Tag Archives: Kaiser Medicare News

At Teaching Hospitals, Aggressive Screening May Lead To Medicare Penalties

CHICAGO — The puffiness along Carol Ascher’s left leg seemed like normal swelling, probably from the high dose of chemotherapy Dr. Karl Bilimoria had injected the previous day. But it could have been a blood clot. He quickly ordered an ultrasound.

“We were just being abundantly cautious,” he said.

Such vigilance is a point of pride at Northwestern Memorial Hospital. But the hospital’s tests have identified so many infections and serious blood clots that the federal government is cutting the institution’s Medicare payments for a year, by about $1.6 million.

Nearly half of the nation’s academic medical centers are being punished similarly through one of the federal government’s sternest attempts to promote patient safety. Medicare is reducing a year’s worth of payments to 758 hospitals, including some of the most prestigious teaching hospitals in the country, with the highest rates of infections and other potentially avoidable complications, including blood clots after surgery, bed sores, hip fractures and sepsis.

The penalties, created by the federal Affordable Care Act, have incited a vehement debate about quality at many academic medical centers often revered for cutting-edge treatments and top specialists. Are these vaunted hospitals really more dangerous than local, unsung hospitals?

Or, as Northwestern and some other academic medical centers argue, are these hospitals being perversely penalized because they are so aggressive in screening patients for problems? At Northwestern, the penchant for ordering lab tests is so prevalent that physicians often refer to a “culture of culturing” that they credit for helping to keep the death rate there lower than at most hospitals.

“If you don’t look for infections, you’re never going to find them,” said Dr. Gary Noskin, Northwestern’s chief medical officer.

Since 2008, Medicare has refused to reimburse hospitals for treating complications they created, but studies have found that the change has not resulted in substantial decreases in harm. Nationwide, infections and other avoidable hospital complications remain a threat to patients, occurring during 12 of every 100 stays, according to a federal estimate. Patients were hurt in some way more than four million times when hospitalized in 2014.

Hurting Hospitals With Sickest Patients?

The new Medicare penalties, which reduce payments by 1 percent for a year, were begun in October 2014. Last December, Medicare announced its second round of penalized facilities, which include Stanford Hospital in California, the Cleveland Clinic, and Brigham and Women’s Hospital in Boston, which trains residents from Harvard Medical School. Intermountain Medical Center in Utah and Geisinger Medical Center in Pennsylvania, both of which President Obama has singled out for excellence, also are being penalized.

The average penalty is estimated at about $480,000, but most academic centers will lose more since they have higher revenues. Medicare says the punishments are effective and notes that teaching hospitals as a group are improving more rapidly than other hospitals.

Andrea Stone, left, and Kaleigh Nolan at Northwestern Memorial Hospital. “Hand hygiene, as easy as it sounds, that takes a lot,” Ms. Stone said. (Joshua Lott for The New York Times)

Andrea Stone, left, and Kaleigh Nolan at Northwestern Memorial Hospital. “Hand hygiene, as easy as it sounds, that takes a lot,” Ms. Stone said. (Joshua Lott for The New York Times)

Dr. Kate Goodrich, Medicare’s quality director, said in a statement that the “scores and penalties show an improvement among large teaching hospitals” since the first year of the fines. In some areas, including catheter-associated infections, the rate of injuries at teaching hospitals decreased faster than at other hospitals, she said.

“It’s not only the magnitude of the penalty, but the publicity that comes out of being penalized,” said Dr. Kevin Kavanagh, a patient safety advocate from Kentucky.

Even hospitals that are improving can be disciplined because Congress required Medicare to fine a quarter of hospitals each year (excluding some special categories such as those serving veterans). Most teaching hospitals penalized this time, including Northwestern, were also fined the previous year.

Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges, said the fines hurt hospitals, such as academic centers, that have the sickest patients. Medicare is “punishing hospitals for taking on cases that nobody else wants,” he said.

If you don’t look for infections, you’re never going to find them.

Dr. Gary Noskin

The Centers for Disease Control and Prevention has been collecting infection reports from hospitals for decades to help experts identify problems and measure progress in combating dangerous germs. Kristen Metzger, an infection prevention specialist at Northwestern, said that since Medicare now uses the CDC reports in determining penalties, physicians sometimes get into disputes with her team about whether a case meets the criteria to be reported.

“Every week at our meetings it almost always turns into an argument” about what Northwestern is calling an infection, and whether the hospital is being too strict, Metzger said.

