Fines for readmit patients and EMS

[sir.shocksalot]

Just read this article today:

http://news.yahoo.com/medicare-fines-over-hospitals-readmitted-084833994.html

I personally believe this would be an excellent opportunity, particularly for hospital based EMS, or private EMS to contract with hospitals and really start pushing for community care paramedics.

This could provide EMS with an opportunity to expand ourselves into the realm of triaging people into the healthcare system. That being said our education would have to increase so that we are not over or under triaging patients (i.e. MI patients don't end up at the urgent care and superficial lacerations don't end up at a trauma center). That being said, I have been in EMS long enough to consider such a move by our profession, as a whole, as unlikely.

What is everyone else thoughts about the ramifications of this rule for EMS, if any?

 

[Veneficus]

Just read this article today:

http://news.yahoo.com/medicare-fines-over-hospitals-readmitted-084833994.html

I personally believe this would be an excellent opportunity, particularly for hospital based EMS, or private EMS to contract with hospitals and really start pushing for community care paramedics.

This could provide EMS with an opportunity to expand ourselves into the realm of triaging people into the healthcare system. That being said our education would have to increase so that we are not over or under triaging patients (i.e. MI patients don't end up at the urgent care and superficial lacerations don't end up at a trauma center). That being said, I have been in EMS long enough to consider such a move by our profession, as a whole, as unlikely.

What is everyone else thoughts about the ramifications of this rule for EMS, if any?

I think what you described is the only viable future for EMS.

 

[Jambi]

I think what you described is the only viable future for EMS.

I believe the same thing.



http://www.communityparamedic.org/

Education needs to make a quantum leap though.

 

[hogwiley]

Part of the reason so many patients are readmitted is because they are friggin medical train wrecks to begin with. If the hospitals only discharged these patients when they were 100%, youd have patients living there permanently. Hospitals arent Nursing homes.

These people often make no effort to take care of themselves and are totally non compliant, which is why they end up being readmitted. They seem to think hospitals are magical places and Doctors are miracle workers. I work as a PCT, mostly on a med/surg unit and ICU and im burned out taking care of demanding patients who think a hospital is supposed to be the ritz carlton.

Our patient census is always full to begin with, so how are they supposed to keep patients even longer? The harsh reality is you sometimes have to either discharge someone, move someone from the ICU to a lower level unit, or start refusing admissions.

 

[Shishkabob]

The issue with this is far too many patients don't give a damn once they leave the hospital. We've all had our fair share of non-compliant patients who for one reason or another don't do what they're supposed to for their own healthcare, and now the healthcare providers will be punished for the patients decision.

 

[JakeEMTP]

Many of the patients CMS is putting into their rules will not be for EMS to decide whether they are appropriate for treatment or not. This is not about who gets a ride to the hospital. Even the community Paramedics will have no ability to prescribe. If treatment is put off too long the patient becomes an ICU stay which results even more costs for the hospital to eat according to the guidelines.

More funding for clinics with PAs and NPs is needed as well as enough to support an NP around the clock at long term care facilities.

 

[VFlutter]

"Readmissions are partially within the control of the hospital and partially within the control of others,"

"Also, for now, hospitals are only being measured on three medical conditions: heart attacks, heart failure and pneumonia. "

I would like to know more about the specifics. I agree that some readmissions are due to poor medical management during their stay or poor discharge instructions when they leave but a large majority is due to factors outside the hospitals control.

I work on a cardiac floor and it is not uncommon for a fresh stent, CABG, NSTEMI patient to sneak off the floor to smoke every hour or for a family member to bring in Fast Food because the patient will not eat the ordered diet. Or my favorite the patients who have a CHF and 20 home medications who come in with edema or SOB and have not taken their meds in a week (Yes some is due to cost but not always). Is it any surprise that these patients will likely be 30 day readmits?

I think it is a good concept however I think it is wrong if hospitals will be fined for readmits on noncompliant patients. Not sure how they would even distinguish that, I am sure they will just go off readmissions in general.

I wonder if this will sway ER Docs decisions to admit certain patients.? Oh you were here 17 days ago? here is some Lasix go home and piss it off

 

[hogwiley]

This sounds like something that is a good idea on paper, but in the real world might cause as many problems as it solves. It might put pressure on ER docs and hospitalists not to admit people they normally would, especially if that person had been discharged within 30 days.

Maybe thats part of the idea, keeping costs down by avoiding frivolous admits? If thats the case, I guess one ramification for EMS is that it will get busier. Instead of repeat admits, they will just be repeat patients to the ED when their condition worsens after being sent home and they show back up in the ED, some of them by ambulance.

