Medicare rule would decrease payments to hospitals with high re-admission rates

[alp227]

Source: The Washington Post

When hospitals discharge patients, they typically see their job as done. But soon they could be on the hook for what happens after Medicare patients leave the premises, and particularly if they are re-admitted within a month.

In an effort to save money and improve care, Medicare, the federal program for the elderly and disabled, is about to release a final rule aimed at getting hospitals to pay more attention to patients after discharge.

A key component of the new approach is to cut back payments to hospitals where high numbers of patients are re-admitted, prodding hospitals to make sure patients see their doctors and fill their prescriptions.

Medicare also wants to pay less to hospitals with higher-than-average costs for patient care. It has proposed calculating the costs by combining a patient’s hospital expenses with fees incurred up to 90 days after discharge. A key component of the new approach is to cut back payments to hospitals where high numbers of patients are re-admitted, prodding hospitals to make sure patients see their doctors and fill their prescriptions.

Read more: http://www.washingtonpost.com/national/health-science/medicare-rule-would-decrease-payments-to-hospitals-with-high-re-admission-rates/2011/07/28/gIQAYwDpjI_singlePage.html

[BattyDem]

1. Am I missing something?

How will hospitals make sure patients see their doctors and fill their prescriptions? Sure, they can do a follow-up phone call a day or two after release, but if the patient won't see the doctor or doesn't get the prescription filled (or can't afford it), how is that the hospital's fault?

[cstanleytech]

3. Some areas they have programs where they send a nurse to the home

like what they are doing with my mother due to her having extremely bad copd and being in and out of the hospital atleast 3 dozen times in the past 3 years alone and they can draw blood and other stuff.

[BattyDem]

5. There are cases that require home care and it certainly should be done ...

but it sounds like they want hospitals to take responsibility for ALL patients, whether they require home care or not. Some patients will be perfectly fine just as long as they follow up with their doctor and take their medication. If they don't do that and end up back in the hospital as a result, I don't see why that's the hospital's fault.

[cstanleytech]

10. Nope not all just those on medicare which is largest at health risk

like my mother and it also encourages them to make sure that they dont try to rush them out the door before they are well enough to return home and have an immediate relapse which has happened a few times with my mother.

[eilen]

22. Patients cannot be forced to accept Homecare. Medicare or not. nt

[No Elephants]

8. And that costs, too. However, it is not available to all patients.

Sometimes, you are just barely well enough to go home, but not sick enough for a visiting nurse.

You are isolated, with no one to send to the pharmacy and no pharmacy that delivers.

No one really cares about people like that.

[murielm99]

4. Some of these hospitals release people too early.

They could keep people in the hospital longer. They could make sure that a visiting nurse goes to their homes and follows up when the patents are released. That sort of thing is already covered by Medicare.

I don't know what to say about the prohibitive cost of some meds. There needs to be more assistance with that. I have no hope that will happen.

[BattyDem]

6. That's true.

Perhaps at least one visit from a visiting nurse should be standard procedure if the patient lives alone. Of course, that costs money. :(

[No Elephants]

9. Medicare does not cover visiting nurses for everyone. You have to be deemed

by the hospital not to be able to take care of yourself without the nurse. And visiting nurses are no universal panacea, either. I've heard some horror stories.

[eilen]

24. That is true. A patient has to be considered "homebound".

Outside of follow-up doctor visits, they are not supposed to leave the house. Homecare covered by medicare is also episodic-- it is temporary in nature. For patients with chronic COPD, CHF etc. that means the nurse will see them for about 4 weeks and discharge them-- about 5-6 visits. During that time the nurse is supposed to teach the patient positive health promoting skills to prevent readmission such as filling their pillbox each week, taking their meds-- as well as what the meds are and what they do; the pathophysiology of their illness and how to prevent crises, proper diet, exercise, etc. Many patients may be readmitted for different things but because they have the CHF or similar chronic disease diagnosis, they default back to that diagnosis and the hospital gets dinged. For example, a CHF patient comes in for syncope-- they have afib as well but not in for fluid overload and are treated for their afib and discharged. Then the patient comes back for fluid overload, say they ate a big ham dinner for the holiday or their renal function just decompensated. Three weeks later, they come in because they fell and are found to have pneumonia--- all these are readmissions under CHF and not viewed as separate issues. The hospital had nothing to do with any of the readmissions but is blamed anyway.

