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Mo. hospitals focus on patient poverty in CMS readmissions penalties

May 27, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , ,

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By LISA GILLESPIE

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.

Here’s the latest in CMS’s hospital-rating saga

May 19, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , , , , ,

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By JORDAN RAU

For Kaiser Health News

Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious.

The Centers for Medicare & Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. The delay came after a majority of members of Congress signed a letter supporting the hospital industry’s concerns.

Hospital leaders who previewed the preliminary rating system say that the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare’s Hospital Compare Web site. The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility’s rating.

Steven Lipstein, president of BJC HealthCare, a St. Louis-based nonprofit that runs 14 hospitals, said the ones in his organization that earned five stars were smaller, located in affluent areas and handled less complicated cases. “They don’t have comprehensive cancer centers, they don’t have major cardiovascular disease, they don’t have neuro-specialties,” he said.

BJC’s more advanced hospitals did worse, he said. “That’s not surprising when you look inside the ratings and see how they’re built,” he added.

Consumer advocates defend the rating system, saying that while not perfect, it correctly reflects higher rates of problems in some big institutions despite their lofty reputations. They worry that delay and congressional resistance are undermining Medicare’s attempt to help consumers select a hospital based on something more substantive.

“The star ratings hopefully will get quality into that decision-making process,” said Andrew Scholnick, a lobbyist for AARP, the advocacy group for seniors.

Medicare officials initially said they hoped to release the ratings to the public in July. But in a presentation to hospitals and other interested parties on May  12, they did not set a firm date.

Medicare already has made minor tweaks in the formula to calculate the stars, but it remains a tough grader, the presentation shows. If Medicare releases the star ratings in July, nearly half of the 3,658 hospitals being evaluated would be getting three stars, according to Medicare’s preliminary calculations. Just 100 hospitals would receive five stars, while 135 would receive a single star.

Officials indicated they were standing firm in their intention to eventually release the scores. “The Overall Star Rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare,” the presentation said. Officials plan to update the scores every three months through the end of this year and then twice thereafter.

The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments.

Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, nearly half of major teaching hospitals are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications. Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates.

Some health care researchers are also skeptical. “If you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they’re the bomb, there’s a disconnect,” said Ashish K. Jha, a professor at Harvard’s public health school. “If it completely contradicts everything you’ve known, you need to ask yourself, ‘Did I not understand the way hospital care works, or is there a problem with the metric?’”

Medicare’s move toward using star ratings is part of a greater focus on easy-to-grasp composite judgments of hospital quality. The Leapfrog Group, a nonprofit patient-safety group, uses report-card letter grades to characterize hospital safety based on many of the same individual measures as Medicare. Healthgrades, a Denver-based company, judges hospital quality with one, three or five stars. Consumer Reports calculates a safety score on a 100-point scale.

Medicare hopes that a star rating from the government will carry even more credibility.

“People need this information now,” Scholnick said. “Trying to wait until everyone’s 100 percent happy with everything just delays it further than it needs to be.”

Attention boards: Four big things to remember

February 9, 2016by Robert Whitcomb in Uncategorized tagged , , , , , , ,

 

This article in Hospitals & Health Networks looks at four areas that hospital boards must pay more attention t0 these days:

1. “Physician relationships and practice patterns: Hospitals increasingly are accountable for physician behavior as a result of the stiffening of Stark anti-kickback rules, widening provisions of the False Claims Act, exposure resulting from the Physician Sunshine Act and Medicare Physician Database, provisions in the Affordable Care Act that heighten scrutiny for physician business dealings and the trend toward physician employment.”

2. “Partnerships and affiliations: Every hospital regardless of size is attempting to reduce its operating costs and evaluating its future. These efforts invariably involve consideration of formal relationships with other hospitals and formal relationships with private insurers, outsourcing partners, technology suppliers and others. Hospital boards must know the details of each deal, how debt covenants and operations are impacted, and where there’s financial or reputational risk if the marriage hits the rocks.”

