Chuck Newcomb: Medicare readmission policy penalizes hospitals, but patients could be next

December 1, 2012 

Have you or a loved one been admitted to a hospital recently?

Perhaps good ol' Uncle Joe got pneumonia and had to stay a few days to get some antibiotics.

When he was discharged, was he given instructions about taking medications or was he told to make an appointment with his primary care physician?

As of Oct. 1, hospitals will be penalized if poor Uncle Joe has to be readmitted within 30 days. This is part of the Patient Protection and Affordable Care Act signed into law in 2010.

More than 2,000 hospitals across America will lose 1 percent of the Medicare reimbursement for services based on their performance from 2008 to 2011. The penalty increases to 2 percent the second year and 3 percent in 2015.

In the past, hospitals actually made out pretty well financially if someone returned within a short time because their insurance would foot the bill whenever the patient was being treated. The idea of the new rule is to have the acute care facility do a better job with care and to make sure the patient continues to follow doctor's orders when at home.

A study in the New England Journal of Medicine in 2009 found that "almost one fifth (19.6 percent) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0 percent were rehospitalized within 90 days."

Most of those readmitted within the month had apparently not been seen by the doctor as an outpatient.

Unfortunately for the hospital, Medicare rules don't distinguish between preventable relapses and those that would have happened regardless of the care a patient received. The rules also don't account for planned readmissions.

Medicare rules acknowledge the poverty factor in readmissions, but hospitals that serve the poor and indigent are expected to perform just as well as those in other communities since doing anything less would be the equivalent of having lower standards of care for the poor. Poor patients are less likely to have insurance, a family physician and the ability to afford medications that can prevent relapses. So these hospitals have a greater burden to follow up with patients and ensure they comply with the lifestyle and medical changes that doctors prescribe.

So hospitals will have to change their discharge procedures to be sure patients know what needs to be done to improve their health after discharge, and they will also have to somehow follow them home and make sure they are taking their pills and making their doctor's appointments.

Some of the questions health care providers will need to ask are as follows:

Has the patient's discharge summary been sent to the doctor?

Does the patient understand what he or she needs to do after leaving the hospital?

Has an appointment with his or her primary care doctor been scheduled?

Does the patient have a way of getting to the doctor's office?

Hospitals certainly can do a better job with discharge planning, but patients and their families or care providers should also be held accountable for their own care at home. As health care dollars get even tighter and those making the rules look for more creative ways to save money, patients may find themselves not able to get some of the care they need because they didn't follow the rules.

It may start with foregoing treatment for COPD because they refused to stop smoking. Or perhaps they will not be eligible for heart surgery because they did not stay within an acceptable weight.

Eventually, the rules may include withholding cancer treatment because someone is too old and would not be living much longer anyway.

For now, the responsibility falls on the hospital to make sure their patients comply with discharge plans.

Chuck Newcomb, MS, RD, CDE is a consulting registered dietitian currently providing medical nutrition therapy services for Memorial Hospital Los Banos. He has a masters of science in clinical nutrition from New York University. E-mail questions to the Attention of ChuckRD at:

MHALosBanos@SutterHealth.org or on his website MySmartRD.com.

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