Readmission Guidelines are Not Without Risk

New Orleans       I’ll admit it.  I’m looking for silver lining in the clouds.  In the midst of the Trump administration’s unraveling of critical labor, environmental, health, safety, and welfare standards to see the FDA continue to crack down on e-cigarettes or HHS continue to hold nursing homes more accountable for care must count as patches of sunlight on dark days.

Of course, touting the readmission penalties imposed on hospitals and now extended to nursing homes with financial penalties seemed like a win all the way in increased accountability and lower costs.  It pains me to be “Debbie Downer” on my own parade here, but there are some big caveats and question marks that are also emerging about these readmission penalties being sounded by cardiologists.  An op-ed in the Times by several of them pointed out some of the risks that are now emerging, partially because of the way hospitals are gaming the rule.

The rule emerged when Medicare officials and researchers realized a decade ago that 20% of Medicare patients hospitalized for fairly common occurrences were being readmitted to the institutions within 30 days with about half of those readmissions coming from causes thought to be preventable.  Implementing the penalties for quick readmissions on a half-dozen different medical ailments saved Medicare about $10 billion a year.

The researchers have now found that hospitals are hustling the rule in order to avoid the penalty, which is a reduction of their Medicare reimbursement rate, by caring for comebacks in the emergency room to avoid readmitting, even if they really belong in a hospital bed. Furthermore, hospitals serving lower income patients with more health issues are also being penalized because they have higher readmission rates.  Those are my people, which is why this piece got my attention!  Worse, they claim that death rates now seem to be rising for pneumonia and some heart cases, even as the penalties are saving money.

These are big-time researchers from Harvard Medical School, Washington University School of Medicine, and Beth Israel Deaconess Medical Center in Boston so they are cautious even as they raise red flags about the rule.  Their concern is prompted by a “save money at all cost” caucus in Washington that wants to extend the six health reasons that can trigger readmission penalties to all Medicare patients for all reasons.

The doctors want an investigation by Centers for Medicare and Medicaid Services before expanding the rule in order to make sure that unintended consequences aren’t killing people. I’m not saying their position will prevail, but I find it hard to argue against looking harder before we leap farther in this direction.  Poor people are dying too fast already.  There’s no reason to kill any more of our people off before their time, even as we hold money-grubbing health institutions accountable.  This shouldn’t be a tradeoff.

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Federal Penalties Coming to Middle South Nursing Homes for Care Failures

New Orleans       There are few lobbies as powerful as the nursing home owners’ groups in Louisiana, Arkansas, and Mississippi.  All of which makes the intervention of federal rules extending some of the same accountability standards that hospitals now face, welcome news.  The fact that the penalties go right to their pocketbooks is even better news.

Here’s the deal on the new rules hitting nursing homes across the country now.  Penalties – or incentives for those doing better – will be meted out to nursing homes based on the frequency of readmission of elderly Medicare patients that are returned to hospitals within thirty days of leaving a skilled nursing home.  The financial penalty can reach up to 2% of the individual Medicare reimbursement rate per patient.  Hospitals already have to measure up to this standard and in recent months nursing homes came under the same regime.

Will this affect many homes?  Yes, indeed!

Kaiser Health News reported an analysis of homes in Louisiana and found that 85% of the 277 skilled nursing facilities in the state would be subject to a penalty based on data from 2015 through 2017.  Not that Louisiana was by itself since the figures for nursing homes in Arkansas and Mississippi was almost exactly the same.  Bottom line:  the vast majority of nursing homes in the three-state area are facing penalties.  The Advocate reports that in New Orleans for example, a dozen facilities will face a penalty and only two will receive small bonuses for doing right.  These are not just problems with for-profit providers.  The three homes overseen by the Catholic Archdiocese of New Orleans will each receive almost the maximum penalty for each new admission at 1.98% of the possible 2%.

The question of how nursing homes can provide better care to patients, often elderly, sick, and frail, is a constant concern for families and appropriately for public policy.  Reading the comments from administrators of homes that got the good grades under the new rule, they cite getting more thorough information from the hospitals about incoming and prospective patients is key as well as offering preventive care on site.

All of that sounds right, but given the long experience that Local 100, United Labor Unions, has had in representing nursing home workers and observing care conditions firsthand, it will be difficult to fundamentally improve care until staffing levels are adequate to the significant health demands of patients as a first priority.  Being able to retain professional caregivers also means compensating workers commensurate to the value of the service they provide to families and patients.  In the thirty or more years that we have been involved with nursing homes we still see a conflict faced by many home owners and operators between seeing the facilities as real estate developments with a sideline in healthcare as opposed to healthcare facilities that happen to be built on real estate.

We’ve got a long way to go still, but hopefully the application of this new rule will bring some change now that owners will feel the pain of nonperformance in dollars and cents.

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