know that risk-adjusted claims data are of dubious value because they themselves are often the reluctant data entry clerk in the byzantine scheme that starts with adding diagnostic items to the medical chart and ends with generating a coded billing claim for Medicare.  Needless to say, there’s a huge potential disconnect between what a claim attempts to convey and the actual condition of a given patient.

Yet another major problem is that the risk-adjustment employed by the HRRP does not take socioeconomic status into account, when that is arguably the single biggest driver of poor outcomes and of hospital readmissions.  The creators of the HRRP program seem to believe that a hospital located in poor area shouldn’t get a break for having high readmission rates, perhaps because they believe that hospital systems in general should be mindful of health inequities and address “care gaps” (differences in care provided to poor vs. affluent patients)  in their neighborhoods no matter what.

Finally, the initial out of the gate benchmark for readmission rates on which the HRRP would adjudicate the need for a penalty was a national average.  In such a scheme, a Johns Hopkins Hospital serving inner city Baltimore could be pitted against a regional hospital in rural Montana with an entirely different patient demographics.  This made the regional hospital in Montana very happy.

Gaming the metrics

Regardless of these technical considerations, it is an adage of social science that any metric will be gamed, and healthcare is unfortunately not immune to that law.

One tool increasingly used by hospitals to comply with Medicare payments rules is to admit patients to short stay units, under so-called “observation status.”  Another is to put pressure on emergency departments to avoid readmitting certain types of patients.

So, instead of primarily functioning as a triage operation where sick patients would be turned over to the care of the cardiologist in the hospital, the ER has been increasingly housing and managing heart failure patients to save the hospital money.

But the ER physician or the hospitalist supervising the short stay unit and who just meet a patient in the setting of an acute illness are poorly equipped to know which heart failure patient to discharge after a diuretic dose and which to keep for advanced heart failure therapies.

Source: MedPAC’s June 2018 Report (http://bit.ly/2CXD0fJ)

Nowadays, the cardiologist is increasingly insulated from those decisions.  I have personally experienced with alarming frequency instances where I learn only after the fact that a complex patient of mine has been treated for heart failure in the ED.

And my experience seems to be shared by many of my cardiology colleagues, especially among cardiologists who work in academic centers that are most affected by the policy.  Luckily, some of them are also clinician-scientists that can do more than just whine to colleagues about the new policy.  They can also study its outcomes.

What do the outcomes data show?

In a pivotal study, a group of cardiologists (Gupta et al.) saw that the drop in readmissions that followed the introduction of HRRP was unfortunately accompanied by a reversal in the decade long downward trend in heart failure mortality. This reversal suggested a serious potential harm from the policy.

But the possibility of harm was quickly challenged by another group of researchers led by one of the biggest names in health policy: Harlan Krumholz, a cardiologist who directs the influential Center for Outcomes Research and Evaluation at Yale University.

The Krumholz group analyzed millions of Medicare claims data from 2007 to 2016.  They also found that mortality for heart failure patients increased, but concluded that no causal link between decreasing readmission and increased mortality could be established.

Krumholz at al. noted that mortality rates for heart failure started climbing before the HRRP program was announced and they noted no inflection point in mortality rates with the policy announcement in 2010.  The evidence for their claim is highlighted in the table below:

As can be seen in the boxed row, Krumholz’ team concludes that the increasing mortality slope post-HRRP is no different from that pre-HRRP because the change did not reach statistical significance at the obligatory and arbitrary P<0.05 level.  The actual P-value was 0.11 and the confidence interval for the positive increase in mortality slope of 0.006 is (-.002 to .015).  Even poor students of epistemology would be loathe to conclude this result excludes a signal of harm.  It seems entirely plausible that, with all the limitations of the data set in question, mortality may in fact have accelerated after the institution of the HRRP.  Yet Krumholz insists that no signal of harm is to be considered.

But this did not stop another group of cardiologists (Wadhera et al.) from adding their contribution to the HRRP literature. Using the same data-set that the Krumholz group used — Medicare claims data — these researchers found once again that accelerating mortality coincided with the announcement of the HRRP.  More troubling, they also demonstrated that mortality rose primarily among patients not readmitted to the hospital.

A messy science

Admittedly this whole business of analysis is incredibly messy, with a number of moving parts.

My brief summary doesn’t do justice to a variety of maneuvers taken by the various groups to account for many of the limitations inherent in this type of study. Two of the competing analyses (Krumholz, Wadhera) used Medicare claims data while the other (Gupta) used a more limited voluntary registry.

During the time period in question, there were also other policy changes such as the introduction of new hospital billing codes (MS-DRG) that sought to adjust hospital payment rates to patient complexity. Better patient coding meant higher reimbursement from Medicare.  Armies of “documenters” were then employed by hospitals to capture more revenue.

This means that the claims data gathered by the researchers might look significantly different from one time period to the next even if the patients themselves were ostensibly the same. As the readmission rate is risk-adjusted, it is eminently plausible and likely that systematically upcoding patient risk could actually have been the primary driver of the drop in hospital readmission rate.

The other program playing a confounding role is the Recovery Audit Contractor (RAC) program begun in 2010 to reduce payments for inappropriate hospital admissions. Hospitals responded to denials for inpatient admissions by expanding ‘observation status’ stays. Which was the biggest driver for expanded observation stays? RAC or the HRRP? Once again an exact attribution is impossible.

Denying the obvious?

Despite the messiness of the data and the variety of analytic methods used, a consistent and uncontested observation remains: Heart failure mortality has increased in the last decade. The question being hotly contested is Why?

Oddly, Dr. Krumholz is steadfast in denying the possibility that the policy may have caused harm, even though the independent and contradictory conclusions from the other research groups at least raises a reasonable doubt.  And Dr. Krumholz has been quick to cast shade on research that does not conform to his conclusion.

By tweet he appears to ask for a level of detail his own papers lack, and he questions the legitimacy of another group’s data-set, all the while resisting any calls to put the program on hold despite the paucity of evidence showing benefit, the signal for harm, and perhaps most importantly, the concern of clinicians who see a mechanism for harm.

Greatly admire @rwyeh and his group…appreciate his focus on readmission &public policy. For such high-profile article, really need more info about statistical weighting. Methods should be sufficient so others can reproduce results. Can’t do that here. Look forward to more info.

— Harlan Krumholz (@hmkyale) December 21, 2018

Can you account for why the registry you used had, on average, such a small number of patients per site. Did you determine how many patients coded with heart failure by CMS were in the Registry? Just curious about the selection. It may not explain your results…but is a question. https://t.co/WSvJAN8Jjd

— Harlan Krumholz (@hmkyale) June 2, 2018

Dr. Krumholz also places much weight on an independent analysis carried out by MEDPAC which concluded there was no link between policy and the uptick in mortality. This particular conclusion rests heavily on the assertion that heart failure patients in 2016 were much sicker than patients in 2010. Recall that this coincides with a period of more intensive coding over the same time frame, so it is impossible to say this with any confidence.

