PA Safety Net Admin, Author at Safety-Net Association of Pennsylvania

Safety-Net Hospitals’ Readmissions Challenge

The March edition of the journal Health Affairs offers a compelling snapshot of a type of patient many safety-net hospitals serve on an almost daily basis: the “superutilizer” who lacks the ability and resources to address his own medical needs.
The article “Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital” tells the story of a patient who

…had been using drugs and alcohol since his teenage years, and he was addicted to crack cocaine and alcohol…He had been released from prison six months before we first met him, without any basic resources to help him transition back into society – not even a state ID. Lacking this fundamental necessity, he could not apply for state health insurance or a Supplemental Nutrition Assistance Program card to receive food stamps. As an ex-felon with no income, he couldn’t find a place to live. He told us he was living on the streets, where he spent his days panhandling and using the money he got to buy tacos from street vendors and hash browns from McDonald’s.

Mr. G’s first several admissions to our hospital were similar. He would walk into the emergency department, unable to breathe, and would be admitted to the hospital for treatment related to heart failure. He had a complex medical history including diabetes and extremely poor heart function – which was complicated by a clot in his heart that required the chronic use of blood thinners. Furthermore, he suffered from schizophrenia.

The hospital faced a problem in addition to caring for Mr. G.

The problem with Mr. G’s admissions, aside from their drain on hospital resources, is that to motivate hospitals to improve care, Medicare penalizes hospitals for certain patients who are readmitted within thirty days. This policy assumes that all patients have the means and internal resources to care for themselves effectively and that hospitals, by simply adhering to best practices of medical management, can avoid redundant care. Medicare fails to consider the complications imposed by poverty and the significant burden safety-net hospitals face in trying to address overwhelming social issues.

A typical admission was set in motion by Mr. G’s nonadherence to his medications, poor diet, substance abuse, or a combination of the three. With each admission, additional problems and complications cropped up that extended his stay.

The problems continue, and the article explains that

Patients like Mr. G frustrate health care providers. These patients are often dismissed as being nonadherent, and their psychosocial needs go unrecognized. Their daily challenges are compounded by poverty, mental illness, substance abuse, lack of social support, lack of transportation, and unstable housing. These factors – and other social determinants of health – set the stage for poor health outcomes in patients with low socioeconomic status.

The article concludes by noting that

Current health care policy emphasizes the reduction of readmissions but does not support the time and resources needed to achieve this goal. As the basis for payment shifts from volume to value, it will become exceedingly expensive to continue ignoring the social determinants of health.

To learn more about Mr. G, the hospital that served him, and the challenges Pennsylvania’s safety-net hospitals face when serving patients CMS has labeled “superutilizers,” go here, to the web site of the journal Health Affairs, to see the complete article “Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital.”

PA Safety Net Admin2016-04-06T06:00:21+00:00April 6th, 2016|Affordable Care Act, Medicare, Pennsylvania safety-net hospitals|Comments Off

Group Organizes Advocacy in Support of 340B Program

Under pressure from federal regulators and MedPAC, the advocacy group 340B Health is attempting to rally hospital groups behind the 340B prescription drug discount program that requires pharmaceutical companies to provide discounts to qualified hospitals for drugs dispensed on an outpatient basis to Medicaid patients.
Last year the Health Resources and Services Administration, which runs the program, issued proposed regulations that would change how the program operates and is governed. Recently, MedPAC proposed reducing the size of the discount hospitals receive for the drugs, with the savings to be redirected to fund additional Medicare disproportionate share (Medicare DSH) payments for selected hospitals.
More than 2100 organizations participate in the 340B program, including most Pennsylvania safety-net hospitals.
For a closer look at the 340B program, the changes that have been proposed, and what hospitals are attempting to do about it, see this report from CQ Roll Call presented by the Commonwealth Fund.

PA Safety Net Admin2016-03-31T06:00:37+00:00March 31st, 2016|Pennsylvania safety-net hospitals|Comments Off

Beware Medicaid Block Grants, Analysis Suggests

When the federal government turns housing, health, and social services programs into block grants, funding for such programs erodes over time, according to a new analysis by the Center on Budget and Policy Priorities.
The study found that

Policymakers advancing these proposals often accompany them… with assurances that the new block grant would get the same overall amount of funding as currently goes to the individual programs that it would replace. This new analysis of several decades of budget data strongly suggests, however, that even if a new block grant’s funding in its initial year matched the prior funding for the programs merged into the block grant, the initial level likely wouldn’t be sustained. History shows that when social programs are merged into (or created as) broad block grants, funding typically contracts — often sharply — in subsequent years and decades, with the reductions growing over time.

