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A provision contained in the Affordable Care Act is about to start hitting hospitals across the nation. With the stated goal of reducing unnecessary readmissions, which costs the Medicare program an estimated $17.5 billion annually, Medicare will begin reducing compensation to any hospitals that have a greater than average readmission rate of patients within 30 days of discharge. This year, Medicare reimbursements to targeted hospitals will be reduced by 1%, increasing to 3% by 2014.

The provision's goal is to encourage hospitals to better coordinate post-discharge care, as part of Obamacare's overall goal of slowing the growth of the cost of healthcare. Over 2,000 hospitals are being penalized for readmissions this year at a combined cost to those hospitals of about $280 million. Only 278 hospitals out of the 2,211 hospitals will suffer the maximum 1 percent penalty.

Further analysis follows.

There is some small amount of controversy that this provision is being unfairly applied, for a number of reasons. Many of the hospitals on this list have high readmission rates for reasons that are not entirely in their control, and all readmissions are counted, regardless of the medical issue.

Patients, especially elderly patients, often get readmitted following discharge for entirely unrelated reasons. An elderly person may be discharged after being treated for pneumona, go home, fall down and break a hip. That person then counts in the statistics. It is not entirely clear that congress intended in the bill to count these scenarios.

Another problem is planned readmissions are also counted. This happens for a number of reasons. A person undergoing chemotherapy and who also has other medical conditions that need to be managed are often treated as in-patients, then discharged between rounds of chemo and radiation therapy. Also, if a condition is discovered that requires surgery, but is not emergent, a patient may have the surgery scheduled for a later date, and be discharged. When the patient checks back in for the surgery, that patient is counted against the hospital.

The list of hospitals being targeted this year also turns up a few surprises, notably that a number of high grade hospitals made the list. These are hospitals that, while otherwise noted for excellence, also seem to have an above average readmission rate. The reasons for that may vary, but often it is because the sickest, hardest to treat patients (that can afford it) end up at these hospitals. Because the hospital prioritizes these patients, they are often admitted more quickly and more often, getting them the treatment they need before it becomes a larger issue.

Specialty hospitals also seem to land on the list with some frequency. Hospitals with large, aggressive cardiac programs, for example, see an awful lot of readmissions. In that case, however, it may be entirely fair: post-discharge care of cardiac patients can and should improve. There is little reason a heart attack patient cannot have great post-discharge outcomes. Heart failure is more complicated to manage, but with home health visits and out-patient followup can also improve.

Another category of hospitals on this list are "safety net hospitals" that serve primarily economically disadvantaged populations. These are the hospitals of last resort, where you go when you are uninsured (or on medicaid) and will not be too picky about whether you can pay or not. The type of persons this hospital serves are also referred to as "underserved," meaning that follow up care is hard, or impossible, to come by in their community. Typically, inner-city, poor, and not enough clinics or primary care doctors (even if there are enough doctors, there is a limit to how many medicaid patients a doctor will take because of how little medicaid reimburses).

The problem in poor areas and with safety net hospitals that leads to readmission is primarily that the people are poor. They do not have reliable transportation. They cannot find a doctor to accept them, and when they do, they often have to wait a long time for an appointment. So, an ambulance ride to the emergency room is usually the only medical care they get. This is also a population with an above average rate of preventable medical problems, often related to obesity, smoking, and alcohol and drug abuse, all of which lead to chronic health problems requiring frequent hospitalization.

Penalizing safety net hospitals is problematic, as these hospitals are already woefully underfunded. The small amount of reduced reimbursement from medicare will hit these hospitals especially hard, since their margins are so tight to begin with. They do not have the resources to apply to aggressive post-discharge care, and with little in the way of government assistance, will not be able pay what it takes to improve. Fortunately, many will be able to take advantage of charity and public services that already exist, and Obamacare does make grants available for hospitals to improve their followup care.

As far as charity and public services are concerned, though, rural communities are disadvantaged by far compared to their inner-city counterparts. Rural hospitals also have rather slim margins, simply because of their low patient volume. Transportation is also an issue for post-discharge care in rural areas, with patients having to travel rather long distances to appointments, and if they need to visit with a specialist, may even have to travel to another county entirely. So home health visits are especially important in rural communities, the very same communities that have the least resources to provide home health care.

Even with all of the problems, though, the fact is the provision is already working as intended. The targeted hospitals are taking the threat to their revenues seriously, and even hospitals who did not make the list are working to improve post-discharge outcomes.

By far the most common solution hospitals are employing is home health visits. These are repeated followups by trained aides or by registered nurses, going directly to the patient, assessing their overall health and condition of their illness. Followup care can be given right there. If medications need to be adjusted, that can be done over the phone with the doctor. If labs need to be done, the nurse can do a blood draw in situ. Whether home health visit programs like this are administered by the hospital or by an outside organization, they are an extremely important part of any post-discharge plan.

Some hospitals are also starting to provide their own transportation services. Especially important in rural areas and cities, and for the elderly, being able to get to and from appointments with little hassle or cost to the patient can dramatically affect whether the patient will adhere to their discharge plan. Medical transport has been available for a long time, of course, but it is a highly regulated industry and can be very difficult to obtain. By the hospitals establishing their own transportation service, neither the patient nor their discharge planner need navigate the arcane bureaucracy of Medicare to get approval, and can transport the patient anywhere they need to go for followup care. The Veteran's Administration hospitals have been doing this for a long time, and private hospitals are starting to catch on.

According to many doctors and hospital administrators, though, the most important and most effective tool they have to reduce readmissions is the patient's family. A supportive, attentive family can do wonders for post-discharge outcome, and in this vein, many hospitals are working to improve patient education. By counselling the patient and their families intensely before discharge, they are hoping to equip the patient's family with the tools and knowledge necessary to manage the patient's condition. A proactive family member is in many ways better than any home visit nurse. Because they know the person intimately they often recognize a potential problem a lot sooner than even a trained professional would. A quick telephone call to the doctor for advice or a new prescription avoids many a hospital admission, and hospitals know this.

Much more can be done to improve post-discharge outcomes and reduce readmissions. It is clear, though, that without the Affordable Care Act, hospitals had little incentive to take any of these actions. Whether the Medicare reimbursement penalty is the way to do it, and whether its being implemented fairly and properly, the evidence is already there. Even long before this month, when the penalty started to kick in, with just the threat of reduced Medicare revenues, hospitals were taking action.

There are valid concerns that the way the penalty is applied, failing to take into context the specific reasons for readmission rates, based on the communities each individual hospital serves. It is also concerning that some of the hospitals being penalized are the least likely to be able to bear the financial hit nor be able to invest in new strategies for improvement. Government grants, public services and charity services can help, if they are available, and despite these concerns, the goal is laudable and important: Improved outcomes, reduced costs, and a financially sound Medicare.

Medicare To Penalize 2,217 Hospitals For Excess Readmissions [Kaiser Health News]
Medicare Penalties For Readmissions Could Be A Tough Hit On Hospitals Serving The Poor [Kaiser Health News]

Originally posted to RadicalParrot on Mon Oct 15, 2012 at 04:22 PM PDT.

Also republished by Community Spotlight.


Do you think the readmission penalty is a good idea?

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Comment Preferences

  •  This will have a dramatic effect on Medicare costs (23+ / 0-)

    sure, bound to be glitches, but in the great scheme of things, Medicare costs will come down. Outcome oriented payments will do that every time.

  •  The outcome oriented structure (42+ / 0-)

    is a great, great idea.  Encourages hospitals to look at the whole of a patient's life, not just their quick stint in the institution.  

    However, the program should DEFINITELY be adapted to figure in planned readmissions.  Not to do so would be grossly unfair to hospitals that provide comprehensive cancer treatment, for example.

    Regarding unrelated or accident-caused readmissions (for instance, admitted for pneumonia, readmitted for a home fall, per your example),  the criteria should be re-evaluated, but in truth, looking at a senior's overall health and home care situation could probably prevent some of these situations.  

    Good article.

    "When a man tells you that he got rich through hard work, ask him: 'Whose?' Don Marquis

    by hopesprings on Mon Oct 15, 2012 at 04:43:49 PM PDT

    •  what is good about this is that hospitals now (28+ / 0-)

      routinely kick out elderly patients when their medicare benefit is about to expire - then they readmit for new costs.  

      also, this is an EXCELLENT reason to revisit the law in congress to make improvements to the law - the beginning of the "tweaking" to get it right.  without the basic law, there is no impetus to improve anything!

      •  Hospitals don't "kick out" Medicare patients (1+ / 0-)
        Recommended by:

        unless they want to lose their operating certificate to practice or get a poor rating from the Joint Commission for Accreditation for Healthcare Organizations.

        •  But do they discharge them too soon? (1+ / 0-)
          Recommended by:

          I don't know any details on this, but there is definitely a meme around that Medicare patients are discharged after three days, if at all possible.  Is that's what's happening?  Again, I don't know, but if patients are suddenly kept in the hospital for much shorter periods immediately on reaching the age of 65, I'd say that qualifies as smoke, at least.

