Medicare penalizes hospitals that readmit too many patients within 30 days of discharge, and Christian expects to lose almost $600,000 in reimbursements this year, hospital officials said. Christian is one of 14 hospitals in the BJC HealthCare System.

Steven Lipstein, chief executive of BJC, which includes Barnes-Jewish hospital in St. Louis, said Medicare doesn’t play fair because its formula for setting penalties does not factor in patients with socioeconomic disadvantages — low-income, poor health habits and chronic illnesses for instance — that contribute to repeated hospitalizations.

Since the program began in 2012, “recent trends in readmissions suggest that (it) is having the desired impact,” reported in January.

Hospitals have lobbied Congress and Medicare to change the rules and gained some ground May 18 when Rep. Patrick Tiberi, R-Ohio, introduced a bill in the House to adjust Medicare’s program to account for socioeconomic status. The bill was co-sponsored by Rep. Jim McDermott,  D.-Wash.

Meanwhile, the Missouri Hospital Association is trying to pull public opinion behind it.

This year, the association overhauled its consumer website, , to include not only the federal readmissions data, but also each member’s readmissions statistics, adjusted for patients’ Medicaid status and neighborhood poverty rates.

The federal government already adjusts its readmissions data for age, past medical history and other diseases or conditions, and that’s public on Medicare’s website.

The association explains its adjustment methodology on the site. “There is emerging national research that suggest poverty and other community factors increase the likelihood a patient will have an unplanned admission to the hospital within 30 days of discharge,” it states.

The hospital group’s alternative data — Lipstein’s source for how Christian could have reduced its 2015 penalty — comes from a study it commissioned. One finding: Missouri hospitals’ readmissions rates improved by 43 to 88 percent when patients’ poverty levels were considered.

“The question is, has [readjustment] been done in a just and fair way,” Lipstein said. The Missouri Hospital Association “has provided methodology that suggests what the feds are doing is unfair.”

The controversy over penalties is likely to grow beyond the readmissions question. Federal health officials have announced that they want to paying doctors and hospitals based on the services they provide and move toward a value-based system that encourages a better quality of care and better outcomes while controlling costs.

Medicare bases penalties on readmissions on the care of Medicare patients who were originally hospitalized for one of these five conditions — heart attacks, heart failure, pneumonia, chronic lung problems and elective hip or knee replacements.

This year, Medicare penalized — 2,592 to be exact — for excessive readmissions. More than 500 were fined 1 percent of their Medicare payments, or more, for the fiscal year that will end Sept. 30.

Still, the system harms so-called safety-net hospitals most, said Herb Kuhn, the Missouri Hospital Association’s president.

“Hospitals in difficult neighborhoods are getting worse scores, and those in affluent [ones] are getting better. It’s time to adjust [rates] for the disease of poverty,” he said.

Kuhn’s experience makes him an influential voice on health policy issues. He was deputy administrator of the Centers for Medicare & Medicaid Services from 2006 to 2009 and before that, director of the agency’s Center for Medicare Management. In April, Kuhn completed a three-year term on the Medicare Payment Advisory Commission, which advises Congress.

The commission to Medicare’s readmission penalties last year. Others are also studying modifications.

The Centers for Medicare & Medicaid Services has taken a cautious stance, but last year CMS announced it is working with the National Quality Forum, a nonprofit group whose research influences CMS’s quality metrics, on a trial to test socioeconomic risk adjustment.

But Leah Binder, CEO of the Leapfrog Group, a nonprofit patient safety group, says Medicare’s readmission penalties have pushed hospitals to improve care and adjusting the data for patients’ poverty levels could deter them.

“Hospitals are paid a lot of money. I think they can find a way to handle their readmissions, the way they should have been handling them all along,” Binder said.

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Lack of access to care for those with substance abuse issues is a major problem, said 58 percent of those surveyed by the Kaiser Family Foundation. (KHN is an editorially independent program of the Foundation.)

The poll found that Americans had somewhat different views of heroin and prescription drug abuse. More than a third called heroin abuse an extremely serious health problem in the U.S., while just over a quarter of those surveyed said the same about the abuse of strong prescription painkillers. In contrast, fewer than a fifth regarded alcohol abuse in the same way.

