Enloe penalized for high readmission rates

On the front page of the Oroville Mercury Register I found this story, “Oroville Hospital hit with maximum penalty under new Medicare requirement.”

When I read through the story, posted below, I found Enloe had also been penalized, but no front page story in the ER?

Apparently, Medicare is now penalizing hospitals who have to readmit too many patients because they’ve become ill again within 30 days of leaving the hospital.

Tom Petersen, executive director of the Association of California Healthcare Districts, says, “The hospital doesn’t have the ability to control behavior outside the hospital.”

But I don’t think that’s the problem – I think these hospitals are discharging too early because of inadequate insurance. That’s just my bet, based on my family’s experience. When a local hospital found out my family was “inadequately” insured, they discharged our patient over a week ahead of the man in the next bed, who had the same condition, but was an executive with Raleys, and had a monster insurance package.

I was shown how to dress the surgical wound by a doctor who greeted me by saying, exactly these words, “I am operating on limited amounts of sleep,” then started jabbering away about the song she heard on the radio as she’d driven over from the out-patient center. She was very nervous – her hands were shaking. I remember wondering, “do you actually operate on people in this condition?”

We were sent home with some gauze, a bottle of wound dressing (a medicated cotton strip that is inserted into a surgical wound to keep it open so you can watch the healing), and a bag to collect the “discharge” from the wound. We were instructed how to empty and clean that bag regularly, and what color the discharge should be. Then she told us to check with her in a month at the outpatient center. Before she left, she said to me, really sternly, shaking her finger at me, “If his face shows discoloration or he has any pain around that surgical wound, you get him in that car and get back to the ER!”

The doc also gave us prescriptions for the strongest antibiotics you can get. In fact, the pharmacist called me over to the window to question me – “are you sure? These are usually administered in the hospital.” I told her, that’s what the doctor gave us, and yeah, our patient was “real sick.” She just rolled her eyes and went back to fill the bottles.

The guy in the next bed was there for another week and a half. Meanwhile, our patient was almost completely disabled for the first week. I performed nursing duties, in fact, I had  been travelling every day to the hospital to help out anyway. Our patient told me they never answered the button, they’d leave him laying there for the better part of an hour having to go to the bathroom, or without water. The whole stay was a nightmare – food that smelled and tasted like warmed over shit, lights turned up at night, constant noise over the intercom that trumpeted through the rooms. It was emotionally traumatizing. We wanted him out of there, but the way they threw us out – we were afraid he’d die, and nobody down there would give a flying fuck at a rolling do-nut.

Well, apparently, that is a common problem, and apparently, not everybody has a family member or friend  available and able and willing to do nursing duties.  It takes a lot of confidence for an untrained person to take on these tasks that could mean life or death, be responsible for knowing when to “get him in that car and get back to the ER!” Our experience was draining, physically and mentally, and then we were left to deal with the billing department. They demanded immediate attention, sick person or not.  Of course we were able to “deal” down the bill, but it was still a financial broadside, and worse – we never knew what caused the illness, or whether our patient was “cured.” The doctor was very tight-lipped when she gave him his last exam – she just yanked the tube out of his wound, applied a Band-Aid, and went to get a nurse to clean up the blood on the floor. We never saw her again.

I’m fairly certain that without support our patient would have  had to stay at the hospital or would have gotten sick at home and had to have  been re-admitted. This is a world where too many doctors don’t care about what happens to you after you are out of their sight, as long as they get that money. In our conversations with our doctor it was clear, she was outright miffed that she was going to have to accept the Medicare Index price for her labors – these people are not doing it to help, they’re doctors to get rich. Hospitals exist to make money, a lot of money.

Although Enloe’s readmission rate was apparently not as bad as Oroville Hospital, they were still fined for what the Medicare administration believes is an unreasonably high readmission rate. If I were them, I’d offer in-home follow-up care. Allstate will pay somebody to walk your dog, mow your lawn – shouldn’t insurers pay for a nurse to come over to your house once a day and dress your surgical wound, take your temperature, check to see if you’re dead?  Does Enloe even offer at-home follow-up care?

I think “care” is the operative word here.

Oroville Hospital hit with maximum penalty under new Medicare requirement

By DEBORAH SCHOCH-CHCF Center for Health Reporting
Posted:   05/14/2013 12:00:46 AM PDT
Click photo to enlarge

Oroville Hospital is seen in a photo taken on Feb. 10. (Ty Barbour/Staff File Photo)

A new Medicare program that punishes hospitals with high patient readmissions rates is forcing administrators to reach out and improve how patients are cared for, even after they’re wheeled out the hospital doors.Working to reduce runaway costs, Medicare is now penalizing hospitals across California and nationwide for patients who must be admitted again within 30 days.

Nearly one in five patients discharged from U.S. hospitals ends up returning within a month, often with problems that could have been prevented if those patients received much cheaper follow-up care.

So the federal government has started disciplining hospitals with high readmission rates, withholding as much as 1 percent of the money Medicare would normally reimburse them.

Oroville Hospital is one of the eight hospitals in California that got the maximum penalty.

The hospital’s Director of Patient Services and Chief Medical Officer, Dr. Matthew Fine, called the rating method simplistic and said the hospital is more concerned with improving patient care than improving numbers.

