A component of the Affordable Care Act is forcing a philosophical shift on how health care and hospital stays are viewed, with Medicare reimbursement dollars as the incentive.
Facilities have to meet certain quality measures to capture those dollars. Quality measures are not new in health care, but the passage of the Affordable Care Act, also called Obamacare, has drawn more emphasis.
"What Obamacare did, from my perspective, is put more teeth in it," said Leslie Rittenmeyer, professor of nursing at Purdue University Calumet. "The penalties are higher. The penalties are in money, reimbursements."
Now that the act is in place, there is a pool of dollars at risk for facilities, said Matt Doyle, chief financial officer for Methodist Hospitals.
"The goal around the Affordable Care Act is to attempt to tie reimbursement to outcomes," he said. "That's certainly one of the centerpieces of the act itself."
Part of the Medicare reimbursement dollars are withheld until the hospital produces results.
"You either earn those dollars back, or you lose them," Doyle said. "There are dollars at risk. Hospitals, once they're aware of that, they start to put in as many measures as possible to get those dollars."
One of the metrics is hospital readmission numbers, which is a challenge for many region hospitals, Doyle said.
"Every facility is working on plans to improve that," he said.
Methodist, for example, started a transitional nurse program, in which nurses work with certain patients, namely those with chronic diseases, such as chronic heart failure, and are prone to readmission.
"We identify those patients, provide a lot of education for those patients while in house and work with Fagen Pharmacy to assist with medication reconciliation," Doyle said.
Nurses will make follow-up phone calls and home visits. They'll help with diet and medication.
"All of that is in an effort not to have them relapse and return to the hospital," he said. "What's occurring, it's a change of philosophy for hospitals."
Linda Delunas is associate dean in the College of Health and Human Services at Indiana University Northwest, associate professor in the School of Nursing and adjunct associate professor of medicine at the Indiana University School of Medicine-Northwest. From a dollars and cents perspective, she said, hospitals used to make a lot of money on issues like blood infections or pressure wounds, because of the price of care.
Now, they're not even being reimbursed.
Rittenmeyer said there is some controversy about the readmission indicator.
"Hospitals are pretty upset by this, because they think they're getting dinged, because patients are not compliant," she said.
The concern is that hospitals treating healthier and wealthier people may get bonuses because of patients following through, but hospitals that serve a sicker, poorer population will be penalized, she said.
Aside from readmissions, other indicators or quality measures include whether a foreign object is left inside a person after surgery, diabetes, surgical site infections and catheter-associated urinary infections. They're called "never" events, she said.
"If you have one of these 'never' events,' they're not going to pay," Rittenmeyer said.
The Medicare reimbursement is tied to pay-for-performance programs and value-based reimbursement. It applies to anyone who receives payment for Medicare, including doctors offices, she said.
No longer is it "enough" to treat a person for a condition, such as hypertension. Now, there needs to be follow-ups, said Pat Bankston, associate dean at Indiana University School of Medicine Northwest and dean of the College of Health and Human Services at Indiana University Northwest in Gary.
"The general notion is that, if you're being paid for something, you ought to produce," he said.