Letters to the Editor is a periodic KHN feature. We welcome all comments and will publish a selection. We will edit for space, and we require full names.
Our coverage of Medicare's penalties for hospitals that fail to meet targets for reducing readmission rates draw a lot of reader attention. So did recent stories about drug coupons and about a new Arkansas initiative to reduce Medicaid spending while adding a new level of transparency to the state's health care payment system. Here's a sampling:
The following was a response to Medicare Revises Hospitals' Readmissions Penalties (Rau, 10/2):
Jacqueline Voss, RN, Henry Ford Macomb Hospital in Macomb, Mich.
I feel the hospitals are at the mercy of the system the government and [insurers] have created. Yes, some readmissions are unnecessary but when the insurance companies dictate how long a patient can stay, when the patient is non-compliant, or the patient can't afford their medications and can't take them correctly the hospitals will be penalized. They need to look into these cases individually. Another suggestion is for the hospitals to band together and all claim bankruptcy.
Readers also commented on an earlier story: Medicare To Penalize 2,211 Hospitals For Excess Readmission (Rau, 8/13).
Allen Round, Porterville, Calif.
At what point does the patient have some responsibility for their own care and for their own actions? How can fault be determined as to whether a patient is following [his or her] doctor's advice which is designed to keep him out of the hospital? Can a hospital refuse admittance to a person in a diabetic coma, for example, when the patient was just released from the hospital after being treated for the same problem two weeks earlier but went home and didn't follow the diet a diabetic must follow?
Paul E. Hacker, Paul E. Hacker Insurance Agency, Gardiner, N.Y.
This kind of baseball-bat tactic has to be implemented. For too long, hospitals have marked up their fees with no real basis except to make more revenue. PPOs and insurance carriers allowed this to happen. Today, hospitals give greater discounts and preferred contracting … to the largest player on the block. … When PPO network development folks come to the hospital reimbursement table to secure discounts, hospitals typically will turn around and say "I cannot give you what I have contract- and discount-wise with [the others] because you [fewer members]." … We all are retooling in this economy. … Hospitals should be no different. The entire public would benefit greatly if hospitals ran their business by taking the "business" word out of the equation and replacing it with "treating patients."
The story, Eyes Turn To Arkansas' Bold Effort To Cut Medicaid Costs, Add Transparency (Kulkarni, 10/1), also triggered readers' reactions.
Brian Eisenberg, Eisenberg Consulting Inc., Martinez, Calif.
This program reads like another government approach to zero-summing total health care expenditures. It penalizes the groups operating below expectations, and benefits those performing better than expectations. … If the Medicaid program really wanted to reduce expenditures then it should simply penalize those groups that operate below expectations. There should be no direct financial reward issued for providing quality care. That should be the basic requirement. If anything, the reward should be that those who provide quality care at the proper cost factor should see an increase in the volume of beneficiaries utilizing their services. … If a facility is continuing to provide poor quality care at a high cost, why continue to finance their operation by allowing beneficiaries to utilize their services? That seems to be an inherent danger to the beneficiary, and sends the wrong signal to the provider community.
Brenda Kaye, Palm Desert, Calif.
I believe that many doctors take advantage of programs that become unlimited in services. Too many tests that are not necessary are given, and the doctors should be more aware of cost factors … and stop giving patients unnecessary meds. I work in a hospital and I am proud to say our doctors keep abreast of what's going on. But I also believe that all doctors should take brush- up courses and be more aware of drug interaction. Accountability is the key word.
Marj Oines, Petersburg, Alaska
This seems to be very similar to the diagnosis-related groups that were established in the 1970s under Medicare. We nurses had to document how much time it took for us to do every task. Then all the info was gathered, an average length of hospital stay was determined for each condition. As a result, if a patient did not fit the average they were often discharged too early, they suffered, and had to return to the hospital. Doctors were forced to come up with some other diagnosis so the patient could remain in the hospital to get the care they needed. That was not and is not good for the patient. The same process is highly likely to inflict more suffering for patients. What kind of flexible process will you put in so doctors can treat as the patient needs? I'll watch this with great interest. Put the patient first.
Another reader offered the following comment in response to Drug Coupons: A Good Deal For The Patient, But Not The Insurer (Schultz, 10/1).
Lee Jarm, Boston, Mass.
On the subject of moral hazard: how is it not a moral hazard for insurance companies to broker contracts with manufacturers for a certain price based upon prescribing market share targets? There are complaints about coupons, but the assumption in this type of contracting is that no matter what the chemical entity, it will work the same for all patients. That simply isn't true. Are formularies even ethical? Why should a patient be stuck with a higher tier copay (excluding the difference between brand and generic -- which is more understandable) if it turns out that that patient responds better to a third-tier branded drug versus a second-tier branded drug? It isn't the patient's fault, but they get penalized.