Question About Reporting

Federal officials are concerned that not all facilities may be diligently reporting infections. In October, the government informed hospitals that it had heard that some employees were discouraging tests that might identify one of the infections the CDC tracks. The government also said it had been told that in some places, employees unnecessarily tested patients upon admission to document infections they arrived with. While saying there was no evidence of widespread fraud, the government invited whistle-blowers to report misconduct.

Northwestern identifies an unusually high rate of infections around the sites of colon surgeries, about one in every 19 operations, according Medicare’s most recent public data. Its rates of blood clots after surgeries are also high. The hospital reports one urinary tract infection for every 260 days that patients in the intensive care unit had catheters in place — a rate that is still higher than at most hospitals even after taking into consideration the fact that teaching hospitals tend to have patients with more infections.

Medicare is scheduled to release updated infection rates later this month and the next year of penalties will begin in October.

The most reliable way to reduce urinary infections is to avoid using catheters or to take them out as soon as possible, infection experts say. Hospitals such as Brigham and Women’s, which says it loses about $2.6 million each year it is penalized, have given nurses authority to remove urinary catheters in specific situations without getting physician approval to limit their usage. Rob Bailey, a Northwestern nurse, said that was not possible for particularly ill patients.

One of his patients, comatose and obese, arrived with bed sores that would have been aggravated by movement. “I don’t think there’s anything we could have done differently,” Bailey said.

During the first three months the patient was at Northwestern, the hospital reported three infections in that patient to the CDC.

It’s not only the magnitude of the penalty, but the publicity that comes out of being penalized.

Dr. Kevin Kavanagh

In some instances, Northwestern officials say, they have room for improvement. The hospital requires nursing supervisors and their teams to “audit” nurses at least 20 times each month by watching them as they insert and maintain catheters.

“Hand hygiene, as easy as it sounds, that takes a lot,” Andrea Stone, the nurse manager, said. “People get busy, and it’s a teaching hospital, and if you’re in a group and the doctor or the attending is talking with the entire team, people might not be as focused.”

Dr. Richard Wunderink, medical director of the intensive care unit, said Northwestern’s focus on the conditions that determine Medicare penalties has detracted from more prevalent medical challenges, such as how to reduce pneumonias in patients on ventilators, he said.

“There’s no penalty right now for pneumonias,” Wunderink said. “We are spending time on things that are maybe less important from a patient care perspective but more important from a financial perspective.”

Not every expert believes teaching hospitals are inherently more meticulous in screening patients. “I see transfers from community hospitals, and they tend to do just as many cultures as we do,” said Dr. Jennifer Meddings, an assistant professor at the University of Michigan Medical School whose research focuses on infections.

Ascher, Bilimoria’s patient with the swollen leg, praised Northwestern for its thoroughness. She has had four surgeries for melanoma on her left leg. During her treatment, doctors inadvertently discovered a brain aneurysm, which she said “they found only because they were so thorough because of the testing they did on me.”

One of the cancer surgeries led to an infection, which Bilimoria said was not unusual for the rare procedure he performed, a type that usually takes place only at academic medical centers.

“It was caught soon enough that I didn’t have any real problems with it,” Ascher, 74, said. “As far as I’m concerned, I’m at the best hospital there is, and we have lots of hospitals to choose from in this city.”

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

Categories: Aging, Cost and Quality, Medicare, Syndicate

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State Highlights: Minn. Lets The Sun Shine On Health Data; Despite Difficulties Southeast Mich. Health Systems Post Profits

News outlets report on health issues in Minnesota, Michigan, Oregon, Pennsylvania, California, Washington, Wyoming, Kansas, Colorado, Maryland and Alabama.

Minnesota Public Radio:
Minnesota Releases Treasure Trove Of Health Care Data

A treasure trove of information on health conditions, medical services and costs in Minnesota is now available to researchers, providers and insurers. The Minnesota Department of Health is publishing the first batch of data from its Minnesota All Payer Claims Database this week, and lawmakers hope researchers will mine the information to learn more about variations in health care services and patient outcomes. (Benson, 4/25)

The Oregonian:
OHSU Recruits For National Autism Registry To Speed Research

Oregon Health Science University is looking for people with autism for a national registry that aims to accelerate research. The registry is open to anyone diagnosed with autism spectrum disorder and their families. The idea is to gather genetic information from 50,000 people to give researchers a big pool of data to help them better understand the condition and find treatments. (Terry, 4/25)

Minneapolis Star Tribune:
Agencies Ask For Time To Comply With New Overtime Rules

