In this year’s evaluation, CMS considered the COVID-19 pandemic and its impact on hospitals, excluding data for the first half of 2020 and Medicare patients readmitted with pneumonia, according to a report in Kaiser Health News.

Nationally, Medicare is penalizing 2,273 hospitals, the fewest since 2014, with an average payment reduction of 0.43%, Kaiser reported.

Hartford Health Care Photo.

CMS fined William Backus Hospital 1.42%.

In Connecticut, 69% of all hospitals in the program face fines, but most are under 1%.

Six hospitals saw significant drops in penalties, including Rockville Hospital, from 2.3% last year to 0.45% this year, and Bridgeport Hospital, from 2.15% to 0.7%.

The others are Bristol Hospital, from 1.34% to 0.28%; Manchester Memorial Hospital, from 1.8% to 0.74%; Middlesex Hospital, from 1.67% to 0.97%; and Waterbury Hospital, from 1.13% to 0.51%.

William Backus Hospital received the highest penalty this year among facilities in the state, at 1.42%, which is slightly lower than last year’s 1.56%.

“We are encouraged that many hospitals in our state showed improvement from last year or sustained past gains,” Alison Vail, RN, vice president of quality and patient safety, Connecticut Hospital Association, said in an email. “Through the Connecticut Hospital Association, hospitals are working collaboratively and transparently to improve the quality of care delivered at hospitals and to focus on patient care needs outside the hospital walls.

“This ongoing collaboration is having a positive effect on patient care,” Vail said. “These efforts to support patients through programs that address social and health care needs will improve patients’ quality of life and minimize the need for hospital readmissions. Hospitals and health systems are committed to continuous quality improvement and will continue working together to achieve even better outcomes for patients.”

Lisa Freeman

Lisa Freeman, executive director of the Connecticut Center for Patient Safety, said, “It is important to move the focus from the monetary consequence of readmissions to the causal reason for them. While I commend our hospitals for much of the good work that was done, COVID or not, readmissions can and should be greatly reduced with well-coordinated hospital care, discharge planning, and aftercare.

“COVID provided a stress test for our health care system, and that provided a window through which the weaknesses that showed up should be identified and addressed,” Freeman said. “As much as hospitals don’t want to be penalized, for many reasons, patients don’t want to be readmitted either. Effective communication among all members of the patient care team, including the patient and home caregiver, coupled with consideration of discharge readiness and medication reconciliation as well as the other related factors must always be addressed—COVID or not.

The hospitals losing less than 1% reimbursement are Charlotte Hungerford, .38%; Danbury, .23%; Day Kimball, .77%; Greenwich, .24%; Hartford, 0.71%; John Dempsey, .58%; Johnson Memorial, .27%; and Lawrence + Memorial, .18%.

Also losing less than 1% reimbursement are MidState Medical, 0.62%; Norwalk, 0.09%; St. Mary’s, 0.6%; Sharon, 0.11%; St. Francis, 0.33%; St. Vincent’s, 0.54%; Stamford, 0.04%; Hospital of Central Connecticut, 0.08%; Windham Memorial, 0.15%; and Yale New Haven, 0.41%.

Griffin Hospital in Derby, Masonicare Health Center in Wallingford, Hebrew Home and Hospital Inc. in West Hartford and Connecticut Hospice Inc., Branford, were not penalized.

Connecticut hospitals exempt from the program include Connecticut Children’s in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan and Albert J. Solnit Children’s Center in Middletown.

This is the 11^th year for CMS penalties, enacted under the Affordable Care Act.  The maximum penalty is 3%.  The penalties take effect as of Oct. 1.

The new reports cover state inspections that were completed in 2021 with approved hospital corrective action plans.

At William Backus Hospital, a pregnant woman suffering from drug abuse disorder delivered a baby who tested positive for fentanyl and buprenorphine.  During the time that the baby was under observation for neonatal abstinence syndrome (drug withdrawal), a parent holding the infant fell and reported “that the infant’s head may have touched the ground a little,” the report said. Following the incident, staff determined that the baby suffered a head injury and was transferred to a higher-level hospital. The state inspector said that the hospital “failed to develop a safe plan of care for the infant to prevent a fall with injury.”

The Hospital for Central Connecticut was cited for failing to identify that an infant was assessed when forceps were used in labor and delivery, which resulted in head injuries to the infant. During delivery, forceps were used unsuccessfully to rotate the baby’s head, so the baby was delivered by cesarean section, the report said. Hours after delivery, the infant was transferred to the neonatal intensive care unit and was later transferred to another hospital for neurosurgical evaluation.

In six instances, Hartford Hospital was cited for failing to follow surgical and invasive procedures which resulted in a wrong-site surgery and objects retained after surgery. In two of the cases, a lumpectomy was performed on the wrong area of a woman’s breast and in another a doctor failed to remove the entire gastric lap band during a removal procedure.