Of course by the time their condition worsens some of them might be unsaveable, which I guess would be another way of keeping costs down eh.

 

[lightsandsirens5]

I think what you described is the only viable future for EMS.

Nailed it in my opinion.

 

[JakeEMTP]

"Readmissions are partially within the control of the hospital and partially within the control of others,"

"Also, for now, hospitals are only being measured on three medical conditions: heart attacks, heart failure and pneumonia. "

I would like to know more about the specifics. I agree that some readmissions are due to poor medical management during their stay or poor discharge instructions when they leave but a large majority is due to factors outside the hospitals control.

I work on a cardiac floor and it is not uncommon for a fresh stent, CABG, NSTEMI patient to sneak off the floor to smoke every hour or for a family member to bring in Fast Food because the patient will not eat the ordered diet. Or my favorite the patients who have a CHF and 20 home medications who come in with edema or SOB and have not taken their meds in a week (Yes some is due to cost but not always). Is it any surprise that these patients will likely be 30 day readmits?

I think it is a good concept however I think it is wrong if hospitals will be fined for readmits on noncompliant patients. Not sure how they would even distinguish that, I am sure they will just go off readmissions in general.

I wonder if this will sway ER Docs decisions to admit certain patients.? Oh you were here 17 days ago? here is some Lasix go home and piss it off

What QA monitors has your hospital been doing? Those are the ones CMS is mostly concerned about. There are many patients in the ER which CMS will not have much control over nor will those patients be covered by any insurance either state, private or federal.

LTC facilities and hospitals are now forming a strong working relationship. Contrary to what some in EMS believe, the paperwork for each transfer and admission for a LTC patient is large and detailed. No nurse or doctor wants to send an nursing home patient out if it can be avoided. They eat alot of the costs and there is only a 7 day bed hold in most cases. But, when hospitals fluff and turf, the bounce back rate is high.

There is a ton of info on the CMS website about this and there should be a copy of the CMS regs to be implimented in just about every hospital's station where doctors and NPs/PAs hang out. This news has been around for the past 3 years and after the monitors have been in place.

example of date collected:
http://www.cms.gov/Medicare/Demonst...downloads/CCTP_FourthQuartileHospsbyState.pdf

Kaiser is of course quick to catch on.
http://www.kaiserhealthnews.org/Stories/2012/August/13/readmissions-sources-and-methodology.aspx

Background
http://www.ncsl.org/documents/health/Medicare_Hospital_Readmissions_and_PPACA.pdf

 

[Veneficus]

This sounds like something that is a good idea on paper, but in the real world might cause as many problems as it solves. It might put pressure on ER docs and hospitalists not to admit people they normally would, especially if that person had been discharged within 30 days.

Maybe thats part of the idea, keeping costs down by avoiding frivolous admits? If thats the case, I guess one ramification for EMS is that it will get busier. Instead of repeat admits, they will just be repeat patients to the ED when their condition worsens after being sent home and they show back up in the ED, some of them by ambulance.

Of course by the time their condition worsens some of them might be unsaveable, which I guess would be another way of keeping costs down eh.

Just like a few years ago when it was decided that "preventable complications" would not be paid for, it did create some problems and changes at first.

However, I think the US is long overdue for performance based reimbursement from the current procedure based renumeration.

Call it: Evolution.

 

[WestMetroMedic]

Disclaimer: I am taking the Community Paramedic Course at Hennepin Technical College in Eden Prairie, MN this year and should have my certification completed by March 2013

Much of what most of us in my class already know, but are actually learning more about, is that although there are some patients who have no interest in being healthy, more often than not, it is a lack of understanding, or a lack of resources.

We all see it every day, patients who don't know how to access their primary care providers and how to use them as their primary health maintenance tool. With that being said, how do we change the tide? As much as many of us would like to turf that issue to someone else, it really comes down to EMS because we are most readily able to identify the problem patients who are using Emergency as Primary care, and we are the ones who probably will have the most one on one time with the patients. These patients often have never had the value of primary care shown to them, and just a little bit of education will go a long way. Simple things like explaining to them how much time they would save and how much less distance they would have to travel to receive primary care, may be enough to at least peak their interest and get them in their primary care MD's door.

The other issue is the lack of resources. I suspect it is the same case in the rest of the US, but here in Minnesota, I rarely run into a patient who is not either covered by insurance, or is not eligible for subsidized care (and I work in an urban center with the largest concentration of low income folks in the state). People have insurance, or can easily get insurance. That, despite what politicians may tell you, is not the issue here. The primary issue as I see it, is smaller things. How am I going to access my primary care, if I don't have a bus card to get there, or how am I going to be able to afford medications, how do I this and how do I that.

