Gannett News Service
August 28, 2013
Patients at Bronson Battle Creek Hospital being treated for heart attack, heart failure or pneumonia are visited by a clinical nurse leader who has the patient "teach back" what they've been told about their condition and what they need to do when they're released.
"So often in healthcare we're using terms that patients may not understand," said Heather West, the hospital's patient safety and quality specialist. "So we have them teach it back to us. If they don't quite get it, then we look at another way to educate them."
Such basic steps can make a big difference not just for patients, but also for hospitals, which are now being held accountable by the federal government for the rate at which Medicare patients have to be readmitted within 30 days of treatment.
Bronson Battle Creek Hospital is getting a modest 0.03% reduction in its 2014 Medicare reimbursements because of too-high readmission rates, according to federal records released this month. That's much less than the national average penalty of 0.38%, and a reduction from its 0.18% penalty for 2013.
Nationwide, two-thirds of hospitals are getting penalized for excess readmissions, according to an analysis of the federal records by Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.
The nearly one in five Medicare patients who have historically been readmitted within 30 days had been costing the federal government more than $26 billion a year.
While not all readmissions can be prevented, Medicare readmissions have been consistently too high and could be lowered through greater coordination of care, according to the Medicare Payment Advisory Commission, or MedPAC, an independent agency that advises Congress.
"There is a concern that in the competition for limited hospital resources, hospitals may choose to allocate funds to revenue-generating or market-share-expanding projects rather than readmissions reduction projects that result in lower hospital revenue," MedPAC told Congress in a June report.
The healthcare overhaul passed in 2010 created the hospital penalty program, one of the ways that the Affordable Care Act is trying to reduce the cost of healthcare while improving quality.
Hospitals face a reduction in Medicare reimbursements that started at a maximum 1% for 2013 and increases to a maximum 3% in 2015 if their readmissions for the previous three years exceed their predicted rate. The program focuses on readmissions for heart attacks, heart failure and pneumonia in the first two years and expands to additional conditions in 2015.
The program does not apply to some hospitals, including critical access and cancer hospitals, and doesn't apply unless a hospital has at least 25 admissions for the covered conditions.
Nationwide, there were about 70,000 fewer readmissions last year after the program started, according to the U.S. Department of Health and Human Services.
But Kevin Downey, spokesman for the Michigan Health and Hospital Association, said the penalties hospitals face are disappointing because "a readmission is about so much more than the hospital."
"However," Downey said, "we believe that care transitions are improving and we would hope that penalties in future years would reflect the progress that's being made."
Bronson Battle Creek Hospital joined in 2009 a program the state association launched to reduce readmission rates for all patients.
"Although it's been a lot of very hard work, we've still got a lot of work to do," West said.
The hospital has been working with others in the community—including nursing homes, skilled nursing facilities, area agencies on aging and local doctors' offices—to work collaboratively on helping patients stay out of the hospital. For example, the local home health agency started checking in with heart failure patients by phone. And doctors' offices would report back when they saw a patient, a program that particularly helped in making sure patients were getting and taking correctly any medications needed after they were released from the hospital.
"I do think it's very important that we look at patients after they leave the organization," said Cheryl Knapp, the hospital's vice president for quality. "It's really changed our focus on how prepared is that patient to take care of themselves when they leave the organization."
Likewise, the state entity that contracts with the federal government to improve care to Medicare beneficiaries, brought together in Lansing hospitals, nursing facilities, home healthcare companies, the county health department and others to identify the major reasons for readmissions and to figure out ways to communicate better and coordinate care as patients moved between facilities or back home.
The pilot program reduced rehospitalizations of Medicare patients by about 4%, according to an article published in the Journal of the American Medical Association. It also saved the federal government $3 million over two years.
"If there is one takeaway, it's that working together as a community is really the key to solving this issue," said Jacqueline Rosenblatt, senior director for corporate growth and development at MPRO, the government's Medicare quality contractor in Michigan.
But hospitals say there are parts of the program that should be changed. It's unfair that a hospital is penalized even if the patient is readmitted for a reason other than the original health problem, said Downey of the Michigan Health and Hospital Association.
And hospitals that treat a lot of low-income patients are more likely to have high readmission rates. The readmission penalties take into account the health status of a patient when first admitted. But that may not fully compensate for socio-economic issues patients may face once they're discharged, such as access to transportation, wellness programs or the ability to get follow-up care.
The Centers for Medicare and Medicaid Services has opposed adjusting for such socio-economic factors as race and income, arguing that that would be an acceptance of poorer performance by hospitals that serve poorer patients, according to MedPAC. In a June report to Congress, the advisory committee suggested ways the program could be adjusted, such as comparing readmission rates for hospitals with a high percentage of low-income patients against similar hospitals, instead of comparing them to the national average. Making that change would require intervention by Congress.
Another challenge faced by hospitals is the fact that the industry agreed to various Medicare cuts, including the penalty program, with the expectation of additional revenue from the millions more people who would be getting health insurance through other provisions of the Affordable Care Act, particularly the expansion of Medicaid. But after the Supreme Court ruled last year that states don't have to go along with expanding the joint federal-state healthcare program for the poor, about half the states have so far declined to participate.
Michigan is still debating the issue.
Downey said Michigan hospitals provided more than $880 million in uncompensated care in 2011.
"If Michigan fails to expand coverage to 450,000 working uninsured residents under Medicaid," Downey said, "the cuts that hospitals face will continue, and sick uninsured patients will still seek care in hospital emergency rooms."
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