Disadvantages to COPD reimbursement program

On Monday I published the post "Obamacare May Benefit COPD Patients." This was my response to an initiative in Obamacare that allows CMS to punish hospitals that have too many COPD readmissions.  It explains the benefits of this initiative on the patients.

I want my readers to know that this post was in no way an endorsement of Obamacare.  It was mainly an objective post to to show that this "initiative" is noble, and will benefit COPD patients.  The post was addressed to COPD patients on a COPD website, and therefore I felt it was not appropriate to address the advantages and disadvantages of this initiative on hospitals.

The truth is, that while the initiative was added into Obamacare because statistics showed that COPD readmissions are both unnecessary and costly, there was no market drive for hospitals to address this issue.  Now that hospitals are being forced to address it or risk a reduction in reimbursement, hospital administrations are scampering to solve this problem.

The problem here is that, while statistics show programs like this that already exist have been effective in reducing COPD readmissions, it might be impossible to meet this criteria.  I will provide here a variety of reasons:

1.  Most COPD patients that fit this category are at or near the end stages of their disease, are frail, and have co-morbidities, any one of which may result in a readmission. It is therefore impossible to prevent all, or even most, of them from being readmitted for one reason or another. In fact, as Stephen F. Jencks said in the April issue of AARC Times, "Two thirds of Medicare fee-for-service medical discharges are readmitted or dead within a year."  In other words, they are very sick, and it may be impossible to keep them out of a hospital regardless of the efforts and good intentions of healthcare providers.

2.  Staffing at hospitals will always be an issue, and this is because, while hospitals do view trends, it is impossible to accurately know when the census will be high or low.  For this reason, there will be times when a hospital simply doesn't have the staff to meet all the demands of the patient population.

3.  Along the same lines, respiratory therapists will be asked to take on more responsibilities when many are already dealing with high workloads and high levels of burnout and apathy.

4.  There is no reimbursement for the added procedures that will be necessary to fully commit to this initiative, and therefore hospitals will hit hard with the cost of applying, and the possible cost of a reimbursement penalty.

5.  Educating COPD patients is always a challenge.  Jencks explains that these patients have anxiety, are on medications that may impair their judgement, are often disorientated, and are simply sick.  They also may be confused or depressed, and this only exacerbates the problem.  Sometimes these patients say they understand what you are explaining, but they don't.

Bottom line:  Consider once more the following quote: "Two thirds of Medicare fee-for-service medical discharges are readmitted or dead within a year." The reason this statistic is true is not because they don't receive good care, it's because they are really sick people.

It only makes sense that efforts made on behalf of the healthcare profession will reduce COPD readmissions.  The questions that remains is: will these efforts be good enough to meet criteria set by the government?  It is my humble opinion that this system is set up to fail.

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New mandate may benefit COPD patients

This post was originally published at healthcentral.com/copd on 5/5/14

Obamacare may benefit COPD patients

The Patient Protection and Affordable Care Act, nicknamed Obamacare by some, might perhaps be the most controversial law of our generation. Despite this, it might prove to be a boon for patients with chronic obstructive pulmonary disease (COPD).

According to the Centers for Medicare and Medicaid Services (CMS):

“Section 3025 of the Affordable Care Act added section 1886 to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to hospitals with excess readmissions, effective for discharges beginning on October 1, 2012."

Readmission is defined as any patient who is readmitted to the hospital within 30 days of discharge from the same or another hospital. While the initial conditions applicable to this measure were heart attack, stroke, heart failure and pneumonia, COPD has since been added.

While hospitals may already be punished for excessive readmissions for these other diseases, hospitals may start being punished for excessive COPD readmissions beginning in October 2014.

So an effort is now ongoing by hospitals and hospital groups to create programs meant to benefit COPD patients.

