The Hospital Readmissions Reduction Program has been a mainstay of Medicare’s hospital payment system since it began in 2012. Created by the Affordable Care Act, the program evaluates the frequency with which Medicare patients at most hospitals return within 30 days and lowers future payments to hospitals that had a greater-than-expected rate of return. Hospitals can lose up to 3% of each Medicare payment for a year.

The pandemic threw hospitals into turmoil, inundating them with covid patients while forcing many to postpone elective surgeries for months. When the Centers for Medicare & Medicaid Services evaluated hospitals’ previous three years of readmissions, as it does annually, the government decided to because of the chaos caused by the pandemic. CMS also excluded from its calculations Medicare patients who were readmitted with pneumonia across all three years because of the difficulty in distinguishing them from patients with covid.

Akin Demehin, senior director of quality and patient safety policy at the American Hospital Association, said the changes were warranted. “The covid pandemic did a lot of really unprecedented things to care patterns of hospitals,” he said.

After making those changes, CMS evaluated 2½ years of readmission cases for Medicare patients who’d had heart failure, heart attacks, chronic obstructive pulmonary disease, coronary artery bypass grafts, and knee and hip replacements. As a result of its analysis, CMS penalized 2,273 hospitals, the fewest since the fiscal year that ended in September 2014, a KHN analysis found.

The average payment reduction was 0.43%, also the lowest since 2014. The reductions will be applied to each Medicare payment to the affected hospitals from Oct. 1 through next September and cost them $320 million over that 12-month period.

Some hospitals will see their penalties greatly reduced from last year. The penalty on St. Mary’s Hospital in Athens, Georgia, is dropping from 2.54% to 0.06%. Saint Joseph East in Lexington, Kentucky, received the maximum penalty, 3%, last year; it will lose 0.78% as of Oct. 1. In Flemington, New Jersey, the penalty for Hunterdon Medical Center is dropping from 2.29% to 0.12%.

To limit penalties, many hospitals in recent years have instituted new strategies to keep former patients from needing a return visit. Dr. Robert Coates, interim chief medical officer at Hunterdon Health, which owns Hunterdon Medical Center, said in a statement that the hospital set up a system to identify patients who visited the emergency room within 30 days of a hospital stay. Instead of readmitting them, Hunterdon helps them set up next-day appointments at a doctor’s office or home monitoring of their health. Hunterdon also calls all discharged patients to ensure they have filled their prescriptions and had a follow-up visit with a clinician within a week of leaving the hospital.

Dr. Jessica Satterfield, director of quality and clinical excellence at St. Mary’s Health Care System, which operates St. Mary’s Hospital, said in a statement that the hospital identified patients at risk of readmission when they were first admitted and focused on making sure that their medications were correct and that they had follow-up visits. “We are proud that our efforts are bearing fruit in the form of greatly reduced penalties but, more importantly, as a reflection of the exceptional care our staff and medical staff provide to our patients,” Satterfield said.

Saint Joseph East did not respond to emails seeking comment.

Despite the changes, 43% of the nation’s 5,236 hospitals were penalized. Of the unpenalized, all but 770 were automatically exempted. The 2,193 exempted hospitals include those that specialize in children, psychiatric patients, or veterans. Rehabilitation and long-term care hospitals are also excluded from the program, as are critical access hospitals, which Medicare pays differently to help them stay open in areas with no other hospitals. The government also exempted Maryland hospitals because that state has a special payment arrangement with Medicare. Of the hospitals that Medicare assessed, 75% were penalized.

For the fiscal year that started this month, Medicare also cited the pandemic in giving hospitals a reprieve from its other major quality-focused effort that assesses penalties: the Hospital-Acquired Condition Reduction Program. It slashes Medicare payments by 1% to the quarter of general hospitals with the highest rates of infections and other potentially preventable patient injuries. For the previous fiscal year, CMS punished 764 hospitals under that program. Those penalties — which would have cost hospitals an estimated $350 million this year — will resume next fiscal year, with adjustments that better take covid patients into account. CMS will also refine the readmissions penalty program to distinguish pneumonia patients from covid patients.

“Covid has been a tremendously disruptive force for all aspects of health care, most certainly CMS’ quality measurement programs,” Demehin said. “It’s probably going to be a couple of volatile years for readmission penalties.”

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Various analyses have found many readmissions within a month of discharge might have been avoided through better care and more attention paid to the patients after they left the hospital. The federal government’s campaign to reduce the frequency of so-called boomerang patients by applying financial disincentives has entered its 10th year with Medicare’s decision to lower payments to 2,499 hospitals throughout the current fiscal year, which began last month and runs through September 2022.