The fight against opioid abuse has generated heavy news coverage in recent months, as well as government concerns. President Barack Obama recently proposed adding $1 billion to the federal budget for treatment programs. Yet more than 60 percent of respondents generally faulted federal efforts as too little. Similar shares were dissatisfied with state governments’ actions and those of doctors who prescribe painkillers, the Kaiser poll found.

But more than 70 percent believed drug users themselves aren’t doing enough.

Many Americans have personal experience with the drug abuse epidemic. More than four in 10 of those surveyed said they know someone who has been addicted to painkillers, and one in five said that person was a family member.

Asked about potential policy actions, more than eight in 10 called these steps very or somewhat effective:

• Increasing pain management training for medical students and doctors
• Increasing access to addiction treatment programs
• Increasing public awareness and education programs
• Increasing research about pain and pain management
• Monitoring the habits of doctors who prescribe prescription painkillers

The Kaiser survey also examined Americans’ views on issues involving access to mental health services. About one in five people surveyed said that they or someone in their family once needed mental health treatment but did not get it, for reasons that included affordability and insurance not covering it.

The poll also found that most people are unaware the federal government requires insurance plans to provide mental health benefits and substance abuse treatment under the same rules they apply to other medical services in terms of copays, deductibles and coverage limits. About four in 10 people surveyed knew that applied to health plans and three in 10 knew that for substance abuse treatments.

The poll was conducted April 12-19 among 1,201 adults. The margin of error is +/- 3 percentage points for questions asked of the full sample.

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The report released Thursday by the National Academies of Sciences, Engineering and Medicine was produced to aid Medicare officials studying how to fairly pay hospitals that disproportionately serve patients with social risk factors for health problems. Those factors include low income, social isolation, disadvantaged neighborhoods and limited health literacy. The report is the second of five commissioned for the Department of Health and Human Services.

Federal officials the plan to move Medicare from a system in which doctors and hospitals are paid based on the volume of services they provide. The goal is a value-based payment system to encourage a better quality of care, better health outcomes and control costs.

Some research has found that hospitals serving disadvantaged patients may be more likely to receive poor quality ratings and receive financial penalties, the report said. Yet, an analysis of actual penalties under one of the new quality efforts to reduce the number of Medicare beneficiaries who are readmitted to a hospital within 30 days reported that so-called “safety-net” hospitals drew only slightly higher penalties than non-safety net hospitals, according to the National Academies panel.

“The drivers of these disparities in both health care quality and health outcomes are poorly understood and differences in interpretation have led to divergent concerns about the potential effect of (value-based payment) on health equity,” the report said.

The National Academies panel said some common themes emerged from its review of 60 case studies and peer-reviewed research. One was what can be accomplished when doctors and hospitals partner with social service agencies, public health agencies, community organizations and the community itself, the panel said.

A health system in that context may prepare a comprehensive needs assessment, according to the report, but its vision will be different if the assessment is grounded by a commitment to health equity and includes social needs as well as clinical needs.

“This report does show that socially at-risk populations do not need to experience low-quality care and bad health outcomes,” the report said.

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Adverse childhood experiences before age 5 were linked with poor academic and behavioral performance in kindergarten, said researchers who examined a sample of about 1,000 urban children. was reported in the journal Pediatrics this month.

“Relative to children with no ACEs, children who experienced ACEs had increased odds of having below-average academic skills including poor literacy skills, as well as attention problems, social problems, and aggression, placing them at significant risk for poor school achievement, which is associated with poor health,” the authors said.

The adverse experiences included varieties of maltreatment — psychological, physical or sexual abuse or neglect — as well as household dysfunction — such as maternal depression, substance abuse, incarceration or violence toward the mother.

Forty-five percent of the children in the study had no adverse experiences, 27 percent had one, 16 percent had two and 12 percent had three or more.

The researchers from children’s hospitals in New Jersey and Philadelphia analyzed data from a national group of participants in the Fragile Families and Child Wellbeing Study, drawing on the study’s follow-up interviews with mothers five years after their child’s birth and data on teacher-reported school performance near the end of the child’s kindergarten year.

