Medicare is withholding more than $1 million from metro Omaha and Lincoln hospitals because too many of their patients returned to the hospitals within a month of being sent home.
Medicare officials, as part of an effort to curb rising costs, are taking aim at avoidable hospital readmissions, which they consider to be one of the biggest problems facing the country's health care system. Twenty percent of elderly patients are back in the hospital within 30 days of leaving, the federal Centers for Medicare & Medicaid Services say.
The penalties are one reason some hospitals are paying nurses to make follow-up home visits and set up doctor's appointments for patients — tasks that used to be left to patients' relatives or the patients themselves.
If someone is readmitted to the hospital so soon after being treated, it “means they have some problem that wasn't addressed or they developed a new problem at home,” said Susan Mende, senior program officer for the Robert Wood Johnson Foundation. Such readmissions, she said, “are really a quality and cost problem that very negatively impacts people's lives and wastes very precious health care resources.”
Readmissions for Medicare patients alone cost $26 billion a year, according to a foundation report, and more than $17 billion of that pays for return trips that don't need to happen if patients get the right care in the first place. The health insurance program for people age 65 and older is financed by U.S. taxpayers.
The total reduction in U.S. hospitals' Medicare reimbursements topped $280 million. Hospitals could lose up to 1 percent of their Medicare payments for fiscal year 2013, up to 2 percent for 2014 and up to 3 percent for 2015.
The government says its efforts to address the problem are paying off already: The country's hospitals had about 70,000 fewer readmissions in 2012, and the national readmission rate is estimated to have dropped to 17.8ápercent in October after averaging 19 percent for the previous five years.
Local hospital officials say they have been working hard to reduce the number of readmissions and say their numbers are improving.
Earlier this week, Maria Hackenberg, a home health nurse for Methodist Hospital, visited Dan Simpson in his home in Valley to make sure his blood was clotting properly after hip-replacement surgery.
Such patients are prescribed blood thinners after surgery to make sure they don't develop clots that could send them back to the hospital or even threaten their lives.
Simpson's blood was fine. The 50-year-old crane operator for Valmont reported that he also was following the directions he had been given at the hospital: “You can't cross your legs, you have to keep them apart and you can't bend past 90 (degrees).”
It will take awhile for hospitals' improvements to show up in the U.S. government database. The recent penalties were assessed for the qualifying readmissions that occurred between the beginning of July 2008 and the end of June 2011.
The government is penalizing hospitals with high rates of readmitting three groups of patients: those with heart failure, heart attacks and pneumonia. (That list is scheduled to expand in fiscal year 2015 to include patients admitted for treatment of a sudden worsening of chronic obstructive pulmonary disease symptoms and those admitted for elective total hip or total knee surgeries.)
In metro Omaha and Lincoln, the first round of penalties ranged from .01 percent of a hospital's Medicare payments to 1 percent, which translated to losses of more than $1,600 to around $350,000, depending on the hospital.
Three years ago, Methodist Health System convened a readmission task force to look at the care provided in the hospital, through home health providers and in the Methodist Physicians Clinics. Today, care coordinators make sure patients have doctor's appointments scheduled within three to five days of dismissal, said Ruth Freed, Methodist Health System's director of clinical alignment.
Nurses also call congestive heart failure patients and pneumonia patients within 24 hours of dismissal to see if they are taking their medications and to find out how things are going at home. In addition, they make sure the patients know which symptoms, such as weight gain for heart failure patients, are serious enough to require a call to their doctor.
Advanced practice nurses also accompany home health nurses on visits to the homes of some of the very ill, Freed said. They look for safety concerns, review the person's medications to make sure none would conflict with newly prescribed drugs and, if the person is a heart patient, check to see if there are lots of foods containing salt in the house.
Dr. Anton Piskac, vice president for performance improvement for Methodist Health System, said Methodist Hospital and Methodist Women's Hospital had 570 admissions for pneumonia in the years covered in the Medicare report. Within 30 days of their dismissal, 128 of those patients returned to one of the hospitals. If 17 fewer patients had returned during the 30-day window, Piskac said, the hospitals could have avoided the nearly $270,000 reduction in its Medicare reimbursement.
