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Top 12 Uncertainties Hovering Over Healthcare

Cheryl Clark, for HealthLeaders Media, November 21, 2011

Hospital executives, however, fear two other ramifications from the readmissions penalty. One is that their emergency departments will be the subject of greater scrutiny from auditors to assure patients who need to be readmitted within 30 days are not put into observation categories or sent home simply to avoid a penalty. The second concern is how they will react to negative publicity if their hospital shows up as one with higher rates of avoidable 30-day readmissions on the federal website, HospitalCompare.

 5. More Civil and Criminal Penalties
The Department of Justice is gearing up in an unprecedented way to punish and curtail fraud, waste, and abuse, which means imposing much more scrutiny on providers.

Armed with more new legal tools, hundreds more investigators, task force operations in more cities, and $350 million more to spend over the next 10 years, HHS is poised to broaden its pursuit of healthcare crooks, holding those it catches as a example of this enhanced national priority.

Concurrent with this, look to the Office of Inspector General to be more involved in quality issues, perhaps stemming from the agency's November, 2010 report that found that of nearly one million Medicare beneficiaries discharged from hospitals in just one month – October of 2008 – one in seven experienced an adverse event and nearly half of those were preventable medical errors, substandard care and inadequate patient monitoring and assessment.

Senators Tom Coburn and Tom Carper have been pushing their bill, called the FAST Act, (Fighting Fraud and Abuse to Save Taxpayer Dollars) which if passed, would strengthen and add new ammunition to fight fraud. For example, FAST would increase penalties, curb theft of physician identities that gives way to abuse, and establish more strategies to prevent the federal government from paying for suspected fraudulent claims when it has so much difficulty recovering the money later.

6.  More Aggressive Health Plan Premium Rate Review

In 2011, the federal government gave away $100 million to help states develop expertise and oversight over health plan premium increases. And while some states are moving forward with such programs, even creating special new agencies, others have held back. HHS Secretary Kathleen Sebelius says her agency is "committed to fighting unreasonable premium increases," such as the 39% requested by Anthem Blue Cross of California last year for 800,000 customers.

The ACA, her agency says, requires health insurers that want to increase their rates by 10% or more in the individual and small group markets as of Sept. 1, 2011 "to submit their request to experts to determine whether the rates are unreasonable."

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6 comments on "Top 12 Uncertainties Hovering Over Healthcare"


Janice (11/30/2011 at 1:52 PM)
I agree with Lanay - having coded and reviewed thousands of records in my career, patient non-compliance is a major reason especially for CHF readmissions. Patients are adequately trained during the admission but it is too easy to slip back into old habits when they go home. What makes non-compliance easy is that many of the CHF patients may be on low incomes, and eating appropriately, which is a major player in CHF, may be next to impossible. Patient non-compliance should be excluded from the readmissions for CHF (there is a ICD-9-CM code for it).

Kandi O'Brien (11/29/2011 at 10:59 PM)
It is great to see that the government wants to [INVALID] measures to prevent harm. However, the affects of some of these measures excludes a lot of common situations. Ex: 30 day rule. Most of these PTA have multiple chronic issues and they have totally separate issues that land them in the hospital. The entire visit /week stay shouldn't be denied when there was no wrong doing in relation to the initial treatment. There also should be more regulation on insurance companies. They are making money every year while everyone else faces cuts. Increases for our tax rates have to be approved, maybe the increase for premiums should have a similar plan. Having worked on both sides I am confident that there is a middle ground, however, the wrong people aren't usually at the table to make those decisions.

Lanay (11/29/2011 at 5:48 PM)
In addition to that which is listed regarding readmission for selected illnesses they need to consider patient non-compliance with treatment that directly leads to the readmission.