Hospitals' Fear of 30-Day Penalties May Speed Hospice Admissions

Cheryl Clark, for HealthLeaders Media , June 6, 2013

The issue, he says is new 30-day mortality measures federal payers have woven into the healthcare reform law's value-based purchasing algorithm for incentive payments starting October 1. Hospitals with higher numbers of pneumonia, heart failure, or heart attack patients who die within 30 days of discharge during the performance period (the latest one ended June 30, 2012) will fare poorly in their overall VBP score.

That's because the weight of those three measures affects 25% of 1.25% of the hospital's Medicare base DRG payments.

But written into the rule is a key exception that Kupfer says has not gone unnoticed by clinicians and the hospitals that employ them:

If patients are designated for hospice care during their first 24 hours of their hospital stay, and then die within 30 days of discharge, they aren't counted against the hospital's score.

Is Kupfer saying that physicians will be a little quicker to enter high-risk, older patients with multiple health issues into hospice, resulting in them not getting care that could benefit them and extend their lives?

"Right," he replies. "I'm concerned that hospitals will exert pressure to move patients into hospice, even if they're appropriate patients for hospice, but will do it within the first 24 hours. Even if it puts them at odds with families," who need more time to make that important and emotional decision.

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5 comments on "Hospitals' Fear of 30-Day Penalties May Speed Hospice Admissions"

James Sinclair, M.D. (6/27/2013 at 4:10 PM)
Excellent point and counter-point. CMS will soon be making public outcomes data regarding our own patient's 30 day mortality rate from agressive intervention such as last chemotherapy given. If peer review could put pressure on us to see our failure in appropriate hospice referral then I agree we wouldn't need payer oversight.

Michael D. Fratkin,MD (6/14/2013 at 9:08 AM)
If the effect of the ridiculous 24 hour timeframe is that hospitals dig deeper to resource and staff Palliative Care programs, I can live with the social engineering of the federal guidelines. It seems more likely, at least in my neck of the woods, that already strapped community hospitals will just try to lean on their underfunded, understaffed, and under-resourced Palliative Care "Teams" (I am a "team" of one) to impossibly improve this metric. The desired outcome is to accelerate the conversations that define patient and family desires and values to occur prior to the initiation of any treatment admission. The culture change required to give time and space for this discussion at the moment of admission is vast. It's not going to be successful putting a Palliative Medicine provider into every hospital admission process. Rather, it will be nessecary for the incentives to favor the TIME it takes to have these conversations at admission by the admitting physician/provider. The pace, pressure, workloads, lean staffing, rising documentation requirements, and the quantification of 'quality medical care' all work to speed the admission process up and pull the provider from the central human dilemma of our patients understanding the reality of their circumstances and choosing their own path. The solution awaits us at the bedside if our systems can accommodate another 15-30 minutes to meet these people on their own terms rather than in terms of their role as data in an industrial medical machine.

T R Patterson (6/12/2013 at 4:18 PM)
As an HPM doc who practiced so far 35 years, I feel there is merit in the claim that incentives will be followed by actions. Anyone who doesn't see this has not watched medicine evolve. BUT, the real question, I feel, is WHY are doctors not asking questions that raise end of life care and getting answers long before the terminal hospitalization. A large percentage of elderly patients, and those with life limiting diseases are KNOWN to be at risk well before. We as doctors have allowed (encouraged?) the myth that we can fix anything and extend life for over two generations! Are we surprised now when no one wants to ration care or allow death to be a natural part of life? We must get directives before the crisis develops- it is too hard in a crunch for most patients and families to suddenly confront death when they have been misled for so long that it won't happen.




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