3.  “Performance risk: Historically, bread and butter operational functions like purchasing, business office operations and clinical documentation have been a key focus for hospital compliance efforts and rightly so. They’re complicated and costly, and where ethical or legal lines are crossed, whistleblowers are increasingly watchful. Adding complexity, the shifting of incentives from fee for service to value-based payments, is ripe for performance risk….”

4. “Reputation risks: ...How a {hospital’s} reputation is measured and its accessibility to outside parties including lenders and the community is increasingly more sophisticated. Achieving recognition on credible report cards, like those offered by U.S. News & World Report, Truven, Leapfrog Group and others is an important start, because their methodologies are credible. But access to data about a hospital’s clinical, operational and financial performance is expanding exponentially through social media and proprietary vendors. …”

 

Who pays the bill for a medical mistake?

November 10, 2015by Robert Whitcomb in Uncategorized tagged , , , , , , , , , ,

By SHEFALI LUTHRA

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.”

 

Lethal variability in surgical outcomes

March 12, 2015by Robert Whitcomb in Uncategorized tagged , , , ,

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An analysis shows that the probability of surviving any of four high-risk surgeries can vary by as much as 23 percent depending on the hospital,  Reuters reported today.

The report is by the nonprofit Leapfrog Group, a patient-safety organization supported by large employers, and Castlight Health Inc, which sells software for employers to manage healthcare spending.

Ashish Jha, M.D., of the Harvard School of Public Health, who was not involved in the Leapfrog report, told Reuters. “It’s amazing there is such variability in mortality from these common surgeries, and patients should know that.”

”Leapfrog asked 1,500 hospitals for 2013 data on four risky surgeries, including number of procedures and patient deaths. It adjusted the numbers to come up with a ‘predicted survival estimate for each,” Reuters reported.

”For pancreatectomy (removing all or part of the pancreas, usually to treat cancer), predicted survival rates ranged from 81 percent to 100 percent. Of 487 hospitals reporting data, 203 had rates of at least 91.3 percent, which Leapfrog chose as the benchmark for quality.”

”For esophagectomy (removing all or part of the esophagus), expected survival ranged from 88 percent to 98 percent. Only 182 of 535 hospitals had rates of at least 91.7 percent.”

”For repairs of abdominal aortic aneurysm, survival ranged from 86 percent to 99 percent; 268 of 792 hospitals met the benchmark of 97.3 percent.”

”For replacing the heart’s aortic valve, survival ranged from 92 percent to 97 percent; only 95 of 544 hospitals hit 95.6 percent.”

”The study didn’t analyze which kinds of hospitals – nonprofit or for-profit, in one region or another – excelled, but in general those that performed more procedures did best. National stalwarts such as Brigham and Women’s Hospital in Boston and the Mayo Clinic in Rochester, Minn.,  did well in all four surgeries, but so did Hoag Memorial in Newport Beach, Calif. and Morristown Medical Center, in New Jersey.”

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Vast differences in prices for knee, hip surgeries

January 25, 2015by Robert Whitcomb in Uncategorized tagged , ,

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A study  by the Blue Cross and Blue Shield Association shows gigantic price variations  across America for  the same kinds of knee and hip surgeries.

Will this new transparency lead to more equal and reasonable costs? We’d guess that since most insured patients are now being called upon to pay more of their medical costs as part of high-deductible policies, that there will indeed be price pressure — downward.

 

Erica Mobley, director of communications at the Leapfrog Group, an employer-backed organization that promotes healthcare quality, told Modern Healthcare that quality and safety measures have to be released in conjunction with price information.

”’Displaying cost information is great,’ Mobley said. ‘But it really is important that people and organizations who display this information think more than just cost.’ …”Blue Cross does rate higher quality providers for a handful of procedures, including knee and hip replacements,” Modern Healthcare noted.

Fine, still, indications are that patients will be most interested in cost of these common but very expensive procedures. Orthopedic surgeons may see their revenues fall substantially as a result of the new transparency, which  lets payers of all kinds finally  be able to do real comparison-shopping.

More and more patients will be traveling to the least expensive places for surgery. That means  that teaching hospitals  in some big cities may take a big hit in the next few years as the pricing gaps become vividly apparent.

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