At the Cleveland Clinic's sprawling main campus, patient Morgan Clay is being discharged.
Clay arrived a couple of weeks ago suffering from complications related to acute heart failure. And he's ready to go home but before Clay can leave, pharmacist Katie Greenlee stops by…
"What questions can I answer for you about the medicines?" Greenlee asks.
" I don't have too many questions; I've been on most of that stuff for a - a long time," Clay says.
Greenlee is making sure Clay understands the importance of taking his pills at the right time and at their full dosage. Non-compliance 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 Clinic began sending pharmacists into cardiovascular patient rooms at discharge, it has drastically reduced the number of those patients returning to the hospital within 30 days.
And, this is key: If hospitals decrease returning patients, they get to keep millions of dollars from the federal Medicare program. That's because the federal government financially penalizes the hospital when too many patients return.
The Clinic's Chief Quality Officer Dr. Michael Henderson says the rule is improving care by making sure a team of people are paying attention to the patient.
"One of the real benefits of some of these programs that have come in place is its really put coordination of care on the map for patients," Henderson says.
But - there's a catch. Hospitals serving a larger percentage of poor patients regularly report higher penalties.
It takes money to buy the medications, in -home help or transportation needed to get to follow up appointments.
Dr. Helen Burstin is at the National Quality Forum, an advisory group which works with federal regulators on creating the penalty metrics.
She says one main question is being asked: "How much should these issues around socioeconomic status, poverty be considered as well for the readmission program?" Burstin says.
And, in many ways, Cleveland is the perfect place to answer this question.
On the near West Side of Cleveland, Dr. Alfred Connors is chief quality officer at county-owned MetroHealth System. About half of the hospital's patients are uninsured or on Medicaid, which is government coverage for the poor.
"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.
MetroHealth had a .83 percent cut in Medicare reimbursement for 2015, as compared with a .45 percent in 2013. University Hospitals - the city's other big hospital system - also serves a high proportion of the region's low income patients at its main campuses. UH reported a .59 percent penalty in Medicare reimbursements for 2015 up from a .11 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 the 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 originally went into the hospital with at least 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 Clinic's Henderson says socioeconomic issues like poverty are an important factor. Indeed, leaders at all three systems say that regardless of the amount of care and coaching a patient gets in the hospital, the environment a patient goes home to is critical.
Dr. William Annable is chief quality officer at University Hospitals: "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."
There's movement to change the penalties.
In January 2015, the National Quality Forum began two-year trial period that adjusts the metrics to account for poorer patient populations. 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."