          I am become Man, the destroyer of worlds

          by tle on Tue Oct 16, 2012 at 06:37:23 AM PDT

          [ Parent ]

          •  Under the Prospective payment system (0+ / 0-)

            there is an incentive to discharge the patient as quickly as possible. However, Medicare patienrs have the right to appeal that decision if they think they're still too ill..

          •  I Think The Current Medicare Rules Say That (1+ / 0-)
            Recommended by:

            medicare will pay for up to three days of hospital care.  If you are well enough as determined by the hospital/doctor  to go home you cannot continue using the hospital bed as a place to recuperate and if you can't afford to go home and have someone care for you or go to assisted living or a nursing home then you need to apply for Medicaid which will then pay for this kind of assistance.

            Medicare does not pay for home assistane or use of a nursing home (that is "room and board" costs).  Many people think that Medicare is going to pay for longer term care, it does not.  It still pays for medical bills, but does not pay for assistance in daily living such as when you are discharged from a hospital stay but still need some assistance to recuperate at home or in assisted living.

            So people BEFORE you get old (or get into a serious accident or get a major disease, etc.) you better have a plan in place of how you are going to be taken care of.  Are you going to "spend down" all your assets ( meaning you can only have $2000 to you name) to pay for home assistance, assisted living,  nursing home, or if you don't have any assets then apply for medicaid and hope they approve you (and hope Romney and his 1% ilk haven't destroyed it) or buy a "Long Term Care Insurance" policy way in advance (at $3000 to $10,000 premium per year).

            The Republican Party is Simply a Coalition of Greed and Hate

            by kerplunk on Tue Oct 16, 2012 at 08:21:38 AM PDT

            [ Parent ]

            •  Not three days... (3+ / 0-)
              Recommended by:
              the fan man, ozsea1, tle

              It is based on the "diagnosis" and its DRG.  So abdominal pain could be 2.7 days and hip fracture with surgery could be 6.9 days if there were not complications.  Because of the incentive to get folks out before the days run out, the number of days for a diagnosis have been getting tighter and tigher.  Hip fractures used to be 10 to 14 days, in the old days, now they try to move them to skilled rehab in three days.

            •  Does "spending down" mean having to sell (3+ / 0-)
              Recommended by:
              ozsea1, old mark, kurt

              your home, if you have one?

              We fight so hard to protect Medicare, we regard it as such a great achievement -- and in our context, it certainly is, and we SHOULD defend it -- but is pretty damned inadequate compared to what other affluent countries provide by way of elder care.  Elders can still be unable to pay for medicine, unable to get false teeth, etc.

              The assistance it does provide is very, very important.  And Obamacare will improve it.  But there's still a whole lot to do.

              --------------------- “These are troubling times. Corporation are treated like people. People are treated like things. …And if we ever needed to vote, we sure do need to vote now.” -- Rev. Dr. William J. Barber

              by Fiona West on Tue Oct 16, 2012 at 09:57:04 AM PDT

              [ Parent ]

              •  I Think You Can Keep Your Home If You Can Show (1+ / 0-)
                Recommended by:

                that you will be returning to your home.  If you are married, you can keep the home to have a place for your spouse to live.   Medicaid puts a lien on  your home, so you don't have to sell it right away.  Eventually though once your house is sold, medicaid gets the amount from the house sale based on the amount of the lien they put on it.  Also if married, the spouse can keep a small amount to be able to live on while all the other assets are drained for the care of the other spouse.  Also if the person going on medicaid has a disabled child, the home can be kept for the disabled child.  Also assets can be gifted to a disabled child (disabled based on social security definition) without being affected by the "look back period".  The look back period is 5 years and means if you give away your assets to qualify for medicaid, the medicaid office will look at your financial records for the past 5 years to find out if you gave assets away and then you have to wait to be eligible for medicaid based on how much the given away assets would have been worth to be paid toward your nursing home care.  Meaning you better get back what you gave away to whoever in order to live on because medicaid isn't going to pay for your care.  They will force you to wait so many months based on the value of the given away assets.

                If you have significant assets you really need to talk to an estate planning and eldercare attorney because the laws concerning medicaid, medicare, and social security  requires estate planning.  Many people use trusts to somewhat shelter their assets.  That's why the 1% end up being able to keep all their assets,  Thats why they got Bush to change the "estate tax" allowing you to keep $1 million of you estate without taxing to change it to keep $5 million before being taxed.  That is all part of the Bush tax cut law.  Another way for the 1% to avoid paying their fair share.

                The Republican Party is Simply a Coalition of Greed and Hate

                by kerplunk on Tue Oct 16, 2012 at 02:39:04 PM PDT

                [ Parent ]

          •  yes, it is true. it happened to my mother (who (2+ / 0-)
            Recommended by:
            the fan man, lonespark

            died in feb. 2011) after her falls - she was "stabilized" and packed off to rehab facilities in the middle of a raging snowstorm the last time... and she was sent to a different care facility than had previously treated her for a broken arm after a fall because the hospital wouldn't wait a few days for an opening.

        •  Sorry, they do... (8+ / 0-)

          Having supervised Utilization Review and Quality Assurance at a hospital for years, and been active in groups of QA professionals, there is an extreme push to get Medicare Patients out of the hospital as quickly as possible.  Doctors are well aware of "how many days" a particular DRG pays and a hospital person will be monitoring a specific case day by day.  Heaven help you if  your days end on Friday, as there will be a big push for discharge before the weekend.  

          And from the meetings I attended, the for profit hospital chains pushed even harder to get patients "out".  Often one extra day as an inpatient will allow for better discharge arrangements plus a more stable patient.  But that one extra day can mean the difference between making or losing money on the case.  

        •  yes, they DO "kick out" medicare patients - and (1+ / 0-)
          Recommended by:

          poor patients.  they transfer them to "nursing facilities"- "rehab facilities", etc., because their medicare "limit" is up.

          i know this from how my mother was moved too quickly without diagnosing the real problem (which was ultimately the cause of her death - not that the diagnosis would have altered that...)

        •  They DO "kick out" medicade patients or those (1+ / 0-)
          Recommended by:

          on disability. When I worked in a state mental hospital, we often got patients from regional "for profit" hospitals after their government benefits were exhausted, and many times after little or no effective treatment was given other than medication and confinement to a locked ward.

          I recall one patient who was transferred with
          "imagined" leg pain that they were treating with exercise...She had a broken hip, which we found when she was sent for x-ray after she arrived at our place...

          This provision MIGHT make some hospitals work a bit harder to do a bit better even for poor patients.


          Retired AFSCME Steward and union thug-licensed gun carrying progressive veteran.

          by old mark on Tue Oct 16, 2012 at 12:00:48 PM PDT

          [ Parent ]

    •  One Has To Wonder Why This Wasn't Considered (5+ / 0-)

      more carefully in the original legislation.

      But on second thought there is no wonder.  The Right Wing was out drumming up hysteria about "Obamacare" and "Death Panels" so thoughtful debate was thrwarted and precious time was lost and debate about important issues facing the American People were distracted by Sarah Palin marching around screaming "palin' around with terrorists", socialism, communism, gramma gonna get the death panel, etc.

      It is so sick to know we have the Sarah Palins among us and she is still around shitting on everything.

      However, the program should DEFINITELY be adapted to figure in planned readmissions.  Not to do so would be grossly unfair to hospitals that provide comprehensive cancer treatment, for example.

      The Republican Party is Simply a Coalition of Greed and Hate

      by kerplunk on Tue Oct 16, 2012 at 08:01:26 AM PDT

      [ Parent ]

    •  I think this blanket approach is the best way to (2+ / 0-)
      Recommended by:
      lurkyloo, indres

      start. Sure, as with much of Obamacare, tweaking will help, but hitting the hospitals in the head with a 2x4 will get their attention.

      "I believe more women should carry guns. I believe armed women will make the world a better place. Women need to come to think of themselves not as victims but as dangerous." Anna Pigeon

      by glorificus on Tue Oct 16, 2012 at 08:09:32 AM PDT

      [ Parent ]

      •  For rural hospitals and "safety net" hospitals, a (4+ / 0-)
        Recommended by:
        lurkyloo, ozsea1, glorificus, lonespark

        bonk on the head is not a good way to start.  They already function on very thin margins, as the diarist noted.  Any cuts to reimbursement will inevitably hurt the hospital's ability to provide adequate care.  They're already severely underfunded in many cases.

        For specialty hospitals, being charged for a rate of readmission that is inherent to the kind of work they do is not fair.

        And when unfair penalties get applied, that will give ammunition to those who want to attack the ACA as bureaucracy run amok.  

        The best way to start, imo, would have been to write in the predictable, logical esceptions and adjustments from the start, so there's less to fight over and change later.

        But I accept that there's only so much refinement you can do, when writing a very complex law while under constant attack.

        --------------------- “These are troubling times. Corporation are treated like people. People are treated like things. …And if we ever needed to vote, we sure do need to vote now.” -- Rev. Dr. William J. Barber

        by Fiona West on Tue Oct 16, 2012 at 09:33:01 AM PDT

        [ Parent ]

      •  I tend to agree (0+ / 0-)

        There is a lot of improvement to be made, especially in some of the lower acuity diagnoses, like chronic heart failure, COPD, back pain, etc.

