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Mo. hospitals focus on patient poverty in CMS readmissions penalties

revolving door



For Kaiser Health News

Christian Hospital says its costly difference of opinion with Medicare hinges on how to count the large number of poor people that the St. Louis hospital treats.

Medicare penalizes hospitals that readmit too many patients within 30 days of discharge, and Christian expects to lose almost $600,000 in reimbursements this year, hospital officials said. Christian is one of 14 hospitals in the BJC HealthCare System.

Steven Lipstein, chief executive of BJC, which includes Barnes-Jewish Hospital in St. Louis, said Medicare doesn’t play fair because its formula for setting penalties does not factor in patients with socioeconomic disadvantages — low-income, poor health habits and chronic illnesses for instance — that contribute to repeated hospitalizations.

If Medicare did that, Christian’s penalty would have been $140,000, Lipstein said.

As every hospital executive knows, half a million dollars pays for “a whole lot of nurses.”

In total, hospitals around the country lost $420 million last year under Medicare’s Hospital Readmissions Reduction Program, an initiative of the federal health law that seeks to push hospitals to deliver better patient care.

Since the program began in 2012, “recent trends in readmissions suggest that (it) is having the desired impact,” Health Affairs reported in January.

Hospitals have lobbied Congress and Medicare to change the rules and gained some ground May 18 when Rep. Patrick Tiberi, R-Ohio, introduced a bill in the House to adjust Medicare’s program to account for socioeconomic status. The bill was co-sponsored by Rep. Jim McDermott,  D.-Wash.

Meanwhile, the Missouri Hospital Association is trying to pull public opinion behind it.

This year, the association overhauled its consumer Web site, Focus On Hospitals, to include not only the federal readmissions data, but also each member’s readmissions statistics, adjusted for patients’ Medicaid status and neighborhood poverty rates.

The federal government already adjusts its readmissions data for age, past medical history and other diseases or conditions, and that’s public on Medicare’s Hospital Compare Web site.

The association explains its adjustment methodology in an article on the site. “There is emerging national research that suggest poverty and other community factors increase the likelihood a patient will have an unplanned admission to the hospital within 30 days of discharge,” it states.

The hospital group’s alternative data — Lipstein’s source for how Christian could have reduced its 2015 penalty — comes from a study it commissioned. One finding: Missouri hospitals’ readmissions rates improved by 43 to 88 percent when patients’ poverty levels were considered.

“The question is, has [readjustment] been done in a just and fair way,” Lipstein said. The Missouri Hospital Association “has provided methodology that suggests what the Feds are doing is unfair.”

The controversy over penalties is likely to grow beyond the readmissions question. Federal health officials have announced that they want to shift from paying doctors and hospitals based on the services they provide and move toward a value-based system that encourages a better quality of care and better outcomes while controlling costs.

Medicare bases penalties on readmissions on the care of Medicare patients who were originally hospitalized for one of these five conditions — heart attacks, heart failure, pneumonia, chronic lung problems and elective hip or knee replacements.

This year, Medicare penalized almost half of all hospitals — 2,592 to be exact — for excessive readmissions. More than 500 were fined 1 percent of their Medicare payments, or more, for the fiscal year that will end Sept. 30.

Still, the system harms so-called safety-net hospitals most, said Herb Kuhn, the Missouri Hospital Association’s president.

“Hospitals in difficult neighborhoods are getting worse scores, and those in affluent [ones] are getting better. It’s time to adjust [rates] for the disease of poverty,” he said.

Kuhn’s experience makes him an influential voice on health-policy issues. He was deputy administrator of the Centers for Medicare & Medicaid Services from 2006 to 2009 and before that, director of the agency’s Center for Medicare Management. In April, Kuhn completed a three-year term on the Medicare Payment Advisory Commission, which advises Congress.

The commission proposed an alternative to Medicare’s readmission penalties last year. Others are also studying modifications.

The Centers for Medicare & Medicaid Services has taken a cautious stance, but last year CMS announced it is working with the National Quality Forum, a nonprofit group whose research influences CMS’s quality metrics, on a trial to test socioeconomic risk adjustment.

But Leah Binder, CEO of the Leapfrog Group, a nonprofit patient safety group, says Medicare’s readmission penalties have pushed hospitals to improve care and adjusting the data for patients’ poverty levels could deter them.

“Hospitals are paid a lot of money. I think they can find a way to handle their readmissions, the way they should have been handling them all along,” Binder said.

Who pays the bill for a medical mistake?


For Kaiser Health News

When Charles Thompson of Greenville, S.C., checked into the hospital one July morning in 2011, he expected a standard colonoscopy. He never anticipated how wrong things would go.

Partway through, a doctor emerged from the operating room to tell Thompson’s wife, Ann, that there had been complications: His colon may have been punctured. He needed emergency surgery.