At Lawrence + Memorial Hospital, a nurse punched an unruly patient in the stomach and was later disciplined and suspended for a week, an inspection report said.

Hartford Hospital was also cited for not following a patient’s dysphagia diet of puree consistency. The patient was given a tuna sandwich and apple juice. The patient began to choke, a medical code was called, and the patient was revived using CPR, state records said.

MidState Medical Center was cited for not having a policy or guidance for use of a stabilization method after a photo was posted on social media, according to the state report. A child was treated in the hospital’s satellite emergency department for an injury, accompanied by a parent. The child was wrapped in a blanket on a stretcher, secured by gauze tied underneath the stretcher. The hospital was cited for not having a policy or procedure for this type of immobilization.

Several hospitals were cited for dust build-up in operating rooms and torn operating table pads.

Inspectors from DPH generally survey Connecticut hospitals in unannounced visits every two to four years. They tour facilities, observe staff in action and examine documents. Though hospitals are surveyed every several years, DPH usually inspects them more often in response to complaints and investigations, according to DPH.

Another physician was also disciplined by the board for failing to act on test results.

Dr. Syed Hadi and Dr. Waile Ramadan both treated a man who was brought to the Bristol Hospital Emergency Department on Jan. 7, 2019 with a high fever and other symptoms of a bacterial infection but never prescribed antibiotics, according to state Department of Public Health (DPH) investigators.

The man died of sepsis two days later, documents said. The case was the subject of a malpractice lawsuit filed against the physicians, Starling Physicians and Bristol Hospital which was settled in 2021.  DPH opened an investigation of the case after an inspection found violations at the hospital in 2019, documents said.

The physicians failed to meet the standard of care by not reviewing test results including a positive culture for bacteria, not communicating with other hospital staff and not properly diagnosing the patient, a consent order said.

Hadi and Ramadan both received a $5,000 fine from the board. Both physicians have completed coursework in infection control including the diagnosis and treatment of sepsis, communication with other health care providers and documentation standards, documents said.

The board also issued a fine and a permanent restriction on the prescription registration of Dr. Alfred Ranieri, of Medical Associates of New Haven, who prescribed controlled substances several times to two patients without properly determining or documenting the need, documents said.

Ranieri voluntarily gave up his controlled substance registration in July 2020, documents said. The DPH opened an investigation into the allegations in November 2019 after receiving a complaint from the state Department of Consumer Protection Drug Control Division, investigators said.

Under the terms of the discipline approved by the board, Ranieri must pay a $5,000 fine, his drug registration is permanently restricted from prescribing nearly all controlled substances and his Connecticut medical license is reprimanded.

The board also reprimanded the license of a Hartford Healthcare primary care physician who failed to treat a patient’s back pain and irregular urine analysis in 2018, DPH documents said.

Dr. Othman El-Alami treated the patient over the course of two decades but failed to maintain adequate records, failed to act on radiographic and urinalysis test results and failed to adequately treat the patient’s back pain, a DPH investigation found.

El-Alami’s medical license was reprimanded and placed on probation for six months while he completed coursework in proper clinical documentation as part of the discipline issued by the board.

Nationally, Medicare is reducing payments to 2,499 hospitals, about 47% of all facilities, with the average penalty being 0.64%, according to a report by Kaiser Health News (KHN).

Rockville General Hospital Photo.

Rockville General Hospital received the largest penalty from CMS for readmissions.

This year’s penalties were based on tracking patients from July 1, 2017 through Dec. 1, 2019, so the influx of patient care during the pandemic is not included, CMS said.

In Connecticut, 72 % of all hospitals in the program will face a loss in CMS payments, beginning October 2021 through September 2022.

No Connecticut hospital received the maximum penalty of 3%. But Rockville General Hospital will lose 2.3%, the highest penalty of any Connecticut facility; and Bridgeport Hospital will lose 2.15%.

Five hospitals will lose more than 1% of their funds, 19 others less than 1%.

“Connecticut’s hospitals share a strong commitment to the quality of care they provide and to patient safety.  Through the Connecticut Hospital Association, hospitals drive quality improvement through a shared commitment to best practice and clinical collaboration and we are always striving to do better,” said the CHA in a statement.

“Hospitals have been operating under tremendous strain in response to the COVID-19 pandemic while continuing to focus on quality improvement. We are encouraged that many hospitals showed improvement and we will maintain our focus on the quality of care delivered at hospitals across the state,” CHA said.

“This measure, and the results among Connecticut hospitals, demonstrate the need for a higher degree of coordinated care after hospitalization. This is a time when a discharged patient is particularly vulnerable to complications related to their recent hospitalization and when thorough, accurate, and understandable care instructions, new supplies, clarity and access to all medications and oversight of care are particularly important to their continued recovery.”

