Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Photo shows nurses rushing a patient on a gurney into a doorway.
Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Image courtesy Trust for America's Health

In the fourth year of being evaluated for patients who boomerang back into the hospital after being discharged, North Carolina hospitals still have a ways to go.

By Rose Hoban

Seventy-six North Carolina hospitals will receive Medicare fines for having too many discharged patients return within a month for additional care, federal data show.

However, many of those hospitals are seeing their penalties diminish as they do a better job managing patients after discharge, the numbers also show.

Image courtesy Ohio Health Insurance, flickr creative commons
Image courtesy Ohio Health Insurance, flickr creative commons

The readmission penalties, initiated in the Affordable Care Act, are part of the federal Centers for Medicare and Medicaid Services’ efforts to get hospitals to better plan for how patients do once they’re outside hospital walls.

The 68 percent of hospitals facing penalties is higher than the national average of 54 percent, according to an analysis by Kaiser Health News.

Since the fines began, national readmission rates have declined, but roughly one of every five Medicare patients sent to the hospital ends up returning within a month of being released, Kaiser Health News’ Jordan Rau reported this week.

The fines only apply to Medicare, the program that covers seniors and some people with disabilities, and will be levied once the federal fiscal year 2016 starts in October.

In this, the fourth year of the penalties, the average penalty was 0.61 percent. In North Carolina, the average penalty was 0.56 percent. Ten hospitals had no penalties at all; another 25 had penalties that totaled less than two-tenths of one percent.

Want to see how NC hospitals did on the Medicare readmission ratings? Click here.

The maximum possible fine this year is 3 percent. Halifax Regional Medical Center in Roanoke Rapids will be levied that fine. It also had the highest rate of readmissions last year and was fined 2.35 percent.

Since the initiation of the fines in 2013, the criteria for penalties have become more stringent. That year, 29 North Carolina hospitals faced no fines. This year, more hospitals are paying fines of more than 1 percent.

Twenty-four of the state’s hospitals were automatically exempted from the penalties, either because they specialize in certain sectors of patients, such as children or veterans, or because they are federally designated “critical access hospitals,” operating in rural areas with little other care.

Some hospitals had too few cases for Medicare to accurately access.

Mitigating factors

North Carolina Hospital Association spokeswoman Julie Henry said the numbers are really a snapshot.

“You just can’t look at these numbers and say that’s a bad hospital, I don’t want to go there,” Henry said.

But she did say that patients can use the numbers to help fend off potential problems.

“A patient can say to their doctor, ‘I need to have a knee replacement, and it looks like a lot of people get readmitted. What can we do to make sure that doesn’t happen to me?” Henry said.

Often, patients who are readmitted after being sent home from the hospital return through the emergency room. Photo shows nurses rushing a patient on a gurney into a doorway.
Often patients who are readmitted after being sent home from the hospital return through the emergency room. Image courtesy Trust for America’s Health

She also said there are a lot of reasons for readmissions to hospitals, especially hospitals in poor communities that have high numbers of Medicaid and Medicare patients.

“Like any other measures that come out, it’s important to look at the bigger picture,” Henry said.

And she argued that some of the budget cuts experienced by hospitals over the past few years have made it difficult to provide the supports that help keep people at home safely.

“Any health care provider can do a great job in the hospital. But once someone goes home, if they don’t have access to transportation to get back to doctor appointments or to get medications, or a refrigerator to store insulin in, they’ll end up back in the hospital,” Henry said.

She said that patient admissions can be like a revolving door, with people coming in and out in the emergency department.

“Because if they don’t have the resources and support, they can’t stay out of the hospital,” Henry said. “That’s the whole point of payment reform and going to a system where we’re compensated for providing those additional services.

“If the hospital can’t afford to provide those wraparound services and supports, then people will end up coming right back.”

Adjusting the penalties

This year’s fines are based on readmissions taking place between July 2011 and June 2014, including Medicare patients originally hospitalized for one of five conditions: heart failure, heart attack, knee or hip replacement, pneumonia or chronic lung disease.

According to Kaiser Health News’ Rau, since the program began, readmission rates have dropped, but still one out of every five Medicare patients ends up back in a hospital bed within 30 days.

Medicare has said the penalty program helps counter a system that inadvertently rewards hospitals for readmissions. Under that system, a readmission counts as a separate hospital stay, so the facility gets paid for two stays instead of one.

Some hospitals in the state have done a better job at helping people stay at home. Mission Hospital, in Asheville, has started giving patients they believe to be at higher risk of readmission videos and audio recordings of their discharge instructions “so they can refer back to the instructions at a less anxious time.”

But nationally, hospital leaders and some researchers have suggested the penalties don’t give enough consideration to economic factors around hospitals.

The Medicare Payment Advisory Commission, an independent agency established by Congress, has suggested that the penalty formulas have to be refined to take local economics into account and provide clearer targets for hospitals to meet.

The National Quality Forum, another independent group, has lobbied CMS to adjust the performance measures to take factors such as income, education, occupation and demographics into account when measuring the readmission rates.

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