Posts Tagged Medicare penalty

Complications after Surgery — blame or improve?

carrot-stickThe long and difficult training for surgeons often leaves them with little intrinsic drive to improve surgical care.  Anyone who has had to discuss surgical quality with practicing surgeons is lucky to leave the discussion without a fear of losing their job.  So, with little intrinsic drive to improve quality, the government and insurance companies resort to the old carrot and stick methods.

For surgeons the carrot and stick are financial.   So, if a surgeon and associated hospital have patients that are readmitted within 30 days the hospital is penalized — the hospital is unhappy and verbally passes that unhappiness on to the surgeon.

A study just published “Underlying Reasons Associated With Hospital Readmission Following Surgery in the United States” expresses surgeons’ negative opinions of the penalty saying it really won’t have much effect on surgeons — wow, what a stonewall attitude!

The argument is based on the findings that surgical patients return to the hospital because of an infection where the skin was cut or because of bowel problems from pain medication.  Somehow, the surgeons writing the article seem to think complications, coming to light after the patient leaves the hospital, are beyond their control — so the hospital should not be penalized.  In other words, complications are and ACT OF GOD.

Wrong answer!  Patients, families, insurance companies and Medicare do not want to further enrich surgeons and hospitals for bad outcomes.  A much better answer would be to double the efforts to improve quality and reduce complications and to have surgeons spend more time out of the operating room figuring how to improve surgery in the operating room.

Admiral David Farragut is attributed with the phrase “damn the torpedoes, full speed ahead” — was he really a surgeon in disguise?  We all know intrinsic motivation (dedication and innovation)  is much more effective than extrinsic motivation (carrot and stick).   Intrinsic motivation comes from training programs that place emphasis on quality and downplay personal profit.

The solution:  surgeons should be employees of the hospital (an ACO model) so they personally feel the financial pressure to minimize costly complications — not just watch as the hospital is penalized.  And, improve post-graduate surgical training to have more emphasis on quality.

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Hospital Re-admission — do phone calls help?

Jphoneust calling a patient on the phone does not prevent patients from being re-admitted!

Hospitals are very interested in preventing a patient from returning to the hospital (called a re-admission) within 30 days from discharge due to the financial penalties from Medicare.

For example, if a patient is hospitalized with a serious problem called congestive heart failure (fluid retention that causes shortness of breath) the hospital will be penalized financially if the patient gets the condition all over again and has to return.

The government idea is to force hospitals to be more accountable — it’s like a 30 day guarantee from an auto repair shop!  So hospitals are looking for ways to improve their performance (and avoid paying money).

There is no question frequent visits to a physician can reduce re-hospitalizations.  However, a recent hospital study found that hospital nurses who talked to patients before discharge and who called them after discharge did not help the readmission problem — in fact there were more re-admissions!

a)  How can this be?

b) Do well meaning nurses actually make the problem worse?

c) Does this mean hospitals should not be penalized?

The answers are: a) bad science b) yes  and c) no, perhaps they should be penalized more!

The “bad science” part is because there was no intervention to adjust medications or treatments that might prevent readmission.   A hospital nurse only has one option for a telephone  intervention:  “you better get checked at the ER”.  The conclusion from the study should have been stated “chatting with a patient does not prevent re-admission” — brilliant deduction.

The outpatient care provider’s  office is where action can be taken to stop re-admissions.  That’s where medications can be prescribed.  If the hospital wanted to prevent re-admissions they should have made an appointment and given the patient a coupon for a taxi ride to and from the outpatient office.   This is not rocket science.

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Hospital Re-Admissions — the revolving door

revolving door

Hospitals have ignored the obvious problem of patients returning to the hospital soon after discharge.   Decades of re-admissions have enriched hospitals — same charges over and over.  Now re-admissions for heart attacks, heart failure and pneumonia lead to Medicare penalties.  The problem is widespread and as always worse in some parts of the country.

Pneumonia Readmissions

The above graph comes from a an excellent Medicare study.  It show a high rate of re-admission after pneumonia in some areas (dark blue).  It should come as no surprise that some hospitals have been able to quickly drop the re-admission rate by 20% (because they were not trying very hard before).

Why did hospitals not care?

  • Re-admissions were profitable
  • Avoiding re-admission was considered an outpatient problem
  • It was the patient’s fault for not taking the medications they were prescribed at discharge (no matter what the cost).
  • Hospitals have no control over outpatient doctors.

What changed?

  • Dr. Donald Berwick cared.  He was the administrator of Medicare who initiated the penalties.
  • Hospitals purchased doctor practices — so now they really do control the outpatient doctors and thus assume a greater responsibility.
    •  Over 75% of cardiologists work for hospital systems
    • Over 50% of primary care work for hospital systems
    • Many health systems operate visiting nurse services.
  • Hospitals have no excuse for failing connecting discharged patients with primary care (they own primary care)
  • Hospitals have no excuse for failing to engage patients in heart failure clinics (they own cardiology).
  • Hospitals must take an interest in what medications are prescribed at discharge — the right medications and generic medications if possible.

What can patients do to cut the odds of re-admission?  According to a report by Jason Kane of PBS there are 7 things a patient can do:

  1. Work with the hospital to plan ahead (days before discharge)
  2. Understand your illness and ask questions about your health care
  3. Have a written discharge plan
  4. Understand your medications
  5. Don’t go it alone
  6. Follow through with follow-up care
  7. Find out how good the care is in your community for patients leaving the hospital.

A word of caution:  just because you have been re-admitted, it does not mean you need to be on hospice care — indeed that will stop re-admissions but perhaps not the way you want (dead patients don’t return).

Your ace in the hole:  strong primary care.  The hospital team MUST communicate with primary care — make sure they do.  A quick follow-up appointment and several short interval appointments will help to get back on track with the management of chronic illnesses.  If you were just in the hospital for a heart attack, congestive heart failure or pneumonia (or other chronic conditions) an appointment in 6 months is totally inappropriate.

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