NEW HANOVER COUNTY, NC (WECT) - One of the biggest challenges facing hospitals today is figuring out how to keep patients out of them.
Healthcare spending in the United States has grown to $2.9 trillion, according to the
. In an effort to control escalating costs and improve the overall quality of care, the Affordable Health Care Act is targeting what it considers excessive and unnecessary hospital readmissions.
Medicare patient readmissions add up to about $26 billion every year. Of that, $17 billion is for return visits that could have been avoided with proper care either inside or outside the hospital, according to CMS.
has been in effect for three years and since it's inception, has hit thousands of hospitals with more than $200 million in penalties annually. New Hanover Regional Medical Center is now one of them.
“We are being held accountable for the care being done outside the walls of the hospital,” said Terry McDowell, Administrator of Emergency Transport Services.
This new standard is in addition to several others Medicare monitors on a hospital's performance. In fiscal year 2015, the Readmission Reduction Program cost NHRMC $942,000 in lost revenue reimbursements from Medicare.
As part of the Affordable Care Act, the reduction program went into effect in 2012. Initially, if a Medicare patient was admitted for either a heart attack, heart failure or pneumonia and was readmitted within 30 days, it was a strike against the hospital's reimbursement. The penalty applies whether the readmission was for a problem caused by the hospital or the patient.
Readmissions occur for any number of reasons. Some cannot be avoided while others are due to insufficient care in the hospital, confusion of new drug regimes, inadequate follow-up or lack of support at home.
In addition, the penalty program includes readmissions that are not only for the same condition that originally put them in hospital care but also for any other condition imaginable.
That means that if Patient A has a heart attack on Day 5 and two weeks later gets into a car accident that sends him back to the hospital, it's still a strike against the hospital's record.
CMS set a national standard by which all hospitals were measured against. This included a ratio of “predicted” to “expected” readmissions, multiplied by a national rate. The lower the ratio, the better performance rate.
“I think we probably knew too, if you had been looking at the tea leaves that we would end up taking a penalty,” said McDowell.
In assessing a hospital's ratio and subsequent penalties, CMS uses hospital readmission data that dates back to 2010 – before Obamacare was even in effect.
“Even if you made significant improvements in 2015 there may be a year in that three-year data set that's really dragging you down, that you really weren't even focused on,” McDowell explained.
NHRMC has adopted new programs and policies to lower their susceptibility to future penalties, but the rules of the program continue to change. Today, Medicare looks at five different conditions under the penalty system (up from the original three) and can now levy penalties against each individually.
COPD and total knee/hip arthroplasty have been added to the list.
The maximum value of the reimbursement reduction has also increased each year. Originally, hospitals were penalized with 1 percent maximum on the value of their Medicare reimbursements. That value has risen to a maximum of 3 percent.
"They've changed how they're calculating everything and I'm sure they will in the future," admitted McDowell. "It's not our job to chase that if we can put things in place that manage all populations."
Rather than focus specifically on those readmissions, NHRMC has adopted the policy to treat every condition as though it was being monitored. That means every unnecessary and unplanned readmission gets a closer look.
After not being penalized in the first two years of the program, NHRMC took a near-million dollar loss. Penalties that about 80 percent of hospitals nationwide also burdened.
But the Wilmington area bares the heavier load of one eyebrow-raising aspect of the program – treating tourists who become patients.
If a visitor is admitted to NHRMC for any one of the five conditions Medicare measures, goes home and within 30 days is admitted to a different hospital for any condition (unplanned), NHRMC's record still gets a strike.
“If you had done everything right in the hospital and they had all the right tools on the outside you're saving Medicare close to $10,000,” explained McDowell. That's the average cost of caring for a patient who is admitted to the hospital, according to Medicare.
CMS publishes annual reports on the efficacy of the program. Some areas of care have improved under the changes while others have depreciated. With only three years of data history, it may be too early to predict the long-term impact of the program.
Once concern is any change to the number of “Observation Stays” a hospital starts tallying in response to the penalties. While in observation, doctors use short-term treatments and assessments to determine whether a patient should be admitted or discharged. A decision that should be made within 24 hours and rarely any longer than 48 hours.
Concern remains that hospitals will keep patients in observation to avoid adding to their tally of admitted patients. Nationwide, Medicare reports that there has been a small increase in these types of stays.
NHRMC says such finagling of files and classification is simply not done at their facility.
So what are hospitals doing to combat unnecessary readmissions? One of several ways involves something called Community Paramedics. Think of it as mobile medication - bringing treatment into your home.
Monday at 11, WECT's Casey Roman explains Community Paramedics and how the program is helping the hospital avoid costly Medicare penalties.