The MEDPAC conclusion also relies on an analysis that finds no correlation between hospital level readmission and mortality rates.

While technically true, that conclusion overlooks that a large number of hospitals exhibited reduced readmission rates and increased mortality. Perhaps MEDPAC feels that patients dying at low readmit/high mortality hospitals should be mollified by the knowledge that somewhere there’s a low-readmit/low mortality hospital to balance things out?

That Krumholz and MEDPAC display such certainty about the direction of the signal they observe, and take pains to discount other possibilities seems strange and suggests that pre-existing biases may be at work. What might those biases be?

Conflicts of interest: You get what you pay for

In a world where heads roll for undisclosed personal financial conflicts of interest, it is remarkable that the current dispute, while full of scintillating exchanges about “propensity weighting” and other arcane points of statistics, does not reference any other potential conflicts at work that might affect the conclusions being reached.

Medicare’s decision to start the HRRP program didn’t come in a vacuum. It was inspired by years of research from Dr. Krumholz himself, who suggested that preventing admissions should be a goal for any policy that would aim to move the system from one paying for “volume” to one paying for “value.”

As far back as 2003, Krumholz held the view that:

“Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues.”

If Krumholz’s unfavorable and crudely simplistic view of the operations and motivations of hospitals (and of the still relatively independent physicians staffing those hospitals) informs his position on health policy, it stands to reason that serious blinders would prevent him from seeing any evidence of harm in a particular policy that promotes the same view.

But that’s not all.  Krumholz’s group at Yale received grants from CMS under the auspices of the Measure and Instrument Development and Support (MIDS) program to study and produce the metrics and instruments needed to devise the readmission measures.

The MIDS program supports the “development and use of clinical quality measures which remains a critical healthcare priority and the tool of choice for improving quality of care at the national, community and facility levels” and it allocates $1.6 billion dollars to this purpose.

Thanks to a bipartisan act of Congress, a helpful little website, usaspending.gov, provides contract level detail about payments made to the Krumholz’s group from the MIDS program.  Those payments can be seen in the table below:

The numbers are staggering. I know little about how to interpret these data about federal contracts, but it sure appears that the Yale-New Haven Health Service group led by Krumholz has received $144 million dollars since 2008.

Yet the only clue to these payments in Krumholz’ published analyses of the HRRP program comes in one disclosure sentence in a footnote, as seen here:

It seems to me that the disclosure is hardly proportional to the amount of funding that his group receives and understates the inherent pressures it must be under to demonstrate that the policy did not actually result in higher mortality.

And recall that MEDPAC’s “independent” analysis that also rejected a policy-mortality link came from the organization that recommended the policy to begin with.  The bottom line is this: There’s a tremendous amount of face to lose and a massive source of institutional funding at risk if the policy is found to be harmful.

It now becomes more clear why, in the following tweets, Dr. Krumholz feels that only he can say anything definitive about readmission rates and mortality:

Um, @JAMA_current, even the authors say they cannot say their findings are causal… "but whether this finding is a result of the policy requires further research.” Why do you promote the paper as proving harm? Need to treat twitter like you do any of your Editorial comments. pic.twitter.com/xugasHvPWY

— Harlan Krumholz (@hmkyale) December 26, 2018

6/Hospitals that have improved their readmission rates tended to improve their mortality rates. Published in @JAMA_current… https://t.co/R7FXLwTMPp

— Harlan Krumholz (@hmkyale) December 22, 2018

A diversity of biases

Biases are ubiquitous.  When I was a cardiologist-in-training, spending hours on the hospital consult service for a fixed salary, I vividly recall looking for ways to avoid doing any work I considered unimportant or banal: The minor cardiac enzyme leak in a patient with a widespread infection; The extra heartbeats on the ECG that the ER physician didn’t like the look of; etc.  “Are you sure you need an official consult?”  “The chances we’re going to recommend doing anything about a small enzyme leak in an 80-year-old with a severe lung infection are very low… “ I was even successful sometimes.

Contrast these comments to my demeanor in private practice where I am acutely aware that my income relies on such consults: “I just need the patients name or room number…” “I’ll take care of it!…” “I can put in the orders if you’d like!”

But there are other biases and incentives that motivate human beings, apart from personal financial incentives. Do they pale relative to the financial ones as is so often claimed? How does one begin to quantify them?

When it comes to the HRRP policy, no individual person’s bank account ballooned every time a patient didn’t get admitted. And yet this is a story of ideological bias that drove the design of policy and now claims ‘success’ for its own program.  The HRRP saga is illustrative of the importance of non-financial bias and of the dangers of blinding ourselves to that bias.

The story also highlights the downsides of tweaking healthcare systems that were built to deliver more care.

Clearly, I personally have a direct financial conflict of interest to provide more care. Since I haven’t talked anyone out of a consult in 8 years, I’m probably guilty of participating in a system that detractors appropriately criticize for promoting overuse of healthcare.

But the problem is that some of those consults I was trying to avoid as a fellow ended up really needing a cardiologist. There was the 55-year-old Cambodian woman admitted to the medical intensive care unit with pneumonia who went into atrial fibrillation. I recall rolling my eyes and thinking that the ICU could certainly handle this without a cardiologist. It turned out she didn’t have a pneumonia. It was pulmonary edema from heart failure related to undiagnosed rheumatic mitral valve disease. She had been in the wrong unit. She needed diuresis, heart rate control, and eventual surgery to replace her valve, not antibiotics. Less isn’t always more.

Attempt to reduce inappropriate hospital admissions? Get ready to pay a price.  To contradict Dr. Krumholz, it is entirely probable that we are underestimating the upside of our current system when we contemplate changing the status quo.

We are underestimating the downside of our current system when we contemplate change. We need to take some risks to do better. #abimf2013

— Harlan Krumholz (@hmkyale) August 5, 2013

Final Thoughts

Ironically, the HRRP quagmire offers a number of clarifying lessons.

Empiricism in social policy is a subjective enterprise. The often parroted conclusion is that cold, hard, unbiased evidence trumps the biased, unmeasurable judgment of clinicians. Yet, frequently, real world data-sets are complex, the choice of analytic paths can be highly variable, and the instruments to measure success are often imperfect. As it relates to HRRP, which analysis should we trust? The choice requires faith. And if the currency here is faith, perhaps the concern of clinicians at the bedside has more value than advertised.

Metrics won’t save us. The narrative of metrics is an appealing one that promises hard and objective accountability. The problem comes when the metric (readmission) becomes disconnected from outcomes that actually matter (death). False and blind prophets are good descriptors for those who claim to be unable to see without metrics. The fools in this enterprise are easy to identify as those who think the answers lie with ever better metrics.