The (HRRP), created as part of the Affordable Care Act, punishes general acute-care hospitals when more Medicare patients return for a new admission within 30 days of discharge than the government decides is appropriate. The average penalty this fiscal year is 0.64%, with 39 hospitals losing the maximum of 3% of reimbursements.

Over the lifetime of the program, 2,920 hospitals have been penalized at least once. That’s 93% of the 3,139 general acute hospitals subject to HRRP evaluation, and 55% of all hospitals. Moreover, 1,288 have been punished in all 10 years. Only 219 eligible hospitals have avoided any payment reductions since the program’s start in 2013, though more than 2,000 hospitals are automatically exempt from penalties because they have specialized functions: those that focus on children, psychiatric patients, veterans, rehabilitation and long-term care or those that serve as the only hospital in an area.

Hospital readmissions since before the ACA was enacted, and most experts attribute that partly to the financial threat of the penalties, though other factors likely contributed to the improvements. Less debatable is that the penalties have saved the government billions of dollars since their inception. The Centers for Medicare & Medicaid Services estimates that because of the HRRP, Medicare will keep an extra $521 million this fiscal year. You can look up individual hospital penalties using KHN’s interactive tool.

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In its 10th annual round of penalties, Medicare is reducing its payments to 2,499 hospitals, or 47% of all facilities. The average penalty is a 0.64% reduction in payment for each Medicare patient stay from the start of this month through September 2022. The fines can be heavy, averaging $217,000 for a hospital in 2018, according to Congress’ Medicare Payment Advisory Commission, or MedPAC. Medicare estimates the penalties over the next fiscal year will save the government $521 million. Thirty-nine hospitals received the maximum 3% reduction, and 547 hospitals had so few returning patients that they escaped any penalty.

An additional 2,216 hospitals are exempt from the program because they specialize in children, psychiatric patients or veterans. Rehabilitation and long-term care hospitals are also excluded from the program, as are critical access hospitals, which are treated differently because they are the only inpatient facility in an area. Of the 3,046 hospitals for which Medicare evaluated readmission rates, 82% received some penalty, nearly the same share as were punished last year.

The ) was created by the 2010 Affordable Care Act and began in October 2012 as an effort to make hospitals pay more attention to patients after they leave. Readmissions occurred with regularity — for instance, nearly a quarter of Medicare heart failure patients ended up back in the hospital within 30 days in 2008 — and policymakers wanted to counteract the financial incentives hospitals had in getting more business from these boomerang visits.

MedPAC has found readmission rates declined from 2008 to 2017 after the overall health conditions of patients were taken into account. Heart failure patient readmission rates dropped from 24.8% to 20.5%, heart attack patient rates dropped from 19.7% to 15.5%, and pneumonia patient rates decreased from 20% to 15.8%, according to the . Readmission rates for chronic obstructive pulmonary disease, hip and knee replacements, and conditions that are not tracked and penalized in the penalty program also decreased.

“The HRRP has been successful in reducing readmissions, without causing an adverse effect on beneficiary mortality,” MedPAC wrote. The commission added that untangling the exact causes of the readmission rates was complicated by changes in how hospitals recorded patient characteristics in billing Medicare and an increase in patients being treated in outpatient settings. Those factors made it difficult to determine the magnitude of the readmission rate drop due to the penalty program, MedPAC said.

The current penalties are calculated by tracking Medicare patients who were discharged between July 1, 2017, and Dec. 1, 2019. Typically, the penalties are based on three years of patients, but the Centers for Medicare & Medicaid Services excluded the final six months in the period because of the chaos caused by the pandemic as hospitals scrambled to handle an influx of covid-19 patients.

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The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between , so the flood of coronavirus patients that have swamped hospitals this year were not included.

The Centers for Medicare & Medicaid Services it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.

For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.

Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.

The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.

“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”

The penalties are based on readmissions of Medicare patients who initially came to the hospital of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.

A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.

The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.

Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.

“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”

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The severity and broad application of the penalties, which Medicare estimates will cost hospitals $563 million over a year, follows the trend of the past few years. Of the 3,129 general hospitals evaluated in the Hospital Readmission Reduction Program, 83% received a penalty, which will be deducted from each payment for a Medicare patient stay over the fiscal year that begins today.

Although Medicare began applying the penalties in 2012, disagreements continue about whether they have improved patient safety. On the positive side, they have encouraged hospitals to focus on how their patients recuperate, and some now assist them in procuring medications and follow-up appointments.

But the hospital industry and some academics have raised concerns that some hospitals may be avoiding readmitting patients who require additional inpatient care out of fear of the financial repercussions, while others have said the program is not showing major benefits.

“A lot of hard work has gone into trying to reduce readmissions, and the needle has not moved very far,” said Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis, who has been skeptical of the initiative. “It’s been a huge investment by hospitals but not very much in outcomes, but some good things have come out of it.”

