Medicare fines over hospitals' readmitted patients to begin on Monday Oct 1,2012

[kcmylorn]

http://www.usatoday.com/story/money/business/2012/09/30/medicare-fines-over-hospitals-readmitted-patients/1603827/

Medicare fines over hospitals' readmitted patientsding...

By RICARDO ALONSO-ZALDIVAR, AP

42 minutes ago

WASHINGTON-If you or an elderly relative have been hospitalized recently and noticed extra attention when the time came to be discharged, there's more to it than good customer service.

As of Monday, Medicare will start fining hospitals that have too many patients readmitted within 30 days of discharge due to complications. 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.

About 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.

Data to assess the penalties have been collected and crunched, and Medicare has shared the results with individual hospitals. Medicare plans to post details online later in October, and people can look up how their community hospitals performed by using the agency's "Hospital Compare" website.

It adds up to a new way of doing business for hospitals, and they have scrambled to prepare for well over a year. They are working on ways to improve communication with rehabilitation centers and doctors who follow patients after they're released, as well as connecting individually with patients.

"There is a lot of activity at the hospital level to straighten out our internal processes," said Nancy Foster, vice president for quality and safety at the American Hospital Association. "We are also spreading our wings a little and reaching outside the hospital, to the extent that we can, to make sure patients are getting the ongoing treatment they need."

Still, industry officials say they have misgivings about being held liable for circumstances beyond their control. They also complain that facilities serving low-income people, including many major teaching hospitals, are much more likely to be fined, raising questions of fairness.

"Readmissions are partially within the control of the hospital and partially within the control of others," Foster said.

Consumer advocates say Medicare's nudge to hospitals is long overdue and not nearly stiff enough.

"It's modest, but it's a start," said Dr. John Santa, director of the Consumer Reports Health Ratings Center. "Should we be surprised that industry is objecting? You would expect them to object to anything that changes the status quo."

For the first year, the penalty is capped at 1 percent of a hospital's Medicare payments. The overwhelming majority of penalized facilities will pay less. Also, for now, hospitals are only being measured on three medical conditions: heart attacks, heart failure and pneumonia.

Under the health care law, the penalties gradually will rise until 3 percent of Medicare payments to hospitals are at risk. Medicare is considering holding hospitals accountable on four more measures: joint replacements, stenting, heart bypass and treatment of stroke.

If General Motors and Toyota issue warranties for their vehicles, hospitals should have some similar obligation when a patient gets a new knee or a stent to relieve a blocked artery, Santa contends. "People go to the hospital to get their problem solved, not to have to come back," he said.

Excessive rates of readmission are only part of the problem of high costs and uneven quality in the U.S. health care system. While some estimates put readmission rates as high as 20 percent, a congressional agency says the level of preventable readmissions is much lower. About 12 percent of Medicare beneficiaries who are hospitalized are later readmitted for a potentially preventable problem, said the Medicare Payment Advisory Commission, known as MedPAC.

Foster, the hospital association official, said medication mix-ups account for a big share of problems. Many Medicare beneficiaries are coping with multiple chronic conditions, and it's not unusual for their medication lists to be changed in the hospital. But their doctors outside sometimes don't get the word; other times, the patients themselves don't understand there's been a change.

Another issue is making sure patients go to their required follow-up appointments.

Medicare deputy administrator Jonathan Blum said he thinks hospitals have gotten the message.

"Clearly it's captured their attention," said Blum. "It's galvanized the hospital industry on ways to reduce unnecessary readmissions. It's forced more parts of the health care system to work together to ensure that patients have much smoother transitions."

MedPAC, the congressional advisory group, has produced research findings that back up the industry's assertion that hospitals serving the poor, including major teaching facilities, are more likely to face penalties. But for now, Blum said Medicare is not inclined to grade on the curve.

"We have really tried to address and study this issue," said Blum. "If you look at the data, there are hospitals that serve a low-income patient mix and do very well on these measures. It seems to us that hospitals that serve low-income people can control readmissions very well."

Under Obama's health care overhaul, Medicare is pursuing efforts to try to improve quality and lower costs. They include rewarding hospitals for quality results, and encouraging hospitals, nursing homes and medical practice groups to join in "accountable care organizations." Dozens of pilot programs are under way. The jury is still out on the results.

My take on this is: This could have positive implications for nurses in that if alot of these hospitals perform poorly, which I think they will, the hospital may have to look seriously at their staffing levels.

