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Kaiser Health News: Medicare’s Readmission Penalty Dollars Reach New High

August 4, 2016
by Rajiv Leventhal
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The government will punish more than half of the nation’s hospitals; four-fifths of those hospitals evaluated were penalized

The federal government’s penalties on hospitals for failing to lower their rehospitalization rates will hit a new high as Medicare will withhold approximately $528 million—about $108 million more than last year—according to an August 2 Kaiser Health News report.

The government will punish more than half of the nation’s hospitals — a total of 2,597 — having more patients than expected return within a month. While that is about the same number penalized last year, the average penalty will increase by a fifth, according to a Kaiser Health News (KHN) analysis.

The Hospital Readmissions Reduction Program, created by the Affordable Care Act (ACA), was designed to make hospitals pay closer attention to what happens to their patients after they get discharged. The  fines for failure to meet the criteria of the Centers for Medicare & Medicaid Services (CMS) focus on six conditions: heart attack, congestive heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), elective hip and knee replacements, and for the first time this year—coronary artery bypass graft surgery—and are based on readmissions between July 2012 through June 2015.

The new penalties will take effect in October. Since the Hospital Readmissions Reduction Program began in October 2012, national readmission rates have dropped as many hospitals pay more attention to how patients fare after their release. But according to the KHN report’s author, Jordan Rau, “The penalties are the subject of a prolonged debate about whether the government should consider the special challenges faced by hospitals that treat large numbers of low-income people. Those patients can have more trouble recuperating, sometimes because they can’t afford their medications or lack social support to follow physician instructions, such as reducing the amount of salt that heart failure patients consume. The Centers for Medicare & Medicaid Services says those hospitals should not be held to a different standard.”

For each hospital, the government calculated how many readmissions it expected, given national rates and the health of each hospital’s patients. Hospitals with more unplanned readmissions than expected will receive a reduction in each Medicare case reimbursement for the upcoming fiscal year that runs from Oct. 1 through September 2017. And, the payment cuts apply to all Medicare patients, not just those with one of the six conditions Medicare measured, KHN’s Rau reported.

The maximum reduction for any hospital is 3 percent, and it does not affect special Medicare payments for hospitals that treat large numbers of low-income patients or train residents. Forty-nine hospitals received the maximum fine. The average penalty was 0.73 percent of each Medicare payment, up from 0.61 percent last year and higher than in any other year, according to the KHN analysis.

Under the ACA, which created the penalties, a variety of hospitals are excluded, including those serving veterans, children and psychiatric patients. Maryland hospitals are exempted as well because Congress has given that state extra leeway in how it distributes Medicare money. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, are also exempt, according to KHN.

As a result, more than 1,400 hospitals were automatically exempt from the penalties. Other hospitals did not have enough cases for Medicare to evaluate accurately and were not penalized.  Of the hospitals that Medicare did evaluate, four out of five were penalized. The KHN analysis found that 1,621 hospitals have been penalized in each of the five years of the program.




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