Conflicts of interest: Going beyond the simple narrative.  Focusing on biases induced by personal financial interests is a mistake. Personal enrichment is just one bias in a sea of conflicts. In the healthcare context, financial disclosures—while clarifying in themselves—may simply give cover to other, more perverse biases, unless those other biases are equally disclosed.  It requires diligence to ascertain the impact, and direction of bias.  Rarely do we get the opportunity to observe the direction of bias in policy research.  In the case of the HRRP, the presence of bias was made evident because research groups with opposing biases (clinician-scientists versus policy wonks) have reached conclusions that would be expected on the basis of those pre-existing biases.  How often is the problem of such bias examined in the design, implementation, and analysis of health policy?

Beware of technocrats with all the answers.  I am reasonably sure that if practicing clinicians would have been asked to devise a rule to reduce heart failure readmissions for the whole population they would have refused. It seems too challenging a task to get right.  Even if clinicians can be induced to participate in the design of such a policy, most would readily acknowledge the likelihood that it could harm some patients. It requires a special type of hubris to design a policy and refuse to acknowledge its potential for harm. Unfortunately, hubris within a public health community that believes only they can give us a better health system is more feature than bug.

As for Mrs. C, she has been home for 16 days. All fingers on both hands are currently crossed.

Anish Koka is a cardiologist in private practice in Philadelphia.  He can be followed on Twitter @anish_koka. This post originally appeared here on The Accad & Koka Report. 

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag published first on https://wittooth.tumblr.com/

[kristinsimmons]

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

The youngest of six children, Mrs. C was born with many embedded disadvantages. Being born black in a poor West Philadelphia neighborhood in the 1960s is a story that too often writes itself with a bad ending.  But Mrs. C avoided the usual pitfalls that derail young women in the neighborhood early. No drugs. No alcohol. No teenage pregnancies. Finished high school. Mrs. C. worked for the hospital as a unit clerk, had her own place, health benefits, and even a retirement plan.

Certain life habits, however, carry a heavy price. George Burns, the comedian never pictured without a cigar who died past his hundredth birthday, may have been immune to the effects of tobacco.  Mrs. C was not. She started smoking when she was 16. She doesn’t recall why. Her dad smoking didn’t help perhaps. Nausea racked her body after that first drag. It eased up after. Too bad.

That measly cigarette became the great addiction of her life. Day by day, the exquisitely thin membranes of the lungs that mediate gas exchange were destroyed. By the time the disease manifests with shortness of breath and bluish tinged lips, it’s too late. Short of the very few who qualify for a lung transplant, the efforts of doctors at this point are for mitigation rather than cure.

Complicating things further, in Mrs. C’s case, the normally low pressure vascular circuit of her lungs became a high pressure circuit that places ever increasing demands on the normally thin-muscled right ventricle of the heart.  This jeopardizes the ability of her heart to handle changes in blood volume.

A little extra fluid and the right side of the heart ends up causing unbearable swelling in her legs.  A little dehydration and severe disabling dizziness on standing ensues. Adding to that that her tenuous lung function decompensates with the slightest respiratory infection, that chronic steroid treatment to decrease her wheezing suppresses her immune system, and that the young man down the street helpfully drops off Newports at her home for a few extra dollars, and it’s easy to see why the hospital is her second home.

The most recent admission to the hospital was for kidney failure related to taking too much fluid off with diuretics. What was to be a short stay for gentle hydration turned into a longer stay when a pneumonia complicated the matters (though a trip to the intensive care unit and a ventilator was barely but fortunately avoided).  She was treated by the pulmonology team and sent home on a lower dose of diuretics.

The situation I am now confronting puts me in a quandary.  Her edema and weight are up markedly just a few days after returning home.  Could her fluid overload be because her kidneys are shutting down? Or does she just need more aggressive diuresis?

Should I guess? Knowing her present renal function would be helpful. But even if the Theranos lab I could appeal to for help wasn’t fictional, I would have to get her to my office everyday or every other day while adjusting her diuretic dose.

And so it comes to be that, days removed from a hospital admission, I’m sending her back to the hospital to be readmitted.  According to some, this is not supposed to happen.

A policy on readmission

In 2008, the commission that advises Medicare – the Medicare Payment Advisory Commission (MEDPAC), issued a report that focused on hospital readmissions.

The focus on hospital readmissions had been of great interest to the health policy community for some time. At the core of this interest lies the belief that hospitals and physicians are incentivized to treat patients rather than prevent admissions.

The MEDPAC report wanted to discourage readmissions like Mrs. C’s.  And so it wasn’t a terrible surprise that, rolled into the 2010 Affordable Care Act, was a section called the Hospital Readmission Reduction Program (HRRP) which created a system for Medicare to penalize hospitals with ‘high’ readmission rates.  The program was rolled out in 2013.

At first, the program seemed to work like a charm.  Hospitals significantly ramped up their efforts at care coordination.  Teams of nurses and aids were assembled to make sure patients would get their medications as prescribed upon discharge and to check on patients once they got home.

Hospital readmission rates suddenly dropped and Medicare started saving money.  A staggering 81% of all hospitals suffered penalties in 2018, which translates to ~$500 million or 0.3% of total Medicare payments to hospitals.

A complex analysis

But there’s more to this too good to be true story.

The HRRP penalty schemes are risk-adjusted based on administrative claims data. Risk-adjustment is a statistical procedure to take into account the diversity in complexity and severity of disease among patients so they can be compared.

Physicians know that risk-adjusted claims data are of dubious value because they themselves are often the reluctant data entry clerk in the byzantine scheme that starts with adding diagnostic items to the medical chart and ends with generating a coded billing claim for Medicare.  Needless to say, there’s a huge potential disconnect between what a claim attempts to convey and the actual condition of a given patient.

Yet another major problem is that the risk-adjustment employed by the HRRP does not take socioeconomic status into account, when that is arguably the single biggest driver of poor outcomes and of hospital readmissions.  The creators of the HRRP program seem to believe that a hospital located in poor area shouldn’t get a break for having high readmission rates, perhaps because they believe that hospital systems in general should be mindful of health inequities and address “care gaps” (differences in care provided to poor vs. affluent patients)  in their neighborhoods no matter what.

Finally, the initial out of the gate benchmark for readmission rates on which the HRRP would adjudicate the need for a penalty was a national average.  In such a scheme, a Johns Hopkins Hospital serving inner city Baltimore could be pitted against a regional hospital in rural Montana with an entirely different patient demographics.  This made the regional hospital in Montana very happy.

Gaming the metrics

Regardless of these technical considerations, it is an adage of social science that any metric will be gamed, and healthcare is unfortunately not immune to that law.

