Other Topics on this Site: List of all US doctors who offer long office visits
List of the most experienced specialist doctors
Most of the Medicare program provides needed treatment. Some aspects reduce treatment to save cost, as explained here. For example Medicare discourages hospitals from treating patients twice in 30 days. This policy hurts frail elderly patients who need more frequent care than average. Medicare also offers doctors and hospitals bonuses if they reduce treatment. (More sources about this subject)
1. Re-hospitalization, or Readmission into Hospitals
Medicare pays for hospital stays. Then they count how many Medicare patients are readmitted within 30 days after the hospital stay. If readmissions are above the national average, adjusted for patient mix, Medicare will charge the hospital an expensive penalty, even if readmissions are unrelated to the original hospital stay, and even if the readmission is at a different hospital.
84% of hospitals measured pay penalties, and some pay over a million dollars per year. Hospitals cannot give up this much revenue. They are shifting to less treatment of Medicare patients, and patients are dying. There are better ways to save Medicare money, without cutting needed hospital care.
Table A. Readmission Penalties, Paid by Hospitals, for Six Conditions
Examples of the Biggest Penalties (spreadsheet or html)- Estimates include:
Florida Hospital Orlando FL, $5.5 million
Yale-New Haven Hospital New Haven CT, $4 million
$2.5-$2.8 million penalties per year at
Thomas Jefferson University Hospital Philadelphia PA
St Joseph's Regional Medical Center Paterson NJ
Southcoast Hospital Group, Inc Fall River MA
Virtua West Jersey Hospitals Berlin NJ
Beaumont Hospital Royal Oak MI
Advocate Christ Hospital & Medical Center Oak Lawn IL
St Lucie Medical Center Port St. Lucie FL
Kennedy University Hospital Stratford NJ
Lakeland Regional Medical Center Lakeland FL
Presence Saint Joseph Medical Center Joliet IL
CJW Medical Center Richmond VA
Those hospitals have large penalties because of a combination of their large size and the patients they treat, who need extra care.
2. Find Your Local Hospital's Penalties
Maryland and Puerto Rico are exempt.
2015 August 10 - Hospitals Treat Fewer Seniors when Medicare Charges Penalties
2014 August 6 - Hospitals Fined $529 Million or here
2014 May 30 - Readmission Penalties Put Burdens on Hospitals or here
Coverage by Bloomberg BNA
2013 August 14 - Size of Readmission Penalties, or here
Coverage by EHRIntelligence, Orthopedics This Week
If we want legitimate patients treated, how can we penalize their hospitals? Faced with the level of penalties being imposed, hospitals cannot afford to treat many seniors. There are also incentives against treatment in some of the other ratings of hospitals.
Measuring and rewarding medical providers can backfire and reduce quality by reducing motivation (see a very good, broad article on these effects).
Because of these penalties, all hospitals try to be below average on readmissions, which makes the average get smaller (8% smaller in 2013; goal is 20% smaller, p.292). Faced with moving targets, hospitals cannot afford these penalties. They need to prevent as many readmissions as possible, often by emergency treatment without hospital admission, or brief admissions for observations instead of full treatment, or treating fewer patients for these conditions in the first place. If a risky patient is not admitted, s/he can't be readmitted.
The American College of Surgeons has warned Medicare about "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue."
The latest data and several studies show that readmissions prevent deaths, so penalties are deadly. The American Hospital Association reported in Trendwatch September 2011, "mortality is inversely related to readmissions."
Dr. Kripalani of Vanderbilt University asks, "which would we rather have -- a hospital readmission or a death?"
Doctors Krumholz, Lin and colleagues in the Journal of the American Medical Association Feb.13, 2013 reported a 17% correlation between higher readmissions and lower deaths among heart failure patients. These are the same Yale authors who develop Medicare's readmission data, yet their own hospital cannot avoid readmissions. Yale-New Haven Hospital did 253 hip and knee replacements and will pay a quarter of that revenue as a readmission penalty.
Doctors Gorodeski, Starling and Blackstone of the Cleveland Clinic showed with a graph in the New England Journal of Medicine July 15, 2010 that hospitals with higher readmissions after heart failure treatment had significantly fewer deaths among the patients.
Hospitals are disclosing the financial risks of penalties in bond disclosures (p.25).
Evaluations have shown limited results.