        There is a lot of room for improvement in home care protocols, outpatient management, etc. to keep these individuals, mostly elderly, far healthier (and happier) in their homes.

        Yes there are exceptions, and eventually those exceptions will become the rule for those who need it, much like Critical Access has saved small rural hospitals when it turned out (entirely predictably) that the PPS system was dysfunctional at a very small scale.

    •  got my doubts about this... (0+ / 0-)
      An elderly person may be discharged after being treated for pneumona, go home, fall down and break a hip. That person then counts in the statistics. It is not entirely clear that congress intended in the bill to count these scenarios.
      The purpose of the penalties is for excessive re-admissions for the same illness with no positive outcomes.

      "Tax cuts for the 1% create jobs." -- Republicans, HAHAHA - in China

      by MartyM on Wed Oct 17, 2012 at 12:43:16 PM PDT

      [ Parent ]

  •  Very nice Diary, well written and informative (27+ / 0-)

    I learned a great deal. I couldn't help but draw an analogy or metaphor from sports. It always seemed unfair that dropped passes and tipped balls that were intercepted still counted as incomplete passes and interceptions in the Quarterback's stat's. Or an error may lead to a run, but that run counts against a Pitchers ERA.
    I'm not trying to lessen the import of your message, but I was using examples where sometimes things don't work out as fairly as could be and even after some minor tweaking, there will still be inequities. But in the long run people will be served better and lives and money will be saved.
    Once again, thank you for a fine diary.

    "If you tell the truth, you won't have to remember anything", Mark Twain

    by Cruzankenny on Mon Oct 15, 2012 at 04:44:24 PM PDT

    •  FWIW I'm fully supportive (21+ / 0-)

      I think this is the right thing, even if it hurts in the short term. I work in the industry and I see a lot of unnecessary waste, but I also work in the "underserved" area of the industry, so I'm quite sympathetic. I wanted to cover the criticisms, and I do worry the healthcare safety net may be weakened.

      •  I think it can only make it stronger (11+ / 0-)

        People won't be pushed out the door asap and it will force hospitals to be less rigid and use nurse practitioners for what they're trained for and for once, someone outside the AMA will be keeping stats.

        "If you tell the truth, you won't have to remember anything", Mark Twain

        by Cruzankenny on Mon Oct 15, 2012 at 05:28:24 PM PDT

        [ Parent ]

        •  I think you are right (4+ / 0-)
          Recommended by:
          Lujane, Chi, raincrow, lonespark

          but there are big challenges to providing comprehensive healthcare in urban and rural settings. What I see is that these private hospitals have a greater incentive to invest in public health, which may lead to more resources for public health charities and non-profits.

          •  I just had a very personal interaction with (7+ / 0-)

            a doctor who discharged my son with a subdural hematoma and 3 broken vertebrae in his neck because he almost killed him by giving him lovenox, against the protests of a nurse. He basically dumped my son on the street with a neck brace and told him to go to Puerto Rico and check into a hospital there.

            "If you tell the truth, you won't have to remember anything", Mark Twain

            by Cruzankenny on Mon Oct 15, 2012 at 06:32:29 PM PDT

            [ Parent ]

            •  If the accounts I have (2+ / 0-)
              Recommended by:
              raincrow, lurkyloo

              read from people visiting PR via cruise ships & to resorts are any gauge, that would be a huge mistake.   They tell of hospitals where few know English, poor treatment & diagnosis, especially for nerve and brain related issues.  And the way you are discharged (they may refuse to do so, once you are admitted) can impact upon your future treatment & insurance coverage in US based hospitals.

              This is just hearsay, off the Internet, but there seem to be enough horror stories, that some of it must be true.  

              Hope your son is doing better.  Best wishes.

              •  Thank you (2+ / 0-)
                Recommended by:
                PinHole, KenBee

                He's a walking miracle.

                "If you tell the truth, you won't have to remember anything", Mark Twain

                by Cruzankenny on Tue Oct 16, 2012 at 02:36:35 PM PDT

                [ Parent ]

              •  A little note on Puerto Rican Hospitals (1+ / 0-)
                Recommended by:

                If you ever have to be admitted to a hospital in PR, just make sure you bring your own bed clothes,(Pillow and Sheets).
                Other than lacking little stuff like that, there are some fine Doctors there and usually extremely caring. They speak excellent English.
                The nurses and nurses aides more often than not speak either Spanish or Tagalog from the Philippines.
                Almost all the surgery performed on VI vet's are performed in Puerto Rico and there are very few complaints.
                By and large the hospitals are clean and the people are genuinely friendly and will go far out of their way to help.

                "If you tell the truth, you won't have to remember anything", Mark Twain

                by Cruzankenny on Tue Oct 16, 2012 at 02:55:25 PM PDT

                [ Parent ]

                •  You need more than clean sheets (1+ / 0-)
                  Recommended by:

                  This is a recent account.  Couple admittingly had complicated medical issues, but were able to cope and knowledgeable about their medical history and reactions.  And not unusual for people past 50.

                  And the Miami office of the Celebrity Cruise line obviously wanted these folks off the ship.  

                  Both your son and they are on the opposite age range.  But the seriousness of the issues remains.  

                  You don't give us an idea of your location, the cause of his treatment or where the Doctor was, or what the entire story was, or identify some of your abbreviations (VI - Virgin Islands?), so I am at a loss to figure the situation out.  But as I said earlier, there are too many similar tales.  

                  Hopefully, as ObamaCare kicks in, and Romney is kicked out, things will improve in US Territories and the states.

                  •  I'm on St. Thomas (0+ / 0-)

                    and my son was on St. Croix when the accident happened. He was in the crown of a coconut tree, collecting nuts, and a frond hit a high tension line and blew him out of the tree about 50 ft up.
                    Obamacare has already made things better for Employers and Employees who receive insurance by not being able to deny coverage to people due to prior conditions.

                    "If you tell the truth, you won't have to remember anything", Mark Twain

                    by Cruzankenny on Thu Oct 18, 2012 at 05:31:01 AM PDT

                    [ Parent ]

            •  With 3 broken vertebrae? That's outrageous. (4+ / 0-)
              Recommended by:
              lurkyloo, ozsea1, Calamity Jean, KenBee

              I hope your son's okay and getting good care now.

              I also hope he'll consider whether there's a way he can file a complaint against the doctor.  Get something on the record in case this kind of behavior is a pattern.

              --------------------- “These are troubling times. Corporation are treated like people. People are treated like things. …And if we ever needed to vote, we sure do need to vote now.” -- Rev. Dr. William J. Barber

              by Fiona West on Tue Oct 16, 2012 at 09:46:24 AM PDT

              [ Parent ]

              •  We have done so (1+ / 0-)
                Recommended by:

                Sent a letter to the CEO of the hospital and the Governor. We are lucky enough to have an extraordinary Governor and he takes stuff like this personally.
                There is going to be a hearing soon, meaning within a week.
                Thanks for your well wishes

                "If you tell the truth, you won't have to remember anything", Mark Twain

                by Cruzankenny on Tue Oct 16, 2012 at 02:41:45 PM PDT

                [ Parent ]

          •  From your lips (0+ / 0-)

            to God's ear.

            It's surprising to realize how many private hospitals exist as islands in their own communities.  This could provide an incentive for them to participate more.

            "Mitt Romney is Dick Cheney with more charisma"

            by Betty Pinson on Tue Oct 16, 2012 at 06:37:35 AM PDT

            [ Parent ]

      •  I worked in the industry too, and I think (4+ / 0-)
        Recommended by:
        mudfud27, raincrow, ozsea1, lonespark

        the changes the diarist mentioned, could be made without new legislation, just a change in CMS rules or how readmit rates are compiled(i.e. demonstrably unrelated admits within 30 days of discharge would not apply as a readmit, planned admissions as part of ongoing care) or by simple changes within the hospital structure itself (non-emergent surgical interventions could be pushed to 31 days if it would not compromise patient care for example) Legislatively, we may need a waiver of the law for safety net hospitals, if it could be shown by the hospital they are not just "juicing" Medicare, because that is what this is actually designed to prevent.

        Bigotry is the disease of ignorance...Education & free discussion are the antidotes of both. Thomas Jefferson

        by RiverCityMadman on Mon Oct 15, 2012 at 11:26:10 PM PDT

        [ Parent ]

      •  They are going to be further weakened by the cuts (1+ / 0-)
        Recommended by:

        to the disproportionate share amounts...but make up for it in more insured customers...let's hope.

    •  Good analogy (1+ / 0-)
      Recommended by:

      A quarterback's statistics and a pitcher's ERA are subject to the influence of random events, but as long as there's no way of 'gaming' that influence, they're still useful statistics.  In the long run, those random events pretty well even out.  (A pitcher's ERA actually tries to exclude the effect of fielding errors, with the concept of unearned runs, but other things like intentional walks aren't taken into account.)

