Medicare penalizing Montana Hospitals over readmissions


Northern Montana Hospital is one of several hospitals in Montana to be financially penalized by Medicare for failing to meet patient readmission standards, put in place by the Affordable Care Act, during the 2018 fiscal year. Over 2,500 hospitals across the nation were evaluated and found to have failed a Medicare and Medicaid Services requirement that works to reduce the number of patients being readmitted within 30 days of being discharged. Northern Montana Hospital Vice President of Regulatory and Community Services Christen Obresley said that the limited community services play a part in increasing the readmissions.

“The cause of readmissions is said to stem around limited community services when a patient is discharged from the hospital,” Obresley said. “Most of our readmissions revolve around limited community services when a patient is discharged from the Hospital, such as in-home physical therapy or transportation; or patient non-compliance.  We do our best to set up available resources anticipated for a successful discharge but the home environment can be somewhat unpredictable.”

Part of the Affordable Care Act gives the federal government the ability to cut payments by as much as 3 percent per Medicare patient for hospitals that have high rates of readmissions. The penalty is what Kaiser Health News a “signature part of the Affordable Care Act’s effort to encourage better care.”

The Medicare and Medicaid Services penalty has been impacting hospitals since 2012 because patients have continued to end up back in their care within a month for six targeted conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, elective hip, and knee replacement, and coronary artery bypass graft.

In 2018, Medicare penalized nearly 2,600 hospitals, making nearly $565 million in payment reductions. This means that from Oct. 1 through next Sept. 30, these hospitals will see reduced payments for every Medicare patient stay, not just those patients who are readmitted.

The idea behind the penalties is the MMS’ belief that if hospitals reduce the number of returning patients, that will lead them to take better care of patients from the start, which allows them to save Medicare money. Obresley said that NMH has started working on reducing the number of returning patients.

“Within the first week of discharge the patient is contacted to inquire how the transition to home went and alleviate any issues the patient may have identified,” “We are now working on a Transitional Nurse Care Manager that will contact discharged patients within 48 hours of discharge to ensure follow up appointments were made, medications were picked up, answer any questions the patient may have and arrange for any additional services that are identified upon returning home.”

Kaiser Health News date shows that Northern Montana Hospital has been penalized from 2015 to 2019. The percentage has fluctuated over the years, from 0.49 percent and 0.84 percent in 2015 and 2016, in 2018 they faced a 1.14 increase. Most recently they have fallen to a .36 percent penalty.

Kaiser Health News said, “Medicare lowers payments to hospitals even if they have reduced their readmission rates from the previous year—so long as their rate is still higher than what the government believes is appropriate for that hospital.”

The penalties apply only to Medicare reimbursements and do not impact anyone visiting the hospital using private or employer insurance agencies.

Northern Montana Hospital has been penalized since 2015. Starting Oct. 1, Northern Montana will face a .36 percent reduction in the reimbursement dollars the hospital receives for Medicare patients, according to CMS data compiled by Kaiser Health News. This is the third highest penalty in Montana. Only St. Peters Hospital in Helena and St. James Healthcare received higher penalties. Obresley said Northern Montana Hospital is currently seeing a reduction of less than $10,000.

“The way the system operates, the bottom quarter of hospitals, those with high rates of infections and injury are automatically docked, even if they improved from the past year,”  NMH Case Officer Laura Thornton said, “we take safety issues seriously and working to keep these infections and injury rates down.”

“Northern Montana Hospital makes every effort to provide the safest of care to our patients,” said Thornton. “Precautions are in place to ensure patient safety can be as simple as color-coded socks to indicate a fall risk patient or compression stockings to prevent blood clots from following evidence-based care pathways by physicians.”

If an adverse event does happen, it will be reviewed by a committee of physicians to ensure appropriate and safe care was provided. Currently, Medicare has in place multiple quality improvement programs that include safety measures, which primarily revolve around adverse events, such as infection, mortality (death) or procedure complication.

“The possible penalty between all these programs can reach up to an approximate reduction of 3.5 percent of all DRG/Inpatient Medicare Reimbursements for CMS Hospitals,” said Thornton “This is on top of the Readmission Reduction Programs potential of 3 percent Reduction,”  “Some of the Quality Improvement Programs even provide incentives for providing above national average care.”

While Northern Montana Hospital has been penalized, they are the hospital with the smallest reduction in payments.

“Medicare’s Quality Initiative Program penalizes the lowest performing hospitals and redistributes to the better performing hospitals through incentives. “These incentives are in place to push hospitals to continually improve the safety and quality of care. Northern Montana Hospital takes great pride in being grouped with the higher performing hospitals providing safe and quality care to our community,” Thornton said.

The healthcare field is constantly changing, creating an environment that cannot survive without constant quality improvement. NMH attributes their positive performance to “our willingness to change, receptive employees/providers and overall desire to provide good care,” Thornton said.

We believe our community deserves excellent care, accomplished by continually identifying new areas for improvement; mandated and intra-facility.  For example, all departments within the facility are required to participate in quality improvement projects; from environmental services to registration.

Northern Montana Hospital attributes their low penalties from Medicare to several things including understanding and accurate interpretation of Medicare Policies/Procedures, continually analyzing data and identifying areas of improvement, prompt institution of changes that improve quality care, facility-wide willingness to change, receptive and participatory employees and providers, and an overall desire to provide good care.

In order for NMH to keep their penalties low, they have instituted multiple services to improve the quality of care including “bedside rounding, electronic health record with designated record sets, staff education, interdisciplinary team meetings and committee reviews for safety items,” Thornton said.

Other hospitals in Montana listed as having “excess readmissions” for that time frame are, in order of penalty percentage: St Peters Hospital, St. James Hospital, Community Medical Center, Benefis Hospitals Inc, St Vincent Healthcare, Great Falls Clinic Hospital, Billings Clinic Hospital.