The greatest impact on controlling and reducing these readmissions falls under nursing's control. WE are with these patient's 24/7. We are the doctors's eyes and ears. These eyes and ears can only be in one place at one time. Like mentioned- these patients are complex with multiple co morbidities, this is where these hospitals are going to have to face facts. They can't competely take care of this level of complex patient's on a shoe string anymore. They can either increse and hire more nures or pay the fines to medicare. These hospitals need to have enough nurses staffed to competently monitor a patient's progess and the Licensed nurse is the one responsible for discharge teaching. If the staff levels are to low, which we all know they are, this is where the patient's slip through the cracks and are doomed for readmission.

I don't see this as a bad thing. I think it is finially going to make hosptial adminstration face up and be responsible for the poor decisions they have been making .

[morte, LPN, LVN]

one other scenario is that patients won't be readmitted, and they will die.

[NRSKarenRN, BSN, RN]

What I am seeing in SE PA is some gaming of the system. Medicare clients readmitted within 30 days with minor illness: 2-4 day stay is being placed under observation status rather than admision. Readmission now results in homecare referral (should have had as part of 1st admit discharge planning) with RN visiting next day. Even SNF's are having patients be readmitted within 1st week home if they can't function with caregiver support. This never happened in my area prior 2012-had to go to the hospital first.

Two major health systems in my area closed their SNF's 4 yrs ago as losing monies resulting in patient being placed 30 miles away in different counties due to lack of beds. Now health systems are forming alliances with SNF owners to decrease length of stay and readmit rates and lwith bed closer to home.

[tamadrummer]

If anyone thinks the less fortunate are going to have better care now that it is a mandate, just wait there will be more and more blind eyes all over and the seniors and poor will suffer the brunt. It simply sucks.

Sent from my iPhone using allnurses.com

[Sun0408, ASN, RN]

Gotta watch this thread.... I see it as more people not being admitted that need it. Longer stays for people that should be home. The main problem I see with this; we as a whole will be punished for chronic non-compliant pts whom don't take responsibility for their own health. Renal pts as an example in the hospital are a revolving door, they are admitted at least monthly for CHF, overload, missing HD and just going to the hospital to get "fixed". How is this the fault of nursing staff or the PCP, we can't turn them away; this will lead to more law suits and now if they are readmitted we are dinged. From my understanding from our managers, it doesn't matter the cause of the readmission. So say someone had a MI 3 weeks ago and was admitted, DC'd home and was in a MVC, we will not get paid for the MVC admission. I really hope this is not true, but I haven't researched it on my own yet. I don't see how this is going to work sadly.

[morte, LPN, LVN]

that wouldn't be a REadmission, so should not matter, we shall see.

Gotta watch this thread.... I see it as more people not being admitted that need it. Longer stays for people that should be home. The main problem I see with this; we as a whole will be punished for chronic non-compliant pts whom don't take responsibility for their own health. Renal pts as an example in the hospital are a revolving door, they are admitted at least monthly for CHF, overload, missing HD and just going to the hospital to get "fixed". How is this the fault of nursing staff or the PCP, we can't turn them away; this will lead to more law suits and now if they are readmitted we are dinged. From my understanding from our managers, it doesn't matter the cause of the readmission. So say someone had a MI 3 weeks ago and was admitted, DC'd home and was in a MVC, we will not get paid for the MVC admission. I really hope this is not true, but I haven't researched it on my own yet. I don't see how this is going to work sadly.

[kcmylorn]

I see this as identifying problems with diligent monitoring of patients while still in the hospital. I recall while working on a cardiopulmonary step down back in 2010, a post thoracotomy patient I was assigned to was not out of bed for 2 days post op. He asked for assistance to just move forward in the bed, I move him up in the bed and he went into respiratory distress on me. I had to call an RRT, nebs, CXR the whole 9 yards. This was a horrendously busy and heavy nursing unit, and understaffed to say the least for the acuity of patient population. Had the staffing been adequate with a mix of experience levels- (yes, I was the only crabby mean old bat nurse on the floor) with attention to the nursing practices of the days of old, I don't think this would have happened.