A few have even found an increase in mortality since the penalties took effect, but , including a by the Medicare Payment Advisory Commission (MedPAC), an independent body that helped devise the approach for Congress, identified no such link.

“I don’t believe the HRRP kills people,” David Grabowski, a commission member and health policy professor at Harvard Medical School, said at the , using the acronym for the penalty program.

The MedPAC staff’s preliminary analysis, made public last month, found that the frequency of Medicare patients being readmitted within 30 days of discharge dropped from 16.7% in 2010 to 15.7% in 2017. However, the analysis said the decrease was more significant once it took into consideration that the average patient was frailer in 2017 than in 2010 and thus more likely to end up back in the hospital, with all other things being equal.

“On a risk-adjusted basis, it appears that readmissions have declined in 2010 to 2018 without causing a material increase in mortality,” Jeff Stensland, a MedPAC analyst, .

The on the frequency of readmissions of Medicare patients who had originally been treated for heart failure, heart attack, pneumonia, chronic lung disease, hip and knee replacement or coronary artery bypass graft surgery. Readmissions that were scheduled to occur are not counted.

Medicare counts the readmission of patients who returned to a hospital within 30 days even if that hospital is not the one that originally treated them. In those cases, the penalty is applied to the first hospital. This year’s penalties are based on discharges from July 1, 2015, to June 30, 2018.

“This is like driving your car by looking in the rearview mirror of the car three cars behind you,” Dr. Jonathan Perlin, the chief medical officer of HCA Healthcare in Nashville and a MedPAC commission member, said at last month’s meeting. “It’s very difficult to operationalize.”

The average penalty will be a 0.71% decrease in payment for each Medicare patient who leaves the hospital over the next year, according to a Kaiser Health News analysis. The KHN analysis also found:

• 1,177 hospitals received a higher penalty than they did last year.
• 1,148 hospitals received a lower one than last year.
• 64 hospitals received the same penalty as last year.
• 194 hospitals that had not been penalized last year are being punished this year.
• The maximum penalty — a 3% reduction in payments — was assessed against 56 hospitals.
• 372 hospitals avoided penalties in both years.

These figures do not include 2,142 hospitals that Medicare exempted from the program this year, either because they had too few cases to judge; were veterans hospitals, children’s hospitals, psychiatric hospitals or were critical-access hospitals, which are the only hospitals within reach of some patients.

Also, Maryland hospitals were excluded because Congress lets that state set its own rules on how to distribute Medicare money and handle readmissions.

The Centers for Medicare & Medicaid Services determines its penalties by looking at national averages for each of the conditions, so hospitals that have reduced their readmissions from previous years can still take a hit. The hospital industry argues it may be approaching the limits of how much it can do to prevent readmissions. A repeat stay, hospitals say, is sometimes necessary no matter what precautions are taken.

Akin Demehin, director of policy at the American Hospital Association, said: “It raises the question: Is the value of the program to improve care or just to enact penalties on hospitals?”

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Charlotte Potts is the type of patient some hospitals try to avoid. She lives in Livingston, Tenn. — a town of 4,000, tucked between rolling hills of the Cumberland Plateau.

“I’ve only had five heart attacks,” Potts said recently with a laugh. “I’ve had carotid artery surgery. Shall we go on? Just a few minor things.” She joked that she’s “a walking stent.”

The heart trouble has affected the way Potts deals with her health problems. She spends much of her day in a recliner in her apartment, tethered to a pulsing oxygen machine, and listening to the radio.

Fortunately, her apartment sits within spitting distance of Livingston Regional Hospital — a 114-bed facility large enough to have a dedicated cardiac unit. But the hospital doesn’t want to see her every time her heart flutters.

So, the last time she landed in the ER, they helped her connect with a few companies that could provide care at home.

“If I’m going to have certain things going on here in my chest, I call for help, and they’re there,” Potts said of the home care team she chose.

A New Era In Hospital Management

There were days when the hospital might have viewed a home health agency as a competitor. Not anymore.

“When I started this almost 40 years ago, the mission was different,” saidÌý, CEO of Livingston Regional. “We wanted patients in the hospital. That was the incentive. We were paid for it. Now you’re not.”

Hospitals used to run on a so-called fee-for-service model with virtually no limit to how many times they could see a patient. But, under pressure from private and government insurance programs, that model is transitioning to one in which hospitals are rewarded for safety and efficiency — which often results in a patient spending less time in the hospital.

, Medicare began to ding hospitals if too many patients are readmitted to any hospital within 30 days of discharge. The measure is broadly unpopularÌýÌýsince so much falls outside a hospital’s control. Medicare has evenÌýwalked back the rules for safety-net facilities, which tend to treat a sicker population.

