Should physicians be afforded Mulligans for non-reimbursable Medicare readmissions?

Let’s start off by making it clear that most adverse clinical outcome are not medical errors. OK?

Now….

Back about twenty years ago during my tenure as President and CEO of Jersey City Medical Center, insurers when reviewing a claim for hospital reimbursement, would “deny” days. More specifically the hospital got a per diem payment for “approved” days only. But even if the insurer reduced the number of approved hospital days say from six to four, they still reimbursed the physician for six days. With no disincentive for physicians to be concerned about length-of-stay, denied days were costly to the hospital.

Fast Forward. Medicare is penalizing hospitals for certain readmissions.

“Generally speaking, a hospital readmission occurs when a patient is admitted to a hospital within a specified time period after being discharged from an earlier (initial) hospitalization. For Medicare, this time period is defined as 30 days, and includes hospital readmissions to any hospital, not just the hospital at which the patient was originally hospitalized.

Medicare uses an “all-cause” definition of readmission, meaning that hospital stays within 30 days of a discharge from an initial hospitalization are considered readmissions, regardless of the reason for the readmission.” (A)

Some systems are working to align hospital and physician performance, avoid reimbursement penalties, and increase patient satisfaction.

“In 2006, Geisinger Health System transformed the health care industry by testing and rewarding how elective cardiac surgery was performed and by offering a “warranty” on coronary artery bypass surgeries. That innovative effort marked the birth of the Pennsylvania-based health system’s eminent ProvenCare program, which applies evidence-based protocols aimed at reducing mortality rates, improving outcomes and reducing costly readmissions”…..”By eliminating unwarranted variation and applying scientific best practices to coronary artery bypass graft (CABG) patients, Geisinger has been able to reduce readmissions, complications and length of stay while raising its profit margin by 17 percent.” (B)

”Patients who undergo routine hip or knee replacements at Seattle’s Virginia Mason Medical Center, and their employers, now can worry less about paying twice if surgical complications occur. That’s because the hospital has decided to offer a warranty to privately insured patients on avoidable complications stemming from total joint replacements, making it one of the first hospitals in the nation to do so.” (C)

“Surgical warranties vary somewhat in terms of what they cover. Generally, though, it’s a guarantee to fix any avoidable complications related to surgery — at no extra charge to the patient. Warranties are offered as part of a group of bundled services that come as one-price package deals.” (D)

“Hospital readmissions occur for a number of reasons: infections and other complications; premature discharge; failure to coordinate and reconcile medicines; inadequate communication among hospital personnel, patients, caregivers and clinicians; and poor planning for care transitions.” (E)

Warranties sound innovative but can only work to improve outcomes and reduce expense if physicians share the rewards and risks with the hospital. This sounds easy with employed physicians but will it work with unpaid voluntary physicians in private practice or will they simply move their practices to hospitals without warranties?

(A) http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/

(B) http://www.prnewswire.com/news-releases/geisingers-renowned-provencare-program-launches-three-new-orthopaedic-offerings-total-hip-total-knee-and-hip-fracture-274334131.html

(C) http://www.modernhealthcare.com/article/20140905/NEWS/309059944

(D) http://www.latimes.com/business/ Considering surgery? Some healthcare providers offer warranties

(E) http://www.fuqua.duke.edu/news_events/news-releases/health-care-warranties/#.V5j_eo-cFYc

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