One tool increasingly used by hospitals to comply with Medicare payments rules is to admit patients to short stay units, under so-called “observation status.”  Another is to put pressure on emergency departments to avoid readmitting certain types of patients.

So, instead of primarily functioning as a triage operation where sick patients would be turned over to the care of the cardiologist in the hospital, the ER has been increasingly housing and managing heart failure patients to save the hospital money.

But the ER physician or the hospitalist supervising the short stay unit and who just meet a patient in the setting of an acute illness are poorly equipped to know which heart failure patient to discharge after a diuretic dose and which to keep for advanced heart failure therapies.

Source: MedPAC’s June 2018 Report (http://bit.ly/2CXD0fJ)

Nowadays, the cardiologist is increasingly insulated from those decisions.  I have personally experienced with alarming frequency instances where I learn only after the fact that a complex patient of mine has been treated for heart failure in the ED.

And my experience seems to be shared by many of my cardiology colleagues, especially among cardiologists who work in academic centers that are most affected by the policy.  Luckily, some of them are also clinician-scientists that can do more than just whine to colleagues about the new policy.  They can also study its outcomes.

What do the outcomes data show?

In a pivotal study, a group of cardiologists (Gupta et al.) saw that the drop in readmissions that followed the introduction of HRRP was unfortunately accompanied by a reversal in the decade long downward trend in heart failure mortality. This reversal suggested a serious potential harm from the policy.

But the possibility of harm was quickly challenged by another group of researchers led by one of the biggest names in health policy: Harlan Krumholz, a cardiologist who directs the influential Center for Outcomes Research and Evaluation at Yale University.

The Krumholz group analyzed millions of Medicare claims data from 2007 to 2016.  They also found that mortality for heart failure patients increased, but concluded that no causal link between decreasing readmission and increased mortality could be established.

Krumholz at al. noted that mortality rates for heart failure started climbing before the HRRP program was announced and they noted no inflection point in mortality rates with the policy announcement in 2010.  The evidence for their claim is highlighted in the table below:

As can be seen in the boxed row, Krumholz’ team concludes that the increasing mortality slope post-HRRP is no different from that pre-HRRP because the change did not reach statistical significance at the obligatory and arbitrary P<0.05 level.  The actual P-value was 0.11 and the confidence interval for the positive increase in mortality slope of 0.006 is (-.002 to .015).  Even poor students of epistemology would be loathe to conclude this result excludes a signal of harm.  It seems entirely plausible that, with all the limitations of the data set in question, mortality may in fact have accelerated after the institution of the HRRP.  Yet Krumholz insists that no signal of harm is to be considered.

But this did not stop another group of cardiologists (Wadhera et al.) from adding their contribution to the HRRP literature. Using the same data-set that the Krumholz group used — Medicare claims data — these researchers found once again that accelerating mortality coincided with the announcement of the HRRP.  More troubling, they also demonstrated that mortality rose primarily among patients not readmitted to the hospital.

A messy science

Admittedly this whole business of analysis is incredibly messy, with a number of moving parts.

My brief summary doesn’t do justice to a variety of maneuvers taken by the various groups to account for many of the limitations inherent in this type of study. Two of the competing analyses (Krumholz, Wadhera) used Medicare claims data while the other (Gupta) used a more limited voluntary registry.

During the time period in question, there were also other policy changes such as the introduction of new hospital billing codes (MS-DRG) that sought to adjust hospital payment rates to patient complexity. Better patient coding meant higher reimbursement from Medicare.  Armies of “documenters” were then employed by hospitals to capture more revenue.

This means that the claims data gathered by the researchers might look significantly different from one time period to the next even if the patients themselves were ostensibly the same. As the readmission rate is risk-adjusted, it is eminently plausible and likely that systematically upcoding patient risk could actually have been the primary driver of the drop in hospital readmission rate.

The other program playing a confounding role is the Recovery Audit Contractor (RAC) program begun in 2010 to reduce payments for inappropriate hospital admissions. Hospitals responded to denials for inpatient admissions by expanding ‘observation status’ stays. Which was the biggest driver for expanded observation stays? RAC or the HRRP? Once again an exact attribution is impossible.

Denying the obvious?

Despite the messiness of the data and the variety of analytic methods used, a consistent and uncontested observation remains: Heart failure mortality has increased in the last decade. The question being hotly contested is Why?

Oddly, Dr. Krumholz is steadfast in denying the possibility that the policy may have caused harm, even though the independent and contradictory conclusions from the other research groups at least raises a reasonable doubt.  And Dr. Krumholz has been quick to cast shade on research that does not conform to his conclusion.

By tweet he appears to ask for a level of detail his own papers lack, and he questions the legitimacy of another group’s data-set, all the while resisting any calls to put the program on hold despite the paucity of evidence showing benefit, the signal for harm, and perhaps most importantly, the concern of clinicians who see a mechanism for harm.

Greatly admire @rwyeh and his group…appreciate his focus on readmission &public policy. For such high-profile article, really need more info about statistical weighting. Methods should be sufficient so others can reproduce results. Can’t do that here. Look forward to more info.

— Harlan Krumholz (@hmkyale) December 21, 2018

Can you account for why the registry you used had, on average, such a small number of patients per site. Did you determine how many patients coded with heart failure by CMS were in the Registry? Just curious about the selection. It may not explain your results…but is a question. https://t.co/WSvJAN8Jjd

— Harlan Krumholz (@hmkyale) June 2, 2018

Dr. Krumholz also places much weight on an independent analysis carried out by MEDPAC which concluded there was no link between policy and the uptick in mortality. This particular conclusion rests heavily on the assertion that heart failure patients in 2016 were much sicker than patients in 2010. Recall that this coincides with a period of more intensive coding over the same time frame, so it is impossible to say this with any confidence.

The MEDPAC conclusion also relies on an analysis that finds no correlation between hospital level readmission and mortality rates.

While technically true, that conclusion overlooks that a large number of hospitals exhibited reduced readmission rates and increased mortality. Perhaps MEDPAC feels that patients dying at low readmit/high mortality hospitals should be mollified by the knowledge that somewhere there’s a low-readmit/low mortality hospital to balance things out?

That Krumholz and MEDPAC display such certainty about the direction of the signal they observe, and take pains to discount other possibilities seems strange and suggests that pre-existing biases may be at work. What might those biases be?

Conflicts of interest: You get what you pay for

In a world where heads roll for undisclosed personal financial conflicts of interest, it is remarkable that the current dispute, while full of scintillating exchanges about “propensity weighting” and other arcane points of statistics, does not reference any other potential conflicts at work that might affect the conclusions being reached.

