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How A Patient Who Asks For Salt For His Eggs Could Cost A Hospital $2.5 Million

This was a classic moment of comical clarity that only comes along once a week.  As you may or may not know, starting in 2013, The Medicare National Bank has promised to take back 1% of all  of a hospital’s total Medicare revenue (to increase in future years) if the hospital has a higher 30 day readmission rate for  congestive heart failure, acute myocardial infarction or pneumonia than an as yet undefined acceptable 30 day rate of readmission.

What does this mean?  It means if the government decides that 20% is an acceptable rate for congestive heart failure 30 day readmission, and the hospital has a readmission rate of 25%, the hospital will be told to return 1% of all Medicare revenue for the year, not just their heart failure revenue.

Let’s use some hypothetical numbers, shall we?  If a hospital generates $250 million dollars in a year on 25,000 Medicare discharge diagnosis related groups (DRGs)  but only 100 of those discharge DRGs (or $1,000,000) were heart failure in 2013, what would happen if 21 CHF patients returned for readmission  (a 21% thirty day readmission rate) within 30 days for heart failure instead of allowable 20%? The hospital would have to return 2.5 million dollars (1% of their total revenue on all Medicare admissions).
That one patient that took them from 20% to 21% will cost them 2.5 million dollars.  The hospital would generate one million dollars in CHF  revenue for the year and pay back 2.5 million dollars in penalty.  That’s a pretty hefty price to pay considering that hospital profit margins from Medicare have been negative, on average, for most of the last decade.

Perhaps the question that needs answering is how do we keep that 21st patient from returning to our hospital to ruin everything?  Is it going to be this patient that I actually saw once?

Happy:  You’re here with congestive heart.  You have too much fluid in your lungs and we need to help you pee a bunch to get it out.
92 Year Old Demented Guy eating his breakfast in the ED with his wife:  Can I get some salt for my eggs?

I couldn’t stop laughing at the irony here.  This demented old guy just wants to eat his eggs in peace, with a little salt, of course.  He’s ended the hospital stay as a full code, despite all compassionate attempts to guide the conversation toward reality.

Yet, if there are 21 of these 92 year old demented guys living in my community, who love to put salt on their breakfast eggs, and The Medicare National Bank only allows us to have twenty of them, each one of these congestive heart failure men and women are going to cost my hospital $125,000. They will never be able to stay out of the hospital.

So, what’s the solution?

  1. Place a local 10,000% community tax on salt.
  2. Pay the family thousands of dollars to put grandpa into a hospice program.
  3. Transfer all heart failure patients to other hospitals.
  4. Change the DRG to “Acute Hypoxemic Respiratory Failure” instead of CHF
  5. Implement a large community tax on the  elderly.  Call it the ex-lax tax.  Maybe we can get them to move somewhere else and make them some other hospital and community’s problem.

I think any one of these solutions will do.   Others?

*This blog post was originally published at The Happy Hospitalist*

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