Hensley says she preferred drugs like Percocet and morphine, but opted for heroin when short on cash.

By the time she discovered she was pregnant last year, she couldn’t quit.

“It was just one thing after another, you know — I was sick with morning sickness or sick from using,” said Hensley, who is 25 and lives in Cleveland. “Either I was puking from morning sickness or I was puking from being high. That’s kind of how I was able to hide it for a while.”

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The patient walks woozily out to the ambulance from a tan house on a tree-lined street. Anthony Savoy, the head medic, calls ahead to , which has the closest emergency room. Savoy wants to make sure the ER has space for the patient.

The man gets in that day, but it was by no means guaranteed. For years, it’s been common practice for University Hospitals to switch its status to .

That means when Savoy would call the hospital, people in the emergency department would say they didn’t have the room or the staff to handle the patient. The EMS team then would have to drive to another hospital — often the Cleveland Clinic — about a mile away.

“If we get diverted and then we get a call while we’re at the hospital, our response time will be lengthened by maybe a minute, maybe two minutes,” Savoy said.

A released earlier this year found that heart attack patients whose ambulances were diverted from crowded emergency rooms to hospitals farther away were more likely to be dead a year later. And before that study came out, the Ìýhad taken a look at the increasing use of diversions by hospitals nationwide, recommending against them.

Yet, emergency departments across the country, including those in Cleveland, continued to divert patients — often making it even more commonplace. Boston’s Feldman says hospitals across the country routinely operate with thin staffing and find themselves coping with too many patients.

In Cleveland this year, University Hospitals temporarily closed its main campus emergency room to certain patients for more than 550 hours. Another large health system, , clocked more than 400 diversion hours.

Jane Dus, chief nursing officer at University Hospitals, says an aging population and hospital closures have increased demand on emergency departments. “We’ve seen a 56 percent increase in our squad volume over five years, so we’re getting many more squads coming to us,” she said.

Dus recently joined Cleveland-area hospital leaders in negotiating an agreement to stop ER diversion. Indeed, all four major health systems in Cleveland say they will accept all ambulances starting Feb. 15.

If the hospitals are successful, the region will join a select few that have tackled the issue. After years of trying, the Seattle area has stopped nearly all diversions.

Under federal law, every hospital is required to evaluate patients who arrive in the ER and stabilize them before transferring them elsewhere. But the law doesn’t cover patients in ambulances that are diverted before patients are ever seen.

Massachusetts passed regulations in 2009 to ban ambulance diversions after voluntary attempts failed. Feldman, the Boston ER doctor, says hospitals there had to reevaluate operations, in some cases encouraging elective surgeries to be done closer to the weekends to free beds on other floors throughout the week.

But changing the way emergency departments respond is complicated because emergency departments routinely operate with minimum staffing and beds, Feldman said. “The staff are reasonably fearful that the next critical patient is going to push them over the brink of patient safety,” he said. “They really can’t handle another patient.”

MetroHealth’s Chief Clinical Officer says there are things the hospital can do to be better prepared. “This does obligate us to take steps to correct problems that are correctable that will allow us not to go on diversion,” Connors said. “It’s not just simply we’re not going to go on diversion and everybody just sits and hopes that everything will be better.”

Adding bed capacity and refocusing on staff are part of the fix. “It’s an issue of do we have enough beds open, do we have the proper staffing, do we have the capacity in the emergency room,” Connors said.

MetroHealth is frequently the busiest emergency department in the city, and the hospital has struggled with diversions before, logging nearly 1,000 hours of diversion in 2013. Connors says the hospital worked to reduce diversions, getting down to less than 150 hours of diversion status in 2014. But, this year, diversions have risen again.

There are two hospitals in Cleveland that rarely if ever go on diversion: the Cleveland Clinic’s main campus and St. Vincent Charity Medical Center.

The Cleveland Clinic’s main campus logged more than 500 hours of ambulance diversions in 2013, but reduced its diversions to two episodes lasting a total of about 10 hours in 2015.