“This is an imperfect measure of readmissions,” Fine said. “It’s using simplistic numbers to measure a very complex situation.”

The penalties worry some health care experts who say facilities serving low-income communities will be hit the hardest by the new program, part of the 2010 federal health care reform law.

Confirming their fears, most of the eight hospitals in California paying the stiffest penalties this year are located in low-income areas, according to the latest numbers released by Medicare in March.Fine said the Medicare evaluation did not consider socio-economic conditions in areas such as south Butte County communities such as poverty, homelessness, low-education levels and high smoking rates.

In addition, Fine said that many hospitals with higher admission rates — including Oroville Hospital — also had low mortality rates, indicating the rating did not consider the complexity of the conditions in the readmissions study.

Others say with Medicare costs spiraling upward, federal officials need to curb unnecessary patient readmissions, estimated to cost Medicare nearly $18 billion a year. The penalties, they say, will also promote better patient care.

The penalty system is imperfect, but it’s a good place to start, said Dr. Robert M. Wachter, professor and associate chair at the UC San Francisco Department of Medicine.

“It’s forcing hospitals to think about things they never thought about before,” said Wachter, who writes frequently about health care quality. “If you wait until the tool is less blunt, I think you’ll wait forever.”

All the hospitals paying big penalties this year are small or medium-sized hospitals. That does not surprise some hospital leaders familiar with the geographic disparities of the California health care system.

“A lot of problems exist in the Central Valley that don’t exist in Newport Beach,” said Tom Petersen, executive director of the Association of California Healthcare Districts, which represents mainly smaller hospitals with publicly elected boards — half of them in rural areas.

Petersen is taking a wait-and-see approach to the penalty rollout, but he notes hospitals have little control if their patients fail to follow doctors’ instructions after they’re discharged.

“The hospital doesn’t have the ability to control behavior outside the hospital,” he said.

Medicare disagrees, and hopes the new program pressures hospital officials to improve their discharge planning and strengthen ties with primary care doctors and clinics in surrounding communities.

But in California there’s a physician shortage undercutting outpatient care.

Petersen points out the California Medical Board’s most recent annual report lists only nine physicians with current licenses in Colusa County, where Colusa Regional Medical Center is being slapped with a 0.82 percent, penalty, just shy of the worst-case fine.

The penalty system focuses on Medicare patients hospitalized with three types of medical conditions — heart attacks, heart failure and pneumonia. The penalties are expected to recoup about $280 million in the first year.

Next, officials plan to add patients with hip and knee implants and chronic obstructive pulmonary disease, Medicare announced April 26. The largest penalties will rise to 2 percent this October and 3 percent a year later.

In all, 276 hospitals nationally this year are paying the maximum penalty, according to a Kaiser Health News analysis.

Nancy E. Foster, vice president for quality and patient safety policy at the American Hospital Association, calls the program as now structured, “unfair.”

“It puts hospitals serving low-income patients at risk. We don’t think that’s right,” Foster said.

Amid the debate over the program’s fairness, many hospitals statewide and nationally are designing new tools to reduce preventable readmissions.

Some hospitals and clinics have launched pilot projects in partnership with the Centers for Medicare and Medicaid Services.

The first such pilot in the state began last year in Marin County, with county public health employees working with Marin General Hospital and Sutter-owned Novato Community Hospital.

The county provides four trained coaches, all nurses, to assist patients recently discharged from both hospitals, said Ana Bagtas, a program manager in the county Department of Health and Human Services.

“A lot of patients, when you’re discharged, it’s overwhelming. It’s hard to follow your discharge plans. The patient just needs a little attention, a boost,” Bagtas said.

Oroville Hospital takes a slightly different tack. Fine said the hospital’s discharge system already does a good job, but the system is being strengthened in response to the Medicare policy.

For one, the hospital is refining the methods for completing a discharge summary and sending it to the patient within three to five days of release.

On May 20, Fine has scheduled an educational workshop with doctors, nurses and other hospital personnel on completing the discharge summary.

The summary includes the diagnosis and what happened to the patient during the hospital stay including surgeries, tests and recommended treatments. The discharge summary is also provided to the patient’s care provider.

In addition, with a shortage of health care providers, the hospital will connect a patient with a provider before they go home, Fine said.

“I never like to think we are perfect,” Fine said. That’s because there are always ways to improve health care in the complex medical field with advancements coming all the time, he said.

As the penalty program matures, it will likely be tweaked to take into account the disparities among hospitals, such as those serving primarily lower-income patients, Wachter said.

“What you see is an environment that’s shifting from one where, in the old days, the best hospitals and the worst hospitals got paid exactly the same by Medicare and private insurers,” Wachter said.

“We’ve woken up in American medicine,” he added. “We’re seeing a sea change in the level of responsibility that people are going to hold us to. And I think that’s appropriate.”

Four north valley hospitals were docked Medicare reimbursement over the number of readmitted patients. They were:

Oroville Hospital — 1 percent

Colusa Regional Medical Center — 0.82 percent

Enloe Medical Center, Chico — 0.19 percent

Rideout Memorial Hospital, Marysville — 0.06 percent

St. Elizabeth Community Hospital, Red Bluff — 0.04 percent.

Deborah Schoch is a senior writer at the Center for health Reporting, funded by the California Health Care Foundation. Staff writer Mary Weston contributed to this report.

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