Researchers at Columbia and Yale found that even an extra day of hospital treatment for pneumonia or heart attack saves thousands of lives (Table H). So reducing access to hospital treatment will be deadly.
Table H. Lives Saved by More Hospital Treatment
Other sections of this site discuss some of the ways patients and hospitals can respond to readmission penalties, not always healthily. One unhealthy approach that Medicare advocates is to limit care and promote hospice, comfort care (symptom relief or palliative care), and "do not resuscitate" (DNR) orders, so patients die at home and do not come back to the hospital.
The list of all hospitals shows the number of excess readmissions charged to each hospital, though privacy prevents showing the reasons. Many numbers are fractional, because of the adjustment for patient mix, which changes hospitals' baselines by fractions. No matter what they do, half the hospitals will be above average on each condition and will pay penalties. With 6 conditions, over 80% of hospitals will always be above average on some condition and pay penalties. Medicare does not know better than 80% of hospitals, and has no business penalizing them.
The penalty is far worse than simply refusing coverage, as Medicare does with long nursing or hospital stays. When Medicare lacks coverage, people can plan with other insurance or their own money. But hospitals cannot accept other money for these readmissions, since
These pervasive efforts, important to hospitals and life-threatening to patients, only save $1.5 billion per year (p.26), less than a third of a percent of the Medicare budget. There are better alternatives.
Congress is considering similar penalties for skilled nursing facilities (SNFs) which have above-average rehospitalizations. If adopted, SNFs will find it hard to admit and serve the frailest patients, who need them most.
5. Which Readmissions Are the Hospital's Responsibility?
Medicare approves for payment both the initial admission and the readmission. When it fines the hospital years later, it implicitly reverses those approvals, and overrules the doctors who decided hospital care was medically necessary, without even looking at the charts.
Many readmissions are random and unrelated to the original hospital care.
The law requires Medicare to exclude readmissions unrelated to the initial admission. Medicare does exclude planned readmissions, such as cancer treatment, and transfers to other hospitals for specialized care, but otherwise it does not follow the law's exclusion of unrelated readmissions. Medicare penalizes hospitals for unplanned readmissions, whether related or not.
People have commented on this discrepancy and Medicare answered in the Federal Register Aug. 19, 2013, "creating a comprehensive list of potential complications related to the index hospitalization would be arbitrary, incomplete, and, ultimately, extremely difficult to implement." So they found it hard to obey the law on excluding unrelated readmissions, and they decided not to obey the law, which seems even more arbitrary.
Four research papers confirm that low readmissions mean more deaths.
Other research papers show faster deaths for patients with palliative care or "Do Not Resuscitate" (DNR) orders.
Medicare has chosen not to release its own findings on deaths, which it said it was monitoring years ago, in the Federal Register Aug 12, 2012. Deaths save money for both Medicare and Social Security.
The general approach of penalizing readmissions derives from an old estimate that 76% are preventable. This was based on experimental software, not verified by reviewing actual cases and seeing what it would have taken to prevent readmissions. (MedPAC 6/07 pp.107-108)
Dr Ashish Jha, of Harvard's School of Public Health, told PBS, "If you look at, for instance, the U.S. News [and World Report] publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted."
Doctors are begining to reduce care, to save money, throughout medicine, without discussing the options with patients. For example Medicare proposes a payment for less-invasive heart surgery which makes it unaffordable for hospitals
A reader wanted to know when updates happen, so I will try to list them here, back to July 25, 2014.
2017 Jan 30 - Wider text, more on costs and referrals
2016 Dec 8 - added sites on FOIAs
2016 Nov 23 - estimated 8,000 heart failure deaths per year, caused by readmission penalties
2016 Nov 3 - rearranged penalty calculations and hospital quality. Added NICHE levels of geriatric care
2016 Oct 21 - updated readmission penalties to FY2017, with bypass operations for the first time. Added detail on Healthgrades data about hospitals and doctors
2016 Sep 27 - noted BCBS of NC costs on Specialists page
2016 Sep 18 - new format to name medical representative and noting organ donation.
2016 Sep 7 - updated codes for medical procedures with 2014 costs and volume
2016 Aug 30 - gave links to search for hospitals with the most experience in each procedure
2016 Aug 26 - put specialists on a new page, and re-wrote it with instructions for using Medicare's interactive site to search for specialists.