“It's not a small amount,” Piskac said. “Believe me, we notice that.”
Some of the responsibility for avoiding readmissions lies with patients or their families, said Mende, with the Robert Wood Johnson Foundation.
“When you are going to be discharged, have a written discharge plan,” Mende said. “Ask questions, and ask those questions again and again. Make sure you understand.”
The printed discharge report, she said, should list the person's medications, the reason the person was admitted, the type of surgery he or she had, any scheduled follow-up appointments and other details.
“We only can really control so much,” said Angela Ward, quality and ancillary services executive for Alegent Creighton Health. “What the patients choose to do when they leave is hard for us to control.”
Yet the hospitals try anyway, both to avoid penalties and improve the quality of care. Care managers and social workers on the nursing units in Alegent Creighton hospitals work with patients before they leave, and a pharmacist meets with patients to go over their medications. After the patients go home, one of 32 care coordinators from Alegent Creighton clinics checks up on them.
Ward said readmission rates in the system's hospitals have been “trending down very nicely over the last several years.”
Some of the readmission-reduction programs get federal help in the form of grants, but others don't. Methodist's Piskac said it's hard to determine how much the programs are costing, as they supplement efforts that already were in place. Whatever the cost, he said, it's the right thing to do.
It's not as if the government effort was the first to target readmissions. Hackenberg, the Methodist home health nurse, said she has visited joint-replacement patients in their homes for years.
The patients at highest risk for readmissions are those with chronic medical conditions, especially if the person is on multiple medications or has no safety net or family support at home, said Dr. Stephen Smith, the Nebraska Medical Center's chief medical officer. As part of a program the med center has with the Visiting Nurse Association, a health coach visits people after they are discharged to make sure they stay healthy.
Sydney Smith, a certified nursing assistant who works as a VNA coach, met this week with Dan Ostergard at his central Omaha home to review his medications. Ostergard, 56, was diagnosed with Type 2 diabetes after being admitted to the med center in early May with pneumonia.
Smith had Ostergard write in a small book the name of each medication, the dosage, the reason for taking it and whether it was new to him or not. He then could take the book to his doctor's appointments.
Ostergard knew what each drug did and why he was taking it. His job is to help organize estate and moving sales, so he's good with details.
Smith asked Ostergard to set a personal goal, medical-related or not. He said he hoped to adhere to a more healthy lifestyle and reduce stress. “I've been notorious for burning the candle at both ends for quite a number of years,” he said, “and see where it's gotten me.”
In Lincoln, representatives from hospitals, skilled-care centers and home health providers meet quarterly to talk about how they can improve care providers' handoffs of patients, said Pat Hoidal, director of performance improvement at St. Elizabeth Regional Medical Center. Under federal rules, she said, “We will have to function as one long continuum. We will have to build strong relationships with each other.
“We tolerated the readmissions in the past. Clearly it's not the right way to be delivering services.”
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|Metro Omaha, Lincoln hospitals assessed penalties|
|Hospital, funds and penalty withheld (up to 1%)|
|Bellevue Medical Center||$30,000*||. 32%|
|Bergan Mercy Medical Center||$12,907||0.03|
|Creighton University Medical Center||$2,185||0.01|
|Immanuel Medical Center||$18,373||0.11|
|Methodist Women's Hospital||$269,435||0.42|
|Nebraska Medical Center||$350,000*||0.38|
|St. Elizabeth Regional Medical Center||$284,000||0.6|
|* approximate totals|
|Omaha, Lincoln hospitals not assessed penalties|
|In Omaha: Midwest Surgical Hospital,|
|Nebraska Orthopaedic Hospital, Nebraska Spine Hospital.|
|In Lincoln: Bryan Medical Center,|
|Lincoln Surgical Hospital and Nebraska Heart Hospital.|
|Sources: The hospitals, Kaiser Health News|