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Tue Oct 16, 2012 at 06:20:30 AM PDT

      [ Parent ]

    •  This is how resentment against regulation gets (1+ / 0-)
      Recommended by:

      stirred up by Repubs, unfortunately. There is NO way to ensure completely just and fair regulations in all cases. However, Repubs have been blowing up small problems and milking them as a justification to cut all regulation: just join the Free Market Solves Everything religion, and life will magically become totally fantastic! If it isn't, it's because individuals screwed up: the Free Market Fairy ensures total fairness./snark

      Also, the Repubs are masters at crafting horrible regulations that are designed to destroy the system. Witness our schools, California's revenue problems (courtesy of Repub designed restrictions on property taxes), and too many more to list.

      We need good regulations designed to truly help people in need who are at their most vulnerable, and this is at least a start.

      Life is a school, love is the lesson.

      by means are the ends on Tue Oct 16, 2012 at 07:53:56 AM PDT

      [ Parent ]

  •  my dad's lungs filled with water every (1+ / 0-)
    Recommended by:

    couple of weeks.there was nothing anyone could do.under this law the hospital would have probably let him died.

    •  Sorry for your situation... (20+ / 0-)

      that is not good. I have seen people that sick, and its tragic. I totally empathize.

      I also have to say, that is not true. Coming from someone in healthcare, I can assure you, no hospital, no medical provider, would let a person die. There is no provision for rationing of care in health care laws, and indeed there are laws that make it a tort to withhold care. It may hurt the hospital's statistics to readmit someone such as your father (CHF I assume?) but no hospital would or could turn your father away. From basic medical ethics to the patient's bill of rights, your father could not be denied care for his condition. The ACA does not change that, as any hospital refusing care would be liable for damages a lot worse than any reduction in medicare reimbursement.

      Not knowing the specifics of his situation, I won't presume to state that better outpatient care would have made a difference. I do know that there are people out there that are really that sick, that their condition cannot be managed in a home or nursing home setting.

    •  Thoracentesis. (17+ / 0-)

      Actually, ljean, that isn't true.

      What your dad has is either pleural fluid entering his lung space or fluid from a cancerous condition. To alleviate that, he has a Thoracentesis. This is where they put a small catheter between the lung and the chest wall (under ultrasound). Then over the course of several minutes the fluid drains into a vacuum bottle. This is done as an outpatient procedure in hospitals (and even some doctors offices) and does not require an overnight stay unless there is a bleeding issue or the lung is punctured, causing a pneumothorax. Even with coming in several weeks, it is still done as an outpatient procedure and doesn't fall under this policy. So please, lets not get hyperbolic and state the old 'death panels will kill my father' routine.

    •  Did his LUNGS fill with fluid or were they pleural (4+ / 0-)
      Recommended by:
      Shogg, catwho, Calamity Jean, sngmama

      effusions - fluid in the pleural space between the lung and the chest?

      Please DO NOT START with the death panels bullshit. Thoracentesis procedures do not require hospitalization, only localized anesthetic is required.

      "I believe more women should carry guns. I believe armed women will make the world a better place. Women need to come to think of themselves not as victims but as dangerous." Anna Pigeon

      by glorificus on Tue Oct 16, 2012 at 08:18:15 AM PDT

      [ Parent ]

  •  a lot of people will die because (3+ / 1-)

    of this,mainly sick and elderly.

    •  yeah. this makes me very nervous. hospitals (2+ / 0-)

      will become reluctant to readmit patients who need it.

      as someone with a chronic illness where I already deal with the nightmare of insurance companies controlling when and if I get treatment, I am likely to decline to the point where I will have bouts which require hospitalization.

      I have a known illness, with a known way to make my life more manageable. But, insurance companies continue to cut me off, without explanation, or make it nearly impossible to get approval when my ex's employment situation changes and we are forced onto a different insurance plan. Every stall tactic they can employ the will, in order to save money. It has nothing to do with me and my health needs.

      Now, hospitals are de-centivized from readmitting people. Great. Just another avenue for denying people care so that some insurance corporation shareholders make more money.

    •  You are misunderstanding the rules (18+ / 0-)

      Hospitals cannot deny patients who need care via readmission. Everyone understands that some patients will need readmission.

      The point of the rules is to ensure that the initial stay is appropriate and not unduly shortened, to ensure that hospitals transition patients to appropriate and thorough follow up care that keep them out of the hospital, and perhaps most importantly, aggressively manage against hospital-acquired infections, which can kill patients, especially elderly patients, in short order.

      Fry, don't be a hero! It's not covered by our health plan!

      by elfling on Mon Oct 15, 2012 at 10:15:40 PM PDT

      [ Parent ]

      •  But the rules do provide a perverse incentive (3+ / 0-)
        Recommended by:
        ozsea1, lonespark, MGross

        to discourage the initial admission of sicker patients, i.e., those who will most likely require readmission; and to resist readmission.

        There's no way around it, and let's not pretend that for-profit hospital monopolies have suddenly found the milk of human kindness and generosity coursing thru their corporate veins -- they'll shave where they can shave, and these readmission rules will have to be modified or perhaps offset by incentivizing docs to press for timely/appropriate admission.

        !! Four more years !!

        by raincrow on Tue Oct 16, 2012 at 09:23:25 AM PDT

        [ Parent ]

    •  DNF (1+ / 0-)
      Recommended by:

      This is a troll, folks. Check the comment history. From claims that Social Security is on the brink of failure and other RW talking points it has rung up some donuts. This is just the latest attack, bringing up bogus death panels.

      If we got Mitt to be slightly less dishonest and gave him some personality he could pass as a used car salesman.

      by ontheleftcoast on Tue Oct 16, 2012 at 09:25:46 AM PDT

      [ Parent ]

  •  There's an article in the October issue of the (13+ / 0-)

    AARP Bulletin titled "Being Observed - It can cost you plenty" on this very topic, It describes a work-around that some hospitals are using, namely not to admit patients, but to hold them overnight, sometimes for many nights, "Under Observation". For some reason, this is not the same as an actual admission and thus, if the patient returns, no readmission. Neat, eh.

    But here's the kicker: if a patient requires rehab following multiple days of observation, Medicare doesn't cover the rehab because Medicare requires three days as an inpatient before paying for rehab. According to the article, some patients have been stuck with rehab bills of up to $30,000 because of this.

    •  I had not heard of this before (4+ / 0-)
      Recommended by:
      Lujane, jbob, raincrow, lonespark

      Do you have any links? I'm interested in learning more about this. I had not heard of this.

    •  A friend of (4+ / 0-)
      Recommended by:
      PinHole, JanL, raincrow, lonespark

      mine in the industry told me of this practice. Medicare apparently won't pay out for observation and so the cost goes directly to the patient.

      •  "observation" has some legitamacy (8+ / 0-)

        I don't mean to defend the practice if this is really a loophole hospitals are using, but often observation is legitimate. Just for example, there are a lot of people who go to the ER for chest pain but are not having a heart attack. The only way to rule out a cardiac event is by observing enzyme levels over a period of time. If the patient's ECG does not show an acute event, the hospital will "admit" the patient for observation to monitor their cardiac enzymes for a period of time, usually about 24 hours.

        I have no defense to offer in the case that hospitals are "observing" patients that should really be admits simply to pad their statistics, though.

        •  So is this for hospital "admits"? or ER visits (1+ / 0-)
          Recommended by:


          I had an overnight a couple years ago, when the ER wasn't finished with checking out a possible cardiac problem. They technically didn't admit me to the hospital but sent me to the fourth floor "extension" of ER so they could do stress checks and second blood tests early the next morning.

          They did a good job and I was ok.

          Thank you for the informative article. I do see some possible problems for people with severe and complicated conditions.

          Who wants them? And where do they turn?

          Science is hell bent on consensus. Dr. Michael Crichton said “Let’s be clear: The work of science has nothing to do with consensus... which is the business of politics. Science, on the contrary, requires only one investigator who happens to be right,”

          by Regina in a Sears Kit House on Mon Oct 15, 2012 at 10:48:34 PM PDT

          [ Parent ]

          •  It, complicatedly, depends... (9+ / 0-)

            Different hospitals do things differently.

            To get into specifics, diagnosing a heart attack requires one of two things:

            1) S-T elevation on an Electrocardiogram (ECG). This is where they put stickers on your chest and extremities, and it measures the electrical output of your heart. The S-T segment of an ECG is the "refractory" period, essentially when your heart muscle tissue is returning to electrically neutral. S-T elevation seen on an ECG is called a STEMI: S-T Elevation Myocardial Infarction. It refers to what is seen on the ECG tracing in a patient experiencing a MI (Myocardial Infarction), the S-T segment of the waveform on the ECG starts above the baseline, electrically neutral period of the waveform.

            S-T elevation on an ECG is considered to be conclusive of a heart attack (MI-Myocardial Infarction). If you have S-T Elevation on your ECG, your very first stop is then the cardiac catheterization lab where they thread a catheter through your femoral artery (located near the groin) up into your coronary arteries, attempt to locate the blockage using active imaging techniques and radioactive dyes, and reopen the blocked artery with either shunts or balloons.