, a leader in the emergency department at the Cleveland Clinic, says change has to happen beyond the emergency department. The clinic has diversions at other regional hospitals in its system and will have to stop those as well to meet demands of the new ban.

The ban will “drive people to actually address efficiencies throughout the day and not use diversion as a crutch, to not be doing the work they should be doing,” Meldon said.

The small St. Vincent Charity Medical Center in downtown Cleveland hasn’t gone on diversion since 2012. “It’s a matter of working together as a team,” saidÌýBev Lozar, the hospital’s chief nursing executive. “It starts every morning at 8:30. We have a huddle of all the nursing directors and all of the other clinical and support directors just to kind of review the day.”

Still, EMS medic Savoy is skeptical that University Hospitals and MetroHealth can end diversions. Just hours after Savoy dropped off his nosebleed patient, University Hospitals stopped taking all but the most critical injuries for nearly four hours.

“My concern is all of the sudden you guys are willing to put this on paper and say that you’re going to do this,” he said. “What was stopping you guys before? You know, why now?”

Savoy and others on the squad are worried that the emergency departments will stay crowded. It’s something local leaders say they’ll work to avoid.

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Carmen Smith did that for six years when she didn’t have health insurance, and didn’t have a primary care doctor. She bought her insulin without a prescription at Wal-Mart.

“It’s not like we go in our trench coat and a top hat, saying, ‘Uh I need the insulin,'” says Smith, who lives in Cleveland. “The clerks usually don’t know it’s a big secret. They’ll just go, ‘Do we sell over-the-counter insulin?'”

Once the pharmacist says yes, the clerk just goes to get it, Smith says. “And you purchase it and go about your business.”

But it’s still a pretty uncommon purchase.

The availability of insulin over the counter presents a real conundrum. As Smith’s experience shows, without training or guidance from a health care provider, it can be dangerous for a patient to guess at the best dosage and timing from version to version of insulin. On the other hand, being able to afford and easily buy some when she needed it may have saved her life.

There are two types of human insulin available over the counter: one made by and the other by . These versions of the medicine are older, and take longer to metabolize than some of the newer, prescription versions; they were created in the early 1980s, and the prices range from more than $200 a vial to as little as $25, depending on where you buy them.

Dr. Jorge Calles, an endocrinologist at MetroHealth, is alarmed to think that some people are self-medicating with any sort of insulin.

“It’s a very serious situation if they are selling it over the counter — without any control with a prescription, specifically,” Calles says.

According to the medical consulting firm , about 15 percent of people who buy insulin in the growing U.S. diabetes market, purchase it over the counter without a prescription.

The U.S. Food and Drug Administration declined multiple requests by NPR for an interview on this topic. But, in an email, an FDA representative said that the versions of insulin now available over the counter were approved for sale that way because they are based on a less concentrated, older formulation, “that did not require a licensed medical practitioner’s supervision for safe use.”

The broader availability of this form of insulin allows patients with diabetes to obtain it “quickly in urgent situations, without delays,” the FDA says, and is intended to .

Still, some people with diabetes, as well as some doctors, doubt that the benefits of that greater availability outweigh the risks, especially for patients who switch from one type of insulin to another without telling their doctor.

“This is not something that should be done without the help of a professional,” says , who has Type 1 diabetes, and writes the blog. Kliff has followed and written about the expanding business of diabetes for years.

FDA officials are “basically sticking their heads in the sand” on this issue, Kliff says, and making a lot of assumptions.

“They look at insulin as a drug,” he says, “and say, ‘There’s this enormous body of evidence that shows that the drug is safe.’ But, you know, there’s a little asterisk at the end there. What the little asterisk basically says is: ‘You know, that’s assuming that the patient is trained on it.'”

When asked about safety concerns, the FDA told NPR that the agency welcomes more research into the safety of over-the-counter insulin.

One state does require prescriptions for all insulin. , a health officer for Clark County, Ind., led the effort to require prescriptions in his state.

“I didn’t realize that insulin was over the counter in Indiana until two of my patients, who were in good control, suddenly had increased glucoses,” Burke says. He asked them if they had changed their diet, lost weight, altered their workout routines. They had not.