The penalty is meant to encourage hospitals to get it right the first time. In Livingston, the hospital operates on the thinnest of margins — justÌýin the most recent figures. And “readmissions” have been a drag on the bottom line.

Ìýwith heart failure was back within the month. The hospital has paid the maximum penalty in some years — nearly $200,000. So leaders started asking a basic, unifying question of other providers in town, McGill said: “What can we do together so they’ll stay out of the hospital and stay healthier in their home setting? That’s where the work is.”

Collaborating Instead Of Competing

The work took the form of quarterly lunch meetings at the local library.

Mary Ann Stockton, a nurse at the hospital, invites all the home health agencies as well as hospice providers and the leaders of nursing homes.

At one meeting, she applauded the other providers for increasingly meeting patients inside the hospital before they’re discharged. She said it helps patients and families accept these home health workers.

“We know in our area people don’t like to have a total stranger come into their home,” she said.

The group brainstormed how to generate the same kind of acceptance for hospice care, which — as one doctor in the meeting put it — some families view as “assisted suicide.”

And on this day, the group spent much of its time reviewing the value of flu shots, especially for the staff in nursing homes. Stockton said elderly patients with bad lungs become a hospital emergency room’s “frequent flyers.”

“Flu starts off, goes into pneumonia, COPD exacerbation — and they are a revolving door in our hospital,” Stockton said. “They’re hitting that ER a couple of times a week.”

Advance directives are on the agenda for next time — another way to keep people near the end of life from becoming ER regulars.

Livingston’s parent company, LifePoint Health, is launching this community approach in many of its 80-or-so markets, which are primarily in the Southeast and almost all rural. aÌýLifePoint vice president, helps hospitals find willing partners.

“We were very frustrated for many years,” Chamness said, “because we weren’t able to impact readmissions just working on it by ourselves, as a hospital.”

‘Are We Saving Ourselves Right Out Of Business?’

The solution looks different from one town to another. In Lake Havasu, Ariz.,ÌýÌýto make sure they’re following doctors’ orders. The house calls also cut down on government-funded ambulance rides.

It’s not just rural hospitals — all hospitals can be penalized for readmissions now. And threatening the bottom line in that way does seem to be effective. Readmissions have been falling across the board, according toÌý.

But rural hospitals, which already treat fewer patients than urban hospitals, wonder if they’ll have enough patients to survive, said of the Chartis Center for Rural Health.

“[A] CEO from Montana said to me, ‘The problem is, when we do the right thing, are we saving ourselves right out of business?'” TopchikÌýsaid.

The focus on cutting readmissions — by definition — cuts overall admissions too, he noted.

“So, this is the real inherent tension and challenge: Hospitals get reimbursed for doing ‘sick care,'” Topchik said. “But more and more they’re being asked to do population health, and really focus on ‘wellness.'”

To make up the volume, the Livingston hospital is expanding its maternity ward and general surgery offerings.

There is also some immediate financial upside to reducing readmissions: Livingston Regional has cut readmissions more than any other rural hospital in Tennessee and even the nation, according to data compiled by Chartis.

As a result, the hospital’s Medicare penalty in the coming year will be reduced to 0.3 percent of its reimbursements — down from the maximum of 3 percent, which was roughly $200,000 a year.

That’s all because patients like Charlotte Potts now can safely stay home.

“I got a real bad tightness in the chest,” Potts recalled about a recent episode. She’d questioned whether to call an ambulance. “I was very uncertain about what was going on.”

But she phoned her home health agency, took a nitroglycerin pill as the agency advised and, instead of going to the ER, was able to get back to sleep.

This story is part of a partnership that includes , and Kaiser Health News.

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Desde 2012, Medicare ha castigado a los hospitales por tener demasiados pacientes que vuelven a recibir atención en sus instalaciones dentro del mismo mes. El gobierno estima que la industria hospitalaria en la última ronda de sanciones a lo largo de los próximos 12 meses. Las sanciones son parte de la estrategia de la Ley de Cuidado de Salud Asequible (ACA) para fomentar una mejor atención.

Pero a partir de octubre, los legisladores han ordenado que Medicare tenga en cuenta una queja de larga data de los hospitales de la red de seguridad o “safety-net”. Los hospitales argumentan que el hecho de que sus pacientes sufran complicaciones después de abandonar el hospital no es por culpa de las instituciones, sino porque no pueden pagar los medicamentos o no tienen doctores para controlar su recuperación. Las sanciones de Medicare han sido especialmente duras para este tipo de hospitales, que luchan por mantenerse a flote porque muchos de sus pacientes tienen un seguro de pago bajo o carecen de seguro.

