" No mo' money ". WSJ 5-26-99, TA
interactive.wsj.com
May 26, 1999
'Medical Gridlock' Afflicts Hospitals
Looking to Place Some Elderly Patients
By LAURIE MCGINLEY
Staff Reporter of THE WALL STREET JOURNAL
Hospitals across the country are scrambling to find places for elderly
patients who still have complex medical problems but no longer need
hospital care.
The problem: Because of recent Medicare cuts, a growing number of
skilled-nursing facilities are denying admission to high-cost patients,
especially those who depend on ventilators or need intravenous drug
therapy, kidney dialysis or tracheotomy care.
The trend shows how squeezing one part of the health-care sector can
have an unintended impact on another. After intense efforts within the
health-care system to shorten hospital stays, some older patients are
staying longer -- sometimes weeks or even months longer -- because
hospitals can't find nursing centers to take them.
"In some cases, it's medical gridlock," says Charles Smith, president and
chief executive officer of Christiana Care, which owns two hospitals and
other health-care facilities in Delaware.
Administrators of nursing facilities, which are reimbursed by Medicare for
as many as 100 days of care after a patient's hospital stay, contend they
have little choice but to become more selective in their admissions.
Reduced federal reimbursements, which began going into effect last
summer, don't cover the costs of care for patients with complicated needs,
they argue.
Karrie Decker of the Seattle-based Sisters of Providence Health System,
which operates 19 hospitals and several nursing homes, says a Medicare
patient was recently transferred to a Providence nursing home for a
six-day stay. The nursing facility bought a $3,750 prosthetic device for the
patient, whose leg had been amputated below the knee. Its Medicare
payment for the device plus the patient's care: $1,830.
In another case, in New Jersey, an elderly woman taking expensive drugs
for respiratory therapy, renal failure and bed sores was ready for discharge
from a hospital, but was denied admission by two nursing facilities on the
same day. The hang-up was that her drug costs alone exceeded the total
Medicare reimbursement for her care, according to NeighborCare, a
Baltimore company that estimates the drug costs of prospective residents
for nursing homes.
In LaCrosse, Wis., Tom Rand, administrator of the Bethany St. Joseph
Care Center, a nonprofit nursing home, says he reluctantly decided late last
year to close his ventilator-care unit to new patients. The reason: His new
Medicare payment rate for ventilator-dependent patients was $170 a day,
despite the fact that his costs typically run two to three times that amount.
"At that rate," he says, "it doesn't take very long to go bankrupt."
Tough Decision
For nearby Gunderson Lutheran Medical Center, which has worked
closely with Mr. Rand for several years, his decision was a blow. "Our
primary job has been to move patients out of the hospital," says Brian
Theiler, who oversees the discharge-planning process. "But a lot of our
possibilities for placement are being eliminated." The hospital now
discharges its ventilator-dependent patients to a nursing facility 100 miles
away in Chippewa Falls.
In the meantime, the hospital's costs are rising, as discharges of some
patients take longer to arrange. With Medicare patients staying in the
hospital longer, the institution expects its costs to rise by $1 million this
year, says Mr. Theiler.
Christiana Care's Dr. Smith says he's having similar problems. His two
hospitals used to have 25 to 30 Medicare patients waiting to be
transferred to nursing homes at any one time; the average wait was a day
or two. Now, he says, he has 80 patients waiting for placements that could
take days or weeks to finalize. Complicating matters, he says, is the
shutdown of several home-health-care agencies, whose Medicare
reimbursements also have been curbed. "We cannot send patients home
who can't fend for themselves," he says.
The slowdown in discharges frustrates hospital officials who have steadily
reduced patient stays in response to Medicare changes in the early 1980s.
Between 1993 and 1996, Medicare stays declined from an average of 8.1
to 6.6 days, according to the most recent data available from the American
Hospital Association. Now the AHA, which represents 5,000 hospitals,
expects the number to start going back up.
Despite that, there's little dispute among health and budget analysts that
something had to be done to reform government payments to
skilled-nursing facilities. Before the enactment of the 1997 Balanced
Budget Act, Medicare reimbursed nursing centers based on their costs,
thus giving them a strong incentive to provide unnecessary care to patients
to bolster their payments. Moreover, in some parts of the country, there
are many more nursing-home beds than are needed.
In a major reimbursement overhaul, the budget law directed the Health
Care Financing Administration, which runs Medicare, the federal
health-insurance system for the elderly, to pay nursing facilities on a
lump-sum per diem basis. Under the new plan, patients are placed in one
of 44 categories for reimbursement purposes. The method, called the
prospective-payment system, began to go into effect in July. Many
institutions weren't affected until January.
Now, a fierce battle has erupted over the size and scope of the cutbacks.
Officials of the nursing-home industry say that the balanced-budget law cut
more deeply than expected. And, they say, the HCFA has exacerbated
the problem by drastically underpaying for such expensive ancillary
services as respiratory therapy, wound care, prescription drugs and
artificial limbs. Groups ranging from the National Subacute Care
Association to the Catholic Health Association are pressing Congress and
the agency to immediately increase payments for high-cost patients.
'Provisions for Others'
"We're not saying throw out the whole system," says John Sauer, a
spokesman for Wisconsin's nonprofit nursing homes. "But you should have
provisions for outliers -- for the people who have $450-a-day drug bills or
who have to be fed intravenously."
Robert Berenson, director of the HCFA's Center for Health Plans and
Providers, says, "We want all Medicare beneficiaries to have access to the
quality care they deserve." Moreover, he says, skilled-nursing facilities
already are being paid more to care for patients requiring more-complex
care. In addition, many economists note that hospitals made similar
complaints when their reimbursement system was changed, but eventually
adjusted.
But Dr. Berenson adds that the agency is open to raising the payment rates
if data suggest the amounts are too low in certain situations. "We're
expediting research to be able to adjust payment rates appropriately if the
evidence shows that is needed," he says.
Meanwhile, the financial strains have led to increased friction -- and tough
negotiating -- between hospitals and nursing facilities. In Everett, Wash.,
Providence General Medical Center, which is part of the Sisters of
Providence chain, recently wanted to discharge a Medicare patient with a
bone infection to a local nursing facility. But the facility, which wasn't
affiliated with Providence, balked because the man was taking an
expensive antibiotic.
The hospital, after caring for the man for an extra three days, finally paved
the way for his transfer by agreeing to buy the antibiotic for the nursing
facility, says Steve Brennan, a Providence spokesman. Under Medicare
rules, hospitals don't get extra money from the government if a patient
stays longer than is medically necessary.
The trend is creating a soaring business for NeighborCare, the company
that sells nursing centers cost estimates of a prospective patient's drugs. It
is a unit of Genesis Health Ventures, Kennett Square, Pa.
NeighborCare officials say they're also seeing a rising number of Medicare
patients being denied admission by nursing centers. The officials know
when a patient is being rejected because his or her profile keeps being
submitted to NeighborCare by different nursing facilities.
TA you ( <g> ) said: ANSHU, thanx for the reply. My point simply is that it doesn't matter anymore in
healthcare what you are selling. it could be gold or platinum. The fact is that there
is no more "public money" ( read: "tax dollars), to buy it and pay for it.
PFE chart looking uglier by the day. Now @ 108, broke though 200 day moving
average.
Next stop 92+/- ?. I note in your CV that you are interested in palm reading. What
do the palm say today? Maybe we should look at BigK and Peabody's palms.
Where are you Big K when we need you?
askresearch.com
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12&rsi=8&macd=8-17-9&roc=16-8&mfi=13
All in a day's work,
TA |