Thompson, now 61, almost died on the operating table after experiencing cardiac distress. His right coronary artery required multiple stents. He also relies on a pacemaker. “He’s not the same as before,” said Ann Thompson, 62. “Our whole lifestyle changed — now all we do is sit at home and go to church. And that’s because he’s scared of dying.”

When things like this happen, questions arise: Who’s responsible? If treatment makes things worse — meaning that a patient needs more care than expected — who pays?

It depends.

Despite provisions in the Affordable Care Act that put added emphasis on quality of care, entering the hospital still carries risk. Whether because of mistakes, infections or plain bad luck, those who go in don’t always come out better. More than 400,000 Americans die annually in part because of avoidable medical errors, according to a 2013 estimate published in the Journal of Patient Safety.

In 2008, the most recent year studied, medical errors cost the country $19.5 billion, most of which was spent on extra care and medication, according to another report. If a problem such as Thompson’s stemmed from negligence, a malpractice lawsuit may be an option. But lawyers who collect only when there’s a settlement or a victory may not take on a case unless it’s exceptionally clear that the doctor or hospital was at fault.

That creates a Catch-22, said John Goldberg, a professor at Harvard Law School and an expert in tort law. “We’ll never know if something has happened because of malpractice,” he said, “because it’s not financially viable to bring a lawsuit.”

That leaves the patient responsible for extra costs. Ann and Charles Thompson maintain that he experienced an avoidable error. The hospital denied wrongdoing, she said, but the physician’s notes indicated  that they had been advised of the risks of the procedure, including injury to the colon.

The Thompsons tried pursuing a lawsuit but couldn’t find a lawyer who would take the case. The hospital and the doctor declined to comment, with the hospital citing patient privacy laws. Because of his heart problem, which led to the loss of his specialized driver’s license, Thompson lost his truckdriving job. He lost the health insurance he had through his job, depriving him of help in paying for follow-up care.

The couple paid close to $600,000 out of pocket, depleting their life savings. They struggled to pay other bills until Thompson was awarded disability benefits, his wife said. “You would expect if [health-care providers] make the mistake, they would make you whole,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on their record of preventing errors, injuries, accidents and infections. “But that is not what happens. In health care, you pay and you pay and you pay.”

There’s no single rule for how hospitals handle the cost of care when patients have bad outcomes and fault is disputed, said Nancy Foster, vice president for quality and patient safety at the American Hospital Association. Some hospitals have rules requiring that a patient be told right away if something happened that shouldn’t have and, to the best of the institution’s knowledge, why.

Typically, those rules stipulate that if the hospital finds that it erred, the necessary follow-up care is free. Hospitals may not have an obvious financial interest in admitting guilt, though research suggests that patients are less likely to sue when hospitals are transparent about medical mishaps.

“If the [need for further] care was preventable, we’re waiving bills,” said David Mayer, vice president of quality and safety for MedStar Health, which operates 10 hospitals in the Baltimore/Washington area.

Virginia’s Inova Health System has a similar policy, said spokeswoman Tracy Connell. Most hospitals don’t have such rules, said Julia Hallisy, a patient-safety advocate from California.

That may change: A number of professional and safety groups are urging more hospitals to adopt them. Supporters include the American College of Obstetricians and Gynecologists, the American Medical Association, Leapfrog, the National Quality Forum and the Joint Commission, which accredits many health-care organizations. The federal Agency for Healthcare Research and Quality is also on board.

But even when they tell patients that something went wrong, hospitals may say it was unavoidable. Then, patients often pay for the consequences, directly or through their insurance. Determining error can be straightforward, Mayer said, in such instances as misdiagnosis or operating on the patient’s left leg when his problem was with his right leg.

Other times, providers follow correct procedures but things go wrong. Then, hospitals can deny culpability. “Some things happen, and it’s hard to tell if it could truly have been avoided,” Binder said. If hospitals don’t agree to pay for unexpected care, employers might push them to do so because absorbing such costs might eat into the firm’s profits.

On average, a privately insured patient cost about $39,000 more — $56,000 vs. $17,000 — in hospital bills when surgery led to complications than when it did not, according to a 2013 study in the Journal of the American Medical Association.

People with employer-based insurance — 147 million Americans this year — who have experienced complications or otherwise gotten worse while in the hospital should contact their benefits offices, especially if they can show hospital error, Binder said. If that doesn’t pan out, insurance plans may step in.

When insurers add hospitals to their networks, they sometimes stipulate how to handle certain errors. For some mistakes, the hospital may provide necessary follow-up care for free, part of a “bundled payment,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group. For that to apply, complications must clearly stem from bad treatment. In other situations, patients can complain through the insurer, which should work with the hospital to determine who’s responsible.

Patients, Krusing said, shouldn’t pay for what’s out of their control. And if the hospital doesn’t provide financial assistance, insurance should cover these unexpected expenses once the patient has met his or her deductible.

“Patients don’t normally think about these issues — and who would? They don’t think of any of these issues until they’re right in the middle of it,” patient-safety advocate Hallisy said. “At that moment, they’re completely shocked and overwhelmed to think that this is how this works.”