When I do admissions, I flag a patient for homecare if they have had an admission within the last 90 days, a fall, and flag the case manager for altered mental status (they may need a higher level of care).

[smuglysmiling]

13. It's an attempt to begin moving away from fee-for-service to fee-for-outcome

[eilen]

25. Medicare and Medicaid pay by DRG, not by services.

The average cost/stay per episode. There are more sick people thus more outliers. The younger moderate chronically ill seem to have the higher readmission rates. Mostly because they self report feeling stronger/better to get out of the hospital faster (and get back to work) although the hospitals can do better by strengthening their d/c guidelines for various chronic diseases.

[daa]

31. They will just turn away the really sick nt

[Ruby the Liberal]

2. WTF are hospitals supposed to do. Make the appointment, drive them there

and then stop by 2x a day to make sure someone is taking their meds?

How about we look at raising the damn benefit so that having a followup with a doctor and buying meds isn't cost prohibitive.

Ugh.

[InkAddict]

17. Neither scenario, nannying nor increased benefits would help

in some cases; some aggressive/progressive diseases/comorbidities are just too complicated to manage well over days, let alone a month. Any change at all can spike an "unforeseen" complication. Though we'll never know how it really happened, FIL said he fell out of bed shortly after discharge. A visiting nurse noticed a bump on the head and disorientation. DX: sepsis.

My FIL had a stubborn independent nature. He was unable to hear well, so educating him with voice emphasis was difficult. It's possible that he could not read very well, so pamphlets were not useful since he wasn't into medical terminology and healthy strategies like good nutrition. When a hospital discharged him, he considered himself well again or at least "getting better."

He was grateful and nice to everyone, and the nurses loved taking care of him because he never wanted to "bother" any of them. When he was as well as could be expected, home care was resisted at every turn; however, his turns for the worse were often and during the hospitalizations, he was at death's door multiple times, yet he didn't quite fit skilled nursing criteria with a strong like an ox cardiovascular system.

His conditions required planners to "flex" a lot of rules, scrounge for appropriate medical equipment, and plan a lot of "therapies" outside their normal locations. Still, at home, we had a hard time convincing him to even faithfully wash his hands to avoid infection, let alone take the myriad number of required pills on the correct schedule.

During his last year, his problems had him visiting a doctor nearly every week in addition to dialysis three times per week. He fired a nurse's aide we had hired to check on his welfare as he insisted on living solo. Finally, assisted living was the best answer to address his needs. I don't think he really understood how expensive this was, not being a nasty Medicare/Medicaid facility. It was only after he died, that Medicare began a 100-person pilot program across a whole state for Medicare coverage of this living arrangement--don't know if that was expanded or deemed not as good as the passport programs. One thing was clear: he did not want to live with us, but he could not stay alone.

He had Medicare and good insurance to pay a great portion of the costs of his multiple illnesses that required many hospitalizations, and we thanked the Lord he had such a fantastic doctor/specialist who never failed to take our calls nor to seek the best care for his problems.

Well, he died; we lost our jobs, our home, our health insurance, in this train wreck doing the right thing by him, and I lost my mind. The family doctor threw us out for a $50 charge that went to collections. Looks like we'll get whatever the free clinics are passing out or not this week should our health, physical or mental, fail which it surely will at some point. Fun times in the new America!

[JDPriestly]

21. Imagine what would have happened had your Medicare coverage for him

consisted of vouchers that paid even less than current Medicare coverage.

