Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients

https://www.npr.org/sections/health-shots/2018/06/13/619259541/medicare-takes-aim-at-boomerang-hospitalizations-of-nursing-home-patients

“Oh my God, we dropped her!” Sandra Snipes said she heard the nursing home aides yell as she fell to the floor.

She landed on her right side where her hip had recently been replaced. She cried out in pain.

A hospital clinician later discovered her hip was dislocated.

That was not the only injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice a day with a potent blood thinner despite written instructions to stop.

“She said, ‘I just feel so tired,’ ” her daughter, Laura Clark, said in an interview. “The nurses were saying she’s depressed and wasn’t doing her exercises. I said no, something is wrong.”

Her children also discovered Snipes’ surgical wound had become infected and infested with insects. Just 11 days after she arrived at the nursing home to heal from her hip surgery, she was back in the hospital.

The fall and these other alleged lapses in care led Clark and the family to file a lawsuit against the nursing home. Richmond Pines declined to discuss the case beyond saying it disputed the allegations at the time. The home agreed in 2017 to pay Snipes’ family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes’ case was extreme, return trips from nursing homes to hospitals are far from unusual.

With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerangs back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.

“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’ ” said David Grabowski, a professor of health care policy at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or assessing penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Payment Advisory Commission.

“We’re better, but not well,” Grabowski said. “There’s still a high rate of inappropriate readmissions.”

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a typical patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have their own incentives to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

“And they never quite get back to normal,” he said.

‘She Looked Like A Wet Washcloth’

Communication lapses between physicians and nursing homes is one recurring cause of rehospitalizations. Elaine Essa had been taking thyroid medication ever since that gland was removed when she was a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2013 when a bout of pneumonia sent her to the hospital.

When she returned to the nursing home — now named Wellsprings Post-Acute Care Center — her doctor omitted a crucial instruction from her admission order: to resume the thyroid medication, according to a lawsuit filed by her family. The nursing home telephoned Essa’s doctor to order the medication, but he never called them back, the suit said.

Without the medication, Essa’s appetite diminished, her weight increased and her energy vanished — all indications of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, did not grasp the cause of her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return from the hospital, “she looked like a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she demanded the home’s nurses check her mother’s blood pressure. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her deposition that the doctor told her, “I can’t believe that this woman is still alive.”

Essa died the next month. The nursing home and the medical practice settled the case for confidential amounts. Cynthia Schein, an attorney for the home, declined to discuss the case beyond saying it was “settled to everyone’s satisfaction.” The suit is still ongoing against one other doctor, who did not respond to requests for comment.

Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital.

Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.

“We’re always worried the bad nursing homes are going to get the message ‘Don’t send anyone to the hospital,’ ” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, where Sandra Snipes stayed, has a higher than average rehospitalization rate of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she was discharged to a different nursing home, according to the family’s lawsuit. But her hospital trips were not over: When she showed signs of recurrent infection, the second home sent her to yet another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and more than a liter of infected blood clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the blood thinner right off the bat, we don’t think any of this would have happened.”

Snipes returned home but was never able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t want to go back into the nursing home,” Clark said. “She was terrified.”

 

 

 

Would Americans Accept Putting Health Care on a Budget?

https://theincidentaleconomist.com/wordpress/upshot-maryland-global-payments/

Image result for global budget health care

If you wanted to get control of your household spending, you’d set a budget and spend no more than it allowed. You might wonder why we don’t just do the same for spending on American health care.

Though government budgets are different from household budgets, the idea of putting a firm limit on health care spending is far from unknown. Many countries, including Canada, Switzerland and Britain, pay hospitals entirely or partly this way.

Under such a capped system, called global budgeting, a hospital has an incentive to deliver less care — including reducing hospital admissions — and to increase the efficiency of the care it does deliver.

Capping hospital spending raises concerns about harming quality and access. On these grounds, hospital executives and patient advocates might strongly resist spending constraints in the United States.

And yet some American hospitals and health systems already operate this way, including Kaiser Permanente and the Veterans Health Administration. To address concerns about access and quality, these programs are usually paired with quality monitoring and improvement initiatives.

That brings us to Maryland’s experience with a capped system. The evidence from the state is far from conclusive, but this is a weighty and much-watched experiment for health researchers, so it’s worth diving into the details of the latest studies.