Tug of war on physician assessment



By SHEFALI LUTHRA, for Kaiser Health News

When choosing a doctor, patients have long relied on the idea of board certification. It’s a stamp of approval meant to assure them their provider knows current medical practices.

But a rebellion among doctors over recertification requirements has put that stamp in flux, potentially complicating what patients can expect to know about their doctors.

The national credentialing organization has directed the 24 boards that oversee specific medical specialties, such as surgeons, anesthesiologists and internal medicine doctors, to toughen their requirements for renewal of board certification. But pushback from a number of doctors — especially internists — has sparked a debate in the medical community about the best way to evaluate what doctors know and how effective they are at treating patients.

Specialist and primary care doctors who want to stay board certified – a guideline hospitals and insurance plans often look to when evaluating a physician’s quality – already must pass a written exam every 10 years and take classes intended to keep them studying medicine. But the American Board of Medical Specialties is seeking to boost those efforts.

Following the ABMS guidance, the American Board of Internal Medicine last year moved to add a new component to its maintenance of certification program, requiring certified internists to provide information every five years about how they interact with patients and keep them safe. That was supposed to start this year. But the heavy criticism it elicited from a number of doctors led the ABIM to suspend the requirement.

Now, the board is starting over, soliciting more input, said Richard Baron, ABIM’s president.

All 24 specialty boards have been required to expand maintenance of certification. Internal medicine, which is the largest of the groups, is the only one so far to suspend its requirements. However, the Association of American Physicians and Surgeons, a trade group of private physicians that advocates limiting government influence on medical care and more independence for individual doctors, filed a lawsuit against ABMS challenging the recertification efforts in all specialties in 2013. The U.S. District Court in Chicago is weighing  the suit.

But while many internists have praised the ABIM decision to take a harder look at what’s required to maintain board certification, patient advocates have expressed concern that the move could potentially foreshadow a diminished focus on elements such as patient safety.

“ABIM is issuing a mea culpa to physicians, that they’ve held them to too many standards,” said Leah Binder, president of the Leapfrog Group, a nonprofit organization that emphasizes patient safety. “And I think that message has some hazards to it.”

More thorough standards for physicians are worth the effort, said Robert Wachter, a professor of medicine at the University of California at San Francisco who previously chaired ABIM and is now a trustee at the ABIM Foundation, the board’s nonprofit arm. The board, he said, correctly thought that “the public deserved and would want to know that physicians were doing more [to stay certified] than a process that they were doing for a few months every 10 years.”

The goal was to develop ways to assess patient care and patients’ perceptions of their doctors.

Physicians say, however, they were worried that, as proposed, ABIM’s requirements could be too cumbersome without effectively measuring quality. They would have been required to review old charts and paperwork every five years, collecting data to indicate what they had done in treating relevant diseases, as well as surveying patients about the level of care they received.

Doctors “viewed this as a significant burden – very time-consuming,” said Steven Weinberger, chief executive of the American College of Physicians, and at the same time, “they weren’t really clear that it actually improved the practices of medicine and the care that they gave to patients.”

And such criticism, Wachter said, convinced board members that “the methods we had to assess those things were too imperfect and too onerous to force physicians to do them right now.”

But some have said even the existing process is too expensive – completing the ABIM protocol for maintenance of certification, including the exam, costs about $2,000 every decade. Others have argued the exam doctors must take, for which the content is also being re-evaluated, isn’t always relevant, a qualm that could suggest it is not worth the energy and expense of completing.  For instance, a physician who works only with breast-cancer patients might still be required to demonstrate knowledge about prostate cancer, colon cancer or other forms of the disease.

“How relevant do you need to make the exam?” Weinberger asked. “Does the certificate say that I’m in fact competent in a broader area? It’s a very nuanced question.”

But despite these reservations, finding a way to somehow hold doctors accountable is essential when it comes to patient safety, Binder said.

“We are in an environment where there are so many significant problems in quality and safety in healthcare,” she said. “I hope they will turn around quickly and that the new standards they set will be more appropriate and at the same time tougher.”

The prevalence of organizations assessing doctors actually makes a strong board credential more important, Wachter argued.

“We wanted to create a process that we thought was appropriate and credible for the public” and that others could use as a gold standard for evaluating physicians, Wachter said.

And though continuing medical education (CME) programs  already exist, they aren’t a substitute for being certified, Weinberger said, especially given how relatively unstandardized the courses can be. “When you’ve seen one CME program, you’ve seen one CME program – they’re all very different in terms of what their goals are and how effective their goals are.”

Balancing physician and consumer needs can get tricky, Binder said, but effective and stringent standards are important given the significance doctors hold in patients’ lives.

“Physicians are an elite profession – one that is revered and admired by all of us,” she said. “And in return for that admiration and respect, I think, they should reassure us that they are holding themselves to very high standards.”

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