Part 2, Limited Warranty on Patient Care

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.

http://www.amazon.com/Covering-Assets-Exposing-Butt-Ugly-ebook/dp/B007OM83GU

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