Are Hospitals Sidestepping Admissions to Reduce Re-admission Rates?

In Response to “Baby Boomers Not Savi... Where my time has gone and my healthc...

Are Hospitals Sidestepping Admissions to Reduce Re-admission Rates?

In October of 2012 Medicare enacted new federal regulations by penalizing hospitals with high readmission rates. There was an incredibly high rate of seniors being readmitted to the hospital within 30 days of a prior admission. The 2010 rate of re-admissions ranged between 12.2% and 26.7% across the nation, with an average of nearly 20%. When 2 out of 10 people return to the hospital and are sick enough to be re-admitted it makes sense that something needed to be done, but this may not have been the best way to go about it.

Medicare is penalizing hospitals by reducing their overall payments to the hospital for the calendar year by 1-2% in 2013 for high re-admissions in 3 categories, Heart Attacks, Pneumonia, and Heart Failure, but they have been adjusting that rate since the ruling by fractions of a percentage. They are also considering adding other medical conditions such as lung disease. Obviously this is a huge financial loss for hospitals with high rates of re-admissions. It seems to target hospitals in poorer areas where its more difficult to keep or return people to good health, due to of the lack of education, finances, and resources many patients are dealing with in poorer areas. These patients tend to eat less healthy meals, forgo medications they can’t afford, fail to follow up with physicians because of a lack of transportation and the money for co-pays. There is much less of a focus on improving health in the more socioeconomic deficient neighborhoods, where many are just trying to get by. The supports are not available to assist with literacy, education, transportation, and funds to pay for medications, co-pays, and healthier meals and a healthier environment.

There is a lot of discussion about this in healthcare and the news because it becomes a moral issue when healthcare providers are penalized for their patients lifestyles which is beyond their control and how much responsibility is put on the hospital to work in people’s lives outside of the hospital. The New York Times published an article in May of this year titled Hospitals Question Medicare Rules on Readmissions that poses these issues a bit better.

Spending time in hundreds of private homes as a case manager, RN, and homecare agency owner, I can tell you that it’s very difficult to change long standing unhealthy habits. The likelihood of getting an 80 year old to quit smoking or to give up the fried foods in place of more fruits and vegetables is poor. Starting an exercise program when an elderly person has another condition like arthritis, back pain, or shortness of breath from COPD, or emphysema is not likely either. There is more of an effort to keep seniors from returning to the hospital with programs such as checking on patients after discharge, and helping them enroll in healthy living programs, so there is some benefit to the mandate by hospitals being forced to better understand why patients are having difficulties following discharge orders, or improving their health. When your work is only in the hospital its hard to understand what is going on in homes and the community after patients leave the hospital. This forces hospitals to understand they are only part of the healthcare system and can benefit from a team approach with providers out in homes, the community and in long term care facilities.

I personally think that Medicare has gone about reducing re-admissions in the wrong way, but besides that I am seeing another part of the scenario that I believe is harmful to patients. I am hearing about a lot of seniors going to ER for whatever is causing them to seek emergency care and being held in the observation room for days at a time. Observation rooms were initially added to observe patients for less than 24 hours. If the patient is stable and there is no further cause for concern they are discharged home with instructions. If they are unstable or their condition worsens they would then be admitted to the hospital. In the last 3-4 weeks I have talked to a few different family members who said their elderly loved ones were held as long as 3 days in observation, and another was held for the same time frame but was housed in the hallway of the emergency department and didn’t even get into a room. After the 3+ days of being held in “observation” they were discharged home. One patient had one hospital admission and had gone back twice within a month, which is when she was held in observation. She was told that Medicare may not cover her 2nd trip to ER and the subsequent 3 day hold in observation. I have to wonder if she was told that because she was never re-admitted and only held in observation? If they would have gotten to the cause of her complaint, or treated it in some way, she wouldn’t have returned, but they didn’t.

I am seeing a trend here to reduce the possibility of re-admissions by holding seniors in observation rather than admitting them to the hospital. This is not good for patients! If a senior is too sick, weak, injured, or suffers from another condition making it unsafe to go home, or it will be in their best interest to go to a rehabilitation facility for therapy or care, Medicare will not cover any of it unless the patient has spent 3 full 24 hour days in the hospital once the physician orders the patient to be admitted, and that does not include the day of discharge. When physicians write orders they are required to date and time them, so from the time the physician writes “Admit to the hospital” and dates and times it, the clock begins. Medicare requires a full 72 hours of admission before they will pay for rehab. If the hospital holds an elderly person in observation for three days, decides to then admit the patient and discharges them to rehab 2 days later, they will be responsible for 100% of the charges at the rehab facility. If they were actually admitted to the hospital for the full 3 day criteria, Medicare would pay 100% for the first 20 days. The patient then pays a portion of the daily charges from day 21-100. Seniors have been sent to rehab facilities only to later find out they are responsible for all charges. This is a very poor practice. Rather than look out for some of the most vulnerable patients, some providers have failed them.

You must be a healthcare advocate for yourself and your family. If you have an aging loved one who ends up in an observation room you may have to push for an admission. If it looks like your loved one will be on observation for over 24 hours insist on speaking to the doctor about admitting your loved one so they don’t find themselves with an outrageously expensive bill.

Whether we agree on how Medicare is handling readmission rates or not, I think we should all agree that what is best for patients should come first.

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