“They both admitted that they had decided to switch to over-the-counter insulin,” Burke says, “which was different from what I had prescribed.”

Over time, taking the wrong dosages destroys your body, Burke says. Poorly managed diabetes is the cause of a host of complications, such as high blood pressure, kidney disease, nerve damage, loss of eyesight and stroke.

Burke says he took his concerns to the American Medical Association. But the national doctor’s association told him there are no data showing that the drug’s over-the counter availability is a public health hazard. In fact, the AMA’s board noted, getting insulin without a doctor’s prescription may be an important way for some insulin-dependent patients to get access to the medicine they need.

Dr. Todd Hobbs is chief medical officer of Novo Nordisk in North America, which makes Novolin, one of the two versions of insulin sold over the counter. His company partners with Wal-Mart to sell its version under the brand name . (Wal-Mart declined to be interviewed for this story.)

Hobbs says Novo Nordisk’s version of insulin is for people who don’t have insurance, or who have to pay a lot for their other prescriptions — “people who just, for whatever, reason have fallen through the cracks and either don’t have insurance coverage at the time, or are without coverage.”

With ever-rising copayments and premiums, he says, many patients are turning to nonprescription insulin because it’s cheaper and all they can afford.

“But we hope to try to help them to not have to do that,” Hobbs says.

“We clearly think the newer versions are more close to what the body would do on its own,” he says. The prescription versions are better and safer, he agrees, because they make it easier for patients to avoid wild fluctuations in blood sugar.

Carmen Smith doesn’t blame the insulin she was taking for her emergency room visits.

“Insulin is not the problem,” she says. “It is getting the insulin that is the problem. Once I got connected with my physician, life as a diabetic got a lot less complicated for me.”

Smith is now on Medicaid. She has a doctor — and a prescription for one of the newer generation of insulins.

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Burkons liked delivering babies but he is also committed to serving his patients, including those who choose abortions.

On a recent day a 30-something woman comes to the clinic. She is six weeks pregnant because, she says, her birth control failed her. She is mother toÌýan older child, and she has an immune system illness that requires her to take drugs that would be toxic to a developing fetus. Burkons greets her warmly asÌýshe comes to the clinic for the second round of a medical abortion, a two-dose drug regimen to end a pregnancy.

“We’re going to give you this,” Burkons says, handing the woman the pills.

“And what are these two?” asks the woman, who requested anonymity.

“These are the Misoprostol pills,” Burkons says.

On this day, there is a steady stream of women who visit Burkons’ clinic for medical abortions.

leads Ohio Right to Life. He says sweeping bills that propose stopping abortion entirely rarely get approval.

“We believe in an incremental approach to both the legislative side as well as the changing of hearts and minds,” Gonidakis says.

Another Ohio law says clinics must have agreements with nearby hospitals to send patients there in case of an emergency.Ìý It is similar to a that requires doctors who perform abortions have admitting privileges at nearby hospitals. The U.S. Supreme Court that case in the fall.

OhioÌýis embracing that trendsetter role yet again with that would make it illegal to end a pregnancy if the reason for the abortion is that the fetus has Down syndrome.

is a conservative-leaning law professor at the University of Toledo. He says the incremental approach of restricting access to abortion seems to be working across the country.

“At some point in the mid to late 70s, pro-life people recognized that they were in for the long haul,” Strang says.Ìý “Instead of trying to overturn Roe at least immediately, they tried to incrementally undermine Roe through the judicial appointment process and then through state and federal statutory restrictions on abortion.”

The , a nonprofit that supports abortion rights, tracks restrictions. In 2013 alone, 22 states including Ohio enacted restricting access to abortion.

is a law professor at Case Western Reserve University and sits on the board of a clinic in Cleveland that performs abortions called Preterm. She said various provisions of abortion restrictions have gone under the public radar for years.

“It’s hard for people to see how any one of these things in isolation impacts abortion access, but when they add up, they can really constitute a major burden,” Hill says.