That's the Ryan plan.

[kestrel91316]

7. Appropriate sanctions for dumping patients too soon post-op.

[No Elephants]

11. Insurance and government rules are often responsible for that, so it's a Catch 22.

[mzmolly]

15. Yep. Looks like I can hold off on my Purina Cat Food, stock

purchase. ;)

[No Elephants]

23. Funny as it may be that some on OASDI have to eat cat food, what does it have to do with Medicare?

[mzmolly]

32. It has nothing to do with medicare, and everything to do with the freaking

predictions we've read here for the past month on supposedly gutting social security.

[bkkyosemite]

12. The hospital here has let at least 3 people that I know of

or heard of go home and they died because they should have not been released. These hospitals are not doing their jobs. They kick them out as soon as they possibly can and many times it's too soon. Now if this is passed will they keep them longer or let them go even sooner. I dunno...

[cstanleytech]

18. I doubt it will cause the hospitals to let people out sooner

because the hospitals will be held accountable somewhat now if they followup on the patient according to these proposed changes, if anything it will force the hospitals to be more active in making sure people remain healthier rather then tossing them out asap regardless of if they are well enough to be released and then being checked back in because they relapse.

[eridani]

14. This is fine by me. The idea is to prevent kicking people out early and then

--getting a bunch of extra bucks for a readmission. This practice is roughly equivalent to churning in stock accounts.

[No Elephants]

26. Rules set by insurance are often responsible for "kicking people out, though.

Generally, it's the hospital that tells the patient when to leave, not a sick patient begging to home, so the hospital is in near total control of how long a patient stays, the hospital and insurers, including Medicare.

I don't know about your hospital, but mine charges nothing extra for a re-admission. If the point were to get more money, why not just keep the patient in longer, rather than risk the patient goes home and dies or feels to good to come back?

Also there are very valid mental and physical health reasons for sending a patient home as soon as they seem able to go. For just one very simply thing, patients in hospitals tend to stay in bed or in their rooms. Nurses do not have time to monitor and correct that. However, inactivity, even for short periods, deconditions muscles. So, the longer you keep a patient, the less able they become to take care of themselves when sent home. It's a vicious cycle.

[eilen]

29. That does not happen. Currently, the hospitals do not get

paid by medicare for readmissions within 30 days.

[kelly1mm]

16. Isn't this simmilar to NCLB? Judging hospitals/care providers by patient readmisson rather

than pointing to something the did wrong? isn't that the same argument as saying that if students can't pass tests then the school/teacher must have done something wrong?

[indurancevile]

36. yes, it is. the new america, where everything can be perfect, & if it's not it's just because

people are lazy or corrupt.

we should start seeing articles about evil, lazy nurses & doctors soon.

[JDPriestly]

19. This is parallel to what has happened to public schools.

The hospitals with the high readmission rates treat the poorest and sickest people. Many of them are in inner cities.

That's where homeless drug seekers go.

That's where elderly people with no family or support system at home go.

That's where people who drink too much, smoke too much and eat too much because they really don't know better or are addicted to the point that they can't earn enough money to live further out go.

Homeless drug seekers, elderly people with no family or support system at home and people with lifestyles that hurt their health tend to need or seek readmissions.

And inner city hospitals have to accept them when they come for readmission because refusing medical care to the sick could cause the hospital to be sued or face other problems.

[indurancevile]

37. exactly. market approach. which will result in areas/peoples with the worst problems

being served worst, or not at all.

i hate these people. they are truly evil, not a word i use lightly.

[McCamy Taylor]

20. 1. Hospitals will close their emergency rooms. No more critically ill folks to make them look bad.

This will make waits at the few ERs that are still open even longer.

2. More hospice referrals. Heart failure, renal failure, cancer---these cost too much and involve re-admissions. Hospitals will get VERY aggressive with hospice.