Medicare’s decision to start the HRRP program didn’t come in a vacuum. It was inspired by years of research from Dr. Krumholz himself, who suggested that preventing admissions should be a goal for any policy that would aim to move the system from one paying for “volume” to one paying for “value.”

As far back as 2003, Krumholz held the view that:

“Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues.”

If Krumholz’s unfavorable and crudely simplistic view of the operations and motivations of hospitals (and of the still relatively independent physicians staffing those hospitals) informs his position on health policy, it stands to reason that serious blinders would prevent him from seeing any evidence of harm in a particular policy that promotes the same view.

But that’s not all.  Krumholz’s group at Yale received grants from CMS under the auspices of the Measure and Instrument Development and Support (MIDS) program to study and produce the metrics and instruments needed to devise the readmission measures.

The MIDS program supports the “development and use of clinical quality measures which remains a critical healthcare priority and the tool of choice for improving quality of care at the national, community and facility levels” and it allocates $1.6 billion dollars to this purpose.

Thanks to a bipartisan act of Congress, a helpful little website, usaspending.gov, provides contract level detail about payments made to the Krumholz’s group from the MIDS program.  Those payments can be seen in the table below:

The numbers are staggering. I know little about how to interpret these data about federal contracts, but it sure appears that the Yale-New Haven Health Service group led by Krumholz has received $144 million dollars since 2008.

Yet the only clue to these payments in Krumholz’ published analyses of the HRRP program comes in one disclosure sentence in a footnote, as seen here:

It seems to me that the disclosure is hardly proportional to the amount of funding that his group receives and understates the inherent pressures it must be under to demonstrate that the policy did not actually result in higher mortality.

And recall that MEDPAC’s “independent” analysis that also rejected a policy-mortality link came from the organization that recommended the policy to begin with.  The bottom line is this: There’s a tremendous amount of face to lose and a massive source of institutional funding at risk if the policy is found to be harmful.

It now becomes more clear why, in the following tweets, Dr. Krumholz feels that only he can say anything definitive about readmission rates and mortality:

Um, @JAMA_current, even the authors say they cannot say their findings are causal… "but whether this finding is a result of the policy requires further research.” Why do you promote the paper as proving harm? Need to treat twitter like you do any of your Editorial comments. pic.twitter.com/xugasHvPWY

— Harlan Krumholz (@hmkyale) December 26, 2018

6/Hospitals that have improved their readmission rates tended to improve their mortality rates. Published in @JAMA_current… https://t.co/R7FXLwTMPp

— Harlan Krumholz (@hmkyale) December 22, 2018

A diversity of biases

Biases are ubiquitous.  When I was a cardiologist-in-training, spending hours on the hospital consult service for a fixed salary, I vividly recall looking for ways to avoid doing any work I considered unimportant or banal: The minor cardiac enzyme leak in a patient with a widespread infection; The extra heartbeats on the ECG that the ER physician didn’t like the look of; etc.  “Are you sure you need an official consult?”  “The chances we’re going to recommend doing anything about a small enzyme leak in an 80-year-old with a severe lung infection are very low… “ I was even successful sometimes.

Contrast these comments to my demeanor in private practice where I am acutely aware that my income relies on such consults: “I just need the patients name or room number…” “I’ll take care of it!…” “I can put in the orders if you’d like!”

But there are other biases and incentives that motivate human beings, apart from personal financial incentives. Do they pale relative to the financial ones as is so often claimed? How does one begin to quantify them?

When it comes to the HRRP policy, no individual person’s bank account ballooned every time a patient didn’t get admitted. And yet this is a story of ideological bias that drove the design of policy and now claims ‘success’ for its own program.  The HRRP saga is illustrative of the importance of non-financial bias and of the dangers of blinding ourselves to that bias.

The story also highlights the downsides of tweaking healthcare systems that were built to deliver more care.

Clearly, I personally have a direct financial conflict of interest to provide more care. Since I haven’t talked anyone out of a consult in 8 years, I’m probably guilty of participating in a system that detractors appropriately criticize for promoting overuse of healthcare.

But the problem is that some of those consults I was trying to avoid as a fellow ended up really needing a cardiologist. There was the 55-year-old Cambodian woman admitted to the medical intensive care unit with pneumonia who went into atrial fibrillation. I recall rolling my eyes and thinking that the ICU could certainly handle this without a cardiologist. It turned out she didn’t have a pneumonia. It was pulmonary edema from heart failure related to undiagnosed rheumatic mitral valve disease. She had been in the wrong unit. She needed diuresis, heart rate control, and eventual surgery to replace her valve, not antibiotics. Less isn’t always more.

Attempt to reduce inappropriate hospital admissions? Get ready to pay a price.  To contradict Dr. Krumholz, it is entirely probable that we are underestimating the upside of our current system when we contemplate changing the status quo.

We are underestimating the downside of our current system when we contemplate change. We need to take some risks to do better. #abimf2013

— Harlan Krumholz (@hmkyale) August 5, 2013

Final Thoughts

Ironically, the HRRP quagmire offers a number of clarifying lessons.

Empiricism in social policy is a subjective enterprise. The often parroted conclusion is that cold, hard, unbiased evidence trumps the biased, unmeasurable judgment of clinicians. Yet, frequently, real world data-sets are complex, the choice of analytic paths can be highly variable, and the instruments to measure success are often imperfect. As it relates to HRRP, which analysis should we trust? The choice requires faith. And if the currency here is faith, perhaps the concern of clinicians at the bedside has more value than advertised.

Metrics won’t save us. The narrative of metrics is an appealing one that promises hard and objective accountability. The problem comes when the metric (readmission) becomes disconnected from outcomes that actually matter (death). False and blind prophets are good descriptors for those who claim to be unable to see without metrics. The fools in this enterprise are easy to identify as those who think the answers lie with ever better metrics.

Conflicts of interest: Going beyond the simple narrative.  Focusing on biases induced by personal financial interests is a mistake. Personal enrichment is just one bias in a sea of conflicts. In the healthcare context, financial disclosures—while clarifying in themselves—may simply give cover to other, more perverse biases, unless those other biases are equally disclosed.  It requires diligence to ascertain the impact, and direction of bias.  Rarely do we get the opportunity to observe the direction of bias in policy research.  In the case of the HRRP, the presence of bias was made evident because research groups with opposing biases (clinician-scientists versus policy wonks) have reached conclusions that would be expected on the basis of those pre-existing biases.  How often is the problem of such bias examined in the design, implementation, and analysis of health policy?

Beware of technocrats with all the answers.  I am reasonably sure that if practicing clinicians would have been asked to devise a rule to reduce heart failure readmissions for the whole population they would have refused. It seems too challenging a task to get right.  Even if clinicians can be induced to participate in the design of such a policy, most would readily acknowledge the likelihood that it could harm some patients. It requires a special type of hubris to design a policy and refuse to acknowledge its potential for harm. Unfortunately, hubris within a public health community that believes only they can give us a better health system is more feature than bug.