The unique role reversal that comes with Community Paramedicine, is where many of these issues can be solved or mitigated. My impression so far, is that you are a deployable resource, that is able to recognize the needs of a client, and work to connect them with the resources that they need. Sometimes, if your hospital is using an ACO payor model, it may be eating the cost and just delivering them their medications and setting it up for the patient, or else working with the Rx companies to get them involved in the Rx Med discount programs that virtually ALL Rx manufacturers offer. Sometimes, it may be arranging a transportation service to pick up your client and bring them to their primary care clinic, or even on short notice, putting them in your SUV and driving them to clinic or emergency. It is a lot of intangible things that will fall into this realm of Community Paramedicine, and many tangible concepts that will also fall into the realm.

Our classroom work and clinicals are designed specifically with these ideas in mind of reducing re-hospitalization and promoting primary care reliance. Minnesota is the first state to pass a law regarding reimbursement of Community Paramedic services, and their reimbursement schedule is pending at CMS right now after being submitted about a month ago, and PMI providers will create their own reimbursement schedule based on CMS' acceptance afterwards.

My Community Paramedic Course is video-conferenced with 6 other sites in Minnesota and also a site in North Dakota and a site in Idaho, so if anyone is interested in this program, check out Hennepin Technical College in the inter-google-web-face-space place. The staff is really good about this program, despite its relative infancy.

 

[WTEngel]

A terminal bachelor's degree that can lead to a specialized pre-hospital mid level provider would be interesting to consider.

Ultimately, I don't see this having a large effect on the ER or pre-hospital EMS. Emergency Rooms have been monitored and penalized for patients presenting back to the ER within 24 hours of discharge for CC relating to, or the same as original presentation for a while now, to my knowledge.

I haven't read deep enough into the article to determine if the hospitals are penalized for the patient simply showing up and being treated in the ER, or if the patient actually has to be readmitted in order for the penalty to take effect.

Honestly, I think the smart money is on hiring more social workers and setting up more intense follow up systems. The problem is not that the patients actually have an adverse outcome due to care provided, they have an adverse outcome because of failure to follow up on care provided, as they have been advised. Invest in patient transport vans, social workers and follow up nurses to keep in phone contact with the patients and "hold their hand" to get them to the follow up appointments, and we can probably capture more of these patients before they get to the point they go to the ER.

Unfortunately we are discussing the large majority of patients who re-present because they failed to respond to follow up and discharge instructions appropriately. We either hold their hand and get them through the follow up process, or they re-present. It sucks that people won't take personal responsibility in many cases, but ultimately the answer is not community paramedics, in my opinion.

 

[VFlutter]

What is the benefit of a community paramedic vs a home health nurse? What type/level of education does community paramedic require?

Sounds like a great concept but without a major overall in the way paramedics are educated I am not sure it is achievable.

 

[JakeEMTP]

Right now the issue is with hospital readmits where CMS gets heavily involved for reimbursement. CMS has been tracking the 30 day hospital readmit for a long time.

CMS has cut reimbursement for many community and home health services over the past 10 years. Funding has dwindled to almost nothing in some states. Trying to replace them with a 200 - 300 hour tech who may only have at best a 1000 hour Paramedic cert to begin with in a specialty like EMS is not the answers. Some things might get addressed but the lack of chronic care and patient teaching experience along with the appropriate education will only create another bandaid level rather than a more cohesive approach to this situation. The services that have been lost should be brought back. The number of closings for community clinics and the psych services are pretty astonishing. Unfortunately it has also been the Social Workers and Case Managers who get cut when a hospital is hit with budget problems. Unless you have enough people educated and familiar enough with all of the care planning, another cert level for EMS without a credible base education will not be of much use except for welfare checks which has already been done for decades in some places.

Giving a nifty title for another EMS level but forgetting the education part just serves only a short term purpose and may be of a bigger benefit to keep struggling EMS and Fire departments afloat rather than serve a greater purpose to either the EMS professon or the patients in the community.

 

[Veneficus]

I haven't read deep enough into the article to determine if the hospitals are penalized for the patient simply showing up and being treated in the ER, or if the patient actually has to be readmitted in order for the penalty to take effect.

Looking at the system as a whole, this seems to me like a subtle attempt to get providers to increase hospital stay.

When you look at some of the more effective (not to be confused with efficent as the two are not synonomous) healthcare systems in the world, they have longer hospital stays on average than the US.