Starting in 2010 with eight rural hospitals, and expanding its plan in 2014 to the state’s other hospitals, Maryland set global budgets for hospital inpatient and outpatient services, as well as emergency department care. Each hospital’s budget is based on its past revenue and encompasses all payers for care, including Medicare, Medicaid and commercial market insurance. Budgets for hospitals are updated every year to ensure that their spending grows more slowly than the state’s economy.

Because physician services are not part of the budgets, there is an incentive to provide more physician office visits, including primary care. According to some reports, Maryland hospitals are responding to this incentive by providing additional support outside their walls to patients who have chronic illnesses or who have recently been discharged from a hospital. Greater use of primary care by such patients, for example, could reduce the need for future hospital admissions.

In 2013, early results found, rural hospital admissions and readmissions were both down from their levels before the system was introduced.

In the first three years of the expanded program, revenue growth for Maryland’s hospitals stayed below the state-set cap of 3.58 percent, saving Medicare $586 million. Spending was lower on hospital outpatient services, including visits to the emergency department that do not lead to hospital admissions. In addition, preventable health conditions and mortality fell.

According to a new report from RTI, a nonprofit research organization, Maryland’s program did not reap savings for the privately insured population (even though inpatient admissions fell for that group). However, the study corroborated the impressive Medicare savings, driven by a drop in hospital admissions. In reaching these findings, the study compared Maryland’s hospitals with analogous ones in other states, which served as stand-ins for what would have happened to Maryland hospitals had global budgeting not been introduced.

But a recent study, published in JAMA Internal Medicine, was decidedly less encouraging.

Led by Eric Roberts, a health economist with the University of Pittsburgh, the study examined how Maryland achieved its Medicare savings, using data from 2009-2015. Like RTI’s report, it also compared Maryland hospitals’ experience with that of comparable hospitals elsewhere.

However, unlike the RTI report, Mr. Roberts’s study did not find consistent evidence that changes in hospital use in Maryland could be attributed to global budgeting. His study also examined primary care use. Here, too, it did not find consistent evidence that Maryland differed from elsewhere. Because of the challenges of matching Maryland hospitals to others outside of the state for comparison, the authors took several statistical approaches in reaching their findings. With some approaches, the changes observed in Maryland were comparable to those in other states, raising uncertainty about their cause.

A separate study by the same authors published in Health Affairs analyzed the earlier global budget program for Maryland’s rural hospitals. They were able to use other Maryland hospitals as controls. Still, after three years, they did not find an impact of the program on hospital use or spending.

Changes brought about by the Affordable Care Act, which also passed in 2010, coincide with Maryland’s hospital payment reforms. The A.C.A. included many provisions aimed at reducing spending, and those changes could have led to hospital use and spending in other states on par with those seen in Maryland.

A limitation of Maryland’s approach is that payments to physicians are not included in its global budgets. “Maryland didn’t put the state’s health system on a budget — it only put hospitals on a budget,” said Ateev Mehrotra, the study’s senior author and an associate professor of health care policy and medicine at Harvard Medical School. “Slowing health care spending and fostering better coordination requires including physicians who make the day-to-day decisions about how care is delivered.”

broader global budget program for Maryland is in the works. The U.S. Centers for Medicare and Medicaid Services is reviewing a state application that commits to global budgets for Medicare physician and hospital spending. An editorial that accompanied the JAMA Internal Medicine study noted that a few years may be insufficient time to detect changes. It suggests that five to 10 years may be more appropriate.

“Maryland hospitals are only beginning to capitalize on the model’s incentives to transform care in their communities,” said Joshua Sharfstein, a co-author of the editorial and a professor at the Johns Hopkins Bloomberg School of Public Health. “This means that as Maryland moves forward with new stages of innovation, there is a great deal more potential upside.” As former secretary of health and mental hygiene in Maryland, he helped institute the Maryland hospital payment approach.

Global budgets are unusual in the United States, but their intuitive appeal is growing. A California bill is calling for a commission that would set a global budget for the state. And soon Maryland won’t be the only state using such a system. Pennsylvania is planning a similar program for its rural hospitals.

Can this system work across America?