            2) Elevation of cardiac enzymes. In the absence of S-T elevation, the only way to rule out a cardiac event is by measuring the level of cardiac enzymes in the blood stream. As heart tissue dies, it releases specific, measurable proteins into the blood. If these show up as elevated in blood tests, the above mentioned catheterization procedures can be employed to save what heart tissue has not yet died, or bypass surgery can be performed to resupply otherwise starved areas of the heart. This is problematic, because these enzymes do not show up immediately. If the ECG is negative for STEMI, it is still possible that a person is having a heart attack, but it can take quite some time for the cardiac-related enzymes to show up in blood tests.

            This is why the observation period: if a doctor suspects or is concerned about a possible cardiac event, you may be admitted for quite some time for repeated blood tests.

            Interestingly, cardiac hospitals even pre-obamacare have increasingly been making units specifically for this type of observation. Its a common enough occurance, that a patient presents with possible heart attack symptoms without STEMI, that 24+ hour cardiac enzyme observation is warranted, but floor-type admission is not.

            So, it depends on the hospital... cardiac-focused hospitals will probably have an "observation" unit that is simply an extension of their ER. Hospitals that do not have a cardiac focus will admit those same patients as is typically understood as being an admitted patient.

            •  Some doctors have people wear Holter monitors (1+ / 0-)
              Recommended by:

              for 24 hours and then return them for the data to be read.

              Holter monitors are like long-term EKGs, instead of just a single snapshot they hold hours of data.

              "I believe more women should carry guns. I believe armed women will make the world a better place. Women need to come to think of themselves not as victims but as dangerous." Anna Pigeon

              by glorificus on Tue Oct 16, 2012 at 08:21:46 AM PDT

              [ Parent ]

              •  Yes, but (1+ / 0-)
                Recommended by:

                That is done to diagnose completely different and far less immediately dangerous conditions from a STEMI-- paroxysmal atrial fibrillation or other arrhythmias that are not always present. One would never give a Holter monitor to someone to rule out an MI.

      •  Observation status... (3+ / 0-)

        Has been around a long time (I retired 12 years ago and it was used then).  Medicare does pay for it, but under part B, not inpatient.  My husband was kept under observation just last week... After an ER visit for extreme high fever, they kept him to make sure it didn't come back after four hours.  

        Used correctly, it works quite well in certain situations.  It is not appropriate however, to keep someone three days in observation.  The rule was when I was working, a fairly strict "24" hours, then discharge or admit formally.  

      •  It works just the other way around for me (2+ / 0-)
        Recommended by:
        catwho, lonespark

        -- I'm still in the under-65 workforce with AETNA PPO health care insurance. Each time someone one of my most beloved dies, I somaticize the symptoms of a major heart attack. I can't help it and, considering my family history, I dare not ignore it, so about every 6-8 years I end up in the E.R. on the treadmill.

        The last time it happened, they kept me in the E.R. "under observation" for 18 hrs so it would be paid for as an emergency visit. I paid only a $50 copay and the emergency doc's fee. If they had admitted me, I'd've had to pay the E.R. copay + hospital co-pay + 10% of all doc, facility, and testing bills, which would have been a serious chunk of cash.

        !! Four more years !!

        by raincrow on Tue Oct 16, 2012 at 09:30:53 AM PDT

        [ Parent ]

  •  Well written (7+ / 0-)

    and informative Diary.  Thank you for raising awareness of this particular issue.  

    The Affordable Care Act will continue to be improved over time -- which was one of the arguments in favor of an incremental approach to improving national health care coverage.  

    Perhaps one day, we'll progress to universal coverage as a matter of right.

  •  It is important for hospitals to be thinking (6+ / 0-)

    about quality of care and long-term outcomes, and if this penalty will lead to innovative action by hospitals to follow up with their patients, everyone will benefit.

    It is far cheaper (and more effective) for a hospital to provide a few home health visits to ensure patients are OK than to re-admit through the ER.

    It is regrettable that this needed to be done, but the explosion of executive compensation in many private, "non-profit" hospitals has seemingly put the $ ahead of the patient.

    NC-4 (soon to be NC-6) Obama/Biden 2012

    by bear83 on Mon Oct 15, 2012 at 09:31:42 PM PDT

  •  Imagine if we all had Medicare! N/T (2+ / 0-)
    Recommended by:
    raincrow, lonespark
  •  Could that create a terrible incentive (4+ / 0-)

    to deny necessary readmissions?

    I recently had a very bad reaction after being sent home after a lumbar puncture (spinal tap).  By that night I was experiencing a crushing headache and nearly constant vomiting.    I don't know that I could have made it to the doctor's office the next morning for follow-up, my sister came over that night, took me to the ER, and triage whisked me through to readmission.  With these penalties in place, would I have been able to get readmitted?  If not, what would have become of me?

    Ever get the feeling you've been cheated?

    by ActivistGuy on Mon Oct 15, 2012 at 09:53:31 PM PDT

    •  I can only give a little assurance.. (10+ / 0-)

      when a person is having a legitimate medical emergency, the medical professionals you encounter (whether first responders, emergency medical, or in hospital emergency department), there is absolutely no concern, not a single thought, given to compensation. What I mean to say is that, as an ambulance worker, if you are having a medical emergency, I will treat you. I do not care if you have insurance, I do not care if you can pay the bill my company will send you, and to be honest, my company does not really care either, because uncompensated care is already worked into their profit calculations.

      As I wrote in another post in this thread, the entire breadth of the field insists that a person in distress must receive assistance. Medical ethics demands it, taught from the very beginning of medical school, and the law demands it, including the patient's bill of rights, as well as medical malpractice tort in every state in the nation. Any thought given to compensation before care is easily dismissed by the accountants: lawsuits from medical malpractice would far outweigh the 1% to 3% reduction in medicare reimbursement rates.

      •  Deep breaths everybody... (4+ / 0-)

        the penalty is for higher than average readmit rates, not a penalty for every single readmission. Let's say the national average for readmission is 5%, Hospital A has a readmit of 10%, Hospital A gets dinged(from my understanding) for the "overage", the 5% they are over. Admittedly, the way the law is written, it does not take every possible scenario for those overages into account(no legislation could) This is where CMS and it's regulations come into play. I can think of no scenario, none where any hospital admissions clerk would be given the power to "shut the door" if a patient would bring them to 5.1%

        Bigotry is the disease of ignorance...Education & free discussion are the antidotes of both. Thomas Jefferson

        by RiverCityMadman on Mon Oct 15, 2012 at 11:42:05 PM PDT

        [ Parent ]

        •  Gotcha. Yes I'll breathe BUT (0+ / 0-)

          you can bet that HCA et al. have or soon will have near-real-time statistics, and will shave where they can by discouraging a certain number admissions and readmissions. Where there is a shave-to-save incentive, that invisible hand and its invisible supercomputer will be there.

          !! Four more years !!

          by raincrow on Tue Oct 16, 2012 at 09:34:43 AM PDT

          [ Parent ]

    •  Headaches from spinal tap (0+ / 0-)

      I Am Not A Doctor

      But I'll relate an experience I had.

      My SO had a spinal tap and was experiencing persistant severe headaches. Eventually her physician ordered what he called a "blood patch"

      To the best of my limited understanding the headaches are caused by a reduction in pressure in the cerebro-spinal fluid.  The blood patch involves taking a small amount of the patient's own blood and injecting it into the spinal cavity in the lower back. The blood coagulates and forms a temporary blockage.

      In my GF's case, the pain went away like flipping a switch.

      Perhaps a doctor reading this could comment on the accuracy of my recall?


      We are the principled ones, remember? We don't get to use the black hats' tricks even when it would benefit us. Political Compass: -6.88, -6.41

      by bmcphail on Tue Oct 16, 2012 at 09:18:47 AM PDT

      [ Parent ]

  •  Geisinger Health System provides guarantee (16+ / 0-)

    The Geisinger Health System in Pennsylvania implemented a program several years ago that provided a 90-day warranty on elective heart surgery, promising to get it right the first time, for a flat fee. If complications arise or the patient returns to the hospital, Geisinger bears the additional cost.

    It worked so well (Heart patients have fared measurably better, and the health system has cut its bypass surgery costs by 15 percent) that the guarantee was expanded to other procedures.

    Here's the kicker as reported in the 2009 WaPo article about the Geisinger guarantee - the guarantee only applies to patients who have Geisinger health insurance because other insurers won't support it:


    But its success has been limited. Geisinger also treats patients who are insured by other companies, and those insurers are not convinced that the savings would be large enough to make it worthwhile for them to renegotiate contracts with the health system. Many still feel more comfortable with the traditional pay-per-procedure approach, even though they run the risk of having to pay thousands of dollars to fix surgeries that go wrong.

    Most hospitals are also skeptical of Geisinger's innovation, saying they would lose money by being unable to bill for treatment of patients who must return.

    Geisinger achieved this the way many companies achieve results - by identifying best practices.


    For heart bypass surgery, Geisinger guarantees that every patient will receive 40 action items it has identified as best practices. The list includes, for example, properly administering antibiotics within 30 minutes of the operation. The wrong dose increases the likelihood of infection, and infection can lead to a second surgery, prolonged hospitalization and greater risk of death.

    Surgeons can opt out of doing any element if they give a reason, and an operation is canceled if a single step is missed in the preparations. Electronic medical records contain built-in reminders for the surgical team and track the results.

