Most Harrisburg-area hospitals face fines resulting from a new federal program that penalizes hospitals for Medicare patients who have to be readmitted.
But one local hospital, Penn State Milton S. Hershey Medical Center, is among the small portion of U.S. hospitals with a readmission rate so low it escaped a fine.
The Harrisburg region?s other hospitals, PinnacleHealth System, Holy Spirit Health System, Carlisle Regional Medical Center and Good Samaritan Health System, all face fines.
The program began Oct. 1 and is part of the 2010 Affordable Care Act. It?s intended to give hospitals a financial incentive to work harder to prevent admissions. Readmissions are instances when a patient has to go back in the hospital within 30 days of a previous hospital stay.
Critics have long argued that hospitals benefit financially from readmissions, since they fill a bed that might otherwise be empty, and hospitals therefore lack sufficient incentive to prevent them.
But the hospital industry contends the new law unfairly holds hospitals accountable for things beyond their control, such as whether the patient receives adequate medical care after leaving the hospital or keeps follow-up medical appointments.
Overall, 2,217 U.S. hospital are being fined a total of about $280 million. Fines are based on a percentage of the hospital?s total reimbursement from Medicare.
The maximum fine is 1 percent of Medicare revenues. Thus, a hospital due a $10,000 reimbursement would receive only $9,900.
But the maximum fine will rise to 2 percent next year and 3 percent in 2014.
Also, the program currently applies only to Medicare patients hospitalized for heart failure, heart attack or pneumonia. However, the Centers for Medicare and Medicare Services is considering extending it to additional conditions including heart procedures and joint replacements.
Holy Spirit faces fines of 0.22 percent, meaning it will be fined 22 cents for every $100 in Medicare revenues.
Pinnacle will be fined 0.01 percent; Good Samaritan will be fined 0.03 percent; and Carlisle Regional will be fined 0.13 percent.
Pinnacle estimates its fine will be about $32,000. It further estimates that, based on data related to efforts to prevent readmissions, its fine in the next round will drop to $10,000 to $15,000.
Pinnacle attributes the decrease to collaborations with nursing homes and home care agencies, and to its use of concept known as a ?medical home,? which involves using a regular family doctor and staff to coordinate overall care and keep the patient as healthy as possible.
Pinnacle also has began contacting every discharged patient to make sure nothing is wrong and they are able to follow aftercare instructions. Still, Pinnacle has noted that some patients are impossible to reach, and some apparently don?t want to be contacted.
Carlisle Regional?s fine will be about $20,000, said Jerry Askew, a director of government relations for Health Management Associates, Carlisle Regional?s parent company.
Based on its readmission rate and fine, Carlisle Regional sees no major problems with its processes, but will continue focusing on a goal of preventing all readmissions, Askew said. ?We always want to have zero unnecessary readmissions. Anything short of that will give us something to shoot for in the next round,? he said.
Carlisle Regional also reaches out to every discharged patient.
Good Samaritan hasn?t yet calculated the amount of its fine. William Mulligan, the vice president of strategic planning and marketing, said in an email: ?Patients who are readmitted tend to be those who suffer from chronic health conditions. There are many variables that affect scores, including the patient?s health status and what type of care the patient receives after leaving the hospital.?
Some experts contend readmissions are largely preventable. The federal government believes preventable readmissions cost taxpayer-funded Medicare about $17.5 billion in 2010.
The Pennsylvania Health Care Cost Containment Council has said about 14 percent of adult hospital patients were readmitted in 2010. It estimated readmissions add about $500 million to the amount spent by Medicare annually on hospital care in Pennsylvania. The figure doesn?t include the amount spent by private insurers.
Pennsylvania hospitals will lose about $13 million as a result of the first round of fines, said Martin Ciccocioppo, vice president for research for the Hospital & Healthsystem Association of Pennsylvania.
He said the new program is ?a misplaced penalty and it is not being implemented well.?
?You don?t get rewarded for not having high readmissions,? he said. ?There aren?t winners and losers under this program. CMS is just taking money away. It?s hard to call that an incentive program.?
According to Ciccocioppo, a hospital could be fined following a readmission that happened after a discharged heart failure patient fell and broke a hip at home two weeks later.
He said many readmissions result from lapses in care after patients leave the hospital. One of the problems with the new program, he said, is that it lacks incentives for doctors and agencies involved in the patient?s care outside the hospital to prevent readmissions.
Also, the program should take into account factors such as the social and economic status of patients, which can increase the likelihood they will be readmitted, he said.
As it stands, hospitals are being forced to take assorted steps to try to impact care after discharge and for which they don?t get paid, he said. For example, at least one Pennsylvania hospital is considering paying for patients? medications for the first month after discharge in hopes of preventing readmissions, he said.
Yet the Affordable Care Act calls for other steps, such as ?accountable care organizations,? to encourage collaboration between hospitals and providers, including private doctors and home health agencies, and reward those with the best outcomes, including keeping patients out of the hospital.
At Penn State Hershey, which avoided fines because of its low readmission rate, Dr. Greg Caputo said the new program is ?far from perfect.?
However, Caputo, who is the chief quality officer, expressed support for the idea of forcing hospitals to focus on factors surrounding readmissions, which he believes are mostly preventable.
He said the transition from hospital to home, nursing home or home care agency is filled with potential lapses, including those resulting from poor communication.
He said he believes hospitals are in a good position to impact many of them and make the transition ?as smooth and as safe as possible.?
He said Penn State Hershey has systematically analyzed the discharge process, including identifying the kinds of patients who are at high risk of readmission.
It has created special programs aimed at heart attack and heart failure patients, who have especially high rates of readmission, Caputo said. Part of the effort involves intense communication with the patient and their families and caregivers.
Caputo said Penn State Hershey has concluded that one basic problem stems from the sheer complexity of heath care. This can result in patients and families not only failing to understand post-hospital care instructions, but not knowing how to ?be in touch with their care team, so they can know what to do in the event of a problem,? he said.
Yet Penn State Hershey doesn?t claim to have all of the answers when it comes to preventing readmissions. ?We have opportunities that still exist to continue to work on those areas,? he said. ?Our work is not done.?
The movement toward holding hospitals accountable for readmissions goes beyond the government.
For example, Highmark Inc., Pennsylvania?s largest health insurer, earlier this year announced its own pay-for-performance program that will reward and penalize hospitals based on readmission rates.
Source: http://www.pennlive.com/midstate/index.ssf/2012/10/hospital_readmissions.html
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