The Wall Street Journal has a story today about how the timing of Medicare payments is a big driver of when hospitals discharge their patients — maybe even bigger than the patients’ actual condition:
A Kindred Healthcare Inc. hospital in Houston discharged 79-year-old Ronald Beard to a nursing home after 23 days of treatment for complications of knee surgery.
The timing of his release didn’t appear to correspond with any improvement in his condition, according to family members. But it did boost how much money the hospital got.
Kindred collected $35,887.79 from the federal Medicare agency for his stay, according to a billing document, the maximum amount it could earn for treating most patients with Mr. Beard’s condition.
If he had left just one day earlier, Kindred would have received only about $20,000 under Medicare rules. If he had stayed longer than the 23 days, the hospital likely wouldn’t have received any additional Medicare money.
Here’s exactly why:
Under Medicare rules, long-term acute-care hospitals like Kindred’s typically receive smaller payments for what is considered a short stay, until a patient hits a threshold. After that threshold, payment jumps to a lump sum meant to cover the full course of long-term treatment.
That leaves a narrow window of maximum profitability in caring for patients at the nation’s about 435 long-term hospitals, which specialize in treating people with serious conditions who require prolonged care.
The Journal collected some data:
The Journal analysis of claims Medicare paid from 2008 through 2013 found long-term hospitals discharged 25% of patients during the three days after crossing thresholds for higher, lump-sum payments. That is five times as many patients as were released the three days before the thresholds.
The story includes some very interesting charts here, and links to their early coverage of other Medicare problems: fraud, unnecessary surgeries, and now this.
Second, yesterday, Jeffrey A. Singer, a surgeon in Phoenix and an adjunct scholar at the Cato Institute, had a piece highlighting how the federal government’s mandate that health providers adopt electronic records is going.
The result, he explains, is lower quality of care and higher cost:
The debate over ObamaCare has obscured another important example of government meddling in medicine. Starting this year, physicians like myself who treat Medicare patients must adopt electronic health records, known as EHRs, which are digital versions of a patient’s paper charts . . . I am an unwilling participant in this program. In my experience, EHRs harm patients more than they help. . . .
But for all the talk of “evidence-based medicine,” the federal government barely bothered to study electronic health records before nationalizing the program. The Department of Health and Human Services initiated a five-year pilot program in 2008 to encourage physicians in 12 cities and states to use electronic health records. One year later, the stimulus required EHRs nationwide. By moving forward without sufficient evidence, lawmakers ignored the possibility that what worked for Kaiser or the VA might not work as well for Dr. Jones.
Electronic health records are contributing to two major problems: lower quality of care and higher costs. The former is evident in the attention-dividing nature of electronic health records. They force me to physically turn my attention away from patients and toward a computer screen—a shift from individual care to IT compliance. This is more than a mere nuisance; it is an impediment to providing personal medical attention.
A 2014 survey by the industry group Medical Economics discovered that 67% of doctors are “dissatisfied with [EHR] functionality.” Three of four physicians said electronic health records “do not save them time,” according to Deloitte. Doctors reported spending—or more accurately, wasting—an average of 48 minutes each day dealing with this system.
Proponents of electronic health records nonetheless claim that EHRs decrease record-keeping errors and increase efficiency. My own experience again indicates otherwise and is corroborated by research.
The EHR system assumes that the patient in front of me is the “average patient.” When I’m in the treatment room, I must fill out a template to demonstrate to the federal government that I made “meaningful use” of the system. This rigidity inhibits my ability to tailor my questions and treatment to my patient’s actual medical needs. It promotes tunnel vision in which physicians become so focused on complying with the EHR work sheet that they surrender a degree of critical thinking and medical investigation.
Not surprisingly, a recent study in Perspectives in Health Information Management found that electronic health records encourage errors that can “endanger patient safety or decrease the quality of care.” America saw a real-life example during the recent Ebola crisis, when “patient zero” in Dallas, Thomas Eric Duncan, received a delayed diagnosis due in part to problems with EHRs.
Chris Edwards has a great commentary on the piece in a blog post called “Hayek vs. Government Health Care”:
A theme in Jeff’s piece is that there is tacit and localized aspects of his practice that the government did not know about, and did not bother to find out about, before it imposed its top-down rules.
The pretense of knowledge in government is everywhere. It leads to government failures most of the time.
So while we’re on that problem, a few stories about Obamacare that caught my eye today. First, this story about how small budget-squeezed states that also run their own state exchanges are finding it hard to find the means to keep the exchanges open:
The size of smaller states’ markets are small — meaning there’s less revenue from taxes — but they face many of the same fixed costs in maintenance and technology as large states do. Also like their larger counterparts, states like Hawaii, Rhode Island and Vermont plus the District of Columbia can no longer depend on the federal grants they used to initially develop and fund their exchanges. The federal Centers for Medicare & Medicaid Services (CMS) prohibited using those grants toward operations starting earlier this year.
In statehouses over the next several months, debates will rage over how to fund exchanges — but also whether those exchanges are worth maintaining at all, and in what form. The main source of revenue for state-based exchanges comes from fees paid by insurers. Most exchanges, though, are also still counting on at least some financial support from their general funds. California, which has the highest enrollment of any state, is one exception. The state can’t use general revenue to fund its exchange, and is now running into an $80 million deficit that could require raising insurer fees from the current $13.95 per policy.
Second, Peter Suderman over at Reason notes that once again, the White House overhyped Obamacare enrollment numbers:
Yesterday evening, not long after the official (but not actual) end of Obamacare’s open enrollment period, the White House Twitter feed posted some breaking news: “About 11.4 million Americans are signed up for private health coverage,” the tweet said, posting the information with the hashtag #ACAWorks.
It is in some ways remarkable that the White House can provide this information so quickly. Not because the information should be hard to collect, but because other similar information often eludes the administration.
As Bloomberg News health care reporter Alex Wayne noted on Twitter earlier today during a Q&A session with Health and Human Services Secretary Sylvia Matthews Burwell, the administration “still can’t tell us how many people were enrolled in Obamacare at the end of 2014.”
The whole thing is here.