Electronic Health Records

Use & Optimization News

Knee and hip replacement readmissions may cost $265,000

By Jennifer Bresnick

Readmitting a patient after an elective knee or hip replacement?  Prepare for a quarter of a million dollar fine from Medicare.  New accountable care guidelines institute harsh penalties for hospitals that are unable to prevent readmissions for certain conditions, including joint replacement surgeries, emphysema, and COPD treatments, which will start in October of 2014.

While the shift to pay-for-performance medicine is generally seen as a positive step for the healthcare industry, helping physicians reduce unnecessary tests and be more thorough with patient evaluations the first time so nothing gets missed, hospitals take a dim view of penalties for “preventable” readmissions that might not be all that preventable.  With an increasing number of seniors seeking joint replacements to maintain their active lifestyles for longer, and fines getting steeper as Medicare pushes for reduced costs, hospitals are left with only two choices: find better ways of treating patients, or stop accepting them at all, leaving them to deteriorate further and become more expensive to treat down the line.

“Outcomes for chronic illnesses can vary widely, resulting in potentially unfairly penalizing hospitals and physicians for readmissions that are not under their control,” argued the American College of Surgeons in a June letter to CMS.   Since low-income and limited education populations often suffer from higher rates of chronic diseases, sharply increasing fines for chronic illness readmissions “could result in hospitals that care for high-risk populations being inadvertently targeted or incentivized to limit access to care to such high-risk patients.”

Experts are wary that refusing service to higher risk patients or suggesting other non-hospital options such as hospice care will actually increase mortality rates, a phenomenon that Medicare is “committed to monitoring” over the next year.  Fraud is also a concern when it comes to targeting certain conditions for financial penalties.  Providers might simply change the medical codes associated with a patient to avoid falling under the categories that include hefty fines.

Hospitals will begin to pay $265,000 per knee or hip replacement readmission and $32,000 for COPD and emphysema readmissions in October of 2014, but the fines for joint replacements will be assessed for patients going back to 2010.  This may cause some significant revenue issues for organizations already battling to stay in the black, and may sour attitudes towards accountable care and the real benefits it can have for patients.  More information on the fines will be published in the Federal Register on August 19.





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