June 15, 2012 | By | Posted in General News

PA: More than $520M in Medicare, Medicaid fees went to potentially avoidable hospital stays

Report: 1 in 8 hospital stays could've been prevented
By Melissa Daniels | PA Independent
HARRISBURG — Of the nearly 185,000 Pennsylvanians who underwent hospital stays that could have been prevented in 2010, taxpayer-supported programs paid for about 83,000 of them.

Medicare and Medicaid payments totaling about $521 million could have been avoided with better outpatient care, according to a new report titled “Potentially Preventable Hospitalizations in Pennsylvania.”
The report was released by the Pennsylvania Health Care Cost Containment Council, or PHC4, earlier this month. PHC4 is an independent state agency created in 1986 that supplies information on health-care costs to employers and employees, created after the urging of business and public-sector labor groups.
Some say new models of primary care could reduce these hospital stays.
Medicare payments of $480 million covered “potentially preventable hospitalizations,” such as bacterial pneumonia, asthma and heart failure. The average cost per stay was $6,209 for 77,386 patients, or around 41 percent of all stays examined in the report.
An additional $41 million in Medicaid payments went toward similar stays, according to the report, with an average cost of $6,527 per 6,320 hospital stays.
Payment figures from private insurance companies making up the difference were not available to the council in drafting the report.
Overall, the report says one in eight hospital stays in 2010 fell into categories that could have been prevented. But, Gary Tuma, director of communications for PHC4, said not all of the hospital stays tallied in the report could have been prevented.
The goal of the report, he said, was to identify weaknesses to see what the health-care industry could do to address unnecessary stays as a whole.
“This report shows when you look at the potentially preventable hospitalizations, that somewhere in the process there was a breakdown in primary care, and that breakdown can occur at all sorts of points,” Tume said.
The report also showed a higher rate of potentially preventable hospitalizations in Pennsylvania compared with the rest of the United States, with an average of 195.6 per 10,000 residents compared with 182.5.
Molly Talley, director of resident and student initiatives for the Pennsylvania Academy for Family Physicians, a health-care advocacy and policy group, said the report reflects a larger problem in the health-care system as a whole.
Better coordination of medication records and lab results, along with team physician approaches as opposed to traditional offices, could provide better primary care before conditions become severe enough for hospitalization, she said.
Those developments could be useful specifically for the state’s elderly on Medicare, who may be seeing a number of specialists who aren’t coordinating with each other.
“Older people are much more sensitive to medications, so properly managing their medicines is important,” Talley said. “In this particular study, it might be culmination of a bunch of different things that didn’t have to happen that way for this person.”
Some in the state’s health-care industry are looking at new options at the primary care physician level that could reduce the rate of unnecessary hospitalizations.
On Wednesday, regional insurance provider Capital BlueCross announced a new partnership with multi-campus health-care provider PinnacleHealth Systems.
The partnership, called an "Accountable Care Arrangement,” would be the first of its kind in Pennsylvania.
The model increases coordination among providers with electronic medical records, along with nursing resources provided by Capital.
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