Probe: Hospital readmissions take toll in Pennsylvania
By Andrew Conte and Luis Fábregas,
Published: Sunday, March 6, 2011,
Pennsylvania hospitals charged more than $1.25 billion in 2009 to treat patients who were readmitted for complications or infections that might have been avoided, a Tribune-Review investigation has found.
University of Pittsburgh Medical Center's Presbyterian and Shadyside hospitals led the state with a combined 806 readmissions and charges totaling more than $67 million, according to the Trib's analysis of the latest data from the Pennsylvania Health Care Cost Containment Council.
With higher average billing rates, several Philadelphia area hospitals were among the state's highest in charges.
The more than 24,000 patients statewide caught in the revolving door of hospital visits pay an unknown cost physically and emotionally. Charlotte Velemirovich, 69, of Pittsburgh's Westwood neighborhood was discharged Dec. 1 from Allegheny General Hospital after hip replacement surgery, but wound up back at the hospital barely a month later because of an infection she got during her initial hospitalization.
"This ruined me for going in and having this done," she said.
Hospitals nationwide have a financial incentive for readmitting patients rather than keeping them healthy and at home.
"Every time you come to the hospital, I make money," said Dr. Thomas McClure, chief accountable care officer at West Penn Allegheny Health System.
McClure said America's health care system "is driven by sick care. It should be driven by wellness."
The $1.25 billion Pennsylvania hospitals charged for readmissions in 2009 would buy a flu shot for every American 60 and older.
Nationwide, readmissions create waste in the $2.5 trillion Americans spend on health care each year, hospital administrators, doctors and health care researchers said. Rife with redundant testing, growing infrastructure and competing interests, the industry wastes about 40 percent of the medical dollars it receives, burdening strained government budgets and taking money from Americans' paychecks, they said.
Some readmissions are unavoidable, yet even when solutions to stop readmissions are developed that can be as simple as spending more time educating patients before discharge, hospitals lose money by fixing the problem. The average charge for every congestive heart failure patient readmitted to UPMC Presbyterian-Shadyside was $81,349, the data show. Multiplied by 70 cases, the charges in 2009 totaled more than $5.69 million.
"For me, it's out the door," said Tami Minnier, chief quality officer at the University of Pittsburgh Medical Center, which started three pilot programs to cut readmissions. "Hopefully, it keeps a patient loyal to us and they're happy with us that they know we've got their back. But, yeah, it doesn't save me a dime."
Real cost unknown
Pennsylvania hospitals reported 24,197 readmissions in 2009 for people who came back within 30 days because of a complication or infection, according to the Trib analysis of state cost containment council data that included a custom report on readmission charges prepared exclusively for the newspaper. The council tracked readmissions and related charges for 158 hospitals statewide, but did not include children's or specialty hospitals.
The true cost of readmissions remains a secret even to the public officials charged with monitoring waste. Most Pennsylvania hospitals are nonprofit, yet they are not required to say how much money they receive for treatments. Insurers do not have to say how much they spend either.
Temple University Hospital's 381 readmissions were the 11th highest among the state's hospitals in 2009, but the Philadelphia hospital had the second-highest total charges at nearly $60 million. Sandra Gomberg, president and CEO of Temple University Hospital, explained that charges can be an indicator of fluctuating costs, "like a buoy floating on the ocean surface." But she said they are not related to the actual amount hospitals are paid. Confidentiality clauses with insurers preclude hospital administrators from saying how much they receive in payment, she said.
"Charges are not utilized to burden any patient who can't pay," Gomberg said, noting that Temple serves a substantial number of indigent patients.
The state cost council rejected the Trib's Right-To-Know Law request for actual payment information, saying state statute prohibits releasing that proprietary information. However, the council estimates Pennsylvania hospitals received about 26 cents for every dollar charged in 2009. That means readmissions for complications or infections that year cost about $327 million.