Of 13 such transitions from appropriation to block grant status in recent years, 11 of the programs shrunk in inflation-adjusted terms, some of them significantly so, with a median decline for the 13 of 26 percent to date.
The analysis also found that

The marked deterioration in block-grant funding over time controverts the common claim by block grant proponents that if funding levels prove inadequate, Congress will step in to provide appropriate additional funding. The general lack of responsiveness of block-grant funding to changes in need contrasts sharply with the high degree of responsiveness of entitlement programs such as SNAP (formerly known as the Food Stamp Program).

The study comes at a time when some policy-makers are talking about converting Medicaid into a block grant program. This proposal has been around for years and periodically resurfaces, as it has in the past year.
For a closer look at what happens when the federal government turns a program into a block grant, go here to see the Center on Budget and Policy Priorities’ report “Funding for Housing, Health, and Social Services Block Grants Has Fallen Markedly Over Time.”

PA Safety Net Admin2016-03-29T06:00:47+00:00March 29th, 2016|Uncategorized|Comments Off

Socio-Economic Factors Again Tied to Hospital Readmissions

Another study has linked socio-economic factors to increased hospital readmissions.
This latest study, published in the Journal for Healthcare Quality, found that

… meaningful risk-adjusted readmission rates can be tracked in a dynamic database. The clinical conditions responsible for the index admission were the strongest predictive factor of readmissions, but factors such as age and accompanying comorbid conditions were also important. Socioeconomic factors, such as race, income, and payer status, also showed strong statistical significance in predicting readmissions.

Conclusions: Payment models that are based on stratified comparisons might result in a more equitable payment system while at the same time providing transparency regarding disparities based on these factors. No model, yet available, discriminates potentially modifiable readmissions from those not subject to intervention highlighting the fact that the optimum readmission rate for any given condition is yet to be identified.

The study found that low-income patients are more likely to require readmission to the hospital than those with higher incomes and hospitals that serve higher proportions of low-income patients are more likely to incur Medicare penalties for readmissions than other hospitals.
These are the very patients served in especially large numbers by Pennsylvania’s private safety-net hospitals.
To learn more about the study, how it was conducted, and what it found, find the study “Patient Factors Predictive of Hospital Readmissions Within 30 Days” here, on the web site of the Journal for Healthcare Quality.

PA Safety Net Admin2016-03-25T06:00:42+00:00March 25th, 2016|Medicare, Pennsylvania safety-net hospitals|Comments Off

MedPAC Offers DSH, 340B Recommendations

The Medicare Payment Advisory Commission has recommended that Congress direct changes in the 340B prescription drug discount program and in the manner in which Medicare makes disproportionate share hospital payments (Medicare DSH).
In its annual report to Congress, MedPAC recommended a reduction in 340B prescription drug payments to hospitals. The proposed reduction would cut 340B program spending approximately $300 million.
MedPAC then recommended that those 340B savings be redirected to the Medicare DSH uncompensated care pool.
And it also called for distributing the money in that pool based on better data on the uncompensated care hospitals provide, as reported on hospitals’ Medicare cost report S-10 worksheets, so that the Medicare DSH uncompensated care program would “…better target additional payments to hospitals that provide above average shares of uncompensated care.”
Most Pennsylvania safety-net hospitals participate in both the 340B and Medicaid DSH programs.
To learn more about these and other MedPAC recommendations, see the news release that accompanied the MedPAC report to Congress; a fact sheet on that report; and the report itself.

PA Safety Net Admin2016-03-23T06:00:39+00:00March 23rd, 2016|Medicare|Comments Off

MACPAC Unhappy With How DSH is Dished

Medicaid disproportionate share hospital payments (Medicaid DSH) are not getting to the hospitals that need them most, according to the independent agency that advises Congress and the administration on Medicaid access, payment, and care delivery issues.
In its March 2016 Report to Congress on Medicaid and CHIP, the Medicaid and CHIP Payment and Access Commission found

…little meaningful relationship between DSH allotments and three aspects of DSH payments that Congress asked us to study: 1) the relationship of state DSH allotments to data relating to changes in the number of uninsured individuals, 2) data relating to the amount and sources of hospitals’ uncompensated care costs, and 3) data identifying hospitals with high levels of uncompensated care that also provide access to essential community services for low-income, uninsured, and vulnerable populations.

MACPAC also observed that

Although early reports suggest that the coverage expansions are improving hospital finances in general, it is not yet clear how hospitals that are particularly reliant on Medicaid DSH payments are being affected.

MACPAC further maintains that

…DSH allotments and payments should be better targeted, consistent with their original statutory intent.

Noting an obstacle to such an undertaking, MACPAC

…recommends that the Secretary [of Health and Human Services] collect and report hospital-specific data on all types of Medicaid payments for all hospitals that receive them. In addition, the Secretary should collect and report data on the sources of non-federal share necessary to determine net Medicaid payment at the provider level.

Finally, MACPAC promises to continue looking into this challenge and exploring possible solutions.