Paula Hart and Dave Toeniskoetter sat outside the Cannon House Office Building last week after a day of back-to-back meetings with Minnesota’s congressional delegation had ended. … Hart, the CEO of Volunteers of America Minnesota, and Toeniskoetter, CEO of the Mendota Heights-based independent living business Dungarvin, are trying to balance fair pay for workers with the cost of serving their intellectually and developmentally disabled clients. The pair … want Minnesota’s federal politicians to press the U.S. Labor Department to extend the time they get to apply rules that will more than double the base salary of workers who can be declared exempt from overtime. (Spencer, 4/24)

Pittsburgh Post-Gazette:
New Enrollees Rethinking Medicare Advantage Option

For years, Medicare Advantage plans have been big business for private insurers offering one-stop shopping, low premiums and extra benefits to an aging Western Pennsylvania population. But there are signs lately that the plans are losing some luster, as more retirees choose traditional plans with a Medigap supplement that sidestep concerns about access to providers and may represent better value in the long run. (Twedt, 4/26)

Billionaire Bankrolls New Brain Science Center At UC San Francisco

Former banker Sanford Weill transformed the Weill Cornell Medical College in New York with more than half-a-billion in donations in recent years. Now he is pivoting to the West Coast, pledging $185 million to create a neuroscience institute at the University of California, San Francisco. (Piller, 4/26)

The Associated Press:
The Latest: Employee Placed On Leave Over School Lead Levels

Officials say a Tacoma School District manager has been put on paid administrative leave after it was discovered Friday that tests done nearly a year ago showed high lead levels in drinking water at two public elementary schools. District spokesman Dan Voelpel said Monday that the district’s safety and environmental health manager was placed on leave. (4/25)

Wyoming Public Radio:
Email Breach At Wyoming Medical Center

This February, the email accounts of two Wyoming Medical Center employees were compromised in a phishing scam. A phishing scam is an email that looks like it came from a credible source, and tricks the recipient into providing passwords and usernames in an attempt to access sensitive information. The scam won’t work if the recipient ignores the email, and doesn’t open any links. (Sanders, 4/25)

The Kansas Health Institute News Service:
Clients Say Turnover Hinders Regional DCF Office For Disabled Employment

When Shannon Lindsey moved from Missouri to Kansas two years ago, she decided she wanted to go to Johnson County Community College to get a nursing degree that would make her more employable. Lindsey, now 49, has several disabilities, so she contacted Kansas’ vocational rehabilitation office for assistance. In Missouri she had the same vocational rehabilitation counselor for years — a state worker who understood her needs, what was available to help her and how to get it to her quickly. (Marso, 4/25)

Lesson Learned For Baltimore’s Health Commissioner: ‘I Like A Fight’

To wrap up [a] series on public health in Baltimore, Audie Cornish met up with Baltimore City Health Commissioner Leana Wen in Freddie Gray’s neighborhood of Sandtown-Winchester. The health department recently opened a new outpost of its violence prevention program Safe Streets there, employing ex-offenders to mediate conflicts before they erupt in violence. Wen spoke about pushing a public health agenda in a city that has long struggled with poverty, violence and addiction. She also talked about what she, as an emergency physician, has learned in her first stint in government. (4/25)

Doulas Help Pregnant Inmates Give Birth, Say Goodbye

Harley Ezelle gently rocked back and forth on a yoga ball in a meeting room at Tutwiler Prison as the woman next to her helped set her legs for maximum balance. It was the second meeting of the Alabama Prison Birth Project, which is bringing certified doulas to the women’s prison to support pregnant inmates. (Yurkanin, 4/25)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.

Medicare Delays Plans For New Star Ratings On Hospitals After Congressional Pressure

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch.

The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.

But this month, 60 senators and 225 members of the House of Representatives signed letters urging CMS to delay releasing the star ratings. “We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.

Hospital stars 770In a notice sent Wednesday morning, CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July. “CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”

But in a conference call with hospital representatives, CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.

Mortality, readmissions, patient experience and safety of care metrics each accounted for 22 percent of the star rating, while measures of effectiveness of care, timeliness of care and efficient use of medical imaging made up 12 percent in total.

The hospital industry for months has been urging this delay, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.

The industry’s major trade groups said in a letter to CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.

Rick Pollack, president of the American Hospital Association, said in a statement that “the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision.“

Last year, CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.

Hospital Compare received 3.7 million unique page views last year, according to a paper published this month in the journal Health Affairs. The author, analyst Steven D. Findlay called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.

Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me,” he said.