The newspaper's analysis of the council data found:
• Nine of 20 hospitals with the most readmissions are in Western Pennsylvania, including six in Allegheny County and one each in Blair, Cambria and Westmoreland counties. The council counts UPMC Presbyterian and UPMC Shadyside as one hospital for reporting purposes, and their actual readmissions were 114 more than the state agency expected, based on factors that include the types of cases each hospital handles.
• Among the 20 hospitals with the highest total charges for readmissions, every one except UPMC Presbyterian-Shadyside and the North Side's Allegheny General Hospital was from Southeastern Pennsylvania. Sixteen were from Philadelphia and its suburbs.
• Patients with congestive heart failure accounted for the most readmissions (3,144) and the highest charges (more than $174 million) among the 29 conditions the council tracks. Infectious pneumonia and chronic obstructive pulmonary disease also topped the list.
• Readmission charges varied widely for every procedure, often costing 10 times more at one hospital than at another. Hahnemann University Hospital in Philadelphia had an average readmission charge of $556,804 for each of 13 cases of chronic obstructive pulmonary disease, compared to an average of $4,583 for each of three cases at Titusville Area Hospital in Crawford County.
Readmissions cost more than money. Patients can pay for readmissions with their good health, and sometimes their lives.
Former Steelers defensive end Dwight White died in June 2008 because of a blood clot in his lung, a complication his family blames on a previous back surgery in a lawsuit winding its way through Allegheny County Common Pleas Court. Lawyers for the University of Pittsburgh Medical Center, the hospital, doctors and others named as defendants have denied the allegations, court records state.
Alan Krug, 44, of St. Mary's in Elk County, went to a hospital for back surgery in February 2008 and was readmitted days later because his rectum was torn during the procedure, court records show. Months later, when he returned to the hospital for a colostomy reversal, he bled to death, a lawsuit contends.
Velemirovich said the infection pain in her right leg that led to her readmission to Allegheny General was so intense, it felt like someone was trying to cut it off. She spent more than a month in rehabilitation at Kindred Hospital and uses a walker to get around. She was told the cost of her readmission was more than $80,000. She received a letter dated Jan. 26 from the hospital confirming she got the infection there.
"Where is this money coming from?" said Velemirovich, who has supplemental Medicare insurance. "I'm not being charged, but it's got to be coming out of somewhere."
Change on way
Cutting readmissions costs hospitals money, but that will change in 2012 under the federal health care law. Under the rules, Medicare and Medicaid no longer will pay hospitals more when patients with many common conditions come back for treatments. Instead of hospitals making money from readmissions, they will assume the costs of treating people who return.
That shift got administrators' attention, and many institutions are making plans to address the problem. Dr. Steven Shapiro, UPMC's chief medical and scientific officer, said the Pittsburgh area's health care giant started three pilot programs to cut readmissions, and administrators hope to make them widespread by the time the rules change.
"We're getting really good cooperation across the board because, in the future, the government isn't going to pay us for these readmissions anymore," Shapiro said. "We'd better get a handle on it now, so everyone is motivated to do that."
Even without changes to the federal law, hospitals need to reduce waste to survive, said Dr. Christopher Olivia, CEO of West Penn Allegheny Health System. Health insurance has become too expensive, and government programs are going broke.
"Ultimately, all health systems will have to embrace the fact that they're going to have to lower their cost structures and provide care differently, and not just play the game of 'let's do more volume, let's do more procedures and let's charge more for them,' " he said. "All of this is unsustainable."
Quotes regarding readmissions
'Ultimately, all health systems will have to embrace the fact that they're going to have to lower their cost structures and provide care differently, and not just play the game of 'let's do more volume, let's do more procedures and let's charge more for them.' All of this is unsustainable.'
Dr. Christopher Olivia
CEO of West Penn Allegheny Health System
America's health care system 'is driven by sick care. It should be driven by wellness.'
Dr. Thomas McClure
Chief accountable officer at West Penn Allegheny Health System
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