Dando a su evaluación, los Centros de Servicios de Medicare y Medicaid (CMS) este año dejaron de juzgar a los hospitales comparándolos entre sí. En su lugar, se dividió a los hospitales en cinco grupos con proporciones similares de pacientes de bajos ingresos. Medicare luego comparó las tasas de reingreso de cada hospital desde julio de 2014 hasta junio de 2017 con las tasas de reingreso de su grupo de pares durante esos tres años para determinar si justificaban una sanción y, de ser así, cuánto debería ser.

La cuestión es si resulta justo juzgar a los proveedores de servicios médicos que atienden a los pobres comparándolos con los que cuidan a los ricos. Este ha sido un tema de continua discusión mientras el gobierno busca medir, con precisión, la calidad de la atención médica. Y genera preocupación que se consideren los resultados de los pacientes a la hora de establecer las tasas de pago para los médicos, los hogares para personas mayores, los hospitales y otros proveedores.

En total, Medicare descontará pagos a 2,599 hospitales, más de la mitad en la nación, a lo largo del año fiscal 2019, que comenzó el 1 de octubre, según un análisis de Kaiser Health News. La multa más severa es un 3% menos de reembolsos por cada paciente de Medicare dado de alta en el año fiscal 2019. El número de hospitales y la multa promedio (0,7% de cada pago) son casi iguales a las del año pasado.

Pero el nuevo método cambió la carga de esos castigos. Según el análisis, las sanciones contra los hospitales de la red de seguridad (“safety-net”) se reducirán en un cuarto en promedio respecto al año pasado.

“Es bastante claro que estaban penalizando a esas instituciones más de lo necesario”, dijo el doctor Atul Grover, vicepresidente ejecutivo de la Association of American Medical Colleges. “Definitivamente es un paso en la dirección correcta”.

Entre los hospitales “safety-net” que verán reducidas a la mitad sus sanciones se encuentran muchas instituciones urbanas, como el Sutter Health’s Alta Bates Summit Medical Center en Oakland, California, el Providence Hospital en Washington, D.C., y el Hurley Medical Center en Flint, Michigan. Sesenta y cinco hospitales “safety-net”, entre los que se encuentran el Franklin Medical Center en Winnsboro, Louisiana, Astria Toppenish Hospital en Toppenish, Washington, y el Emanuel Medical Center en Swainsboro, Georgia, que fueron penalizados el año pasado, se libraron del castigo este año.

Pero, además, el análisis encontró que la penalización promedio para los hospitales con el menor número de pacientes de bajos ingresos aumentará con respecto al año pasado.

Antes de que comenzara el programa, aproximadamente 1 de cada 5 beneficiarios de Medicare eran reingresados en el mismo mes. A los hospitales se les pagaba la misma cantidad independientemente de cómo les fuese a sus pacientes después de ser dados de alta. De hecho, una readmisión era financieramente ventajosa ya que los hospitales recibirían el pago de la segunda estadía en el hospital, incluso si pudiera haber sido evitada.

Desde que comenzaron las sanciones, Medicare ha evaluado las tasas anuales de pacientes readmitidos que originalmente habían sido tratados por insuficiencia cardíaca, ataques cardíacos y neumonía. Y se han reducido los pagos a más de la mitad de los hospitales según esas tasas. Desde entonces, las evaluaciones se han expandido para cubrir enfermedades pulmonares crónicas, reemplazos de cadera y rodilla y cirugías de injerto de revascularización coronaria.

Medicare cuenta a los pacientes que regresaron a un hospital dentro de los 30 días, incluso si es un hospital diferente al que los atendió originalmente. La penalización se aplica al primer hospital.

Medicare exime a los hospitales con muy pocos casos, los que atienden a veteranos, niños y pacientes psiquiátricos, y a los hospitales de acceso crítico que son los únicos hospitales al alcance de algunos pacientes. Además, los hospitales de Maryland están excluidos porque el Congreso permite que el estado establezca sus propias reglas sobre cómo distribuir el dinero de Medicare.

En el nuevo sistema de este año, Medicare distinguió a los hospitales que atienden a una alta proporción de pacientes de bajos ingresos contabilizando cuántos de los pacientes de Medicare del hospital también eran elegibles para Medicaid, el programa estatal-federal para los pobres. Los funcionarios de la American Hospital Association (AHA) dicen que, si bien consideran que esto es una mejora, no se ha identificado bien a los pacientes pobres. Por un lado, dicen, los hospitales en estados con una cobertura de Medicaid más restrictiva no parecen tener, con esta fórmula, pacientes tan complicados como los de los hospitales en estados con mayor elegibilidad para Medicaid.

Akin Demehin, director de políticas de calidad de la AHA, dijo que CMS podría considerar vincular sus registros con los registros del Censo que muestren los ingresos y el nivel de educación de los pacientes.

“Podría proporcionar un ajuste más preciso”, señaló Demehin.