Nobody can reasonably argue in the US, bed turnover is very important financially. That reality dictates more care will be done in a follow up capacity. This in turn I would say contributes to the trouble with system navigation and follow up resources that have been detailed here.

Honestly, I think the smart money is on hiring more social workers and setting up more intense follow up systems. The problem is not that the patients actually have an adverse outcome due to care provided, they have an adverse outcome because of failure to follow up on care provided, as they have been advised. Invest in patient transport vans, social workers and follow up nurses to keep in phone contact with the patients and "hold their hand" to get them to the follow up appointments, and we can probably capture more of these patients before they get to the point they go to the ER.

Because of not only logistical issues, like fleet maintenence, but also practicality, like non centralized healthcare resources, I think the purpose of community paramedicine is an attempt to basically outsource this to EMS.

I am not sure it is "smart money."

Upeducating and paying a bit more to providers who spend nonemergent time being proactive instead of a FD model of readiness/reaction who for simplicity basically sit around waiting for a call is going to be cheaper or produce better results, while at the same time adding all these new people and resources, is more efficent than a Police style model of concentration on problem areas and responding.

Unfortunately we are discussing the large majority of patients who re-present because they failed to respond to follow up and discharge instructions appropriately. We either hold their hand and get them through the follow up process, or they re-present. It sucks that people won't take personal responsibility in many cases, but ultimately the answer is not community paramedics, in my opinion.

What about people who simply can't follow up?

I would argue it is more of a problem of "can't" than "don't want to."

How do you have a fixed income dialysis patient who gets wheelchair transport for dialysis pay for getting to a PCP or nephrology appointment which may or may not be reimbursed?

Who picks up their medication for them?

Who makes sure they are taking it and it is working?

Who intervenes when they stop taking it because the side effects are more intolerable than not taking it?

What is the benefit of a community paramedic vs a home health nurse? What type/level of education does community paramedic require?

Well, it would be cheaper for one. Nursing in the US has also lost site of its core responsibilities of caring for basic needs. It has farmed these responsibilities out to more and more levels of techs.

A home healthcare nurse may come and decide you need evaluation, but probably won't drive you there.

Are they going to come and help with fall precautions or medication coaching everyday?

If so why are they not doing that in nursing homes where they do not have to travel?

I don't think that home nursing can't do these things. I think they have divested themselves from it.

Somebody needs to fill that role outside of the hospital. You have only 3 options.

Retask nurses to their original role. (I laugh at even the thought. The resistance would be greater than upeducating EMS)

Train and retain an entirely new population of providers. (would take quite a while to develop and impliment)

Retask response providers who already exist to fulfil a more useful role than what they currently do based on today's needs. Which is not emergent care for acute conditions.

 

[JakeEMTP]

Looking at the system as a whole, this seems to me like a subtle attempt to get providers to increase hospital stay.

When you look at some of the more effective (not to be confused with efficent as the two are not synonomous) healthcare systems in the world, they have longer hospital stays on average than the US.

Nobody can reasonably argue in the US, bed turnover is very important financially. That reality dictates more care will be done in a follow up capacity. This in turn I would say contributes to the trouble with system navigation and follow up resources that have been detailed here.

Length of state as concerns for CMS is whether it was increased due to nosocomial infections. In most situations there is no benefit for the hospital to keep a patient longer than necessary or to drag out a patients stay. CMS and other insurances may already have an argreement that x is paid and that is it.

Well, it would be cheaper for one. Nursing in the US has also lost site of its core responsibilities of caring for basic needs. It has farmed these responsibilities out to more and more levels of techs.

A home healthcare nurse may come and decide you need evaluation, but probably won't drive you there.

Are they going to come and help with fall precautions or medication coaching everyday?

If so why are they not doing that in nursing homes where they do not have to travel?

I don't think that home nursing can't do these things. I think they have divested themselves from it.

Somebody needs to fill that role outside of the hospital. You have only 3 options.

Retask nurses to their original role. (I laugh at even the thought. The resistance would be greater than upeducating EMS)

Train and retain an entirely new population of providers. (would take quite a while to develop and impliment)

Retask response providers who already exist to fulfil a more useful role than what they currently do based on today's needs.

Medicine has become more specialized. The GP doc might be okay for some evaluations and to act as a traffic cop to direct people to the more appropriate source. Nurses are essentially doing the same thing. But, techs are no longer in the picture now in many hospitals when it comes to a professional level of care as the expectation. You can hardly call Occupational Therapist, Speech Language Therapist and Physical Therapists all of whom have a minimum of a Masters degrees and well over 2000 hours of an internship besides the degree just to get into the field. Before they do home health they may have a few years of experience plus be integrated into an Interdisiplinary Planning Team to learn all aspects of care.

