Hospitals Continue to Lose Millions in Medicare Infection and Readmission Penalties

CMS data shows how it is cutting reimbursement rates for hospitals based on performance

Recently, the Centers for Medicare and Medicaid Services (CMS) released data which showed how it is cutting reimbursement rates for hospitals based on their performance relating to surgical site and bacterial infections and hospital readmissions. The goal of CMS is to raise the quality of patient care. Under the Hospital Readmissions Reduction Program parameters, hospitals are evaluated based on the frequency in which patients with certain, targeted conditions are readmitted to a hospital within 30 days of their discharge. The CMS put hospitals serving a similar number of low-income patients into groups and compared the hospitals’ readmission rates over the period from 2019-2023. The CMS reduced reimbursement rates by as much as 3% for those hospitals that performed the worst. One region’s hospitals’ evaluations were recently reported in Newsday, a major daily newspaper with a focus on Long Island, NY.

How Long Island Hospitals Performed

As in other regions across the country, 19 Long Island hospitals were reviewed as part of a group of hospitals or individually. The CMS reported that collectively, the average penalty for high readmission rates charged to Long Island hospitals had declined from 0.51% one decade ago to 0.4%. Looked at individually, some hospitals saw penalties over the period increase significantly. For example, in 2013, one hospital’s penalty rate was 0.34% and in 2022, it had climbed to 2.3%. Another went from 0.69% to 1.43%.

Significant Costs

Each year, an estimated 3.8 million patients nationwide are readmitted within 30 days of their discharge at a cost to hospitals totaling $52.4 billion. While some readmissions are related to poor quality of care, others are found to be preventable if the right measures were implemented upon discharge. These measures include engaging a third-party medical case management firm to address the post-discharge needs of patients at high risk of readmissions including those discharged post-surgically, with congestive heart failure, with chronic obstructive pulmonary disease along with other medical conditions targeted by the Hospital Readmission Reduction Program (i.e., acute myocardial infraction, pneumonia, coronary bypass graft surgery, total hip and/or total knee arthroplasty).

The medical case management firm provides patients with transition coaching by a Registered Nurse (RN) Health Coach or Case Manager. This experienced healthcare professional contacts the recently discharged patient, assesses the patient’s health status, coordinates a transition of care provider visit, ensures medication reconciliation, identifies potential problem areas, and educates the patient and family regarding the patient’s condition. The RN Health Coach or Case Manager also strives to ensure the patient’s adherence to the prescribed treatment plan and guides them as to when to contact their physician. The case management firm’s services are intended to achieve the best possible clinical outcomes while preventing so-called preventable hospital readmissions.

Hospital Initiatives to Prevent Readmissions

To avoid Medicare penalties and promote high quality patient care, some hospitals have developed new initiatives. Stony Brook Medicine (Stony Brook, NY) developed a post-discharge call center standardizing how the health system checks in on patients determined to be at high risk of a readmission. A patient is asked how he/she feels and what symptoms, if any, they may be experiencing. As necessary, other professionals are contacted to provide, for example, at home nursing care or physical therapy, or appointments with other medical professionals may be scheduled. Hospitals within the Northwell Health System now strive to schedule physician appointments with one week of a patient’s discharge.

In essence, hospitals won’t gain additional resources for community healthcare needs or improved care from Medicare reimbursements lost to infection rats and readmissions.  This serves as motivation to implement new strategies, services, and programs to prevent hefty penalties.