    The outcome:
    . . .Geisinger patients spend less time in intensive care, go home sooner and experience fewer complications. The in-hospital death rate on elective heart surgeries has dropped from 1.5 percent to zero.

    Health System Program That Guarantees Doing Things Right the First Time, for Flat Fee, Pays Off

    Hospitals undoubtedly will need to change their practices and that's not a bad thing. I think the Geisinger success shows it can be done in a way that actually improves patient care and has a financial benefit.

  •  It may want some tweaks (1+ / 0-)
    Recommended by:

    as we see how it plays out, but I think it's an excellent idea. Like cost-plus accounting in aerospace, sometimes the intent of your billing and payment system ends up gamed to the benefit of the biller and to the detriment of the patient and the payor.

    For example, some of the planned readmissions are currently planned as readmissions precisely because the hospital can bill more for a second, separate procedure.

    It will be hard to make it perfect, maybe impossible, but the status quo isn't acceptable.

    Fry, don't be a hero! It's not covered by our health plan!

    by elfling on Mon Oct 15, 2012 at 10:09:43 PM PDT

  •  I enjoyed reading your diary..... (2+ / 0-)
    Recommended by:
    elfling, raincrow

    you gave me a lot to think about.   It's an idea whose time has come.  It may have rough spots, but only by implementing it will appropriate workable solutions surface to improve it.

  •  Thanks for giving us the heads-up, btw (3+ / 0-)
    Recommended by:
    Odysseus, elginblt, raincrow

    I think it's really valuable for us all to know about new provisions in advance so that we're prepared to explain them in discussions.

    Fry, don't be a hero! It's not covered by our health plan!

    by elfling on Mon Oct 15, 2012 at 10:24:17 PM PDT

  •  I have to echo UnaSencer's comment here: (8+ / 0-)

    I am still struggling to get back to my chronic illness state of normal.

    I have been into ER at various hospitals approximately eight times since June 20.

    The difficulty was unimaginative and limited ability for either primary care or ER docs to figure out what was really going on.

    I got responses of "you look fine", "labs are all normal" to nueropsych which really messed me up in two different hospital systems.

    What was happening? I was increasingly and more rapidly reacting to food I ate, no matter the type or category.

    By the time I hit the door of an Enviromental Medicine doctor I was moving into the third week of no food and becoming allergic to water also.

    The answer? Mast cell activation. The solution? an inexensive plant-based med, used for inflammation in Europe, and prepared by, oh so bad, compounding pharmacists. It is the first level response I needed from the beginning, but no one caught it or understood. I am alive thinks to luck and a doc who has fought hard to take care of very sick patients. Often he has had to fight his own professional colleagues.

    Tomorrow I go to my previous infectious disease doctor who has treated me for Borreliosis (disparagingly called Lyme Disease in the US), Bartonella and Babesia, in Washington DC.

    Getting here I had another episode on the airplane, but thanks to the attendants was able to breathe oxygen and take more meds while we headed this way.

    Infection of the Vagus nerve by Borrelia can lead to inflammation of the GI tract, which is what I am struggling with. It is the likely cause of my current severe reactions, which will most likely resolve with proper use of anti microbials including antibiotics.

    I have been in remission previously and expect to be again.

    In this series of events based on these new rules, I can see easily not being admitted or reseen by ER in the same hospital more than once.

    There  is a real lack of coordination with care after ER and often no tools for the hosital to use to follow the patient or to be sure specialists or a team could sort through the likely scenarios for a very sick person.

    Yes I am one of those ignored and dumped patients.  When you are really sick the last thing on my family's or my mind is suing the last bunch who blew it. We are working hard to find the one medical professional who is practicing the art of his/her profession and trying to bring me back to the world.

    I have a bit of a reprieve, but every bite of food is an excursion into the unknown.

    I go to another doctor tomorrow who has fought long and hard for his right to help very sick patients, using methods and easily available meds that work. He also has had to fight his own colleagues. But we both join in the fight to get me back to health once again.

    Science is hell bent on consensus. Dr. Michael Crichton said “Let’s be clear: The work of science has nothing to do with consensus... which is the business of politics. Science, on the contrary, requires only one investigator who happens to be right,”

    by Regina in a Sears Kit House on Mon Oct 15, 2012 at 10:37:59 PM PDT

  •  Important detail missing...otherwise a great intro (8+ / 0-)

    The CMS Quality Improvement Organizations (QIOs) are initially gathering 30-day readmission data for ONLY three diagnoses: heart failure (HF), pneumonia, and acute myocardial infarction (MI). CMS identified these diagnoses as recurring culprits when it comes to preventable readmissions.

    So it's actually NOT true that the full range of readmissions are subject to the penalty.

  •  This SO would have helped my mom who needed to (1+ / 0-)
    Recommended by:

    be 5150'd long before she was and kept re-entering the hospital.

    She would have gotten better care, more quickly.

    202-224-3121 to Congress in D.C. USE it! You can tell how big a person is by what it takes to discourage them. "We're not perfect, but they're nuts."--Barney Frank 01/02/2012

    by cany on Tue Oct 16, 2012 at 12:04:24 AM PDT

    •  I should add that the third to the final time she (1+ / 0-)
      Recommended by:

      entered the hospital, she was, in fact 5150'd.

      The next time was for a blood transfusion.

      The final time, she was put in hospice.

      202-224-3121 to Congress in D.C. USE it! You can tell how big a person is by what it takes to discourage them. "We're not perfect, but they're nuts."--Barney Frank 01/02/2012

      by cany on Tue Oct 16, 2012 at 12:05:24 AM PDT

      [ Parent ]

  •  Excellent diary, Radical Parrot, very (2+ / 0-)
    Recommended by:
    LI Mike, raincrow

    informative, but I remain a little confused about one point, and maybe you can help clear it up for me. From my perspective as the wife of one who's been hospitalized several times in the last 5 years, it has been the physician not the hospital making the dischharge decision. Can you distinguish between these two roles for me?

    Eliminate tax breaks that stimulate the offshoring of jobs.

    by RJDixon74135 on Tue Oct 16, 2012 at 03:08:44 AM PDT

    •  Are the physicians not part of the hospital (1+ / 0-)
      Recommended by:

      system? Specific physicians are contracted with hospitals, which gives them rights and responsibilities. You can't have any doctors unaffiliated with the hospital come in a treat you. The hospital is responsible for making sure the doctors they contract with are doing their job.

    •  Doctors apply for admitting privileges (1+ / 0-)
      Recommended by:

      They are considered separate contractors that use the physical plant on behalf of the patient.  They bill separately.  This can include the Emergency physicians.

      Mayo Clinic uses a different model.  Physicians are employees of the facility rather than outside contractors.  Some hospitals, as I write, are moving to the Mayo model.  Physicians entering practice are finding this an attractive alternative to maintaining a separate office.  Even if their income is less, their overhead is less also and they can generally count on having a life outside of work.

      Don't look back, something may be gaining on you. - L. "Satchel" Paige

      by arlene on Tue Oct 16, 2012 at 06:06:24 AM PDT

      [ Parent ]

    •  Absolutely the doctor discharges the patient (1+ / 0-)
      Recommended by:

      but hospitals have quality review and quality assurance professionals reviewing charts, making suggestions, etc.
      The QR/QA staffs are hospital employees.

      The way to do this is retrospective reviews. If, for example, the cardiology program has 10 cardiologists on staff and 9 of those cardiologists discharge patients with an avg length of stay of 8 days, but one doctor keeps his/her patients for 20 days you review with the dr what's up with you extra 12 days on avg.

  •  Good diary, not a good provision (1+ / 0-)
    Recommended by:

    This is one of the bits of the ACA that is filled with unintended consequences and is too broad. The problem they're going after is narrow, and the measure is very, very, very gross.

    It seems to be a replica of HMO's and their habit of penalizing hospitals for "keeping patients too long, on average." If Kaiser Permanente decides that open heart patients should be out of expensive care in two days, then, even if you have a la carte gold plated care, you will find yourself at home with a bottle of Tylenol 3 for the bone pain on day 3 (the day when you start to hurt). There are numerous -- and I mean numerous -- potential complications in the recovery period, and having sternotomy patients in cars is one of those things that might be nice for the HMO, but it's not nice for medical outcomes.

    In other words, the HMO's established "networks." For a hospital to qualify, it had to have its averages for all patients fit draconian averages decided by actuaries. This changed all health care to that level, or worse.

    This ACA provision will either lead to greater expense by extending stays (to prevent readmission) or fictions and work arounds like ambulatory centers and a larger in-home industry (which will be, like hospice under W., unregulated). Of course, making the law clearer was impossible with only half a Congress willing to even extend faith.

    If money is the root of all evil, then what is Mitt Romney?

    by The Geogre on Tue Oct 16, 2012 at 03:41:34 AM PDT

    •  I'm confused, first you complain that HMO's forced (2+ / 0-)
      Recommended by:
      The Geogre, raincrow

      hospitals to shorten stays leading to worse outcomes, then you complain that the ACA provision will lead to greater expense by extending stays.