Burkons says his work is very rewarding because virtually all the women he treats are relieved and grateful.

“Nobody grows up saying, ‘I’m planning on having an abortion.’ And, oh, they think, ‘It will never happen to me, I’m too smart for that,’ or whatever,” Burkons says. “And they just assume that if it does happen, someone will be here.”

When he opened for surgical abortions, there was pent up demand: He performed 16 in three days.

In the face of the controversy about abortion, Burkons is very matter of fact. ÌýHe sees abortion as a medical service physicians are obligated to provide, and he recalls what happened before Roe v. Wade passed in 1973.

“The people that were older than me would tell about almost any night that they were on call, they were dealing with septic abortions where people would come in with perforated uteruses or partially completed abortions that were done in some garage somewhere,” Burkons says. “That fortunately was something I never had to deal with in my career.”

More than a decade ago, when Burkons first started performing abortions more regularly, he says he believed there were right and wrong reasons to have an abortion. But his opinion on that has evolved.

Burkons says his patients have included lawyers and doctors, who often arrive embarrassed that they didn’t use birth control properly. But there are other patients, as well.

“You see women who’ve had five abortions, I mean they are using it for birth control,”Ìý he says. “But then you kept thinking about what kind of a parent would that person make, if they can’t figure out how to use birth control?”

In the end, he says, the judgement of which situation is right or wrong is not his to make.

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For my city kids, this is supposed to be heaven. There are freshly laid chicken eggs to gather, new kittens to play with and miles of pasture to explore.

But we’re not outside.

I’m sitting in my childhood bedroom watching my 7-year-old son and his 11-year-old-cousin stare at a screen. The older kid is teaching the younger the secrets of one of the most popular games on Earth: Minecraft.

“You can’t mine ores unless you have a pickax,” explains my nephew to my son. “You need a wooden pickax to get stone, and you need a stone pickax to get iron, and you need an iron pickax to get gold,” and so on.

Minecraft is the megapopular video game that ranges from simple to complicated. But the basics are that players enter a world that looks sort of like Legos on a screen and build anything they want. Think houses, mountains and farms.

But I’m a health reporter, which means I’m more aware than anybody should be about the many rules of raising a healthy, well-adjusted child.

But this is Minecraft. My son’s addiction is acute, and he’s got plenty of company.

Illinois-based graphic novelist Chris Ware was so taken aback by his 10-year-old daughter’s interest that it inspired his recent New Yorker .

Ware’s drawing shows two girls, with their backs facing each other, staring at screens and ignoring the toys littered about them.

“It’s pretty amazing how it seems to almost completely usurp the consciousness of the 6- to 14-year-old set,” he says. “My daughter made all these series of underground classrooms, which I thought was such a strange idea, you know.”

This is no Grand Theft Auto-like video game with guns and graphic violence. Schools and camps use Minecraft to teach basic spatial reasoning concepts, albeit with some odd characters, such as squid and pigs.

Before taking vacation, I caught up with Mel McGee during a she runs in Shaker Heights, Ohio. She was explaining to a handful of preteens how to use red stone dust to make an electrical wire.

“We try to drop some engineering stuff, real-world concepts in there and how it relates to what they’re building in Minecraft,” she says.

So, if you’re using it for good, does it count as screen time? I asked Dr. Victor Strasburger, who helped write the American Academy of Pediatrics recommendations 15 years ago.

“We’re not a bunch of old fuddy-duddies sitting around trying to figure out how we can poke a hole in kids’ entertainment options,” he says.

Research has established that kids who sit in front of TV or video for hours have higher rates of and possibly other health problems. But Strasburger says it’s more complicated than just setting strict time limits.

The academy has no set recommendations on educational screen time or even the use of different types of screens.

“We don’t know about iPads, cellphones, smartphones, new technology because there isn’t the research. When there is, believe me, we would be the first to be talking about it. But there ain’t!”

His advice to parents is to create their own family policies.

Here in my childhood bedroom, I’m watching my son and trying to figure out what our policy should be.

My boy’s virtual person has moved past a pig and is gathering sugar cane, for reasons I am only beginning to understand.