— Lisa Freeman, executive director

Connecticut Center for Patient Safety

Freeman said that while readmission measures have “the potential to slightly mislead patients because the readmission that is being counted can be for any reason, not only the reason for the initial hospitalization, it still addresses the wellness, or un-wellness of the patient at discharge.”

CHA has launched Unite Connecticut to improve hospital readmission rates.  Under the program, “hospitals now have direct referral and communication loops, through a shared digital platform, to refer and support patients in need of community-based social services to help stabilize their living conditions and optimize their health. “

This year, the program has served more than 3,600 patients through referrals to about 280 community-based organizations. “We expect these robust support channels will help patients to realize better health outcomes, by addressing the social drivers of health. Over time, taking down those social barriers supports a patient’s ability to fully follow a course of treatment or make a necessary lifestyle change, reducing the need for readmission and also improving the patient’s health outcomes,” the CHA said. There are 11 hospitals participating and CHA said five more are in the process of joining.

The hospitals receiving penalties of over 1% are: Manchester Memorial, 1.8%; Middlesex, 1.67%; William Backus, 1.56%; Bristol, 1.34%; and Waterbury, 1.13%.

The 19 hospitals losing less than 1% reimbursement are: Charlotte Hungerford, .38%; Danbury, .31%; Day Kimball, .27%; Greenwich, .53%; Griffin, .02%; Hartford, 0.57%; John Dempsey, .78%; Johnson Memorial, .67%; and Lawrence + Memorial, .08%;

Also, Mid-State Medical, 0.45%; Norwalk, 0.74%; St. Mary’s 0.62%; Sharon, 0.02%; St. Francis, 0.56%; St. Vincent’s, 0.41%; Stamford, 0.22%; Hospital of Central Connecticut, 0.64%; Windham Memorial, 0.08%; and Yale New Haven, 0.76%.

Only two facilities received no penalty: Masonicare Health Center in Wallingford and Hebrew Home and Hospital Inc. in West Hartford.

Eight Connecticut hospitals are exempt from the program. They are: Connecticut Children’s Medical Center in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan, the Connecticut Hospice Inc. in Branford, and Albert J. Solnit Children’s Center in Middletown.

This is the 10^th year for CMS penalties, enacted under the Affordable Care Act (ACA).

To review Kaiser Health News’ data on hospital penalties over several years go here.

Dr. Bryan Boffi, of Avon, a psychiatrist at the Hospital of Central Connecticut, was fined $5,000 and his license was reprimanded after he issued a patient a prescription for Ativan, a sedative, without consulting with the person’s regular mental health clinician, documents said.

Boffi cared for the patient while the person was admitted to HOCC’s psychiatric ward in May of 2016, but failed to talk to the person’s out-patient psychiatrist about the patient’s history or inpatient treatment strategy before prescribing the medication, a consent order said.

The state Department of Public Health (DPH) began investigating Boffi after receiving a complaint from the patient’s family, papers said. Boffi has since completed 150 hours of continuing education in the treatment of depression, addiction and the use of Benzodiazepines, such as Ativan, DPH officials said.

The board also agreed to discipline anesthesiologist Dr. Glen Rosenfeld, of West Hartford, with a $5,000 fine after he admitted that he had performed a nerve block on the wrong eye of a patient in October of 2016 and a nerve block on the wrong leg in a second patient in 2017.

He was working at Bristol Hospital as an anesthesiologist at the time and is still working there, according to state officials.

A New Haven woman has agreed to not practice medicine without a Connecticut medical license after she conducted three procedures to remove fluid from a patient who later suffered an infection, documents said.

Lillian Ruiz-Estrepo was listed as a “college graduated nurse in Columbia” in DPH papers. But she had no medical license while working for Pelle Dolce Aesthetics in June of 2019, according to the DPH.

Over a two-week period, Ruiz-Estrepo removed excess fluid with a syringe three separate times that had built up in the abdomen of a woman who recently had surgery, documents said. The woman wound up with an infection as a result of the procedures, documents said.

DPH was notified of the incident in July of 2019. Ruiz-Estrepo told DPH investigators that the woman was not scheduled to see a doctor for another week and she felt bad for the patient so she agreed to remove the fluid, documents said.

The board also agreed to reinstate the medical license of Dr. Sarita Mallya, of California, who is seeking to return to psychiatry after a four-year absence following two serious automobile accidents. She is returning to Connecticut to practice psychiatry at the Capitol Region Mental Health Center, she said.

Statewide, 26 of the 29 hospitals evaluated – 90 percent – will have their reimbursements reduced, by varying amounts, in the 2020 fiscal year that began Oct. 1, according to a Kaiser Health News analysis of data from CMS.