How much spending control is ceded to the government is the major battle line in health care politics. An approach like Maryland’s doesn’t just poke a toe over that line, it leaps miles beyond it.

But the United States has been trying to get a handle on health care costs for decades, spending far more than other advanced nations without necessarily getting better outcomes. A successful Maryland experiment could open an avenue to cut costs through the states, perhaps one state at a time, bypassing the steep political hurdle of selling a national plan.

 

AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance

http://www.commonwealthfund.org/interactives/2017/mar/state-scorecard/

Image result for AIMING HIGHER: Results from the Commonwealth Fund Scorecard on State Health System Performance

The 2017 edition of the Commonwealth Fund Scorecard on State Health System Performance finds that nearly all state health systems improved on a broad array of health indicators between 2013 and 2015. During this period, which coincides with implementation of the Affordable Care Act’s major coverage expansions, uninsured rates dropped and more people were able to access needed care, particularly those in states that expanded their Medicaid programs. On a less positive note, between 2011–12 and 2013–14, premature death rates rose slightly following a long decline. The Scorecard points to a constant give-and-take in efforts to improve health and health care, reminding us that there is still more to be done.

Vermont was the top-ranked state overall in this year’s Scorecard, followed by Minnesota, Hawaii, Rhode Island, and Massachusetts (Exhibit 1). California, Colorado, Kentucky, New York, and Washington made the biggest jumps in ranking, with New York moving into the top-performing group for the first time. Kentucky also stood out for having improved on more measures than any other state.

Exhibit 1Exhibit 1: Overall State Health System Performance: Scorecard Ranking, 2017

Using the most recent data available, the Scorecard ranks states on more than 40 measures of health system performance in five broad areas: health care access, quality, avoidable hospital use and costs, health outcomes, and health care equity. In reviewing the data, four key themes emerged:

  • There was more improvement than decline in states’ health system performance.
  • States that expanded Medicaid saw greater gains in access to care.
  • Premature death rates crept up in almost two-thirds of states.
  • Across all measures, there was a threefold variation in performance, on average, between top- and bottom-performing states, signifying opportunities for improvement.

By 2015, fewer people in every state lacked health insurance. Across the country, more patients benefited from better quality of care in doctors’ offices and hospitals, and Medicare beneficiaries were less frequently readmitted to the hospital. The most pervasive improvements in health system performance occurred where policymakers and health system leaders created programs, incentives, or collaborations to ensure access to care and improve the quality and efficiency of care. For example, the decline in hospital readmissions accelerated after the federal government began levying financial penalties on hospitals that had high rates of readmissions and created hospital improvement innovation networks to help spread best practices. (notes)

Still, wide performance variation across states, as well as persistent disparities by race and economic status within states, are clear signals that our nation is a long way from offering everyone an equal opportunity for a long, healthy, and productive life. Looking forward, it is likely that states will be challenged to provide leadership on health policy as the federal government considers a new relationship with states in public financing of health care. To improve the health of their residents, states must find creative ways of addressing the causes of rising mortality rates while also working to strengthen primary and preventive care.

 

 

 

New integrated model of care for seniors lowers hospitalizations, readmissions, emergency care visits

http://www.fiercehealthcare.com/healthcare/new-integrated-model-care-for-seniors-lowers-hospitalizations-readmissions-emergency

Nurse with patient

The clinical outcomes of a new integrated model of care for frail seniors that bridges housing and healthcare are so significant that researchers believe the program has the potential for substantial Medicare cost savings.

The model provides residents with onsite, comprehensive therapy, medical care, pharmacy, and lab services. Key components to the program include a care navigator who coordinates the residents’ total care and high-tech/high-touch communications that transfer the resident’s information to ancillary and acute care services through an electronic health record.

Although Juniper Communities’ residents were older and more cognitively impaired than the overall Medicare population with similar conditions, independent researchers from Anne Tumlinson Innovations looked at 2012 Medicare Beneficiaries Survey, as well as those living in senior housing that didn’t provide an integrated healthcare program, and found Juniper’s Connect4Life program had:

  • 50% lower inpatient hospitalization rates
  • 80% lower readmission rates
  • 15% lower rate of emergency department use

“I thought the results might be good but you never know until you get the data. But I didn’t expect the significance of the results,” Lynne Katzmann, Ph.D., founder and president of the Bloomfield, New Jersey-based operator of senior communities in New Jersey, Pennsylvania, Florida and Colorado, told FierceHealthcare this morning in an exclusive interview.

