Kaiser Health News: Hospitals Treating The Poor Hardest Hit By Readmissions Penalties


By Jordan Rau

KHN Staff Writer

Aug 13, 2012

Medicare’s new crackdown on readmissions will hit hospitals that treat large numbers of low-income patients especially hard, a Kaiser Health News analysis shows.

The debate over whether readmissions penalties would fall most heavily on safety-net hospitals has been a flash point since penalties were included in the 2010 health law.

The hospital industry has emphasized that poor patients are more likely to be readmitted, as they have a tougher time affording medications, often don’t have access to doctors for check-ups and can have difficulty securing transportation to get follow-up care. Hospitals also have complained that many safety-net hospitals operate on tight margins.

“You’re probably going to end up penalizing those very places that need to put resources into patients when they leave the hospital,” said Atul Grover, chief public policy officer of the Association of American Medical Colleges.

The federal Centers for Medicare & Medicaid Services has noted that some of the hospitals with the most impoverished patients, such as Denver Health in Colorado, are able to avoid excessive readmissions, proving the challenges are surmountable. “We do not want to hold hospitals to different standards for the outcomes of their patients of low socioeconomic status,” CMS wrote in a regulation issued earlier this month. The agency added: “We do not want to mask potential disparities or minimize incentives to improve the outcomes of disadvantaged populations.”

The KHN analysis separated hospitals into four groups based on an index that the Centers for Medicare & Medicaid Services uses to decide whether a hospital deserves extra payments for treating large numbers of low-income patients. The index looks at the number of patients who qualify for Medicaid, the joint federal-state health program for the poor, and Medicare’s Supplemental Security Income benefit for the poor and disabled.

For each group, KHN examined what penalties the hospitals in each group were assessed by Medicare. Those penalties are based on the rates of readmission within 30 days of discharge for heart failure, heart attack and pneumonia patients between July 2008 and June 2010.

One hundred hospitals in the group with the most poor patients –12 percent — will receive the maximum penalty from CMS: a 1 percent decrease in their reimbursements starting in October. By contrast, only 47 hospitals, or 6 percent, in the group with the fewest poor patients will receive the maximum penalty, the data show.

Hospitals with lots of low-income patients were generally more likely to receive a penalty of any size.

The data show that 204 safety net hospitals overcame their patients’ challenges to minimize readmissions to a level that Medicare determined did not warrant any penalty. Among the hospitals with the fewest low-income patients, 379 avoided any penalty.

San Francisco Chronicle: Overcrowded ER points to larger problems



By Victoria Colliver
Updated 9:47 a.m., Tuesday, August 7, 2012

California hospitals in areas with large minority populations are disproportionately affected by emergency room overcrowding, making them more likely to ease the congestion by diverting ambulances to other hospitals, according to a UCSF-led study.
The study, which looked at 2007 data from 202 hospitals around the state, found hospitals that served the greatest percentage of minority patients turned away ambulances because of overcrowding as much as four times as often as those that served the smallest number of minorities.
Health experts say ambulance diversion, the practice of turning ambulances away temporarily when a hospital’s emergency department becomes overcrowded, can lead to delayed care and poorer health outcomes.
What this study points to is that overcrowding is a symptom of larger problems within the health care system, the study’s author said. These include patients who lack primary-care services that could keep them out of the hospital, and hospitals that are overwhelmed by poorer patients or could use better emergency management. These issues can be particularly acute in areas with higher minority populations.
“Diversion originally was created for patient safety; it was created as a safety valve,” said Dr. Renee Hsia, lead author of the study and assistant professor of emergency medicine at UCSF.
“What diversion shows is that the system is not prepared to provide the care it was designed to provide,” said Hsia, who is also an attending physician in San Francisco General Hospital’s emergency department. She said the study is the first to use hospital-level data to show how diversion affects minorities.
Emergency departments become overcrowded for several reasons. Patients – often those who are uninsured or lack adequate access to primary-care services – end up there for nonurgent care or for serious conditions that could have been treated earlier or even prevented.
Sometimes the emergency department becomes overcrowded because hospitals lack the proper staffing to admit patients into the hospital so they get stuck waiting in a room or on a gurney in the emergency department for hours. Other times the hospital may lack the equipment or services it needs to treat a specific medical problem.
Overcrowding, whatever the cause, can lead to ambulance diversions and impact the quality of care. In a separate study, which was published last year in the Journal of the American Medical Association, Hsia found that patients seeking care for heart attacks at busy hospitals undergoing ambulance diversion had a significantly higher chance of dying within 30 days.
Hospital officials weren’t surprised by the results of the new study, which were published online Monday in the journal Health Affairs.
Jan Emerson-Shea, spokeswoman for the California Hospital Association, said communities with high numbers of minorities tend to have more people who are uninsured, are on Medi-Cal or otherwise lack access to care.
“If they had access to primary-care services either through a clinic or an urgent-care center to treat that earache … it would help mitigate the ER overcrowding issue,” she said.
Hsia said a number of issues must be addressed to fix the problem, including better management of hospital flow as well as possible statewide policies to regulate diversion.
Overcrowding can affect all patients, even those who live in areas that are not diverting ambulances. “If another hospital is crowded,” she said, “they may be going to go to your ER.”

Los Angeles Times: Health insurers owe nearly $74 million in rebates to Californians


By Chad Terhune
July 31, 2012

Nearly 2 million Californians will receive $73.9 million in rebates from health insurers as part of the federal healthcare law, according to state officials.
Insurers notified government regulators in June of how much they owed customers in rebates or premium credits because they didn’t spend at least 80% or more of 2011 premiums on medical care. The minimum threshold is 85% for employers with more than 51 workers.
Figures released Tuesday mark the final tally for California; insurers must issue refunds by Wednesday. Many employers and consumers have already received letters informing them of their rebate amount.
The average rebate is $65 per family, according to the state insurance department.
“The Affordable Care Act requires that more of our health insurance premium dollars be spent providing healthcare, rather than on administrative costs and profits,” said California Insurance Commissioner Dave Jones.
Anthem Blue Cross, the state’s largest for-profit insurer and a unit of WellPoint Inc., owed nearly $40 million in rebates and Blue Shield of California had to return about $11 million to customers.
Nonprofit Kaiser Permanente, the state’s biggest insurer, owed $277,000 in rebates to policyholders.
UnitedHealth Group Inc., Aetna Inc. and Cigna Corp. each owed California employers about $3.4 million.
Nationwide, federal officials said health insurers owed $1.1 billion in rebates to 12.8 million Americans. The average rebate nationally was $151 per family, according to the federal government.
For people who receive their health coverage through work, the rebate check or credit goes to their employer. Under the law, employers can share the proceeds with employees based on how much they contribute to annual premiums or apply the savings to future healthcare costs.
Individuals and families who purchase their own policy will receive the rebates directly. Consumer advocates praised the new limits on insurers’ expenses and profit.
“The check is a symbol of the new oversight over the industry to ensure patients got the best value for their premium dollar,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group.