In future reports on DSH payment policy, which MACPAC will include in its annual March reports to Congress, the Commission will continue to monitor the ACA’s effect on hospitals receiving DSH payments. We also plan to explore potential approaches to improving targeting of federal Medicaid DSH funding, including modifying the criteria for DSH payment eligibility, redefining uncompensated care for Medicaid DSH purposes, and rebasing states DSH allotments.

To learn more about what MACPAC had to say about Medicaid DSH and other Medicaid- and CHIP-related issues, go here to see the MACPAC report March 2016 Report to Congress on Medicaid and CHIP.

PA Safety Net Admin2016-03-21T06:00:56+00:00March 21st, 2016|Affordable Care Act, Medicaid supplemental payments|Comments Off

Hospitals Failing to Prevent Avoidable Readmissions

Hospitals continue to fail to prevent many avoidable readmissions, a new study in JAMA Internal Medicine has concluded.
Among the causes? Patients who shouldn’t have been admitted through the ER in the first place, post-discharge instructions written at too high a level for patients, failure of patients to keep follow-up appointments, and hospitals discharging patients too soon.
Two of those causes – hard-to-understand discharge instructions and difficulty keeping follow-up appointments – as problems that are especially prevalent within the kinds of communities served by Pennsylvania’s safety-net hospitals.
In all, the study of 12 academic medical centers concluded that 15 percent of readmissions were preventable, 12 percent were likely unpreventable, and there was about a 50 percent chance of preventing another 15 percent of readmissions.
For a look at the problems the study identified and its recommendations for addressing them, go here to see the JAMA Internal Medicine article “Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients.”

PA Safety Net Admin2016-03-17T06:00:09+00:00March 17th, 2016|Uncategorized|Comments Off

IOM Weighs in on Social Determinants Training

If patients’ symptoms and conditions are the product of who they are, where they are from, and how they have lived, can better understanding those circumstances help providers serve those patients more effectively?
Increasingly the answer to that question has been yes, it can, and now, the National Academies of Science, Engineering, and Medicine and the Institute of Medicine have proposed an approach to training caregivers on the social determinants of health. Their new publication, A Framework for Educating Health Professionals to Address the Social Determinants of Health, notes that

The World Health Organization (WHO) defines social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” These forces and systems include economic policies, development agendas, cultural and social norms, social policies, and political systems. Health inequities, “the unfair and avoidable differences in health between groups of people within countries and between countries” (WHO, 2015b), stem from the social determinants of health and result in stark differences in health and health outcomes.

SNAP has long maintained that the socio-economic challenges their patients face – all important social determinants of health – make serving their low-income communities more challenging and more complex than the patients served by the typical community hospital in Pennsylvania today.
The report’s framework addresses such issues as diversity and inclusion, the importance of a diverse workforce, community participation, health professions education, and more. To learn more about how understanding the social determinants of health might lead to better care and healthier populations, go here to see the National Academies of Science, Engineering, and Medicine and the Institute of Medicine publication A Framework for Educating Health Professionals to Address the Social Determinants of Health.

PA Safety Net Admin2016-03-15T06:00:32+00:00March 15th, 2016|Safety-Net Association of Pennsylvania, Uncategorized|Comments Off

GAO Looks at Supplemental Medicaid Payments

Following up its own 2012 report that identified more than 500 hospitals receiving supplemental Medicaid payments that resulted in Medicaid payment surpluses, the U.S. Government Accountability Office has taken a broader look at supplemental payments state Medicaid programs make to hospitals and how those payments are used.
In a limited study of hospitals in four states, GAO found that some hospitals used supplemental payments for purposes other than serving Medicaid patients and the uninsured – purposes such as ordinary operations, capital purchases, a poison control center, even a helicopter. GAO also found that hospitals were more likely to receive such payments if local funding was used to draw down federal Medicaid matching funds. In some places, hospitals with local governments willing to finance the payments were more likely to receive them than hospitals located in places without such local support.
The GAO recommended that the Centers for Medicare & Medicaid Services take stronger steps to ensure that supplemental Medicaid payments are linked to the provision of Medicaid services and that CMS not permit states to make those payments contingent on local financing.
Learn more about why the GAO looked at supplemental Medicaid payments, what it learned, and what it recommended in the report Federal Guidance Needed to Address Concerns About Distribution of Supplemental Payments.

PA Safety Net Admin2016-03-09T06:00:15+00:00March 9th, 2016|Uncategorized|Comments Off

Latest Edition of Health Law News

The Pennsylvania Health Law Project has released the latest edition of its newsletter.
The February edition includes features about Governor Wolf’s proposed FY 2017 Medicaid budget, the launch of a new “fast track” Medicaid enrollment program, the state’s plans for a new approach to providing managed long-term services and supports, and more.
Find the newsletter here.

PA Safety Net Admin2016-03-03T06:00:55+00:00March 3rd, 2016|Pennsylvania Medicaid policy, Pennsylvania proposed FY 2017 budget|Comments Off

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