3. ICUs will close. If you don't have open ICU beds, you can divert the ambulance with the expensive sick patient to another hospital.

4. Hospitals will fill their staffs with podiatrists, orthopedic surgeons, plastic surgeons and others who do simple, uncomplicated surgeries. Neurosurgeons, on the other hand, will become pariah. If you don't have a neurosurgeon on staff, you can not accept the elderly patient with the intracranial hemorrhage who will be on a ventilator for the next three months.

5. If they extend this to Medicaid, watch hospitals close their neo-natal ICUs. No more complicated obstetrics. If you go into early labor, you will have to travel two hundred miles to get treated at a place that is willing to take the hit for ten months of care for your preemie baby.

6. Don't even think about an organ transplant---unless you plan to get it in India.

7. Oh, and the minority physicians who treat predominantly poor, sicker than average, minorities? They need not apply for privileges. Hospitals will court only doctors with affluent practices.



Fortunately for Medicare, most urban areas have an overcrowded, underfunded public hospital like the one I work at. All the sick Medicare patients will be turfed to Ben Taubs and Gradys of the nation, where they will rub elbows with the homeless and uninsured, and the local government will absorb the cost of their care which is not quite covered (or even halfway covered) by Medicare.

Medicare needs to apply a severity index or they need to drop this idea like a hot potato. The HMOs tried it in the 1990s. All it lead to was cherry picking by providers. And it is very, very easy for hospitals to cherry pick.

[No Elephants]

28. Thank you for a very thoughtful and informative post.

And, since you work at a hospital, I love you. A hospital saved my life and I've been very grateful ever since.

[indurancevile]

35. +1

[No Elephants]

27. Elderly and disabled people tend to have more than one physical issue and tend to be recividists.

as far as being hospitalized.

Most often hospitals "kick" people out because their Medicare or other insurance won't cover but so much hospitalization for each given illness or procedure.

If this is indeed designed to punish hospitals who kick people out to soon, it is a very poorly designed remedy.

Tell the hospitals you'll cover elderly and disabled people who've had surgery under general anaesthesia for more than same day or next day discharge. That should do it.

[slipslidingaway]

30. knr nt

[lbrtbell]

33. This won't solve anything. Why?

Hospitals will just refuse to re-admit patients so they don't violate the new rule. People will die as a result.

That's the thing about businesses and rules: They'll always find a way around them to increase their bottom line, even if it means people die.

They just don't care.

[indurancevile]

38. people dying IS the solution. cost-savings.

[joshcryer]

43. They cannot refuse to admit someone in an emergency situation.

So this is nonsense.

[indurancevile]

44. what the law says and what happens in real life are two different things.

and in real life there have already been cases.

[indurancevile]

34. Hospitals with higher readmission rates are often hospitals with poorer patients.

Cutting back their funding is going to close them down.

[cstanleytech]

39. They wont get penalized if they step up to the plate.

They have some options for example opening clinics away from the hospital to treat people who are on medicare in poorer sections of town on medicare before they get to ill and maybe if no one locally has it then instituting a visiting nurse program for those who cant get to the doctors easily or to the clinics for things like blood work.
If the hospitals do that to monitor patients then hopefully their re-admissions will remain at an acceptable level and they wont get penalized.

[indurancevile]

40. baloney. double-speak. it's the same thing they're doing with schools.

satellite clinics & visiting nurses have nothing to do with the problems. and they also cost money. which, when the hospital is in the process of being defunded, will just take away from hospital care/staff etc.

my guess would be that the endgame is to 1) force wage cuts & 2) privatize the remaining public hospitals.

so sick of this evil.

[cstanleytech]

41. You mean wage cuts for doctors and nurses?

It very well might have such an effect though if they are smart they might look at teaming up with some of the schools and fire departments since those are opened most of the year and building onto them might help to offset some of costs.

[indurancevile]

42. unbelievable.