Categories: Aging, Health Industry, Medicare, Syndicate

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Release Of Hospital Quality Ratings Delayed By Medicare Amid Lawmaker, Lobbying Pressure

Kaiser Health News:
Medicare Delays Plans For New Star Ratings On Hospitals After Congressional Pressure

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch. The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best. (Rau, 4/20)

Research Roundup: Hospital Readmissions; Children’s Health; Medicare Overview

The Kaiser Family Foundation:
An Overview of Medicare

Medicare plays a key role in providing health and financial security to 55 million older people and younger people with disabilities. … Many people on Medicare live with health problems including multiple chronic conditions, cognitive impairments, and limitations in their activities of daily living, and many beneficiaries live on modest incomes. In 2011, two-thirds of beneficiaries (66%) had three or more chronic conditions, more than one quarter of all beneficiaries (27%) reported being in fair or poor health, and just over 3 in 10 (31%) had a cognitive or mental impairment. … Two million beneficiaries (5%) lived in a long-term care facility. In 2014, half of all people on Medicare had incomes below $24,150 per person and savings below $63,350. (4/1)

Medicare Proposes Payment Increases For Skilled-Nursing And Inpatient Rehab Facilities, Hospice Care

Modern Healthcare:
CMS Proposes Raising Payment Rates For Hospice, Skilled Nursing And Rehab

The CMS has dropped three payment rules that propose increased payments to skilled-nursing facilities, inpatient rehabilitation facilities and hospice care, and implemented new quality measures. The agency Thursday proposed nearly doubling the increase skilled-nursing facilities received last year. This would amount to a $800 million bump. Last year they only received a 1.2% Medicare rate increase, leading to $430 million in higher payments from the previous year. Medicare would pay out $125 million a year more to rehabilitation facilities while those facilities would face about $5.2 million in costs related to new quality-reporting requirements. (Dickson, Meyer and Schencker, 4/21)

Some Firms Save Money By Offering Employees Free Surgery

Lowe’s home improvement company, like a growing number of large companies nationwide, offers its employees an eye-catching benefit: certain major surgeries at prestigious hospitals at no cost to the employee.

How do these firms do it? With “bundled payments,” a way of paying that’s gaining steam across the health care industry, and that Medicare is now adopting for hip and knee replacements in 67 metropolitan areas, including New York, Miami and Denver.

Here’s how it works: Lowe’s and other employers pay one flat rate for a particular procedure from any of a number of hospitals they’ve selected for quality, even if they are a plane ride away. And, under the agreement, the hospital handles all the treatment within a certain time frame — the surgery, the physical therapy and any complications that arise — all for that one price.

It was Bob Ihrie, senior vice president for compensation and benefits at Lowe’s, who came up with the idea in 2010. When he told managers at other companies about it, he said, “The first question was always, ‘Oh, this is just for executives, right?’ And I said no, absolutely not, this is for any Lowe’s employee in the Lowe’s health care plans.”

The program is optional for employees. They can still use their local surgeon, if they prefer, and pay out-of-pocket whatever their insurance doesn’t cover. But more than 700 Lowe’s employees have taken the company up on its offer, Ihrie said.

It’s a great deal for patients, he said, and for his company.

“We were able to get a bundled price, which actually enables us to save money on every single operation,” Ihrie says.

The Pacific Business Group on Health negotiates that price for Lowe’s, Walmart and a number of other large employers. Associate Director Olivia Ross oversees these deals, and said her team is able to negotiate rates that are 20 to 30 percent below what the companies used to pay for the procedures.

“We’re seeing savings at the front end,” she said, because Lowe’s pays less for the surgery. And, because the hospital is responsible for all that care, the institution has a strong incentive to be careful and thorough, Ross added.

That means “huge savings on the back end,” she said, “from things like reduced re-admissions, reduced return to the O.R. and lower rates of blood clots. Those are hugely expensive, preventable complications.”

Lowe’s comes out ahead, even after paying for the patient’s travel, Ihrie confirmed.

Participating hospitals win, too, by attracting more patients, said Trisha Frick, who handles such negotiations on behalf of Johns Hopkins Medicine in Baltimore.

“It’s new business for us,” Frick said. “And, for the most part, the reimbursement is acceptable; we believe that we can provide that, within that amount of money.”

Medicare, the health insurance program for people 65 and older, started using bundled rates for hip and knee replacements this month. Medicare had some early evidence from pilot programs that “the model works well,” according to Rob Lazerow, a health care consultant with The Advisory Board Company.

“Medicare is saving something like $4,000 on orthopedic cases,” he said.

