Posted Friday, September 4, 2009
Infections, medical errors, poor communication and Medicare's reimbursement policies are turning hospitals into revolving doors. Almost one fifth of all Medicare patients discharged are readmitted within a month. The cost to the taxpayer? About $15 Billion. Friday morning at 9, join Regina Brett and guests to talk about changes needed to cut the readmission rate -- and what's preventing them.
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Medicare works on benefit periods. IP care is the deductible for the first 60 days. If you are released and readmitted within that 60 day period. IF the patient is released and remains out of the hospital for 60 days and day 61 they are readmitted, this is considered a new admit and the only thing due, again, is the deductible for that year. 2009 is $1068.00.
If a patient remains in the hospital for a continuous 60 days, from day 61 through 90, there is a co-pay amount due, 2009, it is $267.00.
This can happen, even if the patient does not remain in the hospital. If there are multiple admits/discharges within the 60 day benefit period, those days are added up and if the patient does not remain out of the hospital for 60 days, it will follows the same rules as a continuous stay.
After the 90 days have been used for a benefit period, Lifetime Reserve days kick in. They are non-renewable. Once used, that’s it. There are 60 @ $534.00 co-pay a day for 2009.
This works for Skilled nursing. also. 100 days are covered in a benefit period. 20, Medicare pays all charges. Day 21 through 100 there is a $133.50 coinsurance per day and Medicare pays the rest. This has a benefit period, also of 60 days. If out for 60, benefits start over. If not, Medicare does not pay anything. You will definitely need a secondary payor.
I am an internist. Two quick comments:
Bundling (as in current DRG system) equals fixed reimbursement for a condition resulting in more pressure on physicians to minimize length of stay supposedly to reduce expenses. Logically, this would lead to readmissions in many cases.
Secondly, increased quality measurements and mandates similar to managed care alluded to by your guests amounts to nothing but more paperwork & phonecalls for prior authorizations in the physician offices. This was exactly why managed care is so unpopular amongst physicians and patients too.
One another afterthought: conditions like congestive heart failure are to some extent, endstage, hence in the elderly, would lead to recurrent admissions till the eventual outcome. Hence end of life discussions and recalibrating patient’s expectations are extremely important.
As a home health care nurse for the vna of cleveland, I am painfully aware of the need for “old school” discharge planning when a patient is discharged from the hospital. Back in the 80’s in nursing school, we were taught that discharge planning starts the day of admission. Due to minimal staffing on the floors and RN jobs being replaced(supplemented) by a “tech”, discharge planning has suffered. My patients are sent home on totally new med regimes, no prescriptions and a paper medication discharge form without adequate medication education. The majority of my first few visits are consumed by medication teaching and ordering. Medication and dietary non-compliance is the number one reason for my patient being rehospitalized.
I was a social worker working in discharge planning in a skilled nursing facility and later in an acute hospital in the late 70’s early 80’s. To coordinate all the disciplines in the process of discharge was a huge task but it was possible. Today, the social worker or discharge planner are overwhelmed with all that is involved in an ever increasing sickly, elderly population. Today I see how today’s hospital has become so money oriented. When I receive the glossy brochures from these institutions marketing their services, I just bristle. The increase costs in these hospitals need to choose between the direct patient care or employ expensive marketing departments and other unnecessary departments that increase our costs in health care.
Part of the problem is that there is less care from primary care physicians. With the advent of hospitalists, the primary care physician is less likely to be involved in the hospital care. Many hospitals, the Cleveland Clinic being one, do very poorly at making sure the primary care physician is even notified of the admission, much less receives timely notice of discharge. Specialists do not reliably notify primary care physicians of the findings.
When the primary care physician does the bulk of the care, as happens in most other countries, care is both better and cheaper.
If primary care physicians were adequately paid, and if there were better support of the training of primary care physicians, our costs would be lower and care would be better coordinated.
My 79-year-old mother, a smoker for 50 years who now has major breathing problems, plays a game of revolving chair with University Hospitals. She goes in feeling awful—unable to catch her breath.
She leaves for home feeling just marginally better than she did when she went in. How do my brother, my sister and I know if the hospital is pushing her out of the door too soon? Is there a second opinion we can see to make sure when she comes home that she can at least feel somewhat better?
Most of the time, the direct care nurse is responsible for the discharge teaching of the patient and family – Regina called it the “exit interview”. When the nurse is caring for twice to three times as many patients as is safe – this discharge teaching falls through the crack, and patients and families are discharged without complete understanding of their illness, prescriptions, and follow up care.
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