Monday, June 15, 2009

Medicare Bundling

The federal government is concerned about the incidence of Medicare re-admissions.

Typical scenario: an elderly patient is admitted to the hospital for pneumonia and related distress. After a four day stay the patient is discharged to a long-term care facility.

A week later the patient is re-admitted with acute distress, after the nurse requests orders from the patient’s physician. After several days the patient is again discharged to the nursing home.

This cycle is very costly to Medicare, and the feds would like to see it slow down.

(Based on conversations with long-term care nurses and reviews of Minimum Data Set (MDS) summaries, the patients are usually very old, very frail, but not at death’s door quite yet.)

One solution is to ‘train” physicians and families not to be so quick to send the patient back to the hospital. This is tough on families, who often pressure the physician to readmit. Sometimes the patient demands readmission, it is easy for the physician to say yes. This can also be tough on the nursing home, where higher acuities are colliding with the nursing shortage.

A proposed solution is bundling. President Obama mentioned it in his 6/15 speech to the AMA. How does it work? The hospital gets a flat fee per incidence and then has to pay the physician, nursing home, ambulance/transport company, physical therapist, etc.

This requires a lot of administrative work and some intense negotiations, and puts the hospital at significant risk.

Could this work? Maybe. Is it good for Medicare? Probably yes. Good for patients? Unknown. Good for physicians? It depends. Good for the nursing home? Doubtful.

1 comment:

Hmmmmm said...

As someone who just went thru this very thing with an elderly Aunt,there are a number of reasons for the bouncebacks.

1. Hospitals are quick to discharge
2. Nursing homes are cesspools of infection
3. Nursing homes have no doctor or qualified madical personnel on-site eveings, nights or weekends.
4. Neither provider wants the death count on them. Sad to say.

Could be resolved by better care and staff at recovery centers and by seperating the long term care and staff from the recovery center. I would really advocate having the recovery centers next to hospitals to allow better access to qualified staff.

I also think that Medicare payment schedules cause problems. If the Dr. orders thirty days recovery and Medicare only pays for 21 there is a problem. Hospital visits in the middle reset the clock on the timetable.