“Dude, you should start a sugar cane farm,” says my nephew. My son agrees.

The obvious irony here is, they don’t actually have to build a farm. They can just walk outside and be part of a real one.

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“The big thing is to make the patient comfortable with the treatments that they’re going through,” he says of the building’s design. “So lighting, light colors, [and] as much natural light as possible are always very important to cancer patients.”

Kazmierczak came to this project after overseeing construction of the cancer hospital at a few hours south of here. All around the U.S., the health care industry is building up to take care of an expected influx of cancer patients.

Ohio is not alone in this building boom. The , a firm that does health care consulting, works with hospitals and doctors. Last year it found that about 25 percent of its members that have oncology departments were either constructing a cancer center, or had built one in the past three years. The Advisory Board’s says people are more likely to get cancer as they get older.

“Now that everyone is looking forward and seeing the aging of the baby boomers,” she says, “it’s certainly adding some fuel to that fire.”

“In the past five years, volumes go up, depending on location, between 5 and 10 percent a year,” Bolwell says. “And there’s no end in sight to that volume of growth.”

The Cleveland Clinic, along with its local competitor, University Hospitals, treat about 70 percent of the region’s cancer patients. And when the Cleveland Clinic opens its new center, the two will be located within a five minute drive of each other.

Historically, state governments have required hospitals to meet a Ìýbefore building a hospital. But beginning in the late 1980s, states across the country began deregulating. Ohio’s certificate of need requirements for hospitals ended in the late 1990s, though it still requires it for long-term care facilities.

, who heads the cancer center at University Hospitals, doesn’t seem worried about the competition. His 4-year-old hospital, he says, is mostly full every day.

“We discharged over 11,000 patients with cancer in 2014,” Levitan says, “which is about a 20 percent increase over just a few years beforehand.”

He says that’s because both hospitals employ and contract with thousands of doctors. And in the world of cancer care, doctors have a lot of influence.

People usually don’t shop for cancer treatment until they are diagnosed, and at that moment their doctor’s advice on where to go matters a lot.

leads a hospital advocacy group in Cleveland. He says that with so many expected patients, building is good for a hospital’s bottom line and good for patients.

“If you can run enough procedures through a facility, you’re going to get some economies of scale that will generate [a profit] margin,” he says. “The other thing you get when you run enough procedures through a facility, is a level of expertise that improves the quality of care that the individual gets.”

And when talking about the future of cancer care, hospital leaders tend to talk about quality. They insist that focusing on the quality of care will eventually lower the cost to patients, too.

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“I remember hearing Christmas bells from the church across the street,” he says.

Summers was born at this hospital. His sister was born here. This hospital has a special place in his heart. But then he became mayor of Lakewood four years ago and realized the hospital was a financial liability forÌýthe small city, which has seen a sharp increase in poverty levels in the past two decades.

“I’ve grown to understand the situation we are in is not unique. There are considerable forces at play and we are in the middle of all of them and a lot of communities are just like us,” Summers says.

Lakewood Hospital is this community’s biggest employer, with 1,000 workers. It has been a rich source of municipal revenues even as manufacturing jobs left the region.

“It is our intent to keep Lakewood Hospital fully functioning until Avon Hospital opens in September 2016,” says Dr. Toby Cosgrove, the chief executive officer of the Cleveland Clinic, said at the meeting.

Still, residents are pursuing legal action. The city has responded to the residents’ action, and Lakewood’s leaders say they’d like the community to focus on how to overcome the loss of the hospital, rather than a legal battle.

Lakewood something that isÌýÌýacross the country.

The hospital, like others, has fewer patients and they aren’t staying as long – which can cut into revenues.

Who is using the hospital is also a factor, saysÌý, chairman of medicine and public policy atÌýthe University of Southern California.

“Unfortunately as a society we’ve created some powerful incentives,” Ginsburg says. “Hospitals are paid much better to treat privately insured patients than anyone else. After that comes Medicare, and the least payment is for Medicaid patients and, of course, the uninsured. That’s virtually no payments.”