2016 Aug 23 - corrected patient strategies to note how hard it is to drop Medicare Part A.
2016 Aug 22 - lists of independent doctors and nursing home organizations
2016 Jul 8 - 2012-2014 data on 683,000 doctors & others, to find those who give long appointments & treat you in multiple settings
2016 Jun 10 - Signs and letters written by Medicare, telling patients about ACOs
2016 Apr 2 - Doctor's incomes, hours, satisfaction, discipline
2016 Jan 6 - More info on Drugs
2015 Nov 30 - Renamed Advance Directive Form to emphasize Medical Representative, and updated CPR statistics with success outside hospitals.
2015 Nov 17 - Improved labels in financial data, and added Google sheet of doctors' office hours.
2015 Oct 22 - Improved labels in office hours data, and gave numbers of new patient appointments instead of the ratio between later and new appointments.
2015 Oct 16 - Updated Hospitals.xls+Penalty.xls with minor price changes issued Oct.5. Also corrected total US penalties to exclude Maryland, which is exempt from penalties. Removed blank columns, since sorting is sometimes blocked by blank columns. Reformatted advance directive pdf. Clarified definition of 1st visit with a patient.
2015 Oct 3-6 - Linked to better file to find doctors' phone numbers. Described California's ratings of hospitals. Stressed agent in advance directive. Expanded Excel instructions. Noted new data on types of patients seen by each doctor.
2015 Sep 30 - Added links on selecting medical representative; changed background photos
2015 Sep 2 - Better labels for Doctors, dropped diabetes education (30') to stay under 200 MB
2015 Aug 22 - Clarified doctor files & advance directives; added a Creative Commons license
2015 Aug 9 - Added data on hospitals cutting treatment.
2015 Aug 6 - Slightly better sort of Doctors, added longer patient education, better labels of countries
2015 Aug 5 - Updated readmission penalties to October 2016
2015 July 25-31 - Compiled ratings of doctors on one page
2015 July 1-9 - Added length+number of appointments for 636,000 generalist doctors. Updated data on 230,000 specialists. Better advance directives.
2015 Jun 12 - Simplified example of advance directives
2015 Apr 25 - Added percent readmitted for various causes
2015 Apr 7 - Added state totals for each penalty
2015 Mar 20-23 - Added penalties, address, latitude + longitude to Hospital financial statements. Fixed omission of last character of amounts. Expanded description of penalties.
2015 Mar 14 - Added name, address, phone & hospital chain to Hospital financial statements
2015 Mar 4 - Re-ordered columns, and added web links in spreadsheets of doctors
2015 Mar 3 - Added spreadsheets of Hospital financial statements, and highest-volume 25 doctors for each procedure
2015 Mar 2 - Added note on how high-volume doctors get their start
2015 Jan 15-Feb 22 - Article on Advance Directives
2015 Jan 23-26 - Reduced readmission penalty estimates, to omit capital and other costs which are not subject to penalties, and use Medicare's October updates.
2015 Jan 7-14 - Split off sections about unnecessary care, knees, legal searches & patient reviews
2014 Dec 31 - Published article on selecting doctors by experience & other measures
2014 Dec 30 - Updated ACO list with 89 new groups starting in 1/1/2015
2014 Dec 18 - Corrected in my files, errors which Medicare had in 650 doctors' state or zip code.
2014 Dec 1-12 - Added research on doctors' experience
2014 Nov 29 - Added maps of doctors' experience
2014 Nov 26 - Added more complete files on doctors' experience
2014 Sep 8 - Added input on 2015 Dietary Guidelines
2014 Sep 2-5 - Added comments on Medicare ACO rules, an option to create nutrition graphs in USDA file of nutrients, and more comparisons of protein sources, in site & USDA file.
2014 Aug 22 - Re-sorted USDA file of nutrients, added nutrition labels for protein alternatives
2014 Aug 18 - Added Calories in the nutrition labels proposed in the salt section, and identified almond milk with less sodium than average
2014 Aug 7 - Updated readmission rates and penalties with data from p.756 of Medicare's final rule, instead of p.1495. Both tables have the same title and have slightly different numbers. Medicare says p.756 applies to readmissions penalties.
2014 Aug 6 - Added the idea of clearer Explanations of Benefits, as a cost-saving alternative
2014 Aug 4 - Updated readmissions with data released by Medicare today
2014 July 27 - Listed doctors' experience on home page, with files on the Northeast and elsewhere
2014 July 25 - Adjusted readmission penalties at each hospital, for variations in local costs
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