Nursing in home health will do assessments and teachings which they have already done repeatedly at the bedside as part of their daily care. To extend into home health is not a big stretch for most assessments.

Home Health Nurses have their own organization to address issues and to gain support for politics which affect their patients directly. Other professional organizations also have lobbied to keep services for patients.

http://www.hhna.org/

But, EMS and Fire come along with a "what's in if for me" rather than the patient attitude after doing very little to support services which have been dwindling. EMS has been oblivious to what has been happening in healthcare except to complain about being a taxi service and have never addressed any of the policies affecting health care. But, given the opportunity to create a new level that only takes a couple of months to complete, hell yeah we're in! Fire departments who do EMS have political power and can always use the hero factor to get their way.

It is also ironic to read post after post on these forums about Paramedics and EMTs complaining about doing routine calls or babysitting but yet are all excited if there is a new patch to get. That is as long as the education isn't really increased and it doesn't take much time to obtain.

 

[DrParasite]

The issue with this is far too many patients don't give a damn once they leave the hospital. We've all had our fair share of non-compliant patients who for one reason or another don't do what they're supposed to for their own healthcare, and now the healthcare providers will be punished for the patients decision.

exactly. You can lead a horse to water, but you can't make it drink.

not only that, but we all have our share of chronic offenders. you know, the people who you can have the chart 90% completed before you knock on the door, since you picked the patient up yesterday for the same complaint. why should the system be punished for the system abuser?

btw, every ER discharge instructions I have seen say "follow up with your primary physician." if the patient fails to do so (which the vast majority don't go), why is the hospital fined when the condition isn't resolved/

 

[mycrofft]

When "Dignostic Related Groups" (DRGs) were first used for prospective payment criteria around 1982, it was too common for patients to be discharged out the front, and occasionally (literally) wheeled around to the ER for a new admision to meet criteria. A friend died because he was sent home too soon after saphenous vein stripping (severe varicosities), and a neighbor's aghter was sent home with emerging Battle signs because their Utilization and Review/DRG's said that N hours in the ER without appearance of signs XYZ was IT. This new deral should fionally give practtikners an dge when a pt just needs to be watched or treated a little longer, or referral made. I think the patient ought to be given at least half of the fine.
But there are abusers. I had a pt kicked outof a hospital while undergoing central line IV antibiotics (an IV drug auser) when he was caught in his car shooting heroin into his central line port.

 

[Veneficus]

When "Dignostic Related Groups" (DRGs) were first used for prospective payment criteria around 1982, it was too common for patients to be discharged out the front, and occasionally (literally) wheeled around to the ER for a new admision to meet criteria. A friend died because he was sent home too soon after saphenous vein stripping (severe varicosities), and a neighbor's aghter was sent home with emerging Battle signs because their Utilization and Review/DRG's said that N hours in the ER without appearance of signs XYZ was IT. This new deral should fionally give practtikners an dge when a pt just needs to be watched or treated a little longer, or referral made. I think the patient ought to be given at least half of the fine.
But there are abusers. I had a pt kicked outof a hospital while undergoing central line IV antibiotics (an IV drug auser) when he was caught in his car shooting heroin into his central line port.

I think you hit the nail on the head.

Because of the extreme profit nature and way Americans view how medicine is used, the idea of paying for a defined set of diagnostics, procedures, and over a defined period of time is what causes "McMedicine."

Which of course doesn't work for every patient and it is foolish to think it does.

"Your sickness must meet our criteria," just sounds messed up. But it works very well if you own stock in an insurance company or hospital.

This mentality is actually perpetuated by a fair bit of "evidence" based medicine. One of my favorite are the near constant flow of studies showing that the longer you work US residents outcomes don't change.

(Which begs the question, if you get the same results from somebody in their 40th hour as their 80th, is something really messed up somewhere? Pay no attention to the recent study about remediation rates for US surgical residents)

But that is just one example. It helps make the hospital money. So of course there will be a push-back against something that may cost the hospital money.

Look at the uproar of the speed of discharge from birthing mothers some years back.

Like I have pointed out with the NEJM studies on this very website, the amount of money spent compared to the quality of care recieved is complete disproportionate and does not measure comparitively to every other developed nation. That is going to have to be brought into line for the US.

I maintain, this is just one step in a host of coming changes to soften the blow compared to an abrupt change. (I don't think an abrupt change would be fiscally responsible as a matter of point.)