Medicare’s deal is somewhat different than Lowe’s. Patients may pay something out of pocket, depending on the type of Medicare policy that insures them. And while the few hospitals selected in Lowe’s program can bank on increasing their revenue and the number of surgeries they’ll get, the rates established by Medicare’s bundled payment system hold for every hospital in a participating area.

“Entire markets are selected for participating,” Lazerow explains. “If you’re in the San Francisco market or you’re in the New York market, all of the hospitals are actually participating in the program.”

But there are similarities, too, and Medicare may learn some lessons from Lowe’s experience. Lowe’s initially had trouble wrangling all a patient’s medical records from local doctors. And the company found that patients who had questions weeks or months after an operation sometimes had trouble following up with the out-of-town doctor who had performed the surgery.

“You have some setbacks, and things happen, and you just have questions,” Ihrie said. “So what we give every patient now is a little card with the doctor’s name and direct phone line and the nurse’s name and direct phone line. And all of a sudden, things were a lot better.”

Another lesson was startling, Ross said. In addition to cutting the cost of procedures, another chunk of savings to the companies came from avoiding surgeries that probably shouldn’t happen in the first place.

“We’re seeing up to 30 percent — close to 30 percent of cases — who should not be moving forward with the joint replacement,” Ross said.

What typically happens in these cases, she said, is that employees get a recommendation from a local doctor that they should have surgery, only to have physicians at the selected hospitals deem the operation inappropriate.

In some cases that may be because the employee hadn’t first tried less invasive treatments, such as physical therapy, Ross said. Or the employee may need to lose weight first, to make the surgery safer.

Ihrie said what heartens him most about his company’s program is that Lowe’s employees are now taking a more active role in decisions about their care.

“What treatment you receive is not always very black and white,” he said. “The mere fact that people now think about what they’re doing helps us control costs across the board.”

This story is part of a reporting partnership with WFAE, NPR and Kaiser Health News.

Categories: Cost and Quality, Health Industry, Insurance, Medicare, Public Radio Partnership, Syndicate


State Highlights: Pastoral Provider Licenses Stoke Concern In Texas; Pilot Medicare Program Helped Cut Costs In Arkansas

News outlets report on health issues in Texas, Arkansas, Wisconsin, Florida, Massachusetts, Texas, Washington, New Hampshire and Missouri.

Pastoral Medicine Credentials Raise Questions In Texas

You’ve probably heard of the credentials M.D. and R.N., and maybe N.P. The people using those letters are doctors, registered nurses and nurse practitioners. But what about PSC.D or D.PSc? Those letters refer to someone who practices pastoral medicine – or “Bible-based” health care. It’s a relatively new title being used by some alternative health practitioners. The Texas-based Pastoral Medical Association gives out “pastoral provider licenses” in all 50 states and 30 countries. Some providers call themselves doctors of pastoral medicine. But these licenses are not medical degrees. That has watchdog organizations concerned that some patients may not understand what this certification really means. (Silverman, 4/25)

Arkansas Democrat-Gazette:
Savings Seen In New Care Program

Paying doctors to better coordinate care for Medicare beneficiaries in Arkansas and seven other states helped hold down the cost of patients’ medical care over a two-year period, although the savings didn’t fully offset the cost of the extra payments, a report found. Still, the authors of the report by Mathematica Policy Research said the Comprehensive Primary Care Initiative’s effect on medical expenses was bigger than they expected. (Davis, 4/24)

New Hampshire Public Radio:
State Issues Update On PFOA-Contaminated Wells

The New Hampshire Department of Environmental Services has announced updated drinking water well test results for the water contaminant PFOA in Southern New Hampshire. So far, the state has tested over 350 wells, mostly within a 1.5 mile radius of the Saint-Gobain performance plastics plant. Of those, 52 private wells have tested above the state’s threshold of concern: which is 100 parts per trillion of the contaminant. The well with the highest concentration came in at 1600 parts per trillion. So far, these wells are located in Merrimack and Litchfield, with one Manchester well testing above the threshold. (Corwin, 4/22)

St. Louis Public Radio:
What’s Next, After Defeat Of Medical Marijuana Bill?

Supporters of legalizing marijuana for medical use in Missouri now have only one option this year – the ballot box. That comes after the state House last week defeated House Bill 2213. In its original form, the measure would have allowed for medical cannabis centers in Missouri, which would have sold medical cannabis to patients with a “debilitating medical condition.” (Griffin, 4/24)

This is part of the KHN Morning Briefing, a summary of health policy coverage from major news organizations. Sign up for an email subscription.