Local hospitals echo concerns about Medicare readmission penalties

Jul. 14, 2013 @ 10:46 PM

Targeting patients who have been admitted to the hospital multiple times and who are taking 10 or more medications, Beth McKenzie and pharmacist Stephanie Stout work the phones to try to keep those patients from having to come back to UNC Hospitals.
They meet with the patients face to face and then follow up by phone, calling within 24 hours of discharge and the once weekly for 30 days. They ask if patients are having trouble getting medications because of cost or transportation issues, and if they’re able to get to appointments with their regular doctors.
They try to inform patients of signs or symptoms they to need to watch for, McKenzie said, and in some cases, help place them at a nursing home or assisted living facility.
“They have barriers frequently,” Stout of the patients they work with. She tries to find lower-cost drugs or drug manufacturer programs to help patients who can’t afford them and McKenzie, a case manager, said she works to connect patients with family or church members if they need help with transportation.
The two are part of the hospital’s strategy for trying to curb readmissions in the face of financial penalties tied to readmissions from Medicare, the federal health insurance program for people aged 65 years or older and for people with disabilities.
Under the Patient Protection and Affordable Care Act of 2010, hospitals are penalized for patients who are readmitted for heart stroke, heart failure, and pneumonia within 30 days of discharge at higher-than-expected rates.
The penalties went into effect in October of last year at the start of the Centers for Medicare & Medicaid Services fiscal year. In fiscal year 2013, the total penalty was capped at 1 percent of hospitals’ Medicare payments, and resulted in a total dollar figure penalty of $290 million. The penalty cap increases to 2 percent in the next fiscal year and to 3 percent in the one after that.
According to a report by Kaiser Health News, Duke University Hospitals’ second corrected readmission penalty was 0.45 percent. Duke Regional Hospital, a county-owned hospital operated by Duke, had a penalty of 0.18 percent. UNC Hospitals’ readmission penalty was 0.20 percent.
According to the American Hospital Association, a hospital advocacy group, 34.5 percent of approximately 3,300 hospitals had no penalty in the first fiscal year, 36.3 percent had a penalty of less than 0.5 percent, and 29.2 percent of hospitals had a penalty between 0.5 and 1 percent.
Local hospitals leaders raised concerns with the way the penalties affect large academic medical centers, hospitals that see patients with complex conditions, hospitals that have a lot of planned readmissions, as well as hospitals that serve poor populations.
A June report from the Medicare Payment Advisory Commission, which is an advisory agency to Congress, listed concerns about the penalties --  including that some hospitals that serve large shares of poor patients have higher readmission rates, and are therefore more likely to pay penalties.
Nancy Foster, vice president of quality and patient safety policy for the American Hospital Association, said the Centers for Medicare & Medicaid Services has “stubbornly refused” to address that concern, although she said it is addressing concerns about planned or unrelated admissions.
“(CMS) says that they see no reason that people living in impoverished communities should expect less than quality care,” she said. “However, that’s (not) the question in front of us, the question is how much of penalty hold hospitals accountable for. It really is a team effort that is required, and no part of the team is missing an impoverished community, and we think it’s incumbent that (CMS) make an adjustment.”

A spokeswoman for the federal agency said in an email that the Centers for Medicare & Medicaid Services does make an adjustment based on differences in patient illness so hospitals that treat sicker heart or pneumonia patients are not unfairly penalized.
“However, we don’t believe we should have different standards of quality for lower income patients – high-quality care should be the same for everyone.”

Foster also said had concerns about penalties for large teaching hospitals.
“In fact, virtually any hospital that cares for a large number of complex patients, whether teaching or not, would be subject to significant penalties, particularly if they’re caring for a poor population,” she said.
Dr. Thomas Owens, chief medical officer for Duke University Health Systems, said Duke wants to do better than it’s doing, but he also said Duke does “significantly better” than some peer institutions nationally serving similar populations.
Duke has a large heart and lung transplant program, he said, and transplant patients tend to have a “higher burden of illness.” He said patients with advanced heart disease or cancer - as well as patients who have had transplants and have suppressed immune systems - can get pneumonia.
He also said that academic medical centers that care for more complex patients, in general, will have a higher rate of readmissions.
“I think for readmissions, although we still continue to question readmissions as the best marker for health care quality, we do … we want (patients) to do well, we want them to not be readmitted,” he said.
Brian Goldstein, UNC Hospitals’ chief operating officer, said the Chapel Hill hospital’s penalty is “kind of in the middle for academic medical centers.” He argued that the program does not accurately account for how sick patients are at those centers, and that the hospital has more planned readmissions. He also said it has a broad mix of Medicare patients, including some with complex social situations.
“And yes, we get penalized if they get readmitted,” he said.
Currently, the financial impact of the .20 percent penalty is “relatively small,” he said, but noted the amount at-risk goes up in the next couple of years.
He outlined work at the hospital to try to curb readmissions including the work to identify patients at-risk for readmission and to follow-up with them after they’re discharged. He also said the hospital has tried to make a nurse phone line more accessible to patients.
Owens said Duke has worked to improve patients’ transition to and from the hospital as well as communication with patients.  The hospital has pharmacists and nurses doing phone follow-ups with patients to make sure they understand their medications and their care plan, he said.
“We have made significant improvements in getting our patients in to see their primary care providers or their specialists early after discharge, ideally in the first seven days after discharge,” he added.