Teachers rated about a quarter of the children below-average for literacy and math skills. Children with more adverse experiences generally showed worse academic, literary and behavior outcomes, the study said.

, the study’s lead author and assistant professor of pediatrics, family medicine and community health at Rutgers Robert Wood Johnson Medical School, said that when he sees children having academic or behavioral difficulties, there are often deeper problems that originate at home. The analysis adds to a growing body of research that shows behaviors that start in early childhood can lead to dropping out of school, committing crimes and poor health in adulthood.

“This affects children’s ability to do well in school, the work world and the likelihood in ending up with trouble with the law or fitting into society. All those things come together and it’s a vicious cycle that repeats itself. And if we don’t intervene, then they evolve in less healthy ways and that repeats for the next generation,” said Debra Ness, president of the

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The 72-year-old Pennsylvania man, who had been a hairdresser with his own salon and volunteer firefighter in his younger days, was being treated for late-stage kidney failure. Three times a week for five years he had gone to a dialysis facility to have his blood cleansed of waste, a job his kidneys could no longer do. The sessions gave him cramps and tired him, but they kept him alive.

He could still sit up and walk a few steps. He wasn’t bedridden. That’s why Medicare cut off his rides.

In 2013, said that Medicare paid almost $700 million for ambulance service to and from dialysis facilities in 2011 — 13 percent of all Medicare ambulance spending — and the volume of claims for those transports rose 20 percent between 2007 and 2011.

So the Centers for Medicare & Medicaid Services, the part of HHS that oversees Medicare, announced it would for “repetitive, scheduled, non-emergency” ambulance transport in New Jersey, Pennsylvania and South Carolina. All three states showed evidence of high usage and improper payments. Up to 12 rides could be provided without prior approval, but authorization would be needed every 60 days.

This year, CMS expanded the test to the District of Columbia, Delaware, Maryland, North Carolina, Virginia and West Virginia.

The experiment is set to continue until Dec. 1, 2017, CMS said in a .

CMS will continue to test “whether prior authorization helps reduce expenditures while maintaining or improving quality of care,” according to the notice.

At some point, the prior authorization requirement could be expanded nationally. HHS was authorized to do that in and signed into law by President Obama in 2015.

CMS said last month it did not yet have any “conclusive findings” about the impact on beneficiaries. It plans to do an evaluation after the policy ends next year.

The restrictions have aggravated some families and ambulance companies.

In New Jersey, Terry Wasko said she’s been paying $500 a week to cover a private ambulance since December 2014 when Medicare stopped paying for her mother’s transportation to dialysis by stretcher three times a week. She lives two hours away from her mother’s home on the Jersey Shore.

“She’s in an in-between place where she can’t really cross the room because of the arthritis in her hips and knees, and as a result of sitting so much, she has pressure wounds on her behind and backs of legs,” Wasko said.

“What’s a shame is that it’s not the individual patients who were abusing anything, and they’re the ones that are getting punished. But shame on Medicare, because they allowed themselves to be abused by vendors,” she said.

Some ambulance operators say they feel caught between wanting to help sick people and obeying the rules that determine whether Medicare will pay them.

Monet Daniels, with Cardinal Ambulance in Montclair, New Jersey, said her firm has dropped many patients who no longer qualify for Medicare-paid nonemergency transport and has also reduced the fee for stretcher service to some people who pay out of pocket.

“We feel bad because they’ll still call from time to time, but basically there is a gap in the system. We have had patients call crying and say, ‘What am I going to do, just sit here and die?’ ” Daniels said.

Marsha Simon, a medical transportation consultant in Washington, D.C., suggested Medicare start paying for wheelchair vans to dialysis. The government would save money in the end by avoiding costly emergency room visits and subsequent hospitalizations, she said.

In fact, Medicaid, the federal-state health program for low-income people, pays for nonemergency wheelchair transport and it has been picking up some of the costs for those enrollees who qualify for both Medicaid and Medicare. In New Jersey last year, Medicaid paid for 400 more wheelchair van trips a day and 600 more trips a day to dialysis, according to LogistiCare, which manages transportation benefits for Medicaid in the state.