CMS began in the 2013 fiscal year to penalize hospitals that have high rates of patients who are readmitted within one month of being discharged. The penalties were enacted as part of the Affordable Care Act, intended to encourage better health care delivery. Nationwide, 2,583 hospitals will be penalized this year, according to Kaiser Health News.

CMS penalized Bridgeport Hospital 2.66 percent, the highest penalty among CT hospitals.

To help reduce the rate of readmissions, the Connecticut Hospital Association will be working with hospitals to partner with community-based organizations to address social determinants of health including housing, transportation, food insecurity and access to medical providers, said Mary Cooper, chief quality officer and senior vice president for clinical affairs at CHA.

“It’s not just about what happens at the hospital,” said Cooper.

In Connecticut, no hospital received the maximum penalty of a 3 percent reduction in reimbursements, but several will see payments reduced by more than 2 percent.

They are: Bridgeport Hospital with a 2.66 percent penalty, Waterbury Hospital at 2.44 percent, Manchester Memorial Hospital at 2.38 percent; and Bristol Hospital at 2.23 percent. Each of those hospitals were penalized in the 2019 fiscal year as well and, in each case, this year’s penalty is greater.

Medicare levied a 0.78 percent penalty on Yale New Haven Hospital and a 0.50 percent penalty on Hartford Hospital. Both penalties were lower than the previous year, St. Francis Hospital and Medical Center’s penalty was slightly higher at 0.39 percent.

Sharon Hospital has the lowest penalty, at 0.02 percent, followed by William W. Backus Hospital in Norwich and Windham Community Memorial Hospital & Hatch Hospital, which each will be penalized 0.03 percent.

Three hospitals in the state weren’t penalized at all: Stamford Hospital, Hebrew Home and Hospital Inc. in West Hartford, and Masonicare Health Center in Wallingford. Stamford Hospital and Hebrew Home and Hospital had no penalties last year as well.

Waterbury Rep-Am Photo.

Waterbury Hospital’s penalty is 2.44 percent.

Some hospitals are making strides in reducing readmissions, but doing so is a complex challenge, said Lisa Freeman, executive director of the Connecticut Center for Patient Safety. And more needs to be done, she added.

“Readmissions are a huge problem but, at the same time, it’s not a problem that falls solely on one entity’s shoulders,” said Freeman. “It’s a shared burden. The solution is a hard one.”

In launching the new hospital-community partnerships, Cooper said all Connecticut hospitals have committed to a new technology-based program that will make it easier for them to refer patients to community-based resources upon discharge, and then receive reports back from those resources about how patients fared, she said.

The program will begin rolling out – not merely within hospitals, but within communities – in three areas of the state this fall, and is expected to be implemented statewide by 2021, Cooper said.

Hospitals have an obligation to the communities they serve and should learn as much as they can about patients’ living conditions and social determinants if they aim to reduce readmissions long-term, Freeman said.

“I don’t think it’s fair to necessarily pick on particular hospitals,” she added. “We really, really have to all work together. [In some cases] we’re not going to get patients out of that cycle [of readmissions] unless we get them out of their environment.”

CMS’ reimbursement penalties alone aren’t significantly reducing the number of readmissions, Cooper noted, but a more community-based approach could.

“Given the number of hospitals that are penalized across the country, and given the lack of movement in the metrics of readmission, we have to look for other strategies,” she said, noting all hospitals want to reduce readmissions. “It’s on everybody’s radar. Everybody is working on it across the board.”

Register-Citizen Photo.

Sharon Hospital received the lowest penalty at 0.02 percent.

“The good thing of this whole program is that it’s caused folks in the industry to look at this whole issue differently. It’s caused them to be a little creative – for the most part, in good ways,” Freeman said. “I think the shift is occurring very, very slowly. We have to start looking at this as a human problem, not a dollar and cents problem, and not a numbers problem.”

Medicare exempts some hospitals from the penalty program, including children’s hospitals, psychiatric hospitals and veterans’ hospitals. Nationwide, 2,142 hospitals were exempt this year.

In Connecticut, exempted hospitals are: Connecticut Children’s Medical Center in Hartford, Connecticut Valley Hospital in Middletown, Natchaug Hospital in Mansfield, Connecticut Mental Health Center in New Haven, Southwest Connecticut Mental Health in Bridgeport, Silver Hill Hospital Inc. in New Canaan, the Connecticut Hospice Inc. in Branford, and Albert J. Solnit Children’s Center in Middletown.

View the hospital penalties provided by Kaiser Health News here.