As for Mrs. C, she has been home for 16 days. All fingers on both hands are currently crossed.

Anish Koka is a cardiologist in private practice in Philadelphia.  He can be followed on Twitter @anish_koka. This post originally appeared here on The Accad & Koka Report. 

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag published first on https://wittooth.tumblr.com/

[kristinsimmons]

Commissioning Healthcare Policy: Hospital Readmission and Its Price Tag

By ANISH KOKA MD 

The message comes in over the office slack line at 1:05 pm. There are four patients in rooms, one new, 3 patients in the waiting room. Really, not an ideal time to deal with this particular message.

“Kathy the home care nurse for Mrs. C called and said her weight yesterday was 185, today it is 194, she has +4 pitting edema, heart rate 120, BP 140/70 standing, 120/64 sitting”

I know Mrs. C well. She has severe COPD from smoking for 45 of the last 55 years. Every breath looks like an effort because it is. The worst part of it all is that Mrs. C just returned home from the hospital just days ago.

The youngest of six children, Mrs. C was born with many embedded disadvantages. Being born black in a poor West Philadelphia neighborhood in the 1960s is a story that too often writes itself with a bad ending.  But Mrs. C avoided the usual pitfalls that derail young women in the neighborhood early. No drugs. No alcohol. No teenage pregnancies. Finished high school. Mrs. C. worked for the hospital as a unit clerk, had her own place, health benefits, and even a retirement plan.

Certain life habits, however, carry a heavy price. George Burns, the comedian never pictured without a cigar who died past his hundredth birthday, may have been immune to the effects of tobacco.  Mrs. C was not. She started smoking when she was 16. She doesn’t recall why. Her dad smoking didn’t help perhaps. Nausea racked her body after that first drag. It eased up after. Too bad.

That measly cigarette became the great addiction of her life. Day by day, the exquisitely thin membranes of the lungs that mediate gas exchange were destroyed. By the time the disease manifests with shortness of breath and bluish tinged lips, it’s too late. Short of the very few who qualify for a lung transplant, the efforts of doctors at this point are for mitigation rather than cure.

Complicating things further, in Mrs. C’s case, the normally low pressure vascular circuit of her lungs became a high pressure circuit that places ever increasing demands on the normally thin-muscled right ventricle of the heart.  This jeopardizes the ability of her heart to handle changes in blood volume.

A little extra fluid and the right side of the heart ends up causing unbearable swelling in her legs.  A little dehydration and severe disabling dizziness on standing ensues. Adding to that that her tenuous lung function decompensates with the slightest respiratory infection, that chronic steroid treatment to decrease her wheezing suppresses her immune system, and that the young man down the street helpfully drops off Newports at her home for a few extra dollars, and it’s easy to see why the hospital is her second home.

The most recent admission to the hospital was for kidney failure related to taking too much fluid off with diuretics. What was to be a short stay for gentle hydration turned into a longer stay when a pneumonia complicated the matters (though a trip to the intensive care unit and a ventilator was barely but fortunately avoided).  She was treated by the pulmonology team and sent home on a lower dose of diuretics.

The situation I am now confronting puts me in a quandary.  Her edema and weight are up markedly just a few days after returning home.  Could her fluid overload be because her kidneys are shutting down? Or does she just need more aggressive diuresis?

Should I guess? Knowing her present renal function would be helpful. But even if the Theranos lab I could appeal to for help wasn’t fictional, I would have to get her to my office everyday or every other day while adjusting her diuretic dose.

And so it comes to be that, days removed from a hospital admission, I’m sending her back to the hospital to be readmitted.  According to some, this is not supposed to happen.

A policy on readmission

In 2008, the commission that advises Medicare – the Medicare Payment Advisory Commission (MEDPAC), issued a report that focused on hospital readmissions.

The focus on hospital readmissions had been of great interest to the health policy community for some time. At the core of this interest lies the belief that hospitals and physicians are incentivized to treat patients rather than prevent admissions.

The MEDPAC report wanted to discourage readmissions like Mrs. C’s.  And so it wasn’t a terrible surprise that, rolled into the 2010 Affordable Care Act, was a section called the Hospital Readmission Reduction Program (HRRP) which created a system for Medicare to penalize hospitals with ‘high’ readmission rates.  The program was rolled out in 2013.

At first, the program seemed to work like a charm.  Hospitals significantly ramped up their efforts at care coordination.  Teams of nurses and aids were assembled to make sure patients would get their medications as prescribed upon discharge and to check on patients once they got home.

Hospital readmission rates suddenly dropped and Medicare started saving money.  A staggering 81% of all hospitals suffered penalties in 2018, which translates to ~$500 million or 0.3% of total Medicare payments to hospitals.

A complex analysis

But there’s more to this too good to be true story.

The HRRP penalty schemes are risk-adjusted based on administrative claims data. Risk-adjustment is a statistical procedure to take into account the diversity in complexity and severity of disease among patients so they can be compared.

Physicians know that risk-adjusted claims data are of dubious value because they themselves are often the reluctant data entry clerk in the byzantine scheme that starts with adding diagnostic items to the medical chart and ends with generating a coded billing claim for Medicare.  Needless to say, there’s a huge potential disconnect between what a claim attempts to convey and the actual condition of a given patient.

Yet another major problem is that the risk-adjustment employed by the HRRP does not take socioeconomic status into account, when that is arguably the single biggest driver of poor outcomes and of hospital readmissions.  The creators of the HRRP program seem to believe that a hospital located in poor area shouldn’t get a break for having high readmission rates, perhaps because they believe that hospital systems in general should be mindful of health inequities and address “care gaps” (differences in care provided to poor vs. affluent patients)  in their neighborhoods no matter what.

Finally, the initial out of the gate benchmark for readmission rates on which the HRRP would adjudicate the need for a penalty was a national average.  In such a scheme, a Johns Hopkins Hospital serving inner city Baltimore could be pitted against a regional hospital in rural Montana with an entirely different patient demographics.  This made the regional hospital in Montana very happy.

Gaming the metrics

Regardless of these technical considerations, it is an adage of social science that any metric will be gamed, and healthcare is unfortunately not immune to that law.

One tool increasingly used by hospitals to comply with Medicare payments rules is to admit patients to short stay units, under so-called “observation status.”  Another is to put pressure on emergency departments to avoid readmitting certain types of patients.

So, instead of primarily functioning as a triage operation where sick patients would be turned over to the care of the cardiologist in the hospital, the ER has been increasingly housing and managing heart failure patients to save the hospital money.

But the ER physician or the hospitalist supervising the short stay unit and who just meet a patient in the setting of an acute illness are poorly equipped to know which heart failure patient to discharge after a diuretic dose and which to keep for advanced heart failure therapies.

