Monday, August 5, 2013

Medicare fines: Hospitals that treated large number of low income patients were more likely to be penalized than those treating the fewest impoverished people.

Armed with bigger fines, medicare to punish 2,225 hospitals for excess readmissions.

According to the Kaiser Health News, Medicare will levy $227 million in fines on 2,225 hospitals in an attempt to reduce the number of patients readmitted within a month. While this is an effort to incentivize better patient care, it may result in poorer care for poorer patients. It is noted that hospitals that treated large number of low income patients were more likely to be penalized than those treating the fewest impoverished people. Among the safety net hospitals with the most poor patients, 77 percent were penalized, while only 36 percent of the hospitals with the fewest poor patients were penalized. Academic medical centers are more likely to get penalized than were community hospitals. As previous posts have indicated, indigent individuals have more complex health issues and are more likely to have complications needing readmission and are less likely to have resources at home to care for them on discharge.  Low-income patients may have a harder time adhering to their post-hospital instructions and buy the prescribed medications. So, hospitals may encourage their physicians to restrict surgery to patients who are very healthy, reducing the risk of readmission. Or hospitals may encourage their physicians to try outpatient management of heat attacks, pneumonia, and heart failure for a month until the patient is outside the 'penalty window'. The article states that Medicare does not see a need to take the socio-economic populations of hospitals into account in the penalties, since it "already factored in the differing health of those populations".

On the other hand, it is recognized that hospitals can earn more money if their patients' health deteriorates after they are discharged, because they can be paid for two stays instead of one. The Medicare Payment Advisory Commission (MedPAC), which reports to Congress, has estimated that 12 percent of Medicare patients may be readmitted for potentially avoidable reasons. Averting one out of every 10 of those returns could save Medicare $1 billion.

This is a classical ethical dilemma. We need to make sure that poor patients are not the casualty of attempts to save money. In practices with which we are familiar, we observe that the health of the patient plays an increasingly pivotal role in the decision to offer elective surgery, declining to offer the procedure to those in poorer health or those with poorer resources to support them after surgery even though the patient may meet all the classical 'indications'. It's the second of the 4 P's.

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