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Hospitals to see Medicare payments tied more closely to readmission rates

Published: Sunday, Aug. 17, 2014 10:00 p.m. CDT • Updated: Tuesday, Aug. 19, 2014 8:53 a.m. CDT
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(Kyle Grillot – kgrillot@shawmedia.com)
Emergency Department social worker James Messerschmidt works to provide information Friday at Advocate Good Shepherd Hospital in Barrington on resources available for a caretaker who became ill while caring for another patient. Four years ago, the Advocate Health Care System rolled out a series of programs and positions designed to address the coming penalties hospitals would face if their readmission rates rose too high. Two of those positions include a case manager and social worker specifically targeting Medicare patients that come into the emergency room.

Scrolling through a slew of files stored on his desktop, James Messerschmidt looked for an updated list of home-care providers.

As the social worker specifically assigned to the emergency department at Advocate Good Shepherd Hospital, Messerschmidt's goal is to give his clients the resources they need to stay healthy back home.

The couple he was helping Friday afternoon landed back in the hospital after the husband found himself in excruciating pain. He wasn't taking as much care of himself because he was his wife's primary caregiver after a cardiac issue that brought her to the hospital not long before this visit, Messerschmidt said.

To make sure this cycle doesn't repeat itself, Messerschmidt is supplying the couple with information on home care to help with laundry and light housekeeping, as well as nonprofits such as Meals on Wheels.

The focus on readmissions – keeping patients who don't need to be admitted to the hospital out of it – started at Advocate Good Shepherd Hospital and its parent health care system, Advocate Health Care, about four years ago.

It was about the time that a lot of hospital systems were taking another look at the issue, nudged by the Affordable Care Act and an escalating penalty system that was being exacted on their Medicare payments.

Starting Oct. 1, the beginning of the 2014-15 fiscal year, health care providers will have the Medicare reimbursements they receive cut by up to 3 percent depending on their readmission rates.

The Centers for Medicare and Medicaid Services calculates how much hospitals are penalized based on their readmissions for patients that initially enter the hospital for pneumonia, heart failure, heart attacks, hip or knee replacement, or chronic obstructive pulmonary disease and return within 30 days.

Advocate Good Shepherd Hospital will see their payments dinged by about 0.02 percent, according to preliminary numbers released by the federal government. (Hospitals have a chance to review the numbers before the final ones are released in October.)

The only area the hospital saw too many readmissions was in the heart attack category, something the system's vice president of medical management, Dr. Barry Rosen, suspects could have tipped over into not meeting expectations by the lower number of cases in that area. Rosen is a part of the effort at Advocate Good Shepherd Hospital to reduce readmissions.

Centegra Hospital – McHenry will see its payments hit by 0.76 percent, and Centegra's Woodstock hospital will see its payments penalized 1.39 percent.

The discrepancies between hospitals aren't unusual, said Dr. Kumar Nathan, Centegra Health System's vice president of clinical effectiveness. Many hospitals within the same hospital system can see their readmission rates vary widely.

"The patients are different," he said. "That can involve the degree of illness, the average age of these patients and how they perceive the care they're going to get."

Like Advocate, Centegra has been working to address readmissions as well as other indicators of care quality such as hospital-acquired conditions and infections.

One issue Centegra was seeing was that patients weren't following up, Nathan said. They weren't scheduling an appointment with their primary physician or picking up their prescriptions.

To address that, Centegra now makes sure that if a patient needs to come back for an appointment within seven days, they leave with that appointment already scheduled, he said. Both hospitals also are having in-house pharmacies installed – to be open come January – to make sure patients get the prescriptions they need before they leave.

"We've taken the steps to do as much as we can," Nathan said. "We even call the patients back and check in to see how things are going."

Messerschmidt and his colleague – emergency department care manager Shelley Coleman – are doing follow ups, too.

They're also coordinating with physicians – at Advocate and at the primary care physician's office or long-term care facility – and developing care plans to make sure that when patients return to the emergency room, the staff knows what to do.

"You should ask a patient what it feels like to be in and out of the hospital over six months," Rosen said. "We've developed a system to address the sickest of our sick patients. Keeping them out of the hospital provides their highest quality of life."

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