Penalizing local hospitals for excessive readmissions causes controversy

Columbia-area hospitals that readmit an excessive portion of patients after discharge have been denied hundreds of thousands of dollars in payments under the Affordable Care Act.

University of Missouri Health Care lost about $454,000 in reimbursements for Medicare patients since the federal Hospital Readmissions Reduction Program began in 2012. Boone Hospital Center lost $99,300. Jefferson City-based Capital Region Medical Center, an affiliate of MU Health Care, lost more than $28,500 according to information provided by each hospital.

The program took effect in October 2012 as part of the ACA each fiscal year. the Centers for Medicare & Medicaid Services computes each hospital’s portion of patients readmitted within 30 days after discharge and determines whether that was excessive. If it was, Medicare fines the hospital by reducing payments when the federal fiscal year begins in October.

Missouri hospitals are estimated to lose more than $14 million through inpatient payments in FY2017 with the maximum payment reductions for each hospital being 3 percent based on the Readmissions Reduction Program analysis.

More than half of the hospitals in Missouri have been penalized five years in a row since the program began according to a report published by Kaiser Health News and CMS.

Dave Dillon, spokesman of the Missouri Hospital Association, said that hospitals serving poor patients who use Medicaid tend to be penalized more under the program.

“Patients may not have access to care locally like a primary care physician. They may not have access to transportation for follow-up appointments. They may not have access to healthy food. All of these factors can be important to whether they need to be readmitted within 30 days,” Dillon said. “By penalizing hospitals that serve those people who are social economically disadvantaged, you are taking away the resources that are necessary for the hospital to extend out into the community to do that work.”

However, in the latest version of Hospital-Wide All-Cause Unplanned Readmission Measure released by the CMS in March 2015, socioeconomic status was disqualified as a risk adjustment variable. The measure only adjusts for age, principal discharge diagnosis and concurrent diseases. More recently CMS said, in a final rule for hospital payments, that it excluded socioeconomic factors because it did not want to deter hospitals from improving the outcomes of disadvantaged patients.

Area hospitals are trying to improve care and prevent excessive readmissions.

MU Health Care has been losing payments every fiscal year since FY 2014. Capital Region Medical Center has been penalized five years in a row since the policy was implemented in 2012.

Boone Hospital Center is one of the eight Missouri hospitals that have only been penalized for excessive readmissions in two fiscal years out of the last five.

Leslie Duckworth, manager of clinical quality, patient safety and infection prevention at the hospital, said that the partnership with private physicians not employed by the hospital to improve communication with patients as they leave plays an important role in controlling the number of readmissions. Physicians at Boone Hospital Center usually update private physicians to the status of the patients and medication changes during their visit before discharge.

Another part of the hospital’s discharge planning, according to Duckworth, is educating patients during their stay. Some patients are asked to recite back what the physicians have suggested to ensure that they understand the instructions.

“If we’re talking about something in very medical terms, jargons that’s not familiar to the layperson, we have to be very conscientious that our patients understand what it is that we’re trying to teach them about their own care,” Duckworth said.

MU Health Care has had program to reduce readmission rates since 2013 according to Jennifer Coffman, senior strategic communications consultant. The program is dedicated to addressing factors including patients’ adherence to medicine schedules, understanding of necessary care and follow-up care after leaving the hospital.

As a safety net hospital system, MU Health Care serves low-income patients regardless of their ability to pay, but patients who are at greater risk for avoidable readmissions are identified based on a data-collection process that includes socioeconomic status.

Capital Region Medical Center relies more on specific medical professional and social workers to reduce readmissions.

Manager of case management Jamie Wilson said that the hospital has a case management team comprised of case managers, nurses and social workers to identify patients’ needs. They collaborate with both in-house and community-based physicians to conduct assessments on specifically on patients’ most recent stay when they are readmitted.

“We have a case manager and a social worker on each of our three care units determined by different levels of care,” Wilson said. “They work together to make sure that we’re meeting patient needs.”