Perhaps the driving force behind this movement are the following statistics, provided by the American Lung Association, the COPD Foundation and the Agency for Healthcare Research and Quality:

• COPD is now the third leading cause of death in America
• About 1 in 5 hospitalized individuals over 40 has a diagnosis of COPD
• 24 million adults have it
• About 715,000 patients were discharged from hospitals with a COPD diagnosis in 2010
• The disease cost the nation an estimated $49.9 billion in 2010
• Over 800,000 hospitalizations per year from COPD
• About 20% of hospitalized patients are readmitted within 30 days
• Up to 76% of readmissions occurring within 30 days are potentially avoidable
• Avoidable hospitalizations and re-hospitalizations are potentially painful, harmful, and always prolong recovery
• The average cost of an initial hospital admission with COPD is $7,100
• An average cost for a 30-day readmission with COPD is $8,400, which is 18% higher than for the initial admission

It’s understandable that COPD patients will have flare ups and will need to be admitted to a hospital from time to time. However, readmissions can often be prevented. So the crux of this movement is to prevent COPD readmissions.

So, should you ever find yourself admitted to a hospital with a diagnosis of COPD, what changes should you expect to see? Based on successful programs already created, here is what you might find.

1. More questions: Health care providers are going to ask you a plethora of questions to learn more about you and why you were admitted or readmitted. Questions may include: Do you understand your disease? Do you understand your medicine and why you need to take it exactly as prescribed? Do you know how to use your inhalers and nebulizer properly? Do you understand why you need to take your medicine? Do you understand how to prevent lung infections? Do you understand why it’s important that you quit smoking? Do you know how to recognize your COPD signs and symptoms? Did you wait too long to come in?

2. Better education: You will literally be the center of attention for health care providers, who will visit you often, not just to treat you, but educate you about your disease. You will learn basic lung anatomy, and how COPD affects your airway. You will learn about pulmonary function testing and how COPD is diagnosed. You will learn the stages of COPD and what one you are in. You learn that, while there is no cure, COPD can be controlled. You will learn about COPD medicine, how they work, and why it’s important to take them exactly as prescribed. You will learn the difference between maintenance and rescue medicine. By the time you are discharged you will know this disease inside out and upside down. By the time you go home you will feel confident and competent about how to effectively manage your disease.

3. Caregiver involvement: In many instances you will need help managing your disease. This person could be a spouse, parent, child, other relative or even a friend. If you have a caregiver, this person should be involved in the entire process. Every time there is a scheduled teaching opportunity, your caregiver will be strongly encouraged to be present.

4. COPD Action Plan: This is a plan that teaches you to recognize your COPD signs and symptoms, and what action to take. Ideally, you will learn to recognize when your breathing is just starting to flare up so that the action you take stops it. The idea here is to help you treat yourself at home so you do not need to seek help. However, should you need it, the plan will also help you decide when to call your doctor, and when to call 911.

5. Bronchial Hygiene: Since COPD is a condition that may result in increased and thick secretions blocking your air passages, you will need to learn methods of clearing these from your air passages.

6. Breathing techniques: There are certain breathing techniques that may help you to keep your lungs open. One technique commonly taught is pursed lip breathing, where, when you are having trouble breathing, you purse your lips and slowly exhale. You may also be taught some methods that should help you create a better cough.

7. Pulmonary rehabilitation: This is a program made just for COPD patients to help you keep in shape. It is a proven fact that if you keep your heart and lungs strong, you are more likely to stay healthy. Upon discharge, arrangements should be set up for you to participate in such a program, with transportation arranged.

8. Follow-up interview: This might include a visit to your home or a phone call by a caregiver. The purpose is to make sure you are feeling okay, but it is also to answer any questions that might have developed since your discharge. For instance, there have been instances where patients kept returning to the hospital with a COPD flare-up, and upon visiting the patient's home it was realized the nebulizer or oxygen equipment wasn’t working right. So, this is our opportunity to keep an eye on you, making sure you’re doing alright post-discharge.

9. Follow-up doctor visit: Not only will staff schedule you a follow-up appointment with your doctor in 2-10 days, they will make sure you have transportation. This is the type of thoroughness that is essential to helping you control your COPD.

10. Discharge instructions: Last, but not least, you will be discharged. In the past this may have been the only education you received during your visit, but no more. Now, by the time you are ready to go home, you will have already been presented with any wisdom you need to live with COPD, and had time to hash it over in your head and review it with your caregivers. Ideally, anything you hear at the time of discharge will simply be a summary of what you already know.

Bottom line: It’s surprising it took a government initiative to focus on preventing COPD readmissions, as studies clearly show they are both unnecessary and costly. Likewise, it’s impossible to know what methods individual hospitals will create; although, one might imagine that any efforts in this regard will help COPD patients live better lives.