      I can say from personal experience that I wish they had kept my husband a little longer when he was in a few weeks ago after a heart attack. If they had maybe they would have figured out that the shiny new blood thinner they gave him was working too well and prevented the stroke (and re-admission) it caused.

      Fortunately the stroke did not cause lasting damage but he is now on anti-seizure meds until the blood in his brain clears. And he's also now on a well known, long used blood thinner.

      I do agree that the law needs improvement, but as you say that has been known from the start.

      •  "Too long" will be as bad as too short (1+ / 0-)
        Recommended by:

        Imagine the conflict between HMO and Medicare for hospitals.

        The HMO networks are not going anywhere. If anything, they'll get stronger. They put hospitals on accountant medical care, and this is evil. A hospital thus treats for averages, and surgeons will not take on surgeries that will lower their averages. The effects are evil.

        Medicare will encourage longer stays that will increase the costs to the ACA governmental plans. This may enbolden "cost cutters" who like to point out how "efficient" the free market is, or it may mean that hospitals develop work arounds, per above.

        The genuine medical good will be sacrificed either way to the demands of non-medical forces.

        If money is the root of all evil, then what is Mitt Romney?

        by The Geogre on Tue Oct 16, 2012 at 07:46:46 AM PDT

        [ Parent ]

    •  The problem with your scenario is that (2+ / 0-)
      Recommended by:
      The Geogre, raincrow

      hospitals are paid under a prospective payment system. Meaning, they are reimbursed for the stay, not for the length of stay. Each patients medical diagnosis, treatment, complications, comorbidities are run through an algorithm and grouped into a "Diagnosis Related Group."

      Hospitals extending stays to prevent readmits run the risk of several things:

      * Incurring more costs than you will be reimbursed through the DRG system.

      * Exposing the patient to nosocomial (hospital acquired)infections.

      •  I completely agree with you (1+ / 0-)
        Recommended by:

        This is why I believe the actual result will be work arounds that are not medically satisfactory. My greatest fear is more cowboy crap like hospice was 2003 - 8. When small towns had more hospices than churches or groceries, there was profit being made.

        The hospitals will either be forced into a schizophrenic position where they go into two-tiered treatment, or they will offload their Medicare patients after the current (minimal) stay onto a provisional center staffed with PA's that can be a non-admitting center.

        In other words, by taking a wide path to a narrow problem and failing to address the way that private insurers are able to control medical practices, they can distort care in unintended ways.

        If money is the root of all evil, then what is Mitt Romney?

        by The Geogre on Tue Oct 16, 2012 at 07:51:35 AM PDT

        [ Parent ]

  •  "safety net hospitals" (2+ / 0-)
    Recommended by:
    LI Mike, raincrow

    Sounds like Kings County Hospital Center to me - that place has been struggling for a while.  This article makes some very good points.  The intent of the bill was good in this area, but the articulation of the policy is a bit off.  Here's to hoping we can improve on it going forward.

    Keep up the great work. :-)

  •  When does Medicare for all kick in? (4+ / 0-)
    Recommended by:
    LI Mike, raincrow, enhydra lutris, ancblu
  •  Great diary Radical Parrot (2+ / 0-)
    Recommended by:
    raincrow, Chance the gardener

    Also kicking in this month is ACA's Value-based Purchasing Program, i.e., those hospitals that shine on certain quality outcomes get bonus payments. $815 million available.

    You can check it out here

  •  Needs Fixed (1+ / 0-)
    Recommended by:
    Fiona West

    These stats are just too inaccurate to run the program. They need to do something like tie them to average rates for the type of illness the patient has and count different major reasons for admittance as not "readmission".

  •  One thing I find shocking is... (4+ / 0-)

    how soon hospitals send home patients. Years ago, a woman who just gave birth stayed in the hospital for almost a week. There she rested, bonded with her child and learned how to care for the child.
    Surgery? That too used to be something where you would stay so they could change wound dressings and monitor your progress to ensure you wouldn't have a problem.
    My roommate is having reconstructive surgery on her heel (Achilles tendon with accompanying bone spur, etc.) and will be home the same day. THE SAME DAY. Whatever happened to at least an overnight stay?
    I realize that so-called modern medicine is mainly patch 'em up and get them gone, but I wonder how much of that is due to costs as far as what insurance will pay.

    I don't know the answer, but perhaps some folks need a day or two more that might ensure they won't be back due to complications.

    Isn’t it ironic to think that man might determine his own future by something so seemingly trivial as the choice of an insect spray. ~ Rachel Carson, Silent Spring ~

    by MA Liberal on Tue Oct 16, 2012 at 07:53:58 AM PDT

    •  All my surgeries have been fast. (0+ / 0-)

      Reduction of dislocated bones with screw inserted and K-wires through the skin? Slap a cast on that and home that afternoon.

      All three kids; in around eight, birth around noon, home around seven pm.

      Thyroid, take half of it out, slap a drain in and send her home.

      Tubal ligation? In at eight, out at four.

      When you come to find how essential the comfort of a well-kept home is to the bodily strength and good conditions, to a sound mind and spirit, and useful days, you will reverence the good housekeeper as I do above artist or poet, beauty or genius.

      by Alexandra Lynch on Wed Oct 17, 2012 at 09:20:01 AM PDT

      [ Parent ]

  •  RadicalParrot (2+ / 0-)
    Recommended by:
    raincrow, Fiona West

    Thank you for one of the best written articles on healthcare  administration I have seen.

    Very informative, in simple terms, but carries a clear and yet concise message.



    What is this I hear of sorrow and weariness, Anger, discontent and drooping hopes... Life is too strong for you-- It takes life to love Life

    by Nebraska68847Dem on Tue Oct 16, 2012 at 08:25:22 AM PDT

    •  Agreed. This level of detailed, specific (0+ / 0-)

      information is helpful in getting a grasp of the scope of ACA and all the issues it is grappling with.

      RadicalParrot did a great job.

      --------------------- “These are troubling times. Corporation are treated like people. People are treated like things. …And if we ever needed to vote, we sure do need to vote now.” -- Rev. Dr. William J. Barber

      by Fiona West on Tue Oct 16, 2012 at 10:31:33 AM PDT

      [ Parent ]

  •  Wow, this conflicts 180 degrees w what a (0+ / 0-)

    friend's mom has just been told by the health care team treating and rehabilitating her husband after a stroke.

    I just came from said friend's office, distressed because his dad's treatment team has told them that:

    (1) Fines are about to kick in that will penalize over-cautious/premature admissions, for instance, admission to test for suspected pneumonia that turns out not to be pneumonia; i.e., hospitals will be discouraged from admitting patients until they are unequivocally sick. My friend's family was told nothing about penalties for readmissions.

    (2) Changes to Medicare in November will remove all subsidies for home health care, so my friend's dad will have to begin paying 100% out of pocket for home physical therapy, home vital signs monitoring, and someone to come 2X/week to bathe his dad. His dad will still be eligible for outpatient treatment, but that means this elderly couple will have to drive to the hospital 2-3 times a week instead of help coming to them.

    I don't know what to think about this; don't have time right now to research the super-fine print so will have to pursue it later.

    * * * * *
    The above aside, the readmission rules in your diary sound in part like a backdoor reduction in Medicare payments to hospitals (posed as a fine) for return chemotherapy and other treatments. Moreover, it seems to me any readmission penalty will provide a perverse incentive for hospitals to discourage admission of the sickest patients.

    !! Four more years !!

    by raincrow on Tue Oct 16, 2012 at 09:15:04 AM PDT

  •  I just went through this (1+ / 0-)
    Recommended by:

    While I was in the hospital for another complaint, the radiologist found a 1cm tumor in my liver that appeared to him to be malignant.  I asked that the hospital, with fresh diagnostics, suck that little sucker out and biopsy it.
    Instead, they waited 4 months and my little guy grew to 5cm and had 5 sibling.  They removed only the first one and I will come back at some time in the future and they will check the others, because the one was not cancer.
    The failed part of this whole thing is that I do not go to the hospital when I should because I know I will only get a partial treatment.

  •  admitting for observation (0+ / 0-)

    Thank you for this excellent diary.

    I read this article in the AARP news recently warning readers on Medicare to be aware that they may not be 'admitted' but rather 'observed,' even for days in the hospital in an effort to skirt the new readmissions portion of the ACA.  

    In addition, being admitted as an outpatient or for observation is charged to Medicare Part B  instead of the normally charged Part A and can place the patient at risk of massive out of pocket expenses.  

  •  The world runs on incentives (0+ / 0-)

    Provide an incentive to reduce readmission then the rates of readmission will be reduced.  There are, of course, forseeable repercussions.  Worst case scenarios are cycling patients among hospitals so they don't show as a statistic (is this possibility addressed? I don't know).  If we had a legislature actually interested in patient care and citizen well being then the law could dynamically adjust to the issues as they develop.  I don't have that confidence but we need to reign in cost of care and improve effectiveness of care.  ACA is a great first step.