Overall, the total number of “adverse events” reported by hospitals dropped from 431 in 2016 to 351 in 2017, a 19 percent decline, the Department of Public Health (DPH) said. But most of the decline was due to the elimination of two categories in 2017: serious injuries or death resulting from perforations during open, laparoscopic or endoscopic procedures; and those resulting from surgeries. Together those categories accounted for 72 adverse events in 2016.

Yale New Haven Hospital reported 62 adverse events, the highest number among acute-care facilities.

The reporting requirement for the two categories was eliminated after a work group of the Quality in Health Care Advisory Committee concluded that the vast majority of perforations that occur during some procedures aren’t preventable, and that serious injuries or death resulting from surgery are already better captured by other categories, the DPH report said.

There were 208 reports of Stage 3, Stage 4 and unstageable pressure ulcers in 2017, up from 186 the year prior. Falls increased from 74 to 84, patient death or injury associated with a burn rose from four to eight; and serious injury or death associated with intravascular air embolism rose from zero to two.

In 2017 several categories showed improvements: surgeries performed on the wrong site dropped from 18 to 10; the wrong surgical procedure performed on a patient fell from six to three; and the retention of a foreign object in the patient after surgery dropped from 20 to 17. Medication errors dropped from seven to four.

Connecticut hospitals began a series of “high reliability” initiatives six years ago, intended to focus more on patients’ perspectives and improve care and outcomes, and that work continues, said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association (CHA).

“We’re happy overall that we’re showing some progress in various areas,” she said.

Over the past year, Cooper said, high reliability efforts have focused on educating and training hospital workers in self-care to help them in turn better provide care to patients, and bedside efforts to get patients and family members more proactively involved in patients’ care.

But Lisa Freeman, executive director of the Connecticut Center for Patient Safety, sees little improvement. If you consider the two categories no longer included in the reporting, there were only eight fewer adverse events in 2017 than in 2016, Freeman said.

“That’s not a change. It’s just reflective of no improvement in my mind,” Freeman said.  “There are still far too many medical harm events. And these aren’t minor ones, these are ones resulting in death or substantial injuries. This is very discouraging, actually. We’ve got to look as to why we continue to have this level of harm.”

Ctpost.com Photo

Milford Hospital’s rate was 30.2, based on 100,000 in patient days.

Even as hospitals work to reduce adverse events, the events keep happening, Freeman said. “We’re doing some good things, [but] we need to look at why are they still failing to cut down on medical harm events.”

The number of sexual assaults reported, which had surged to 24 in 2016 compared to previous years, dropped to five in 2017 — due in part to a change made last January in guidelines for reporting sexual assaults that clarified what constitutes a “substantiated allegation,” according to the DPH report.

“These numbers [under the new definition] are more accurate,” Cooper said.

The most common adverse events in 2017 were Stage 3, Stage 4 or unstageable pressure ulcers, which accounted for 59 percent of all events. The pressure ulcer number has been on the rise since about five years ago when DPH added unstageable pressure ulcers to the tally, according to Cooper. The term “unstageable” includes skin that is at risk of breakdown, even before it reddens and becomes a Stage 1 pressure ulcer, she said. Various factors can affect patients’ risk for pressure ulcers, including whether they smoke or have diabetes, she said.

“We have seen the serious [pressure ulcers] really, really, really go down,” Cooper said. Identifying something as unstageable, she said, “allows us to take preventative measures before it starts to evolve into ulcerated skin.”

The majority of adverse events in 2017 (296, or 84 percent) occurred at acute-care or children’s hospitals. Slightly more than half of events (188, or 54 percent) occurred among patients aged 65 and older, the report said.

As expected, some of the state’s largest hospitals reported the highest number of total adverse events: Yale New Haven Hospital, 62; Bridgeport Hospital, 32; Hartford Hospital, 24, and St. Francis Hospital and Medical Center in Hartford and St. Vincent’s Medical Center in Bridgeport, 20 each. Stamford Hospital reported 18.

The hospitals with the highest rates of events based on inpatient days were Milford Hospital with 30.2 per 100,000 patient days; Bridgeport Hospital, 29.4; Stamford Hospital, 24.7; Norwalk Hospital, 22.5; St. Vincent’s, 23.9, and Bristol Hospital, 23.7.  Yale had 14.4 and Hartford reported 10.3.

Among the 28 acute-care hospitals, three reported zero adverse events in 2017: Day Kimball Healthcare in Putnam, Rockville General Hospital in Vernon, and Sharon Hospital in northwestern Connecticut.

High reliability efforts should help reduce adverse events, but more needs to be done, Freeman said.

“Nobody wants to see these numbers,” she said. “These are big problems and we really owe it to every patient and every person in Connecticut to have this at the very top of our concerns.”

Statewide, 27 of the 29 hospitals evaluated—or 93 percent—will be penalized in the 2019 fiscal year that began Oct. 1, according to a Kaiser Health News analysis of  CMS data.