Still, suitable transportation options are few in some places. In the four counties that surround Columbia, South Carolina, the only alternatives to Medicare-paid dialysis transportation is to qualify for Medicaid or pay for the transportation out of pocket. There is scheduled bus service for disabled people, but the bus does not pick up at individual residences.

Twenty ambulance companies have closed in South Carolina since the new Medicare policy went into effect. To Greg Shore, president of Medshore Ambulance Service in Anderson, South Carolina, that’s a sign that the program is weeding out fraud. “I feel more comfortable with this program,” he said, because he knows before picking up patients if Medicare will pay him.

Josh Watts, CEO of MedTrust, an ambulance company in Charleston, South Carolina, said Medicare rejects a third of the prior authorizations that MedTrust submits and pulling together the authorization requests is time-consuming and difficult. The ambulance company has to rely on doctors’ offices to provide information it needs to seek those authorizations and that can take longer than Medicare allows.

“I’ll go out of business before I let someone die because they haven’t been to dialysis for two weeks.”

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They’re both factors, but the bigger culprit is almost two decades of stalled progress in fighting leading causes of death — such as heart disease, diabetes and respiratory disease — according to a Commonwealth Fund analysis of data from the federal Centers for Disease Control and Prevention. The fund studied actual and expected death rates, and causes of death, for working-age adults from 1968 through 2014.

Its analysis follows a much-discussed study circulated late last year that found death rates had been rising for non-Hispanic, white Americans between ages 45 and 54 since 1999, following several decades of decline. The two Princeton economists who authored — one was Angus Deaton, last year’s winner of the Nobel Memorial Prize in economic science — attributed the turnabout to rising rates of drug abuse, suicides and alcohol-related liver disease.

“White Americans are now facing a substantial ‘mortality gap’,” according to Commonwealth, which cited higher-than-expected death rates for white adults ages 45 to 54 in 2014.

Since 1968, death rates had fallen nearly 2 percent a year across most middle-age groups, races and ethnicities. Other high-income countries experienced similar trends, Commonwealth said.

But that shifted in 1999. From 1999 to 2014, death rates in the U.S. rose for non-Hispanic white adults between the ages of 22 and 56, peaking at about age 30 and age 50, the fund said.

Without a health crisis, mortality rates for those white Americans should have been falling, the authors said.

According to Commonwealth’s analysis, death rates for that group would have been expected to fall 1.8 percent annually, but instead mortality rates in 2014 resulted in more than 100 excess deaths for every 100,000 middle-aged white adults.

Commonwealth said the “death gap” was most pronounced in seven states: West Virginia, Mississippi, Oklahoma, Tennessee, Kentucky, Alabama and Arkansas. The difference between observed and expected rates was narrowest in New York, New Jersey, California, Connecticut, Minnesota, Massachusetts and Illinois, the study found.

Deaths from suicide and substance abuse explain about 40 percent of the “mortality gap,” while 60 percent is tied to death rates failing to drop as expected for nearly all of the top-ranked causes of death of middle-aged whites, Commonwealth said.

Commonwealth suggested the root causes might be tied to that population’s decline in social and economic status.

“For working-age whites — especially 45-to-54-year-olds — we are witnessing regression that has little precedent in the industrialized world over the past half century,” the report said.

For example, they have lower incomes, fewer are employed and fewer are married, it said. Research published last year found that the higher death rate for the group was concentrated among whites without four-year college degrees.

Commonwealth said its findings increase concerns about continuing lack of health insurance — some states with the highest mortality rates did not expand their Medicaid programs to low-income adults. But insurance expansion alone won’t close the mortality gap, it said.

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About 300,000 Hispanic children gained insurance in 2014 from 2013, dropping the number of uninsured to 1.7 million, researchers said. Their uninsured rate fell to 9.7 percent, almost 2 percentage points below the year before. The rate for all U.S. children fell to 6.0 percent from 7.1 percent.

