Georgia hospitals face the loss of hundreds of thousands of dollars in federal funding for having too many Medicare patients come back through their doors just weeks – or sometimes days – after being sent home.
Starting this month, more than 2,000 hospitals across the nation will be penalized for having too many discharged patients readmitted within 30 days as part of a massive effort to curb government health costs and improve the quality of care. Avoidable readmissions cost Medicare — the federal health program for people 65 and older — about $17 billion each year.
A lack of discharge planning and poor follow-up care lead to many unnecessary readmissions, experts say. The result: more tests, more treatments, more time away from home for patients and higher health care costs.
“We’re at the point where readmissions have been on our radar screen for over 10 years, and we still haven’t seen significant progress,” said Dr. David Goodman, director of health policy research at The Dartmouth Institute.
The Medicare penalty is part of the Affordable Care Act and will affect more than 70 hospitals in Georgia, according to an analysis by the nonprofit Kaiser Health News. Penalties will be calculated by comparing a hospital’s readmission rate against national averages, focusing initially on heart attack, heart failure and pneumonia patients.
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It’s just one of a number of financial challenges hospitals face.
Statewide, one-third of hospitals ended 2011 in the red, said Kevin Bloye, a spokesman for the Georgia Hospital Association. Starting this fiscal year, hospitals face up to a 1 percent penalty of their total Medicare funding if readmission rates are too high, followed by 2 percent in fiscal 2014 and 3 percent the year after that.
Nationwide, the average penalty is roughly $125,000, Bloye said.
For a large health system a small penalty may not have a big impact on its operations. But for a small rural hospital, even a half a percent loss in Medicare funds could be the difference between survival or shutting the doors, Bloye said.
Hospital officials say reducing readmissions is not as simple as just improving care within their own doors. Some patients can’t afford medications or simply don’t take them. Some don’t have a way to get to follow-up appointments with their primary care doctors or receive inadequate care at a nursing home or other facility.
“This policy lays all of the blame on the hospitals, and that’s just not right,” Bloye said
Georgia’s hospitals are increasingly working to help coordinate care beyond their walls.
WellStar Health System is among several metro Atlanta providers that have created transition coaches who help guide high-risk patients through the complex health care system. They make follow-up calls to answer questions and visit patients at home. They make follow-up appointments with family doctors and find transportation services in the community if patients need helping getting there.
It’s about improving patients’ quality of life, said Dr. Marcia Delk, WellStar’s chief quality officer.
“If we can save them a day of being in the hospital, that’s a day given to them to enjoy with friends and family,” Delk said.
At DeKalb Medical, patients can opt to have a one-on-one consultation with a Walgreens pharmacists and have medications delivered to their rooms before they even leave the building.
The readmission rate for patients with the bedside delivery program is 5.5 percent — just half of what it is for those who don’t opt for the program, said Jackie Paynter, DeKalb’s executive director of quality and care management.
Education for patients and family members is critical — and challenging, experts say.
Patients who are feeling sick and have been stuck in a bed for days are expected to learn about medications, dietary needs, physical therapy and more, said Dr. Mark Cohen, chief quality officer at Piedmont Atlanta Hospital.
“How can anybody be expected to learn this?” Cohen said. “Our traditional expectations for patients have been unrealistic.”
At Piedmont, doctors use what’s called the “teach back” method, which asks patients or family members to explain back to the physician what they’ve just learned as a way of helping them remember often complex instructions.
Steve Nestor has been in and out of hospitals and doctor offices for most of his adult life.
The 68-year-old Kennesaw man, who suffers from heart failure, ended up in the hospital yet again last December after his blood thinner medication got out of control.
Instead of just handing Nestor prescriptions and sending him home, medical staff sent him to WellStar’s heart failure resource center where he can go in for checkups, get blood tests and regularly talk to a nurse practitioner in person or over the phone.
Now, Nestor weighs himself religiously every morning, knowing rapid weight gain means he’s retaining too much water – a common problem among heart failure patients. If his leg starts swelling up, he knows to lay down and elevate his feet.
“With their wisdom and advice, I know what to avoid,” he said. “I know more about my own health than I ever did.”