Lakewood has become a poster child for the challenges of inner-ring suburbs.

A Brookings InstitutionÌýÌýin 2012 on the nation’s growing suburban poverty includes Lakewood. It notes that free and reduced price lunches for high school students shot up from 9 to 46 percent between 1999 to 2010.

Mayor Summers says that there is no question Lakewood Hospital’s percentage of privately insured patients has dropped in recent years.

“In 2000, we were about maybe four or five percent of residents were at the poverty level. Today, we’re pushing 16 percent,” he says. “It’s been fairly dramatic.”

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But it’s not just the cancer she’s fighting. It’s the bills.

“Think of those old horror flicks,” she says. “The swamp creature … comes out and is kind of oozy, and it oozes over everything.”

Koller, who lives in the Cleveland suburb of Strongsville, just turned 65 years old. She is petite and sports a stylish auburn wig. When she was able to work, Koller was in the corporate world and safely middle-class, with health insurance and plenty of savings.

But when she got sick, her high deductible health plan soon became a burden. And her monthly premiums kept increasing, reaching nearly double her mortgage payment. She soon found herself unable to keep up with the bills. They piled up.

“You start looking at these bills,” Koller says, “and, as much as you know it’s expensive, the shock itself is like, ‘What?'”

Her response was to begin asking her doctors about the cost of the treatments they recommended and whether there was a less expensive alternative.

Middle-income patients are — more than ever — feeling the pressure of that financial burden, , an oncologist at University Hospitals in Cleveland. He took over Koller’s care a couple of years ago.

“Patients are weighing this in their calculus now,” Meropol says.

high-deductible health plans and soaring prices for a new generation of drug therapies that came onto the market in the late 1990s.

“We went from drugs that cost a few hundred dollars for a course of therapy that might be a month or six months or a year, to drugs that were costing $10,000 a month,” Meropol says.

Total cost of cancer care in the United States is projected to reach more than , according to the National Cancer Institute. The U.S. Centers for Disease Control and Prevention released a last year that found that, compared to people without a cancer diagnosis, cancer survivors are less likely to work and more likely to struggle financially. Another study, out of Washington state, found that the longer a cancer patient survived, the .

University of Chicago’s argues that it’s time for oncologists to begin considering the financial consequences as to cancer care.

“We talk about hair loss,” de Souza says. “We talk about numbness and tingling in the hands and feet. We talk about, ‘This chemotherapy will cause low blood counts.’ Right. Should we also be talking about, ‘Well, this chemotherapy is expensive?’ ”

He and Meropol are part of a growing field of researchers studying the for cancer patients.

Anne Koller will tell you cancer does cause financial stress.

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Hospital officials credited the federal health law for the improvement. “The decrease in charity care is primarily attributable to the increase in Medicaid patients due to the expansion of Medicaid eligibility in the State of Ohio and the resulting decrease in the number of charity patients,” the hospital’s year-end financial statement .

That 40 percent drop spotlights a trend in how payments are changing for all providers since the health law rolled out the Medicaid expansion and subsidies that help some lower-income people purchase policies on the new insurance marketplaces, said John Palmer, spokesperson for Ohio Hospital Association.

“Now that you’re starting to see that shift from uninsured or underserved on over into health care programs such as Medicaid and the exchange, that has had a good impact,” he said. “And, obviously, it is reflective of what hospitals are experiencing with uncompensated care in the areas of charity care especially.”

The clinic is not alone. The federal Department of Health and Human Services announced last week that the number of uninsured and self-pay patients has fallen substantially in Medicaid expansion states since the program went into effect last year. In addition, states with expansion saw significant reductions in uncompensated care costs – which includes charity care and bad debt, such as when an insured patient doesn’t pay her share of a hospital bill. Hospitals in those states had an savings of $2.6 billion over that seen in non-expansion states.

Dr. Toby Cosgrove, the clinic’s chief executive, noted then that the economic improvement came from a reduction in expenses, with cuts in energy use, employee health insurance costs and staff.

