Most hospitals in the region are being penalized this year by Medicare for having too many patients who are readmitted to the hospital soon after they are discharged, according to standards created by the Affordable Care Act.
About one in five Medicare patients end up back in the hospital within 30 days, and the health law has sought to reduce this. Medicare penalizes hospitals up to 3 percent of what they get paid by the government insurance program if they have too many patients who are readmitted after receiving treatment for six conditions.
The Medicare penalties are among a host of efforts from both the government and commercial insurance companies aimed at making sure medical insurance payments achieve the ultimate goal of improving patients’ health.
The health care business model has traditionally meant insurers pay more for frequently sick patients and less for healthy patients who need less care. But these payers have become concerned about whether this means hospitals are not motivated toward preventative care since hospitals get paid less for healthier patients.
By creating penalties for Medicare readmissions, the government is seeking ways to pay more for better performance instead of paying more for more health care services given. The goal is to motivate hospitals to keep people healthy by docking how much they get paid if it appears the need for additional hospital care could have been prevented with proactive types of care.
“What you see is the payers placing more value on quality than they have in the past,” said Brenda Kuhn, chief quality officer for Kettering Health Network.
Bryan Bucklew, president of the Greater Dayton Area Hospital Association, said hospitals are in favor of improving community health and lowering readmissions. But he said it can be difficult to control whether a patient takes proactive steps to maintain their health once they leave the hospital.
If a patient doesn’t adhere to a doctor’s orders to exercise or take a certain medication and then soon returns to the hospital, the hospital pays a financial penalty for something it could not control.
“The biggest challenge is that hospitals and health care providers that provide Medicaid and Medicare are being held responsible for what patients do outside of the hospital,” Bucklew said.
The average penalty paid by local hospitals is 0.79-percent, which is slightly above the national average penalty of 0.73-percent, according to Kaiser Health News.
Even when a hospital’s penalty is less than 1 percent, Bucklew said the financial impact can add up quickly.
On an average day in the Dayton region, about 53.1 percent of patients are paying with Medicare.
“It’s important. Every percentage point is extremely important,” Bucklew said.
These penalties to Medicare reimbursements apply for fiscal year 2018 which started Oct. 1 and applies through Sept. 30.
No hospitals in the Dayton area will pay the maximum 3 percent penalty. The only hospital in Ohio to get the maximum penalty is King’s Daughters Medical Center Ohio in Portsmouth.
Some types of hospitals were exempted from the law including veterans hospitals, psychiatric hospitals and children’s hospitals.
Most hospitals have not been able to satisfy all the the readmissions standards. About four out of five Ohio hospitals will pay some penalty and the same goes nationally.
The penalties are based on whether patients return within 30 days for six conditions: heart attacks, heart failure, pneumonia, chronic lung disease, hip and knee replacements and coronary artery bypass graft surgery.
Officials with Premier Health and Kettering Health Network, the region’s largest two hospital operators, both said they had efforts in place to reduce Medicare readmissions before the law created the penalties.
Tammy Lundstrom, Premier’s chief medical officer, said Miami Valley Hospital and Atrium Medical Center had been participating in early pilot programs to reduce readmissions long before the penalty was in place.
“All of our facilities are improving. I think the ones in the early pilots improved a little faster,” she said.
Higher poverty rates in regions the hospitals serve tend to be connected to higher readmissions. In the Dayton region however some of the hospitals with the highest percent of low-income patients were also hospitals with the low rates of readmissions, which Lundstrom credits to the pilot programs. Miami Valley Hospital will not pay any penalty this fiscal year. Atrium Medical Center in Middletown will pay a 0.13-percent penalty.
Some things that help patients avoid readmissions include:
- making an sure an outgoing hospital patient is connected with a primary care doctor
- following up with a phone call to make sure patients understand the discharge instructions
- connecting the highest risk patients with a care manager.
There are also specific ways to help patients with specific conditions avoid readmissions. Premier officials said they learned patients with chronic lung disease often don’t know how to clean their equipment at home so a home visit can be helpful.
Kettering Health network is working with Geisinger Health, a health care system based in Pennsylvania, to develop a better care management process, which Kuhn said she expected to help reduce readmissions.
Kuhn said one of the keys to lowering readmissions is coordinating with organizations that provide care after the patient leaves the hospital like primary care doctors. Kettering Health is also looking at ways to collaborate with post-acute-care providers like home health agencies and skilled nursing facilities.
“Because this is the direction that health care is going, we have to have conversations on how we have better hand offs,” she said.