Source: MedPAC’s June 2018 Report (http://bit.ly/2CXD0fJ)

Nowadays, the cardiologist is increasingly insulated from those decisions.  I have personally experienced with alarming frequency instances where I learn only after the fact that a complex patient of mine has been treated for heart failure in the ED.

And my experience seems to be shared by many of my cardiology colleagues, especially among cardiologists who work in academic centers that are most affected by the policy.  Luckily, some of them are also clinician-scientists that can do more than just whine to colleagues about the new policy.  They can also study its outcomes.

What do the outcomes data show?

In a pivotal study, a group of cardiologists (Gupta et al.) saw that the drop in readmissions that followed the introduction of HRRP was unfortunately accompanied by a reversal in the decade long downward trend in heart failure mortality. This reversal suggested a serious potential harm from the policy.

But the possibility of harm was quickly challenged by another group of researchers led by one of the biggest names in health policy: Harlan Krumholz, a cardiologist who directs the influential Center for Outcomes Research and Evaluation at Yale University.

The Krumholz group analyzed millions of Medicare claims data from 2007 to 2016.  They also found that mortality for heart failure patients increased, but concluded that no causal link between decreasing readmission and increased mortality could be established.

Krumholz at al. noted that mortality rates for heart failure started climbing before the HRRP program was announced and they noted no inflection point in mortality rates with the policy announcement in 2010.  The evidence for their claim is highlighted in the table below:

As can be seen in the boxed row, Krumholz’ team concludes that the increasing mortality slope post-HRRP is no different from that pre-HRRP because the change did not reach statistical significance at the obligatory and arbitrary P<0.05 level.  The actual P-value was 0.11 and the confidence interval for the positive increase in mortality slope of 0.006 is (-.002 to .015).  Even poor students of epistemology would be loathe to conclude this result excludes a signal of harm.  It seems entirely plausible that, with all the limitations of the data set in question, mortality may in fact have accelerated after the institution of the HRRP.  Yet Krumholz insists that no signal of harm is to be considered.

But this did not stop another group of cardiologists (Wadhera et al.) from adding their contribution to the HRRP literature. Using the same data-set that the Krumholz group used — Medicare claims data — these researchers found once again that accelerating mortality coincided with the announcement of the HRRP.  More troubling, they also demonstrated that mortality rose primarily among patients not readmitted to the hospital.

A messy science

Admittedly this whole business of analysis is incredibly messy, with a number of moving parts.

My brief summary doesn’t do justice to a variety of maneuvers taken by the various groups to account for many of the limitations inherent in this type of study. Two of the competing analyses (Krumholz, Wadhera) used Medicare claims data while the other (Gupta) used a more limited voluntary registry.

During the time period in question, there were also other policy changes such as the introduction of new hospital billing codes (MS-DRG) that sought to adjust hospital payment rates to patient complexity. Better patient coding meant higher reimbursement from Medicare.  Armies of “documenters” were then employed by hospitals to capture more revenue.

This means that the claims data gathered by the researchers might look significantly different from one time period to the next even if the patients themselves were ostensibly the same. As the readmission rate is risk-adjusted, it is eminently plausible and likely that systematically upcoding patient risk could actually have been the primary driver of the drop in hospital readmission rate.

The other program playing a confounding role is the Recovery Audit Contractor (RAC) program begun in 2010 to reduce payments for inappropriate hospital admissions. Hospitals responded to denials for inpatient admissions by expanding ‘observation status’ stays. Which was the biggest driver for expanded observation stays? RAC or the HRRP? Once again an exact attribution is impossible.

Denying the obvious?

Despite the messiness of the data and the variety of analytic methods used, a consistent and uncontested observation remains: Heart failure mortality has increased in the last decade. The question being hotly contested is Why?

Oddly, Dr. Krumholz is steadfast in denying the possibility that the policy may have caused harm, even though the independent and contradictory conclusions from the other research groups at least raises a reasonable doubt.  And Dr. Krumholz has been quick to cast shade on research that does not conform to his conclusion.

By tweet he appears to ask for a level of detail his own papers lack, and he questions the legitimacy of another group’s data-set, all the while resisting any calls to put the program on hold despite the paucity of evidence showing benefit, the signal for harm, and perhaps most importantly, the concern of clinicians who see a mechanism for harm.

Greatly admire @rwyeh and his group…appreciate his focus on readmission &public policy. For such high-profile article, really need more info about statistical weighting. Methods should be sufficient so others can reproduce results. Can’t do that here. Look forward to more info.

— Harlan Krumholz (@hmkyale) December 21, 2018

Can you account for why the registry you used had, on average, such a small number of patients per site. Did you determine how many patients coded with heart failure by CMS were in the Registry? Just curious about the selection. It may not explain your results…but is a question. https://t.co/WSvJAN8Jjd

— Harlan Krumholz (@hmkyale) June 2, 2018

Dr. Krumholz also places much weight on an independent analysis carried out by MEDPAC which concluded there was no link between policy and the uptick in mortality. This particular conclusion rests heavily on the assertion that heart failure patients in 2016 were much sicker than patients in 2010. Recall that this coincides with a period of more intensive coding over the same time frame, so it is impossible to say this with any confidence.

The MEDPAC conclusion also relies on an analysis that finds no correlation between hospital level readmission and mortality rates.

While technically true, that conclusion overlooks that a large number of hospitals exhibited reduced readmission rates and increased mortality. Perhaps MEDPAC feels that patients dying at low readmit/high mortality hospitals should be mollified by the knowledge that somewhere there’s a low-readmit/low mortality hospital to balance things out?

That Krumholz and MEDPAC display such certainty about the direction of the signal they observe, and take pains to discount other possibilities seems strange and suggests that pre-existing biases may be at work. What might those biases be?

Conflicts of interest: You get what you pay for

In a world where heads roll for undisclosed personal financial conflicts of interest, it is remarkable that the current dispute, while full of scintillating exchanges about “propensity weighting” and other arcane points of statistics, does not reference any other potential conflicts at work that might affect the conclusions being reached.

Medicare’s decision to start the HRRP program didn’t come in a vacuum. It was inspired by years of research from Dr. Krumholz himself, who suggested that preventing admissions should be a goal for any policy that would aim to move the system from one paying for “volume” to one paying for “value.”

As far back as 2003, Krumholz held the view that:

“Hospitals may not support programs that improve the quality of care delivered to heart failure patients because these programs lower readmission rates and empty beds, and therefore further diminish already-declining revenues.”

If Krumholz’s unfavorable and crudely simplistic view of the operations and motivations of hospitals (and of the still relatively independent physicians staffing those hospitals) informs his position on health policy, it stands to reason that serious blinders would prevent him from seeing any evidence of harm in a particular policy that promotes the same view.