“Everybody in the organization contributed from whether we were turning off the escalators at night or not doing duplication of lab studies,” Cosgrove said. “But it was a total organization involvement in this and it was very gratifying to see people step to the plate.”

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Clay arrived a couple of weeks ago suffering from complications related to acute heart failure. He’s ready to go home. But before Clay can leave, pharmacist Katie Greenlee stops by the room.

“What questions can I answer for you about the medicines?” Greenlee asks as she presents a folder of information about more than a dozen prescriptions Clay takes.

“I don’t have too many questions,” Clay says. “I’ve been on most of that stuff for a long time.”

Clay is 62 years old and has been on many of the medications since he was in his 20s, when he developed heart problems.

Still, Greenlee wants to make sure Clay understands the importance of taking his pills at the right time and at their full dosage. Not taking medicine correctly is a big reason patients return to the hospital. And research has found that as many as 30 percent of prescriptions are never filled.

Since the Cleveland Clinic began sending pharmacists into cardiovascular patient rooms at discharge, it has drastically reduced its number of readmissions. And that means it has reduced its Medicare fines, mandated by the Affordable Care Act.

During the trial period, researchers will gather data on which penalty measurements are related to poverty and how they could be risk adjusted, Burstin says.

“Socioeconomic status may be a proxy for some other really important factors, such as whether somebody has social support at home, whether somebody has the ability to come back and have a follow-up appointment with their doctor after hospitalization,” she says.

The key, Burstin says, is to understand which factors hospitals could be accountable for improving.

“So we would also like to begin to understand what’s underlying those differences,” Burstin says. “And, ultimately begin to understand which of those lend themselves towards improvement strategies, like making sure somebody does in fact have what they need to make sure they don’t bounce back into the hospital.”

Burstin says federal regulators at the Centers for Medicare and Medicaid Services are part of the discussions and “willing to participate in the trial going forward.”

Cleveland may be the perfect place to help answer this question.

On the near West Side of Cleveland, Dr. Alfred Connors is chief quality officer at county-owned MetroHealth System.ÌýAbout half of the hospital’s patients are uninsured or on Medicaid, which is government coverage for the poor and disabled.

“So we take care of people who are homeless, people who don’t have places to go when they leave, people who really don’t have family supports. They are living by themselves on a very limited income,” Connors says.

Unlike the Cleveland Clinic, MetroHealth has seen its Medicare fines increase since the program began in 2012. MetroHealth had a .83 percent cut in Medicare reimbursement for 2015, as compared with a .45 percent in 2013.

The Clinic’s main hospital is more likely to have privately insured patients, like Clay. Since 2013, the Clinic’s main campus has seen its penalty drop to .38 percent of Medicare payments from .74 percent.

There are several factors at play in the numbers. First, the maximum penalties increased to a 3 percent cut in Medicare funding in the fall of 2014. The penalty has ratcheted up from 1 percent when the program began.

In addition, federal regulators began tracking two new conditions. The penalties were originally based on readmissions of Medicare patients who went into the hospital with one of three conditions – heart attack, heart failure and pneumonia – and returned within 30 days. Now, federal regulators are also including readmissions for hip/knee replacement surgery and chronic obstructive pulmonary disease, or COPD.

Still, the Cleveland Clinic’s Chief Quality Officer Dr. Michael Henderson says socioeconomic issues like poverty are an important factor.

“One of the real benefits of some of these programs that have come in place is it’s really put coordination of care on the map for patients,” Henderson says.

Leaders at Cleveland-area hospitals say that regardless of the amount of care and coaching a patient gets in the hospital, a patient’s home environment is critical.

University Hospitals – the city’s other big hospital system – also serves a high proportion of low-income patients at its main campuses. It reported a .59 percent penalty in Medicare reimbursements for 2015 up from a .11 percent hit in 2013.

Dr. William Annable, chief quality officer at University Hospitals, is skeptical about the program and its penalties: “There are some people in the health care industry who see it as the government trying to solve society’s problems on the back of the hospitals.”

This story is part of a partnership that includes , and Kaiser Health News.

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