Stanley Feld M.D.,FACE,MACEPrior to October 1,2012 Medicare revised hospitals' readmissions penalties rules. On October 1 Medicare started fining hospitals that have too many patients readmitted within 30 days of discharge due to complications of their disease.
The formula for determining these penalties is extremely complicated. The formula is almost impossible to understand.
Hospitals whose admission rates are above the national average will be penalized. The data analytics are supposed to risk weight patients to see if the hospital should be penalized.
Patients with multiple co-morbidities have a higher chance of readmission.
“The penalties are part of a broader push under President Barack Obama's health care law to improve quality while also trying to save taxpayers money.”
The gigantic perverse incentive is for hospitals to avoid the initial admission of sick patients with multiple morbidities. Those are the patients that have a better chance of being readmitted within 30 days.
It is also impossible to evaluate quality of medical care using claims data. False conclusions will not be a true reflection on who is at fault and should be blamed and penalized for the readmission.
It could be that patients did not adhere to the discharge instructions.
“About two-thirds of the hospitals serving Medicare patients, or some 2,200 facilities, will be hit with penalties averaging around $125,000 per facility this coming year, according to government estimates.”
The formula for penalty assessment is extremely complicated. The Centers for Medicare & Medicaid Services has discovered errors in its initial calculations in August 2012.
“Nearly one in five Medicare patients return to the hospital within a month of discharge, costing the government an extra $17.5 billion in 2010.”
A total of 2,217 hospitals are being punished in the first year of the program, which began Oct. 1. Of those, 307 will be docked the maximum amount: 1 percent of their regular Medicare reimbursements.
Only acute myocardial infarction, congestive heart failure and pneumonia will be evaluated the first year.
“Overall, Medicare has estimated it will recoup about $280 million from hospitals where it determined too many heart attack, heart failure or pneumonia patients returned within 30 days.”
The Dartmouth Atlas of Health Care and the Robert Wood Johnson Foundation latest report "The Revolving Door Syndrome on hospital readmissions points out highly variable rates.
Ninety two (92) academic medical centers and 37 hospitals saw readmission rates for their patients actually increase.
David Goodman, MD, co-principal investigator
for the Dartmouth Atlas Project said. "Despite
awareness of the problem, progress and improvement has been slow."
The report divided readmissions into two types, those affecting patients whose first admission was for a surgical procedure and those affecting patients whose first admission was for a medical condition such as congestive heart failure, pneumonia, or heart attack.
The report shows wide variations among academic medical centers.
“The highest readmission rates in 2010 were the
Cleveland Clinic, with 21.6%, and the Hospital of the University of
Pennsylvania, with 21.4% among AMI, congestive heart failure and pneumonia.
The hospital with the lowest rate was NYU Langone Medical Center, with 14.4%. “
The University of Medicine and Dentistry in New Jersey (UMDNJ) had the highest surgical readmission rate with 20.7%, and the Stony Brook University Medical Center on Long Island, with 20.6%.
If this data is correct academic institutions will not be in the mood to be penalized for taking care of sick patients.
Other studies have shown that there is only a 50-60% adherence rate by patients to prescribed treatment. This lack of adherence can be a significant driver to readmission rates. There is no data evaluating patients’ role and responsibilities in re-admission rates.
What are patients’ responsibility for their care? If patients do not receive enough education to avoid hospitalization they should demand the education.
If patients are not interested in self-management of their disease they should tell their physicians.
If the patient is too sick to learn to self-manage a family member should be involved.
Patients have responsibility for their self management to avoid readmission is high!
Yet the government is quick to blame hospitals and physicians for high re-admission rates without examining all the facts.
Another factor not evaluated in determining readmission rates is the pressure on the hospitals to discharge patients quickly.
doctors feel they are caught in a squeeze play," the report says.
"Hospital administrators carefully monitor length of stay—they are eager
to send people home because the longer a patient stays, the less money they
make. Thus providers said that the prevailing pressure is to discharge
patients as early as possible" even if it's too soon.”
This is the slippery slope the healthcare system is on. The data management is faulty. The government is not evaluating all the complex variables resulting in hospital readmissions. This defect leads to faulty decisions. Those decisions lead to more complicated unintended consequences.
Consumer should be driving the healthcare system not the government. The government should make the rules to level the playing field for all stakeholders.
The government should defend the interests of patients.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.
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