But that’s not all.  Krumholz’s group at Yale received grants from CMS under the auspices of the Measure and Instrument Development and Support (MIDS) program to study and produce the metrics and instruments needed to devise the readmission measures.

The MIDS program supports the “development and use of clinical quality measures which remains a critical healthcare priority and the tool of choice for improving quality of care at the national, community and facility levels” and it allocates $1.6 billion dollars to this purpose.

Thanks to a bipartisan act of Congress, a helpful little website, usaspending.gov, provides contract level detail about payments made to the Krumholz’s group from the MIDS program.  Those payments can be seen in the table below:

The numbers are staggering. I know little about how to interpret these data about federal contracts, but it sure appears that the Yale-New Haven Health Service group led by Krumholz has received $144 million dollars since 2008.

Yet the only clue to these payments in Krumholz’ published analyses of the HRRP program comes in one disclosure sentence in a footnote, as seen here:

It seems to me that the disclosure is hardly proportional to the amount of funding that his group receives and understates the inherent pressures it must be under to demonstrate that the policy did not actually result in higher mortality.

And recall that MEDPAC’s “independent” analysis that also rejected a policy-mortality link came from the organization that recommended the policy to begin with.  The bottom line is this: There’s a tremendous amount of face to lose and a massive source of institutional funding at risk if the policy is found to be harmful.

It now becomes more clear why, in the following tweets, Dr. Krumholz feels that only he can say anything definitive about readmission rates and mortality:

Um, @JAMA_current, even the authors say they cannot say their findings are causal… "but whether this finding is a result of the policy requires further research.” Why do you promote the paper as proving harm? Need to treat twitter like you do any of your Editorial comments. pic.twitter.com/xugasHvPWY

— Harlan Krumholz (@hmkyale) December 26, 2018

6/Hospitals that have improved their readmission rates tended to improve their mortality rates. Published in @JAMA_current… https://t.co/R7FXLwTMPp

— Harlan Krumholz (@hmkyale) December 22, 2018

A diversity of biases

Biases are ubiquitous.  When I was a cardiologist-in-training, spending hours on the hospital consult service for a fixed salary, I vividly recall looking for ways to avoid doing any work I considered unimportant or banal: The minor cardiac enzyme leak in a patient with a widespread infection; The extra heartbeats on the ECG that the ER physician didn’t like the look of; etc.  “Are you sure you need an official consult?”  “The chances we’re going to recommend doing anything about a small enzyme leak in an 80-year-old with a severe lung infection are very low… “ I was even successful sometimes.

Contrast these comments to my demeanor in private practice where I am acutely aware that my income relies on such consults: “I just need the patients name or room number…” “I’ll take care of it!…” “I can put in the orders if you’d like!”

But there are other biases and incentives that motivate human beings, apart from personal financial incentives. Do they pale relative to the financial ones as is so often claimed? How does one begin to quantify them?

When it comes to the HRRP policy, no individual person’s bank account ballooned every time a patient didn’t get admitted. And yet this is a story of ideological bias that drove the design of policy and now claims ‘success’ for its own program.  The HRRP saga is illustrative of the importance of non-financial bias and of the dangers of blinding ourselves to that bias.

The story also highlights the downsides of tweaking healthcare systems that were built to deliver more care.

Clearly, I personally have a direct financial conflict of interest to provide more care. Since I haven’t talked anyone out of a consult in 8 years, I’m probably guilty of participating in a system that detractors appropriately criticize for promoting overuse of healthcare.

But the problem is that some of those consults I was trying to avoid as a fellow ended up really needing a cardiologist. There was the 55-year-old Cambodian woman admitted to the medical intensive care unit with pneumonia who went into atrial fibrillation. I recall rolling my eyes and thinking that the ICU could certainly handle this without a cardiologist. It turned out she didn’t have a pneumonia. It was pulmonary edema from heart failure related to undiagnosed rheumatic mitral valve disease. She had been in the wrong unit. She needed diuresis, heart rate control, and eventual surgery to replace her valve, not antibiotics. Less isn’t always more.

Attempt to reduce inappropriate hospital admissions? Get ready to pay a price.  To contradict Dr. Krumholz, it is entirely probable that we are underestimating the upside of our current system when we contemplate changing the status quo.

We are underestimating the downside of our current system when we contemplate change. We need to take some risks to do better. #abimf2013

— Harlan Krumholz (@hmkyale) August 5, 2013

Final Thoughts

Ironically, the HRRP quagmire offers a number of clarifying lessons.

Empiricism in social policy is a subjective enterprise. The often parroted conclusion is that cold, hard, unbiased evidence trumps the biased, unmeasurable judgment of clinicians. Yet, frequently, real world data-sets are complex, the choice of analytic paths can be highly variable, and the instruments to measure success are often imperfect. As it relates to HRRP, which analysis should we trust? The choice requires faith. And if the currency here is faith, perhaps the concern of clinicians at the bedside has more value than advertised.

Metrics won’t save us. The narrative of metrics is an appealing one that promises hard and objective accountability. The problem comes when the metric (readmission) becomes disconnected from outcomes that actually matter (death). False and blind prophets are good descriptors for those who claim to be unable to see without metrics. The fools in this enterprise are easy to identify as those who think the answers lie with ever better metrics.

Conflicts of interest: Going beyond the simple narrative.  Focusing on biases induced by personal financial interests is a mistake. Personal enrichment is just one bias in a sea of conflicts. In the healthcare context, financial disclosures—while clarifying in themselves—may simply give cover to other, more perverse biases, unless those other biases are equally disclosed.  It requires diligence to ascertain the impact, and direction of bias.  Rarely do we get the opportunity to observe the direction of bias in policy research.  In the case of the HRRP, the presence of bias was made evident because research groups with opposing biases (clinician-scientists versus policy wonks) have reached conclusions that would be expected on the basis of those pre-existing biases.  How often is the problem of such bias examined in the design, implementation, and analysis of health policy?

Beware of technocrats with all the answers.  I am reasonably sure that if practicing clinicians would have been asked to devise a rule to reduce heart failure readmissions for the whole population they would have refused. It seems too challenging a task to get right.  Even if clinicians can be induced to participate in the design of such a policy, most would readily acknowledge the likelihood that it could harm some patients. It requires a special type of hubris to design a policy and refuse to acknowledge its potential for harm. Unfortunately, hubris within a public health community that believes only they can give us a better health system is more feature than bug.

As for Mrs. C, she has been home for 16 days. All fingers on both hands are currently crossed.

Anish Koka is a cardiologist in private practice in Philadelphia.  He can be followed on Twitter @anish_koka. This post originally appeared here on The Accad & Koka Report. 

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