The report released Friday was co-authored by the Georgetown University Health Policy Institute’s Center for Children and Families and the National Council of La Raza, a civil rights and advocacy group for Hispanic Americans.

One reason for the improvement, researchers said, is that the Affordable Care Act produced opportunities for Hispanic adults to get health coverage, such as providing premium subsidies for buying health insurance in federal and state marketplaces and expanding Medicaid programs in many states. When parents enrolled, they generally signed up their children, too.

States that extended Medicaid to low-income adults had an average 7 percent uninsured rate for Hispanic children, about half the average 13.7 percent uninsured rate of states that did not expand Medicaid.

Twenty states had rates of uninsured Hispanic children that were lower than the national average in 2014, the Georgetown-La Raza report said.

Still, Hispanic children made up 39.5 percent of the nation’s uninsured children in 2014, but only 24.4 percent of the overall child population under 18, according to the report.

Other findings:

– Of 10 states with the largest populations of Hispanic children, California, New York, Illinois and New Jersey were the only ones with uninsured rates below the 9.7 percent national average for 2014. New York’s was 3.8 percent; Illinois, 4.5 percent; California, 6.8 percent; and New Jersey, 7.0 percent.

– Four other states in that top 10 group had the highest rates of uninsured Hispanic children. Georgia and Texas were at 15.3 percent; Arizona, 12.7 percent; and Florida, 12.1 percent.

– Colorado and North Carolina, the other two states in the top 10, posted uninsured rates of 9.6 percent and 10.5 percent, respectively. Those were not statistically different from the national average, the report said.

– Two-thirds of the nation’s uninsured Hispanic children lived in Texas, California, Florida, Arizona and Georgia in 2014.

– In Texas, 15.3 percent of Hispanic children were uninsured in 2014, representing 30.6 percent of all uninsured Hispanic children in the U.S.

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The typical Medicare beneficiary who is 65 or older then will more likely be obese, disabled and suffering from chronic conditions such as heart disease and high blood pressure than those in 2010, according to by the University for Southern California’s Schaeffer Center of Health Policy and Economics.

Adjusted for inflation, overall Medicare spending is projected to more than double between 2010 and 2030 to about $1.2 trillion. A massive influx of baby boomers into Medicare will be the main driver. With the last baby boomers turning 65 in 2029, Medicare rolls are expected to number 67 million Americans in 2030, the Schaeffer Center said.

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The U.S. has scribes today and their numbers will reach by 2020, estimates ScribeAmerica, the largest competitor in the business. After buying three rivals this year, it employs 10,000 scribes working in 1,200 locations.

Regulation and training are not rigorous. Scribes are not licensed. About a third of them are certified and that’s voluntary, according to the sole professional body for scribes. was created by ScribeAmerica’s founders in 2010.

Others suggest that scribes can be a benefit to doctors and patients by shouldering the minutia of recording many of the details on a computer. “They’re capturing the story of a patient’s encounter — and afterward, doctors make sure everything is accurate. That way, the doctor can focus on interacting with the patient and give them good bedside manner,” said Angela Rose, a director at the American Health Information Management Association, a professional group that has published a set of best practices for scribes.

The minimum qualification to be a scribe is generally a high school diploma, but some pre-med students take the jobs to gain experience from shadowing doctors. One company, says it prefers candidates with at least two years of college and it only hires pre-med, nursing or EMT students. ScribeAmerica provides two weeks of training to new scribes while a large rival, PhysAssist, gives one week. That’s followed by close supervision in care settings for one week at ScribeAmerica and 72 hours at PhysAssist.

Vendors stress the potential benefits for doctors when they spend less time on record keeping. “Don’t let paperwork stand between you and your patients,” PhysAssist tells physicians “Imagine a doctor not being able to make correct diagnoses because documentation distractions caused her to miss a symptom.”

Another selling point involves money. ScribeAmerica says physicians using scribes can gain enough time to see five to eight more patients a day, boosting a primary care practice’s annual revenue by .

Not everyone is sold. Patrick Tempera, a gastroenterologist in Union City, N.J., said he uses scribes but does not allow them to come into the exam room with him because patients discuss sensitive health matters with him.