La industria hospitalaria sigue siendo crítica con el programa, diciendo que eliminar los ingresos de los hospitales debido a su bajo rendimiento solo hace que sea más difícil para ellos cuidar a los pacientes.

La Comisión Asesora de Pagos de Medicare del Congreso, en junio, de años anteriores presionaron a los hospitales con éxito para reducir el número de pacientes que regresaban, y ayudó a ahorrar a Medicare unos $2 mil millones al año.

En su análisis de la efectividad del enfoque, la comisión asesora del Congreso rechazó algunas de las quejas de la industria sobre el Programa de reducción de readmisiones hospitalarias de Medicare: sobre que los hospitales hayan manteniendo a los pacientes en “estado de observación” y sobre el hecho de que al desalentar las rehospitalizaciones se han producido .

La comisión encontró que entre 2010 y 2016 las tasas de reingreso disminuyeron en 3,6 puntos porcentuales por ataques cardíacos, 3 puntos porcentuales por insuficiencia cardíaca y 2,3 puntos porcentuales por neumonía. Al mismo tiempo, las readmisiones causadas por condiciones que no tienen en cuenta las sanciones cayeron en promedio 1,4 puntos porcentuales, lo que indica que los hospitales se estaban centrando en reducir las readmisiones innecesarias que podrían perjudicarlos financieramente.

La comisión escribió: “Llegamos a la conclusión de que [las sanciones] contribuyeron a una disminución significativa en las tasas de reingreso sin causar un aumento importante en las visitas al servicio de urgencias, un aumento importante en las estadías de observación o un efecto negativo en las tasas de mortalidad”.

Este otoño, Medicare atacará los reingresos desde otro ángulo mediante la imposición de sanciones a los centros de enfermería especializada que envían a los residentes recién dados de alta al hospital con demasiada frecuencia.

La cobertura de KHN relacionada con el envejecimiento y la mejora de la atención de los adultos mayores es apoyada en parte por la Foundation.

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READMISSION PENALTIES BY HOSPITAL AND STATE

Medicare is penalizing hospitals that see patients return to the hospital too soon after being discharged. Medicare reduces what it pays each hospital per patient, per stay.

• Medicare Readmission Penalties By Hospital (.csv)
• Medicare Readmissions By State (.csv)

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Since 2012, Medicare has punished hospitals for having too many patients end up back in their care within a month. The government estimates the hospital industry will in the latest round of penalties that will stretch over the next 12 months. The penalties are a signature part of the Affordable Care Act’s effort to encourage better care.

But starting next month, lawmakers mandated that Medicare take into account a long-standing complaint from safety-net hospitals. They have argued that their patients are more likely to suffer complications after leaving the hospital through no fault of the institutions, but rather because they cannot afford medications or don’t have regular doctors to monitor their recoveries. The Medicare sanctions have been especially painful for this class of hospitals, which often struggle to stay afloat because so many of their patients carry low-paying insurance or none at all.

In a to its evaluation, the federal Centers for Medicare & Medicaid Services (CMS) this year ceased judging each hospital against all others. Instead, it assigned hospitals to five peer groups of facilities with similar proportions of low-income patients. Medicare then compared each hospital’s readmission rates from July 2014 through June 2017 against the readmission rates of its peer group during those three years to determine if they warranted a penalty and, if so, how much it should be.

The broader issue is whether medical providers that serve the poor can be fairly judged against those that care for the affluent. This has been a continuing topic of contention as the government seeks to accurately measure health care quality. It is particularly a concern in efforts to consider patient outcomes in setting pay rates for doctors, nursing homes, hospitals and other providers.

Overall, Medicare will dock payments to 2,599 hospitals — more than half in the nation— throughout fiscal year 2019, which begins Oct. 1, a Kaiser Health News analysis of the records found. The harshest penalty is 3 percent lower reimbursements for every Medicare patient discharged in fiscal year 2019. The number of hospitals and the average penalty — 0.7 percent of each payment — are almost the same as last year.

But the new method shifted the burden of those punishments. Penalties against safety-net hospitals will drop by a fourth on average from last year, the analysis found.

“It’s pretty clear they were really penalizing those institutions more than they needed to,” said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges. “It’s definitely a step in the right direction.”

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Safety-net hospitals that will see their penalties cut by half or more include many urban institutions, such as Sutter Health’s Alta Bates Summit Medical Center in Oakland, Calif.; Providence Hospital in Washington, D.C.; and Hurley Medical Center in Flint, Mich. Sixty-five safety-net hospitals — including Franklin Medical Center in Winnsboro, La., Astria Toppenish Hospital in Toppenish, Wash., and Emanuel Medical Center in Swainsboro, Ga. — that had been penalized last year escaped punishment entirely this year.

