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How area hospitals fared in Obamacare penalties for avoidable readmissions

The battle over health insurance coverage in Obamacare obscures an important fact: The Trump administration is quietly continuing with other big parts of the 2010 legislation.

This includes the Affordable Care Act program to reduce avoidable hospital readmissions within 30 days of discharge, with penalties to facilities with readmission rates that are higher than expected for certain conditions.

The federal Centers for Medicare and Medicaid this month determined the penalties for the next fiscal year, starting in October, that will hit 2,573 hospitals, including all but two in Western New York, according to an analysis by Kaiser Health News.

Major medical facilities in the Buffalo Niagara region will all receive penalties below the national average for 2018.

The original goal, despite calls for repealing the health law, appears likely to remain no matter what happens: improve quality and control costs by preventing readmissions that result from medical errors, confusing discharge instructions, poor coordination among different health care providers or inadequate support at the patient’s home.

The latest penalties represent a percentage of the hospitals' traditional Medicare program payments, up to a maximum of 3 percent, for excessive readmissions over a three-year period – 2013 to 2016 – for certain conditions: heart attacks, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary bypass surgery, and hip or knee replacements.

The government did not release dollar figures for the penalties. But it estimated Medicare, the federal health program for people 65 and older, will save about $564 million in 2018, slightly above 2017 savings.

The government evaluated 3,241 hospitals, penalizing 80 percent of them, Kaiser Health News found. About 1,500 hospitals nationally were exempted from the penalties. The average penalty will be 0.73 percent of each payment Medicare makes for a patient between Oct. 1 and Sept. 30, 2018.

Based on data from Kaiser Health News and the Centers for Medicare and Medicaid Services, area hospitals and their percentage penalties of their Medicare payments over the years have been:

Has the program worked?

A 2016 study in the Journal of the American Medical Association found that Medicare fee-for-service patients at hospitals subject to penalties had greater reductions in readmission rates compared with those at nonpenalized hospitals. Another study in 2016 in the New England Journal of Medicine concluded that readmission rates began to fall faster in 2010, after the passage of Obamacare, than before, and that rates continued to decline through 2015, although more slowly.

More recent research published in July in the Journal of the American Medical Association found that reducing hospital readmission rates for heart attack, heart failure and pneumonia didn't increase the risk of death for recently discharged patients.

The federal program is not perfect but helps hospitals stay focused on issues that can reduce the cost of care, said John Kane, senior vice president of quality and patient safety at Catholic Health, which includes Mercy, Sisters and Kenmore Mercy hospitals. Organizations like Catholic Health are using an assortment of strategies to reduce avoidable readmissions.

"A lot of this is about treatment in place, having programs in place that talk to each other at different levels of care, and making sure patients visit their primary care doctor shortly after they are discharged," he said. "We work on these things all the time."

Kane said the increase in patients insured under the Affordable Care Act may have helped control avoidable readmissions by linking them with primary care physicians and reducing their use of emergency rooms for basic care.

One of the criticisms about the readmission reduction effort is that it disproportionately penalizes hospitals that serve low-income and medically complex patients. To address that, Congress last year directed the program, starting in 2019, to measure hospitals based on peer groups of facilities with similar shares of patients who qualify for both Medicare and Medicaid, as well as to make other adjustments, as needed, in the future.

Another criticism is that hospitals get penalized regardless of the reason for the readmission.

"If a heart failure patient goes home, breaks a leg and ends up back in the hospital, that's not something we could have avoided," Kane said. "We need an adjustment to link the readmission to the issues that cause them."

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