    The third-rate mind is only happy when it is thinking with the majority. The second-rate mind is only happy when it is thinking with the minority. The first-rate mind is only happy when it is thinking. A. A. Milne

    by Memory Corrupted on Tue Oct 16, 2012 at 09:55:26 AM PDT

  •  Related (1+ / 0-)
    Recommended by:

    I got out of a hospital and was put on a visiting nurse.

    That guy found that my blood count and blood pressure were both dropping. He went through some effort to get me readmitted. When my blood count was tested at readmission, all the medical personnel agreed that I was in an emergency condition.

    Later, I learned that this nurse was evaluated -- negatively -- interms of how many readmissions his patients got. I'm quite thankful that he didn't let that influence him.

  •  Everyone must be above average!! (0+ / 0-)


    -9.63 -6.92
    Fox News - We Distort, You Deride

    by rick on Tue Oct 16, 2012 at 11:10:44 AM PDT

  •  An example of why this needs fixed: (0+ / 0-)

    Memorial day:  I got tired of the spicy-food heartburn issue that had plagued me all weekend.  I called my doctor's on-call line, got through to his intern, and --- after listing the symptoms, was told to go into ER.  20 minutes later, an EKG readout confirmed that I was actually experiencing a heart attack.  Further tests showed multiple blockages in both the left anterior descending and left circumflex arteries.  In short, I had a problem.  Now, I've got enough hardware in me to give airport security the heebie-jeebies....

    About the time I was assigned a room, there was a guy being discharged who had been in for diabetic issues related to severe obesity and oh-so-wrong dietary habits.  It didn't help that family and friends kept sneaking junk food into his room.

    Two days later --- on Wednesday --- he was back in.  He had gone home after being told by not one, not two, but three different doctors that he had to change his diet --- but it turns out that his first stop after being discharged was an all-you-can-eat buffet.  He and his friends/relatives had decided they knew better than the medical professionals.

    Do you punish a hospital for this kind of patient arrogance?

    I count even the single grain of sand to be a higher life-form than the likes of Sarah Palin and her odious ilk.

    by Liberal Panzer on Tue Oct 16, 2012 at 12:13:46 PM PDT

  •  Correct me if wrong (2+ / 0-)
    Recommended by:
    cocinero, indres

      I read the HHS info a few weeks back and HHS is trying to cut down the re-admission rate relative to institutions current re-admission rate.   There is not a national standard, and some hospitals, including rural locations are exempt.
        In short, this is not a "one shoe fits all" criteria.

        I've been outside the DRG billing info for a few years, but before I retired, new DRG codes for complications increase not decrease the reimbursement rates.

        Also not talked about was the upgrade to ICD10 coding which will not take affect for a couple of more years, but will improve clarity into a patient's diagnosis.

        The consternation about the delay in changing from ICD9  to ICD10 is that having the time, money and staff to reprogram all hospital billing departments to reflect the much expanded 10 system.

         Changes of that magnitude is not a task done over-night.   A change in a large institution with a number of trained professional billing coder's takes 2 or so years...small hospitals lack that expertise, for a whole variety of reasons.

         Every situation is different, but what many would see it recycling of patients to SNF for 3 days and then re-admitted.   Individuals will have stories, good and bad, but not addressing the problem because it is hard should not be the reason not to try and improve healthcare.

         Many progressives complain about lack of action on climate change, etc...not fast enough....and then we complain when a change comes with a variety of N=1 variations on a theme.   The point being that this is not a surprise to  healthcare systems.   If they haven't considered a plan  through their quality / risk management departments - shame on them.

  •  Re-admission rates? (0+ / 0-)

    Is that really an appropriate focus? And should that statistic be a basis for punitive funding reductions? The goal should be better health outcomes at lower cost.

    I heard some of these same concerns from a hospital worker when I was canvassing. (She plans to vote for Romney.)

    Somehow, this reminds me of No Child Left Behind where the statistic was standardized test scores -- not whether children are learning what they need to know and be able to do. There have been and still are a lot of undesirable, unintended consequences from NCLB. I hope HHS will continue to listen to hospitals' concerns and tweak the law as needed to improve health care and slow the growth in cost.

  •  Readmission rates can LOOK much worse (2+ / 0-)
    Recommended by:
    KenBee, indres

    than they are, if a hospital fails to exhaustively document all of a patient's diagnoses at the time of admission, EVERY time.    If someone has a long laundry list of serious chronic health problems, it does not always strike hospital staff as a good use of time to make a NEW list of all those problems EVERY time they come back in.

    But it is now essential for self-protection, otherwise the hospital looks bad when it turns out that yes, the patient still has many serious health problems.  Thorough and extensive coding, is the only way for hospitals to protect themselves against excessively severe readmission penalties.  

    I think such penalties make sense, and we need them -- but the devil can be in the details.  Allowing carry-over of coding done within the previous 3 months, would be a huge saving of duplicative effort.  

    "The extinction of the human race will come from its inability to EMOTIONALLY comprehend the exponential function." -- Edward Teller

    by lgmcp on Tue Oct 16, 2012 at 01:24:42 PM PDT

  •  This is what I love about this place. (1+ / 0-)
    Recommended by:

    It's a one-stop shopping place for useful fact-based information.


    "The fears of one class of men are not the measure of the rights of another." ~ George Bancroft (1800-1891)

    by JBL55 on Tue Oct 16, 2012 at 02:04:10 PM PDT

  •  I am a true blue Democrat. I am also (3+ / 0-)
    Recommended by:
    KenBee, Amber6541, lgmcp

    a registered nurse.  I DO NOT support this policy.  People get sick, people relapse, people have unexpected complications.  This is not a good policy.  

    Expose the lies. Fight for the truth. Push progressive politics. Save our planet. Health care is a right, not a privilege.

    by lighttheway on Tue Oct 16, 2012 at 03:36:32 PM PDT

  •  We had this happen to us (3+ / 0-)
    Recommended by:
    KenBee, indres, Amber6541

    Wife had an asthma attack around midnight ... probably not life-threatening, but bad enough to go to the ER.

    ER doc screwed up her prescriptions and gave her something that made the attack worse. She landed in the hospital for 5 days.

    So something that should have been handled for probably under $2000 ended up being way way more. I forget the exact numbers (thankfully we have good insurance from my job) but I'm pretty sure it was over 15,000.

    "What could BPossibly go wrong??" -RLMiller "God is just pretend." - eru

    by nosleep4u on Tue Oct 16, 2012 at 09:22:12 PM PDT

  •  Is there any way to make an appeal? (1+ / 0-)
    Recommended by:

    This policy sounds like it needs some fine tuning.  I hope that once it is put into practice the awareness of the faults of the system will be easily observed and corrected.

    Mother Teresa: "If we have no peace, it is because we have forgotten that we belong to each other."

    by Amber6541 on Wed Oct 17, 2012 at 08:36:04 AM PDT

  •  ohh the humanity (0+ / 0-)

    how are the poor billionaire hospitals ever going to survive... America's favorite past time... feeling sorry for the billionaires

  •  As a physician its good in theory, but (0+ / 0-)

    awful in practice.  The problem is with "care managers" who are basically nurses who are shills of the insurance companies/hospital administration who really only think about the bottom line.

    Hospitals/Insurers want patients to be admitted for the least possible time and use "care managers" to pressure the admitting physicians to discharge patients ASAP - even if the patient may benefit from a more prolonged admission.  The key is, if the patient can walk, go to the bathroom and eat on his/her own - he/she is safe for discharge.

    Often times, when patient's are discharged home prematurely, they "bounce back" to the hospital within a few days - with pneumonia, a urinary tract infection or some other complication.

    For a patient, the transition from the care of a hospital to home is quite difficult. Right now, hospitals do not prepare patients properly for their continued recovery/healing at home and often times, due to poor instruction, patients do the wrong things and end up putting themselves at risk for complications making it more likely that they need to be readmitted.

    A little further investment in educating patients properly about how to ensure proper care at home will do wonders to decrease the "bounce back" rate.  Getting rid of the culture where "care managers" continuously pressure physicians to discharge patients ASAP will help by allowing patients a little more time to fully understand how they best can continue caring for themselves at home when they leave the hospital.

  •  how to battle the " turn down patients" meme (0+ / 0-)

    In a refreshingly well reasoned exchange with an elderly moderate Republican (does not like but still voting for Mitt) the "ACA will hurt seniors because the 768 billion in savings negotiated already has hospitals and DRs already refusing new patients" talking point (talking paragraph?) came up. "this will hurt seniors"

    Any pointers on rebutting this? I used my standard "didn't like the sausage that got made but there had to be a step in the right direction" line along with "the only people I've heard complain about UK national health are US citizens" (which is true and I have friends all over the UK). I'd like more, not that her vote will matter (she ain't in Ohio or Fla) but to get the ammo out there into the social media sphere for friends in Ohio, Florida etc ...

    If you didn't like the news today, go out and make some of your own.

    by jgnyc on Wed Oct 17, 2012 at 12:38:48 PM PDT

  •  Family members should also be paid (0+ / 0-)

    If they are going to spend much time taking care of the patient, just as if it were someone not related taking care of them.

    That way they can survive with some dignity while doing the very important work.

    Women create the entire labor force.

    by splashy on Wed Oct 17, 2012 at 09:46:07 PM PDT

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