Conversely, the average penalty for the hospitals with the fewest low-income patients will rise from last year, the analysis found.

Before the program began, roughly 1 in 5 Medicare beneficiaries were readmitted within a month. Hospitals were paid the same amount regardless of how their patients fared after being discharged. In fact, a readmission was financially advantageous as hospitals would be paid for the second hospital stay, even if it might have been avoidable.

Since the sanctions began, Medicare has evaluated each year rates for readmitted patients who had originally been treated for heart failure, heart attacks and pneumonia. And it has reduced its payments to more than half of hospitals based on those rates. The evaluations have since expanded to cover chronic lung disease, hip and knee replacements and coronary artery bypass graft surgeries.

Medicare counts patients who returned to a hospital within 30 days, even if it is a different hospital than the one that originally treated them. The penalty is applied to the first hospital.

Medicare exempts hospitals with too few cases, those serving veterans, children and psychiatric patients, and critical-access hospitals, which are the only hospitals within reach of some patients. In addition, Maryland hospitals are excluded because Congress lets that state set its own rules on how it distributes Medicare money.

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In its revised method this year, Medicare distinguished hospitals that serve a high proportion of low-income patients by looking at how many of the hospital’s Medicare patients were also eligible for Medicaid, the state-federal program for the poor. American Hospital Association officials say that while they considered this an improvement, it isn’t a perfect reflection of poor patients. For one thing, they say, hospitals in states with more restrictive Medicaid coverage do not appear through this formula to have as challenging patient populations as do hospitals in states with higher Medicaid eligibility.

Akin Demehin, the association’s director of quality policy, said CMS might consider linking its records to Census records that show income and education level of patients.

“It might give you a more precise adjuster,” he said.

The hospital industry remains critical of the overall program, saying that stripping hospitals of revenue because of poor performance only makes it harder for them to care for patients.

Congress’ Medicare Payment Advisory Commission in June from previous years successfully pressured hospitals to reduce the numbers of returning patients — and helped save Medicare about $2 billion a year.

In its analysis of the approach’s effectiveness, Congress’ advisory commission rejected some of the hospital industries’ complaints about Medicare’s Hospital Readmissions Reduction Program: that hospitals may have by keeping patients under “observation status” and that discouraging rehospitalizations may have led to .

The commission found that between 2010 and 2016 readmission rates fell by 3.6 percentage points for heart attacks, 3 percentage points for heart failure and 2.3 percentage points for pneumonia. At the same time, readmissions caused by conditions that do not factor into the penalties fell on average 1.4 percentage points, indicating hospitals were focusing on lowering unnecessary readmissions that could hurt them financially.

The commission wrote: “We conclude that the [penalties] contributed to a significant decline in readmission rates without causing a material increase in ED [emergency department] visits, a material increase in observation stays, or a net adverse effect on mortality rates.”

This fall, Medicare will attack the readmissions from another angle by issuing penalties on skilled nursing facilities that send recently discharged residents back to the hospital too frequently.

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Following two of the procedures, the implanted metal socket didn’t integrate with the bone of her own hip socket and was loose, causing excruciating pain. Most recently, the titanium metal ball in her hip corroded.

The surgical complications were bad enough, but after one of the operations, Radach, 63, also developed that if left untreated can turn deadly.

Having to pay for medical mistakes added insult to injury, said Radach, who explained that each surgery typically cost her about $5,000 out-of-pocket.

“Nobody should come out of the hospital with an infection,” she said. “Why does any patient pay for a medical error like that? … Because that’s the way the system is set up.”

Now Radach, who lives in Seattle, is trying to change that system. She is a patient advocate with the a program established by the state LegislatureÌýto improve the quality and cost-effectiveness of care.

One recommendationÌýis that patients shouldn’t have to pay for their care if they experience certain avoidable complications up to 90 days after surgery. A participating hospital would guarantee its work, or patients would be off the hook for the copayment or would get that money back.

“I think the warranty is something that really resonates with patients,” said Ginny Weir, program director for the Bree Collaborative. “They think, ‘If something goes wrong in the hospital, I know that I’d be taken care of financially if any of these things happened.”

Guarantees Rare In MedicineÌý

You wouldn’t pay a mechanic for a faulty muffler or a restaurant for spoiled food. If you did, you would expect a refund. But the same arrangement between buyer and seller hasn’t historically existed in medical care.

Some argue that maybe it should. “Medicine is certainly not like making widgets, but there is a production process to it,” said Dr. Ezekiel Emanuel, chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. HeÌýadvocated for the government to test a 90-day money-back guarantee in the Medicare program in his 2014 book, “Reinventing American Health Care.”

“There are things you can do that are in your control that reduce the error rate and improve quality,” he added.Ìý“A guarantee makes people [more motivated to adopt] this kind of process.”

