Photo from SD Union-Tribune 2012
Photo by SD Union-Tribune

One of the less well-known conditions of the Affordable Care Act took effect in 2013 and affects hospitals’ Medicare reimbursement rates. Flipping government health care on its head, hospitals aren’t rewarded for treating the same patient over and over, but instead will be penalized for it. A provision of the ACA called the Hospital Readmission Reduction Program (HRRP) measures hospital readmission rates for Medicare patients, and fines hospitals whose Medicare patients return within 30 days up to 3% of their total Medicare reimbursements for the fiscal year, and CMS estimates that total fiscal year (FY) 2015 penalties will be $428 million. In San Diego, 11 hospitals incurred fines for fiscal year 2014, including Scripps Mercy, whose revamped patient post-care follow-up program isn’t enough sometimes to prevent readmission. Loved ones living in San Diego with caregivers and home care companions to help with medication, healthy meals and follow-up doctors’ appointments are poised to beat these odds.

After the enactment of the HRRP in 2012, hospitals across the country like Scripps Health began to create and implement specialized post-discharge support programs for high-risk patients that doctors, nurses, pharmacists and case managers collaborate on to reduce or hopefully eliminate a readmission within 30 days. The HRRP protocol currently measures readmissions only for heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and elective hip or knee replacement, and does not count a planned readmission such as a required follow-up surgery. While the large majority of hospitals have dramatically reduced readmissions since 2012, [http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/] the data reveals that certain kinds of hospitals are simply more likely to experience high levels of readmission. Major teaching hospitals and hospitals with a higher number of low-income Medicare beneficiaries are lagging behind the national average in reducing their readmission rates, and Scripps Mercy falls into both those categories.

According to a recent story in the San Diego Union-Tribune, Scripps Health’s post-discharge program for high-risk patients is thorough and pains-taking. First, “navigator” nurses visit the patient’s home within 48 hours of discharge to check on the medication regimen, and the follow-up appointment schedule. This nurse stays on the case for at least 30 days, checking in by phone. But some of Scripps Mercy’s patients are homeless, and don’t have a fixed address or a caregiver. For these patients, Scripps will actually rent a bed at a local shelter to avoid discharging anyone onto the streets. But the hospital can’t control whether or not the patient will stay in the shelter, and shelter staff isn’t equipped to take on the role of caregiver. One of Scripps’ doctors was quoted in the Union Tribune:

“If you take one of our typical patients who lives in Balboa Park, all bets are off. They have no home. They have no phone. They have no cupboard in their bathroom where they tidy up their pills. They probably don’t understand how to take their meds because they have a psychiatric diagnosis,” said Dr. Megan Hamreus, a director at Scripps Mercy in Hillcrest.

Scripps Mercy will pay the biggest fine of all San Diego county hospitals this year under the HRRP Medicare assessment, despite all the changes Scripps has made to its post-hospital care. There are more than 70 navigators on staff throughout the network who work with all patients at risk of readmission, and who are happy to coordinate with family caregivers and home care companions. San Diego can be proud of a hospital that goes to such lengths to care for all its patients.