Waterbury Rep-Am Photo.

Waterbury Hospital received the largest penalty, 2.19 percent.

The Medicare program has penalized hospitals since the 2013 fiscal year for having high rates of patients who are readmitted within a month of being discharged.  Nationally, hospitals will lose $566 million in penalties, which were instituted as part of the Affordable Care Act to encourage better health care delivery.

No hospital in the state received the maximum penalty of 3 percent, but nine will have their Medicare reimbursements reduced by 1 percent or more. They are: Waterbury Hospital at 2.19 percent, Bridgeport Hospital at 2.01, Bristol Hospital at 1.91, Manchester Memorial Hospital at 1.74, Johnson Memorial Hospital in Stafford Springs at 1.71, Midstate Medical Center in Meriden at 1.37, St. Vincent’s Medical Center in Bridgeport at 1.21, Griffin Hospital in Derby at 1.17 and Yale New Haven Hospital at 1.03.

Norwalk Hospital had the lowest penalty at 0.02 percent.

Two facilities, Hebrew Home and Hospital Inc. in West Hartford and Stamford Hospital, were evaluated and received no penalty. Last year, Stamford was penalized 0.2 percent and Hebrew Home and Hospital had no penalty.

Two acute care facilities, The Connecticut Hospice Inc. in Branford and Connecticut Children’s Medical Center in Hartford, aren’t evaluated under the program.

In the years since penalties were introduced, hospitals have taken various steps to reduce readmissions, said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association.

Hospital staffs throughout the state are more attentive now to social determinants that impact people’s health—things like housing, transportation, food insecurity and the ability to understand discharge instructions. Increasingly, hospitals are working with community groups to connect patients with resources they need once they leave the hospital, Cooper said.

“It certainly has had an impact on behavior in hospitals. It’s drawn the attention to what happens after the hospitalization, things that hospitals had said [previously] they were not in control of,” she said.

Still, Connecticut had a relatively high share of its hospitals penalized, compared with other states, data show. Just seven states had more than 93 percent of evaluated hospitals punished.

While fines have motivated hospitals to take more creative approaches to their work, more needs to be done, said Lisa Freeman, executive director of the Connecticut Center for Patient Safety.

“It’s bigger than just a hospital problem,” she said, alluding to the broader health care system. “We’re treating sickness, we’re not providing health. That’s the problem with not appreciating that a patient’s health and their well-being is dependent on so much more than medication.”

CMS penalized Bridgeport Hospital 2.01 percent.

Continued efforts to seek new approaches and re-examine how care is provided would help reduce readmissions, Freeman said.

The penalties imposed for the 2019 fiscal year reflect a major change in CMS’ methodology. For the first time, hospitals were placed into “peer groups” and their readmission rates were compared against facilities that serve similar proportions of low-income patients. CMS then examined readmission rates among the various peer groups from July 2014 through June 2017 to determine whether penalties were warranted.

Prior to the change, officials at some “safety net hospitals,” which treat a large share of Medicaid- or Medicare-eligible patients, argued that readmissions sometimes happen through no direct fault of the hospitals. Low-income patients are less likely to have a primary physician or seek follow-up care, for instance.

“Safety net hospitals are going to have greater challenges in terms of readmissions and other things,” Freeman said. “To penalize hospitals just because that is their primary customer is not reasonable. On the other hand, it is reasonable to expect that care can be provided at a better level so these people can lead healthier lives.”

She added, “Everybody’s entitled to receive the best care we can give. We have to keep trying to make it better.”

Addressing the myriad social factors that impact health is the biggest challenge facing hospitals, Cooper said, but the work they are doing with community-based organizations is a good start. Many hospitals are working with consultants to better understand and address social barriers to care, she added.

“It’s always a partnership among multiple groups,” she said. “Patients are having a voice and organizations are being respectful of that patient voice. The hospitals are asking to be partners with the patients. That’s a big change in culture. That’s really going to have a tremendous impact.”

You can view all the CMS hospital penalties here.

Twenty-two of Connecticut’s 30 hospitals charged these fees, bringing in $600.7 million in 2015 and another $488.8 million in 2016, according to an analysis by Conn. Health I-Team.

The state’s two largest hospital systems, Yale New Haven Health and Hartford HealthCare, accounted for almost half of the total facility fee revenue in 2016. Yale and its four hospitals billed $144.3 million; Hartford and its five hospitals, $80.9 million. Stamford Hospital charged $118.2 million, the most of a single hospital.

Photo Stamford Hospital

Stamford Hospital charged $295.9 million in facility fees over two years.

Patients have long complained about facility fees, which hospitals charge for outpatient services at facilities they own to cover operational expenses. Of the 1.4 million outpatient visits in 2016 facility fees were charged for everything from five-minute office visits to diagnostic tests such as MRIs and mammograms.

