In Part 1, Michael Ryan and I discussed:
1. The definition of readmissions - CMS defines readmission as “an
admission to a subsection (d) hospital within 30 days of a discharge from the
same or another subsection (d) hospital.”
2. Parties affected by the readmission penalties - If a
hospital receives Medicare funds, the readmission reduction initiative applies…
most likely.
In Part 2, Michael and I discussed
3. A concern from blog readers – how does patient
responsibility figure in the readmissions scenario?
4. How are penalty rules applied?
5. Grants associated with reducing readmissions
How does patient responsibility figure in the readmissions
scenario? It’s not as clear as one may think. Here is a real
example. The names were changed.
I received a call one evening from a couple very close to my
family. As you may have guessed, I was writing. Raoul is an
entrepreneur that has owned a stable business for 30 years. Mae has a
Master’s Degree and has received awards for her work. They have health
insurance.
Mae didn’t even bother to greet me. Worry sent her into a
high-pitched, high-geared request for help. When she stopped, I asked her
to start again.
Mae responded, “You remember that Raoul had a knee replacement
right?”
“Yes!”
“He wanted me to call you. Something is not right.
It’s very swollen. It looks so tight. He’s in pain.”
“So why are you calling me?” I asked. “You should be calling
the doctor or the hospital. I’m sure they gave you the number.”
“I looked. I didn’t see anything.”
I knew that it was possible but not probable that the hospital had
not given them anything.
“They gave you a bag, right? What happened when you got home?”
Mae fell silent. Then, “Wait a minute.”
I could not hear what she was doing. Moments later, “I found
something. I’ll call you back.”
“Don’t call me. Call the doctor!”
She hung up.
What happened? In getting home and comfortable, trying to
make sure that everything was fine, key paperwork got separated. The
conversation prompted something in her mind that helped her locate the
documents.
This incident could have ended in a preventable readmission.
Instead, Raoul and Mae were able to avoid an unplanned visit and had a good
recovery. So, was the incident totally the fault of Raoul and Mae?
Please share your thoughts in the comments area.
Michael Ryan stated that this could be very typical of what
happens. “Discharge instructions are given to patients when they go home.
The instructions may contain subsets of instructions on diet, wound care,
after visits, sometimes who to call, etc. Even the most diligent patient
is sometimes caught in a situation where they may not have read the discharge
instructions. Even when they do, discharge instructions can conflict.
The instructions may come from different sources or applications.
Hospital staff may not have read through all the instructions to insure there
are no conflicts. The instructions should be reviewed and put in layman’s
terms. This could help reduce readmissions as well.”
“Michael, can you give us an example?”
“I will give you one example. A person was readmitted
because of a surgical wound. The instructions stated that the wound
should be ‘dressed’ with a particular antibiotic. Three days later, the
patient ended up back in the hospital because the instructions did not say to
put on a new bandage.
“Here, it appears that the patient sought to follow the
instructions to the letter. It may have been something as simple as not
really knowing what dressing a wound meant.”
Michael went on to say hospitals can’t take for granted that the
average patient will understand instructions simply because they pulled it from
a source.
Readmission prevention from a policy standpoint is a work in
progress at every level. The penalties are meant to bring attention and
action to reducing them. The Centers of Medicaid and Medicare Services
(CMS) looks to cut cost for hospital acquired infections and readmissions.
Michael stated that these 2 areas account for $25B USD in readmission
costs. One implication is that these payments could be counted as revenue
for hospital, not leading to a comprehensive push by the respective providers
to reduce them.
Let’s put that $25B in perspective. Between 2009 and 2011,
the Federal government sent about $90B to the states. So that’s a little
more than 1/4 of 2 years of funding.
Michael remarked, “CMS sought to figure out a starting point to
measure readmission reduction. They acknowledge that readmissions will
never go completely away.”
CMS uses a code called DRG (Diagnosis-Related Group) to identify
targeted categories: Acute Myocardial Infarction, Heart Failure, and Pneumonia.
What follows is a mathematical story that has a progression of ratios as
the plot. Among those ratios is a comparison of payments for readmissions
over payments for discharges. To restate, CMS compares the amount
of money that it has paid to a particular hospital at which
beneficiaries/clients were treated and discharged. CMS then
compares how much they have paid for treatments that landed their beneficiaries
back into the hospital. If the hospital exceeds CMS’ target, up to 1% is
deducted from the hospital reimbursements for 2013. The maximum penalty
will increase to 2% in 2014. "The penalty is a three year rolling average which
goes into effect the beginning of each fiscal year," stated Michael.
Also, there are positive incentives meant to help reduce
readmissions. This takes the form of grants. The grants are
administered through Hospital Engagement Networks (HENS). This initiative
is a joint public and private collaborative. HENS work at the Federal,
state, and regional level “to keep patients from being harmed while in the
hospital and heal without complication once they are discharged.” – CMS Website