“Patients might not tell the doctor in full disclosure certain personal things if there’s someone else in the room,” he said.

Federal law limits some of the work that scribes can do. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the 2009 stimulus package and sent $32 billion to doctors, hospitals and other providers to spur them to move to electronic health records (EHRs), mandated that unlicensed workers, which includes scribes, not enter orders such as those for prescriptions and X-rays. However, sometimes scribes are allowed to enter pending orders, subject to a doctor’s review and approval.

A key hospital accreditation group also stresses those limitations. The Joint Commission, which accredits hospitals, said in that scribes can enter information such as family history, symptoms and doctors’ tentative diagnoses into EHRs. But it said scribes should not put in orders for prescriptions, X-rays or tests.

One concern is that scribes don’t have the background to make sure they put the right information in the orders.

Doctors are also responsible for reviewing scribes’ entries, making corrections if needed and signing off before leaving the patient care area, according to the guidelines.

But there is no enforcement mechanism to ensure adherence.

Some health care experts have raised concerns that sometimes scribes could be pressured to make the entries to save doctors time.

“We’re concerned that there will be a situation where inevitably these scribes are used to enter an order,” Gellert said.

Lap-Heng Keung, a scribe at MetroSouth Hospital in Blue Island, Ill., said he’s never been asked to enter orders and wouldn’t be comfortable doing so.

“We don’t have the same expertise as providers…there are so many drugs that sound the same but have one letter difference. It’s not within our scope of skill,” said Keung, who is studying information technology and taking pre-med courses at the Illinois Institute of Technology.

Even so, some scribes may face pressure to go beyond their training.

“Put yourself in the position of a 21-year-old pre-med student, here’s a doctor in the ER, you want a letter of recommendation so you can go to medical school — it’s a lot of pressure,” said Cameron Cushman, a vice president at PhysAssist. He said company officials work with scribes to help them know how to handle that situation. “We [say] …’you’re going to be starstruck by these doctors, but you have to play your role and if you don’t, there will be consequences.’”

Cushman says the company has been fired by clients 10 to 20 times — mostly by smaller emergency room providers and outpatient clinics — because it refuses to let scribes enter orders into electronic health records.

Surgeon Richard Armstrong of Newberry, Mich., said doctors are still coming to grips with the demands of electronic health records. Armstrong uses a transcriptionist to type his notes, but he enters all EHR information himself. A doctor for 34 years, Armstrong said he doesn’t use scribes because he’d have to check their work, and he’s more confident in his ability to do the job accurately.

“We’re forcing a technology into primetime onto physicians who don’t know how to handle it. And they’re using scribes because they need assistance,” Armstrong said.

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More than 56 percent of the public say they have a personal connection to the issue, reports the of the Kaiser Family Foundation. That share includes those who say they know someone who died from a painkiller overdose, have been addicted themselves or know someone who has and those who know someone who took painkillers not prescribed to them, the poll’s results show. (KHN is an editorially independent program of the Foundation.)

Details from the poll:

— 16 percent say they know someone who has died and 9 percent say that person was a close friend or family member.

— 27 percent say either they have been addicted to painkillers or they have known a family member or close friend who was.

— 63 percent of whites say they have a personal connection to the abuse of prescription painkillers compared with 44 percent of blacks and 37 percent of Hispanics.

Half of those surveyed rank prescription painkiller and heroin abuse as a top priority for their governor and legislature, behind improving public education and making health care more accessible and affordable, which drew 76 percent and 68 percent shares, respectively.

Sixty-two percent of those polled said the drug Naloxone, which can reverse an overdose and is handed out in some states without a prescription and for little or no cost, should only be available via prescription.

Efforts to reduce painkiller abuse would be at least somewhat effective, many Americans say. Providing treatment for addicts is cited by 85 percent, monitoring doctors’ prescribing habits by 82 percent and encouraging people to dispose of leftover medication by 69 percent.

Kaiser’s tracking poll was conducted Nov. 10 to 17 among 1,352 adults.The margin of error for the full sample is +/- 3 percentage points.

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