Connecticut, which had earned an F from health advocates for its lack of transparency in medical costs, passed a law in 2015 requiring hospitals to notify patients if they will be charged a facility fee. Hospitals must clearly identify facility fees in bills, notify patients if they acquire a physicians’ group and file an annual report with OCHA on how much they earn in fees.

Patient advocates say that the law has made consumers more aware of the fees, but it is often confusing for patients who get a second bill for hundreds or sometimes thousands of dollars for care.

The fees are paid by consumers, their private insurance, Medicaid or Medicare.

“It’s a trap for the unwary,” said Ted Doolittle, head of the state Office of Healthcare Advocate. “It’s still something that is happening.”

Doolittle says his staff is currently working a few cases where patients were charged large facility fees, including a woman who received outpatient surgical care and expected to pay a $50 co-pay and was hit with a $930 facility fee.

West Hartford resident Leslie Silverman said she took her 15-year-old daughter to their doctor’s office to get blood drawn for a tendon in her ankle that wouldn’t heal in 2014. The doctor’s office had difficulty drawing blood and sent her to the West Hartford Surgical Center, which is owned by Hartford Hospital.

“We had no idea we were going to get walloped with a $1,200 facility fee, it cost four times as much as we thought,” said Silverman, who added that because it was part of an experimental procedure not covered by insurance, they paid the fee out-of-pocket.

“Our doctor wasn’t trying to mislead us; it just wasn’t on anybody’s radar,” she said. “We went there because our doctor said we have to do this and then we see the bill and we go, ‘Whoa.’”

Hospitals say facility fees are necessary to upgrade infrastructure costs. “Generally, when a facility becomes part of a hospital, the technology, including software and hardware, must be of a certain standard,” said Michele Sharp of the Connecticut Hospital Association. “Additionally, these facilities must have emergency stand-by capacity and meet more stringent regulatory requirements. As a result, the infrastructure costs associated with hospital-owned facilities are greater than the costs of a standalone office.”

Patient advocates say the public filings are a step in the right direction, but there’s a long way to go.

“As a consumer representative, it’s flabbergasting,” said Lisa Freeman, executive director of Connecticut Center for Patient Safety. “We’re paying more and more and we can’t figure out how much it will be ahead of time.”

What The Filings Reveal

In 2016, Connecticut hospitals charged facility fees at 184 off-campus facilities, the reports show. Some of the most frequent types of care that patients were charged facility fees for include radiation treatment, echocardiograms, sleep disorder testing, colonoscopies and mammograms.

Ellen Andrews, executive director of the Connecticut Health Policy Project, says the fact that mammograms are among the most frequent service for which facility fees are charged is “stunningly stupid.”

“A mammogram is preventive care,” she said. “Every time you institute another hassle and you make it harder to go to the same place you’ve always gone, you are going to get some people who just don’t go through the trouble. So, if it’s a problem for people getting preventive care, that’s really penny wise and pound foolish.”

The fees that caused the most outrage a few years ago were facility fees charged at doctor’s offices owned by hospitals. According to a 2014 report by Attorney General George Jepsen, facility fees became more common as hospitals acquired physicians’ practices. Patients complained about showing up to the same doctor they’ve seen for years, expecting to pay the same co-pay as always, but were later hit with a big facility fee.

Some of those fees are now banned in Connecticut, however.

Effective Jan. 1, 2017, hospitals cannot charge existing patients facility fees for a routine doctor’s visit that is billed as Evaluation and Management, which was part of the 2015 health bill spearheaded by state Senate President Pro Tem Martin Looney, D-New Haven, and Senate Republican President Pro Tem Len Fasano, R-North Haven.

Yale New Haven Hospital charged $103.1 million in facility fees in 2016.

Some hospitals will feel the impact of this change. In 2016, Yale New Haven earned $9.9 million for five-minute outpatient visits—its highest facility fee charged—which is now banned.

Congress also tightened regulations on facility fees in its 2015 budget by limiting what hospitals can charge at facilities acquired after Jan. 1, 2017.

There are signs that hospitals got the message, too. A spokesman for Hartford HealthCare said that as they’ve grown they’ve tried to employ physicians at outpatient facilities through the Hartford HealthCare Medical Group rather than through one of their hospitals so their patients won’t be hit with extra fees.

“This helps us limit facility fees for patients,” said Hartford HealthCare spokesman Shawn Mawhiney. “We do our best to limit the financial impact on our patients. In order to provide the latest technology and the best care possible, we need to have a sustainable business model. In some cases, that means charging facility fees.”

