Stanley Feld M.D.,FACE,MACE
Prior 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.
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.
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
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.”
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
David Goodman, MD, co-principal investigator
for the Dartmouth Atlas Project said. "Despite
awareness of the problem, progress and improvement has been slow."
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
among academic medical
“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
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
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
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
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.”
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.
should be driving the healthcare system not the government. The government
should make the rules to level the playing field for all stakeholders.
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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