These patients were so sick on this unit, right out of CVICU/CVSICU and only in those 2 units for the absolute bare minimum 1,2 maybe 3 days max, they went to those 2 units fresh from the OR- no PACU. With the amount of nurses staffed- I hated every minute I was at work. It was sheer hell. The nurse patient ratio= 5-6:1!!! all telemonitored, with drips, pump, tubes, chest and vascular dressings, sometimes the internal pacing wires were just capped and surgeons pulled them on the floor, not to mention the army of meds they were on. And we discharged from this floor, ?Amount of time to do discharge teaching??? Discharge what??? Throw the discharge instrutions at them was more like it, because SICU was on the phone for the bed. and the supervisor was in your face to see what the hold up was!!! If the patient had to pee before discharge, give them a urinal and tell them to use it on the way home or cross the old legs in the car Which is another issue this regulation is addressing: there needs to be more staff on the floor so the nurse discharging the patient can do a competent job going over discharge instructions. That nurse is the bridge for that transition, but a CEO wouldn't know that.

I hink this is going to fall on the admistations shoulders. I don't think the staff nurses should be accepting blame for this. There's not much staff nursing can do on the staff level.

These patient satisfation surveys are nice CEO ego building fluff BS. If the nurse smiles and does the ADIET script, and behaves like unskilled the maid service the CEO thinks they are, the patient thinks 'service' in this hotel is wonderful. Then gets home and bang- CHF or sepsis a few days to weeks after discharge. Goes to show just how much the CEO really knows the health care industry. This Medicare reg. is objective data.

I also agree- these sick patient's should always be sent home with a Home Health RN next day follow up visit. How come the hospital CEO didn't come up with that solution.

[BlueDevil,DNP, DNP, RN]

The fines may be just be going into effect, but this has been coming down the pike for 3 years. Our area hospital system hired nurses called "Nurse Navigators." They coordinate with us (the PCPs), make sure we have all of the pertinent hospital records, and arrange all of the discharge planning, out-patient therapies, pharmacy fills, etc. It's been going well and the local system apparently has data that reassures them they are nowhere near having to worry about owing medicare money on readmits. I know they (the Navigators) make my life a helluva lot easier! Sadly, they only use the Navis, as we call them, for the diagnoses being followed for readmit, and only for the allotted time period. They do good work and help the patients a lot. I believe they told us one has to be a MSN prepared RN with gobs of bedside experience under ones belt to be qualified to be a Navi. I've no idea what they are paid, but they apparently save the system a lot of money. I can't believe this is the only hospital system in the country to have prepared for the changes, lol.

[Sun0408, ASN, RN]

I completely agree with you. I was on the floor before going to the ICU. My background was a renal, pts coded almost daily in HD yet DC planning was trying to get them out...why, because reimbursement was cut and although the pt needed to be in the hospital per insurance there admitting dx was a 2-5 day stay only. A time limit on hospital stays was part of the downfall, now hospitals will be fined for readmission's, how is that going to fund more staff. Sounds like we as nurses will be blamed for more while expecting to do more with/for less.

[kcmylorn]

There are quite a few hospitals in my area that have nurse navigators. and there is a company around me who is contracted by the patient's insurance company as a benefit, to do nurse navigator. The video of this company I watched, the nurse navigator goes with the patient to the doctors visit- the example was a patient who just recieved a diagnosis of breast cancer. The nurse navigator listens to the doctor's opinnion with the patient, discuses/explains the doctors infromation with the patient, taps into the data based back at the office for which ever treatment options the patient would like to pursue but does not make any treatment decisions or recommendations for the patient.

In addition there is also private Nurse navigators, a nurse who opened her own office in my area, who the patient can hire on their own. I have her card and got it theough a freind of my.

I have looked into these positions. I don't read that they all have to have their MSN but I do know the consistent requirements through all areas of employment for the nurse navigator I checked into is "atlleast 10-15 years experience", and I if I recall correctly, it has to be 10-15 years acute care bedside.

[SC_RNDude]

If the average fine in $125k over a year, I don't think that will have much impact on staffing. The type of places who are going to be fined will try to do more with what they have and hope for the best, but that fine alone isn't enough to justify adding staff.

The places that have positions such as Nurse Navigators have them because they believe it is the right thing to do and probably believe there is a cost benefit, regardless of the new fines.

[BlueDevil,DNP, DNP, RN]

I have not had a nurse navigator come to a visit with a patient, but that sure would be fabulous. That would save me so much time! I would love it. I have heard of concierge PCPs going to specialty visits with patients as well, which would be a terrific asset to the patient.