Medicare Readmissions and You

In October, a little more than 2,500 hospitals are going to start getting paid less per patient by Medicare as a result of one part of Medicare reform set up by the Affordable Care Act. This part penalizes hospitals when patients are readmitted within 30 days of discharge, without regard for the readmission diagnosis or factors such as the patient’s failure to follow discharge instructions.

It sounds bizarre, and although I see the intent behind it, I think nurses need to brace for impact. This penalty will apply if a man is admitted for a fall, goes home, and is back in 3 weeks with a congestive heart failure exacerbation. It will apply if an obese diabetic woman admitted for chronic obstructive pulmonary disease is readmitted after continuing to smoke and not take her prescriptions.

It applies across the board, yes or no, black or white. Facilities can do only so much to prevent readmissions. Too many factors are outside anyone’s control but the patient’s, and unfortunately patients all too often do nothing to help themselves. Facilities cannot force them to follow their discharge instructions, and they certainly cannot foresee and prevent unrelated illnesses or accidents that result in another hospital admission.

Also, the reduced reimbursements beginning in October will occur for all Medicare patients at the facility—not just the ones who are readmitted. In other words, the government is using historical data to establish reimbursement percentages. The ball started rolling a long time ago, but now facilities will actually see less money.

Implications for nurses are many and profound.

The most obvious implication is the stark reality that there will be less money. The less money there is, the more nurses will be laid off, the more short cuts will be taken, the more experienced staff will leave, and the more pressure there will be to do more with less. Inevitably, patient care will suffer, as it has been shown to do when these things happen. When patient care suffers, then patients will be readmitted more often.

Nurses will be laid off. We are the first to go when budget cuts occur, despite both common sense and evidence that inadequate staffing is disastrous to patient outcomes. Nurses working in facilities where layoffs are occurring will feel constantly stressed and fearful about losing their jobs, and their performance and job satisfaction will decrease. Next, their productivity will decrease, and burnout will increase.

More experienced nurses will leave such an environment for a better one, leaving only nurses who for whatever reason cannot work elsewhere. The remaining staff will be largely inexperienced and dissatisfied. Again, patient care will suffer.

In this spiral, facilities receiving less reimbursement will squeeze nurses to produce more with fewer staff, and nurses will have to take short cuts. They will miss developing pressure ulcers, pneumonia, and fluid overload. Patients will die, and those who are discharged will be more likely to return because the care they received the first time will have been subpar. Also, nurses will not have time to provide sufficient discharge education and care planning—clearly necessary to prevent readmission.

I hope I’m wrong, but it is difficult to paint a different outcome. I hope that the government quickly realizes that this part of the Affordable Care Act is a bad idea for everyone and revises their plans for reducing Medicare spending. For more background, read this post from Kaiser Health News.

About Megen Duffy

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Megen Duffy, RN, BA, BSN, CEN, is a practicing nurse, blogger, and contributing editor for the American Journal of Nursing. Megen has practiced in a variety of settings from emergency rooms to prisons.