“The results show when you provide supportive housing and services and integrate with clinical care services you can avoid high utilization of the highest cost services,” said Katzmann, noting that it has the potential to address population health among the 5% who use 50% of healthcare resources.

Aetna, UnitedHealth show increasing appetite for value-based care contracts

http://www.healthcarefinancenews.com/news/wisconsin-hospitals-slash-readmission-rates-penalties-through-partnerships-hospital-association

Aetna has long held a goal to reach 75 to 80 percent of its medical spend in value-based relationships by 2020.

The biggest health insurers are moving quickly towards to value-based care arrangements, their recent earnings reports show.

While Aetna has long-held a goal to reach 75 to 80 percent of its medical spend in value-based relationships by 2020, Aetna’s medical spend is now 45 percent tied to value, CEO Mark Bertolini said during last week’s fourth quarter earnings call.

“One way we measure our success is by how well we are able to keep our members out of the hospital and in their homes and communities,” Bertolini said. “For example, in 2016, we reduced total acute admissions by approximately 4 percent, and we deployed predictive modeling to target members at the greatest risk of readmission.”

Aetna has achieved a 27 percent reduction in readmission rates using multidisciplinary care teams that engage facilities to develop effective discharge plans, he said.

Aetna, UnitedHealth show increasing appetite for value-based care contracts

http://www.healthcarefinancenews.com/news/aetna-unitedhealth-show-increasing-appetite-value-based-care-contracts?mkt_tok=eyJpIjoiWmpKaE5ETXhZVGc0TkdJNSIsInQiOiJjWXBGUGRYOWwySVVDRnRsdjhpOTJEK09yNSt1dzcyN1d0TmNucCtzN1A4cWlVcGl2NmM3M1wvR0lYQjRUa3ZQdzd2b2g4ZnFQWFRlYVhBMFwvY3I2VFlJaEVkdXhlODhNSGk4VUpVempaVUloZVBmRjRtekZXQ1ZGYVdjNFRJdkZRIn0%3D

Aetna has long held a goal to reach 75 to 80 percent of its medical spend in value-based relationships by 2020.

The biggest health insurers are moving quickly towards to value-based care arrangements, their recent earnings reports show.

While Aetna has long-held a goal to reach 75 to 80 percent of its medical spend in value-based relationships by 2020, Aetna’s medical spend is now 45 percent tied to value, CEO Mark Bertolini said during last week’s fourth quarter earnings call.

“One way we measure our success is by how well we are able to keep our members out of the hospital and in their homes and communities,” Bertolini said. “For example, in 2016, we reduced total acute admissions by approximately 4 percent, and we deployed predictive modeling to target members at the greatest risk of readmission.”

Aetna has achieved a 27 percent reduction in readmission rates using multidisciplinary care teams that engage facilities to develop effective discharge plans, he said.

“Collectively, these clinical programs have driven a best-in-class Stars readmission rate among national competitors,” he said.

Aetna sees more opportunities for reducing utilization over the long-term in readmission rates, and in a reduction in inpatient days. Unit price is still the driver in value-based purchasing, Bertolini said.

“I think value-based contracting is going to continue to be encouraged by even the current administration as a way of getting a handle on healthcare costs,” he said. “We have a healthy pipeline of opportunities. They will not all be joint ventures. I think there are other models emerging.”

UnitedHealthcare is increasingly helping states manage care for their complex, vulnerable and most costly populations, as well as assisting employers with programs to support the needs of retirees and employees with chronic conditions, according to CEO Stephen Hemsley in the insurer’s earnings report.

Sepsis Tops Conditions Tracked for Readmission Rates, but Triggers No Penalties

http://www.healthleadersmedia.com/quality/sepsis-tops-conditions-tracked-readmission-rates-triggers-no-penalties?spMailingID=10315063&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1082253801&spReportId=MTA4MjI1MzgwMQS2#

Sepsis Tops Conditions Tracked for Readmission Rates, but Triggers No Penalties

Sepsis has a higher rate of readmission than heart failure, but the federal government does not penalize hospitals for excessive readmissions due to sepsis.