Examples of health care systems offering money-back guarantees are thin. The one notable exception is Geisinger Health System in central Pennsylvania, which Since Geisinger in 2006 for coronary artery bypass graft surgery, the ProvenCare program has added other procedures, including hip and knee replacement and lumbar spine surgery.

ProvenCare aims to ensure that providers use evidence-based best practices to improve patient outcomes and reduce avoidable hospital readmissions. In the past five years, for example, the health system’s 30-day readmission rate for coronary artery bypass graft surgery has declined from 10.2 percent to 4.4 percent, according to Geisinger figures.

Under ProvenCare, if patients are hospitalized or need other follow-up care for complications that could have been avoided in that 90-day window, Geisinger absorbs the cost to both patient and health insurer.

Two years ago, the health system expanded its money-back promise to include customer satisfaction measures related to care. The new program, ProvenExperience, deals with patient complaints about poor staff communication, difficulty making appointments, a long wait to be seen in the emergency department, bad food or construction noise, for example.

“I thought, what if we put it all together?” said Dr. David Feinberg, Geisinger’s president and CEO. “I know we’re really good at anticoagulation, but are we really good at transitions of care? Are we really good at the phones?”

So far, ProvenExperience to consumers, he said.

When Kim Walsh, 52, had her thyroid removed at a Geisinger facility in Wilkes-Barre in 2015, the surgery went extremely well. Her hospital stay, not so much. Assigned to a room without a bathroom, Walsh had to hike down three hallways in her hospital gown to a restroom located just off a public hallway. When she got there, there was no toilet paper and there was urine on the seat.

“I was so angry,” she said. After she complained, a patient advocate came to her room and told her to call her when she got the bill. Walsh was never charged her $785 copayment.

Misplaced Priorities?Ìý

Although no one would argue that paying attention to quality is a mistake, some believe that “mint-on-the-pillow” efforts could distract people from focusing on what really matters: The quality of the medical care they receive.

“We start to emphasize parking, nice meals, but we’re not really paying attention to how good the care is,” said Arthur Caplan, director of the division of medical ethics at New York University.

Others argue that focusing on patient experiences helps capture the caring dimension of health care.

“These kinds of things matter a lot to feeling you’ve gotten health care that’s personalized for you, and that your experiences and interactions are taken seriously,” said Rachel Grob, director of national initiatives at the University of Wisconsin’s Center for Patient Partnerships.

In Washington, the Bree Collaborative warranty is one element in a larger effort to reform how doctors and hospitals get paid.ÌýThe group recommends “bundled payments” for some surgeries that cover a whole “episode of care,” from preoperative doctor visits through postoperative rehabilitation. The collaborative recommends for five types of surgery: total knee and total hip replacements, lumbar fusion operations, coronary artery bypass and bariatric surgery.

To date, though, there have been no warranty claims under the Bree program. Participation by employers and hospitals in the bundled payment and warranty model is voluntary. The first contract that includes a financial warranty started in January and covers public employees who receive a total hip or total knee replacement at Virginia Mason Medical Center in Seattle, Weir said.

In addition to its Bree work, Virginia Mason incorporates bundled payments with limited warranties for some of its larger, more progressive employer clients, said Dr. Robert Mecklenburg, medical director at the Virginia Mason Center for Health Care Solutions.

The motive behind the Bree Collaborative is to reduce avoidable hospital readmissions by aligning payment for care with quality rather than the number of services provided, Weir said. These themes have cropped up with growing frequency in health care, adopted to varying degrees by health care providers, employers and government health care programs like Medicare.

The Bree warranty covers very specific complications that are considered directly related to the operation. For hip and knee replacements, for example, hospitals that participate would agree to hold patients and health plans harmless financially if the patients got pneumonia, sepsis or had a heart attack within seven days of the surgery. Within 30 days, the warranty would cover wound infections, surgical site bleeding and pulmonary embolisms. Patients and insurers would be protected for up to 90 days if they develop an infection around the artificial joint or if the joint suffers a mechanical failure.

If a complication arises during the warranty time frame that is directly attributable to the initial procedure, the Bree warranty recommends that there would be no charge for hospitalization related to that care, even if care extended beyond the warranty period, Weir said.

The collaborative is revising its current recommendations, Weir said. One change will be to eliminate “death” from the list of 30-day complications under the warranty.

“You can’t really warranty against death,” she said.

Had a hip replacement warranty been in place when Radach had her surgeries, she would likely have saved a lot of money.

Radach believes that surgical warranties should be even more comprehensive than Bree recommends, holding manufacturers responsible for the production of safe and effective devices. For now, she said, the current warranty is reasonable.

“Starting with a warranty for the procedure itself and the hospital care is a good start,” she said.

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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