Note: This is Part 3 of a 3-Part transparency series.
(Which hospitals got penalties due to poor performance?)
If you’re not “an insider” you may not be familiar with the term “Hospital Readmissions”, but maybe you should be. In most cases being RE-admitted to a hospital is bad. It’s bad for your health, it’s bad for your wallet, and it represents a waste of resources.
CMS (Centers for Medicare and Medicaid Services) calculates the readmission rates for each eligible hospital and has the power to penalize hospitals as much as several percent of their revenue (for the following year) if they fail to meet targets.
Sounds simple, but what is a readmission?
And, don’t we WANT to have people come back in if they require care? Simply put, a readmission is a second (or subsequent) time that you are “confined” to a hospital within 30 days of discharge for some initial (called an “index”) admit.
Let’s say, you had a blood vessel bypass in your heart. After you go home (or back to the nursing home), you should get appropriate follow-up care and you should follow your doctors’ instructions so that you make a full and speedy recovery.
What if you don’t?
Sometimes it’s YOUR fault.
Maybe YOU didn’t follow medical advice and you went sky-diving and broke your leg? Well, that actually doesn’t count as a readmission, because the second admit was due to “trauma” which might include automobile accidents, etc.
Maybe you refused to take your medications and got black-out drunk instead. This is outside the hospital’s control, although they should do their best to dissuade you from that. So, there is a margin built-in to account for “bad patients”.
But for the most part, what CMS is trying to reduce falls into TWO categories.
- The first is medical error or improper treatment. Did the surgeon leave a sponge in (which got infected)? Did they fail to stitch-up your new blood vessel properly? Did they send you home TOO SOON? Maybe you needed an extra few days, but policy (or insurance) said “They’ll be fine.”
- The second is improper (or lack of) follow-up care. Did the hospital explain what you needed to do? Did they discharge you with proper medication? Did they follow-up afterwards? This may include both phone calls as well as visits with a doctor. If you live alone and cannot provide your own follow-up care, other accommodations should be made. It’s MUCH cheaper to have a nurse or home-health worker come by than to have you back in the hospital!
Maybe the easiest way to understand a “good” readmission from a “bad” one is whether or not they tell you IN ADVANCE that it is going to happen.
- If your doc says “OK, tomorrow we’ll operate on your heart and as soon as you’re well enough, we’re going to replace your hip.” Those are “planned” admissions.
- If they say “Two days after we operate, you should be able to go home. Ooops, looks like I didn’t connect that vessel properly, fingers crossed that second-times the charm.” Then…well…
The bottom line is simple.
Readmission rates are one indicator of the quality of care being provided. Hospitals that are constantly readmitting patients have a problem (with the care they’re providing).
You might ask “Well, if that’s so obvious, why don’t hospitals already WANT to prevent readmissions?”
The answer is probably a mix of TWO reasons.
- First of all, hospitals are getting paid to render services. The more days you spend in their beds, the more money they make. Kind of like a carwash that does a mediocre job, so you have to put more money into the machine.
- The second reason might be inadequate care. Maybe they are grossly overworked/understaffed and just don’t have time to provide proper care. Maybe they are using doctors who aren’t as good or are working outside their specialty. After all, a person might be the best obstetrician (baby doctor) on the planet, but that doesn’t mean they should be performing a liver transplant.
Wow! Never thought (much) about all that.
How do I know if MY HOSPITAL got penalized?
Go to this webpage from the Kaiser Foundation and search for your area, or specific hospital. It will show whether your facility is eligible and if it got a penalty, how much it will cost them. You should know that some types of facilities cannot be counted because the very nature of their care may necessitate multiple admits (such as cancer care, for example).
What actions should you take?
If your hospital is doing a good job, you should still be aware and make sure to follow the medical advice they give you (as it’s been working for their other patients).
If your hospital is NOT doing very well, you might consider having your elective procedure at another hospital (possibly in another city, if necessary).
But as a BARE MINIMUM, you need to remain focused on watching the care you receive, asking questions of their staff AND maybe another independent doctor. Read-up on what “after care” is normally given for your situation and question anything that concerns you. Secondly, as regular readers of our blogs will know, “quality” is a crucial component of getting the best care for the best price.
- Doc: “You need a joint replacement, I can send you to my affiliated hospital for that.”
- You: You might do some research (using our guides about “Price Transparency”) and tell your doc “It looks like hip-replacement surgery costs the same under my insurance at both your hospital and the one across town (both charge $15,498 if you’re covered by my insurance) but I notice that your hospital is having a problem with readmissions, and CMS is penalizing your hospital at 2.77% compared to 0.9%. That’s more than 3 times worse and that worries me. Why are the outcomes so much better over at Desert Springs? Should I have my procedure there instead?”
- Doc: After picking their jaw up off the floor, he/she might try to reassure you that they DO provide good care, at least most of the time. Or they might belittle any quality measure that shows otherwise. Then again, they may explain what steps have been taken to correct the problem, which has grown MUCH worse over the last 4 years, as you can see in the accompanying chart (data as of 11/1/2021).
Your doctor’s explanation in the scenario above may reassure you.
Sometimes though, you need to put the health of yourself/loved-one ahead of hurting your doctor’s feelings/wallet and select the facility with the best outcomes (and hopefully acceptable price-points). That might mean traveling, possibly some distance.
Here are the published rates for DRG-469 at two of the hospitals in my area:
Please note: That $15,498 is the contracted rate between Sierra Health and the two hospitals. It is NOT necessarily the amount YOU WOULD PAY. You might have a lower “out-of-pocket” cutoff, or you might have already met your deductible, or you might have a secondary insurance policy through your spouse that could help. But for purposes of comparison, both facilities have agreed to accept that amount for members covered by this plan.
It’s also interesting that IF you were covered by Kaiser Permanente, then that EXACT same procedure would be charged at $109,516 at Centennial Hills and a staggering $118,320 at Desert Springs! That’s an increase of over 700%. Hey, Kaiser members, it could be MUCH worse, you could be covered by First Health Network! They are OVER $174,000!
I cannot stress enough how important it is to become an active consumer regarding your health and healthcare, not a passive patient.
Asking thoughtful questions and doing research (as consumers should!) isn’t about studying medical trivia so you can win on Jeopardy!
It’s meant to help you or a loved one get the best care possible.
In the case of my father’s coronary bypass surgery, the local hospital was honest and said “Well, the Mayo Clinic performs a LOT more of those operations than we do, and they are recognized as one of the very best for that surgery anywhere in the world. However, Rochester, MN is 1,600 miles away and the University of Washington Medical Center has comparable quality but is only 200 miles.”
 Like many topics relating to healthcare, readmissions can be complex. If you want to read all the details, you can search for CMS HRRP. Some common questions we get are “What if you had an operation and then got in a car-crash?” or “My uncle had to go in for chemo every two weeks, is that a readmission?” In both cases, NO, those are not counted against the hospital as unplanned readmission. In the first case, trauma is considered unavoidable. In the second case, scheduled therapy, like chemo or post-partum care, are considered “planned”.
 You can ask your doctor which procedure they are recommending. For example, DRG-469: Major Hip and Knee Joint Replacement, which I used for this example.