Re­duc­ing fines for read­mis­sions

Pre­ventable read­mis­sion penalty brings con­cerns

Modern Healthcare - - Front Page - Jen­nifer Lubell

Hos­pi­tals want to do their part to re­duce pre­ventable read­mis­sions, hos­pi­tal lob­by­ists say, but a forth­com­ing penalty on high read­mis­sion rates in the health re­form law needs some tweak­ing be­fore it can be fairly im­ple­mented.

In par­tic­u­lar, the Amer­i­can Hos­pi­tal As­so­ci­a­tion will be lean­ing on Congress to re-ex­am­ine the penalty, so that it “only ad­dresses those read­mis­sions that were un­planned and could have been pre­vented, in­stead of hav­ing all read­mis­sions be sub­ject to penalty,” said Nancy Fos­ter, vice pres­i­dent for qual­ity and pa­tient safety for the Amer­i­can Hos­pi­tal As­so­ci­a­tion.

The Obama ad­min­is­tra­tion has long touted high read­mis­sion rates as a costly prob­lem that needs to be reined in. A re­cent re­port from Cal­i­for­nia’s Of­fice of Statewide Health Plan­ning and Devel­op­ment added grist to this ar­gu­ment, con­clud­ing that read­mis­sions added $31 bil­lion to charges billed to Medi­care in 2005, ac­count­ing for half of all charges for hos­pi­tal ser­vices in the state. In ad­di­tion, read­mis­sions cost the state Med­i­caid pro­gram $10 bil­lion and pri­vate in­sur­ers $11 bil­lion.

“Read­mis­sions are an im­por­tant is­sue be­cause they are ex­pen­sive, can in­volve ad­di­tional dif­fi­cul­ties for pa­tients and care­givers, and of­ten can be pre­ventable,” David Carlisle, di­rec­tor of the Of­fice of Statewide Health Plan­ning and Devel­op­ment, said in re­sponse to the re­port’s find­ings. “Our hope is that this data can spur dis­cus­sion on low­er­ing rates of read­mis­sions to ef­fect change in di­rect pa­tient care, dis­charge plan­ning and case man­age­ment.”

Changes are good, claim the hos­pi­tal in­dus-

for any of those three con­di­tions they will be sub­ject to a penalty al­though the CMS still has to work out the ex­act for­mula. Some hos­pi­tals, par­tic­u­larly low vol­ume providers, will be ex­cluded from the penalty.

Based on the way the law is writ­ten, un­re­lated or un­planned read­mis­sions also shouldn’t count, Fos­ter said. As an ex­am­ple, “If I go in for treat­ment for a heart at­tack and am asked to come back in two weeks so the hos­pi­tal can im­plant a de­fib­ril­la­tor de­vice, that read­mis­sion wouldn’t count against the hos­pi­tal.”

The caveat is how the CMS will ac­count for these things when they is­sue their reg­u­la­tions, Fos­ter said. Ac­cord­ing to the AHA, a math­e­mat­i­cal er­ror in the leg­isla­tive lan­guage could re­sult in far greater penal­ties than what’s ac­tu­ally war­ranted for ex­cess read­mis­sions, she said.

If, for ex­am­ple, a hos­pi­tal treats 100 heart at­tack pa­tients within a given year, and 25 were read­mit­ted but the CMS cal­cu­lates that only 20 read­mis­sions should have oc­curred, “you would ex­pect the penalty for the hos­pi­tal to ap­ply to just those five ex­cess read­mis­sions,” Fos­ter said. But that’s not what the law does, she con­tin­ued. In­stead, the for­mula would pe­nal­ize the hos­pi­tal for the cu­mu­la­tive num­ber of read­mis­sions—in this case, 25, mean­ing the hos­pi­tal would in­cur a penalty of $100,000, based on the fact that a heart at­tack pa­tient on av­er­age costs about $4,000 per case, she said.

The AHA has brought up this is­sue with the CMS and law­mak­ers, and the re­sponse has been “that this was not an er­ror, that they chose to pe­nal­ize hos­pi­tals in this way,” Fos­ter said. A CMS spokes­woman said this was a mat­ter for Congress, since it in­volved statu­tory lan­guage.

Bot­tom line is “we need to get the let­ter of law changed,” Fos­ter said.

A spokesman for Rep. Pete Stark (D-Calif.), the House Ways and Means Health Sub­com­mit­tee chair­man, said that the panel was “pleased with the read­mis­sions pol­icy as it will change provider be­hav­ior, re­duce pre­ventable read­mis­sions and thereby im­prove pa­tient care. We will monitor im­ple­men­ta­tion closely, as with all parts of the Af­ford­able Care Act within our ju­ris­dic­tion.” The com­mit­tees be­lieve the read­mis­sions pol­icy un­der the law could be ex­tended to post-acute providers as well and physi­cians, if fea­si­ble.

Most hos­pi­tals ac­knowl­edge that they need to “own” the read­mis­sions is­sue, but to keep in mind that other play­ers are in­volved in pre­vent­ing read­mis­sions. “To put it all on hos­pi­tals and say it’s the hos­pi­tal’s fault over­sim­pli­fies the prob­lem,” said Mar­cia Nel­son, vice pres­i­dent for med­i­cal af­fairs at En­loe Med­i­cal Cen­ter, Chico, Calif.

In her view, the en­tire con­cept of pe­nal­iz­ing hos­pi­tals makes it seem as if “there’s this one arm of this very com­plex health­care sys­tem that’s drop­ping the ball, whereas read­mis­sions are com­plex.” While it’s true that hos­pi­tals need to ad­dress this is­sue in part by rais­ing the bar on best prac­tices, “we also need to make sure the in­surance com­pa­nies are pay­ing for nec­es­sary ser­vices.”

Pa­tients play a role in the read­mis­sions fig­ures as well, other ex­perts say. Some pa­tients are grossly over­weight and their chances of get­ting read­mit­ted for high blood pres­sure or con­ges­tive heart fail­ure are fairly high, said Mar­ion Gold­berg, part­ner at Win­ston & Strawn, Washington. If a read­mis­sion oc­curs, “is it the hos­pi­tal’s re­spon­si­bil­ity?” Gold­berg said.

Gold­berg: Pa­tients play a role in read­mis­sions as well.

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