Hospitals That Don’t Charge

Eight hospitals did not charge facility fees for outpatient services in 2015 or 2016, either because they did not have outpatient facilities or because they chose not to. They include, Bristol Hospital, Day Kimball Healthcare, Gaylord Hospital, Griffin Hospital, Hebrew Hospital, Natchaug Hospital, Sharon Hospital and Silver Hill Hospital.

Bristol Hospital did not charge fees in 2015 or 2016 but started charging them last year for certain services provided by its Bristol Multi-Specialty Group because they needed the money.

“We made a conscious decision going back years based on patient dissatisfaction and just our philosophy that we were going to not have patients get these fees,” said Bristol Hospital President and CEO Kurt Barwis. “When we made that decision, we were solely reacting to our community.”

“I’m not sure that it was the right choice,” Barwis added.

The decision to charge facility fees was made last summer after, Barwis said, an increase in the hospital tax caused them to end the 2016-17 fiscal year with a $3 million loss. The hospital’s tax bill increased significantly over the last few years according to state estimates. In fiscal year 2012, Bristol Hospital paid $2.94 million for the hospital tax, which increased to $7.6 million in fiscal year 2016.

Barwis said, “The initial reaction was very strong, we had quite a few patients say, ‘All of a sudden, I have to pay this additional fee?’ and obviously some of it is covered and some of it’s not covered based on the insurance carrier that they have.”

“If they are on a high deductible plan, it’s pretty significant for them,” he said.

You can listen to WNPR’s report on this story here.

The hospitals are among 751 nationwide that will lose 1 percent of their Medicare reimbursements in this fiscal year. The penalties are part of the Centers for Medicare and Medicaid Services’ (CMS) Hospital-Acquired Condition Reduction Program, which is part of the Affordable Care Act.

UConn John Dempsey Hospital has been penalized by Medicare all four years.

The program penalizes hospitals with the highest rates of patients who got infections from hysterectomies, colon surgeries, urinary tract catheters and central line tubes. It also tallies those who suffered from blood clots, bed sores or falls while hospitalized.

The 15 Connecticut hospitals penalized mark a slight uptick from the 14 that were penalized in the 2017 fiscal year, according to the data reported by Kaiser Health News.

“Any safety issue or hospital-acquired condition is one too many,” said Dr. Mary Cooper, chief quality officer and senior vice president for clinical affairs at the Connecticut Hospital Association. “Connecticut hospitals have always been dedicated to providing excellent quality care to patients. While we are making progress, we recognize that there is still work to be done, and are committed to continuously improving safety, quality of care and patient satisfaction.”

All hospitals in the state have adopted “high reliability” standards intended to reduce instances of preventable patient harm, which Cooper said “is changing the way healthcare is delivered and is saving lives every day.”

Of the 15 Connecticut hospitals that received penalties for 2018, six have been penalized in all four years since the program launched, according to CMS data. They are Bridgeport Hospital, Connecticut Hospice Inc. in Branford, Hartford Hospital, UConn John Dempsey Hospital in Farmington, Windham Community Memorial Hospital and Yale New Haven Hospital.

Five facilities on this year’s list also were penalized last year: Charlotte Hungerford Hospital in Torrington, Day Kimball Hospital in Putnam, Johnson Memorial Hospital in Stafford Springs, Masonicare Health Center in Wallingford, and St. Mary’s Hospital in Waterbury.

Others on the list for penalties in 2018 were MidState Medical Center in Meriden, Norwalk Hospital Association, Rockville General Hospital in Vernon and Waterbury Hospital.

While many hospitals are making progress when it comes to patient safety, more needs to be done, said Lisa Freeman, executive director of the Connecticut Center for Patient Safety.

Yale New Haven Hospital is among the 15 hospitals penalized.

“We’re not making any major strides,” she said. “There are certain hospitals that get penalized every year and there are certain hospitals that are not penalized ever. Unfortunately, money is a tremendous motivator for change. My hope is the hospitals that are being rated [in rankings like the CMS one] will use them as information to improve things.”

Cooper noted that by law the program must impose penalties on the lowest-performing 25 percent of hospitals ever year, “so even when hospitals are improving, one-quarter of all hospitals will still be subject to payment reductions.”

There are seven Connecticut hospitals that have never been penalized under the program. They are: Bristol Hospital,  Griffin Hospital in Derby, The Hospital at Hebrew Senior Care in West Hartford, Milford Hospital,  Sharon Hospital,  St. Vincent’s Medical Center in Bridgeport and William Backus Hospital in Norwich.

The CMS program is controversial and some hospitals have claimed in the past that it unfairly puts certain hospitals at a disadvantage if they treat certain populations or are “teaching hospitals.”

But, Freeman said, “Patient safety is patient safety. It shouldn’t matter what kind of hospital you are at.”

She hopes hospitals that have made improvements will share their successes and strategies with other hospitals.

“There is so much to learn from each other, and it can be done,” she said.