BY DANIEL CHANG
Most South Florida hospitals are improving their quality of care by one important measure under federal healthcare reform: reducing the number of Medicare patients readmitted within a month, according to recently released government data analyzed by Kaiser Health News.
But while many hospitals in Broward and Miami-Dade counties have reduced their readmission rates, Medicare identified 30 hospitals in the region that remained too high. Those hospitals will receive lowered Medicare reimbursement payments for one year beginning Oct. 1 as part of the government program’s efforts to pay healthcare providers for the quality of care they deliver and not just the number of patients they serve.
The effort seems to be working: Of the 35 area hospitals included in the federal data, a majority — 22 — received decreased penalties for 2014 compared to the prior year. Only five South Florida hospitals met Medicare’s readmission standards and will not be penalized at all, up from the three that received no penalty in 2013. And nearly a dozen — including Memorial Regional in Hollywood and Palm Springs General in Hialeah — will pay bigger fines.
The readmissions reduction program, which began in October 2012, is one of Medicare’s toughest, in part because there is no reward for improvements, and it’s not optional. Penalties for 2014 are based on readmissions of Medicare patients who originally were admitted to a hospital for a heart attack, heart failure or pneumonia and were discharged between July 2009 and June 2012.
Patients readmitted to any hospital within 30 days counted against the discharging hospital, unless the readmission had been planned when the patient originally left the hospital.
Hospitals that had more readmissions than Medicare predicted after adjusting for the severity of patients’ illnesses received a reduction in total payments.
Because Medicare applies the penalties to every payment for a patient stay, hospitals can only estimate the dollar amount of the fines.
One example: At Jackson Health System in Miami, penalties totaled about $900,000 for the year, hospital administrators said. Jackson’s penalty rate was .85 percent and dropped to .73 percent for 2014.
Healthcare experts believe the program will work to improve the overall quality of hospital care while helping to control medical costs by reducing readmissions.
The Medicare Payment Advisory Commission (MedPAC), which reports to Congress, has estimated that 12 percent of Medicare patients may be readmitted for potentially avoidable reasons. Preventing one out of every 10 of those readmissions could save Medicare $1 billion, MedPAC says.
Sal Barbera, a former hospital executive who teaches healthcare administration at Florida International University, said Medicare’s readmission reduction program has forced hospital administrators across the country to assume additional responsibilities at their own expense to ensure the well-being of their discharged patients
“It’s going to really move hospitals toward looking further than, ‘Hey, here’s a patient to discharge,’ ’’ Barbera said. “Now they’re going to have to look at the support a patient has when they go home. Who’s going to watch after them? Do they have a home? Do they need more education on medication?’’
Some South Florida hospitals are opening pharmacies on site so they can send patients home with medications, Barbera said, noting that patients’ failure to fill a prescription or follow instructions for medication frequently leads to readmissions.
At Memorial Regional in Hollywood, pharmacists and case managers visit the homes of targeted elderly patients after discharge to ensure they are taking prescribed medications, eating appropriate diets and making follow-up appointments with primary care physicians, said Dr. Stanley Marks, chief medical officer and senior vice president for Memorial Healthcare System, which includes Memorial Regional, Memorial West, Memorial Pembroke and Memorial Miramar.
“Those are the kinds of things — reconciling the medications that people are on, assuring they have an appointment with their primary care physician, assuring that the environment is safe for them to go home — that can actually decrease readmissions,’’ Marks said. “There’s a lot of responsibility placed on the hospital, and we’re responding.’’
Yet despite such programs, Memorial Regional was one of two South Florida hospitals whose readmission penalties increased to more than 1 percent from 2013 to 2014.
Memorial’s three other hospitals, however, all had their readmission penalties reduced from 2013 to 2014.
Marks said Memorial Regional “does tend to get sicker patients than the other hospitals,” and also skews to what he calls the “super elderly’’ or those over the age of 85 years old. The hospital also sees a higher number of Medicaid and indigent patients than its sister hospitals.
Reducing readmissions can be a challenge, he said, because physicians and nurses are effective at delivering care to patients in hospitals, not on the outside, where patients can no longer be as closely monitored.
“That becomes the real challenge,’’ he said. “Who is that population of patients that’s at higher risk for not doing what they’re supposed to be doing? Who’s going to go home and their first stop is going to be McDonald’s if they’re in congestive heart failure?’’
Healthcare experts agree that elderly patients with multiple medical conditions can be difficult to keep out of the hospital. Hospitals that treat large numbers of poor people also have been disproportionately affected by Medicare readmission penalties nationwide, though locally some of those safety net hospitals performed very well.
Broward Health Medical Center in Fort Lauderdale, a safety net hospital for Broward County, is one of five South Florida hospitals that will receive no penalty from Medicare next year after sufficiently reducing readmissions. Last year, Broward Health received a penalty of .19 percent.
The hospital serves a significant number of Medicaid and indigent patients, said Dr. Marc Bivins, medical director for quality and clinical resource management.
Bivins said Broward Health administrators, physicians, nurses, home health workers and case managers began working on reducing readmissions several years ago when they realized federal healthcare reform would focus on correcting the incentive hospitals have to readmit patients: More readmissions result in more billing.
Broward Health uses a patient assessment before discharge and “transition coaches” to visit discharged patients at home, ensuring they follow medical instructions and receive needed support. Broward Health also established “continuity clinics” at the hospital to improve access to primary care physicians for indigent patients, Bivins said. Preventive care is considered key to reducing hospital stays.
The hospital’s readmission reduction efforts are applied to all patients, he said.
“We feel like appropriate care is something we should be delivering to everyone,’’ Bivins said.
Jackson Health System, Miami-Dade’s public hospital network, takes a similar approach to reducing readmissions by assessing targeted patients while they are still hospitalized and sending “health coaches’’ to their homes after discharge, said Kevin Andrews, vice president and chief quality officer.
Patients with any of about 25 diagnoses, including diabetes and hypertension, are paired with a “nurse navigator” who assesses their needs, helps with appointments with doctors, nutritionists and social workers, and educates patients about disease progression and navigating the healthcare system.
Jackson also established “transitional clinics’’ in the community exclusively for discharged patients because the hospital system’s primary care clinics were backlogged, Andrews said.
At the transitional clinics, discharged patients can receive a follow-up visit with a physician or a nurse practitioner, typically within seven to 10 days after leaving the hospital. The goal is to change patient behavior so they visit the doctor regularly and learn to manage chronic conditions such as heart disease and diabetes.
“There’s no magic bullet,’’ Andrews said of reducing readmissions, “and it’s not one thing.’’
But there’s a clear financial incentive. Unless hospitals succeed at reducing readmission rates, they will pay stiffer penalties.
For 2014, Medicare will increase the maximum possible penalties to 2 percent of the total payments. And for 2015, that number goes to 3 percent — the same year that the federal healthcare law will add hip and knee surgery and chronic obstructive pulmonary disease to the list of conditions used to determine the penalties.
This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.