Health plans in ideal position to identify readmission risks


The Patient Protection and Affordable Care Act specifically calls for and funds a "hospital readmissions reduction program" designed to help hospitals smooth the transition

NATIONAL REPORTS-Unplanned and preventable hospital readmissions are a major cost driver of healthcare costs. So much so that the Patient Protection and Affordable Care Act specifically calls for and funds a "hospital readmissions reduction program" designed to help hospitals smooth the transition for patients following their discharge and to reward hospitals that are able to reduce avoidable readmissions.

In the Medicare program alone, the Center for Medicare and Medicaid Services (CMS) Office of the Actuary expects these efforts to reduce costs by $8.2 billion through 2019. Some estimates put the rate of unplanned readmissions as high as 20% among Medicare fee-for-service patients.

Clearly, reducing the rate of unplanned readmissions even slightly can help commercial health plans to reduce their costs.

By contrast, health plans have information from claims data, risk adjustment analysis and predictive modeling to identify patients at high risk of hospitalization in general and readmission in particular. Using this data, Sommers suggests that health plans can act as an intermediary between hospitals, primary care physicians and specialists to facilitate communication at the time of discharge.


Independence Blue Cross (IBC), based in Pennsylvania, has implemented several programs to reduce unplanned readmissions with some success. IBC's programs are designed to address a major issue that can lead to unplanned readmissions-fragmentation in care and communication.

"We have the ability to capture a larger portion of the spectrum of care providers," including acute care, primary care and pharmacy, says Victor Caraballo, senior medical director at IBC. "As a health plan, have we the ability to provide the bigger picture and have more comprehensive data."

To leverage that data, IBC has implemented a case management initiative to contact patients who are in the hospital to make sure the patient understands the discharge instructions before they leave. Once at home, these patients are contacted by a healthcare coach.

"Patients are readmitted for a variety of reasons but medication-related issues are a key concern," says Caraballo.

Given the concerns about medication post-discharge, it is not surprising that IBC has focused on that aspect in its three major work groups designed to reduce readmissions. These work groups focus on medication reconciliation upon discharge, the discharge process, and creating better personal healthcare records so that patients better understand what happened to them in the inpatient setting. For example, the discharge-process work group found that simple things like making follow up appointments and providing simple instructions can help patients to understand why they were admitted to the hospital in the first place and how they can prevent it from happening again.

After about 18 months, the hospitals participating and reporting data in the project reduced their 30-day same-hospital readmission rates by 7%, from 12.2% to 11.4%. In dollar terms, this reduction represents more than $3.8 million in savings on unnecessary healthcare spending and allowed 400 patients to avoid being readmitted.

Sommers sees this type of approach growing among health plans and notes several other roles health plans can play to reduce readmissions. Health plans often have to approve a hospitalization or are notified when their members are in the hospital.

"Plans can use this information to design notification procedures to let the primary care physician know when a patient will be discharged," she says.

For example, she notes that some health plans contact patients three days after discharge to see how the patient is doing and whether the patient has scheduled their follow-up appointments.

"Plans may also need to consider how they can adjust reimbursements and provide appropriate incentives to lower those unplanned remissions," says Warren Skea, a director in the health enterprise growth practice at PricewaterhouseCoopers in Dallas.

For example, some structural changes might include changing reimbursement to reward physicians for timely follow-up after discharge and giving these patients priority or same-day scheduling. As plans allow billing for electronic visits via e-mail or telephone, these visits and follow up could be a boon to patients who are less mobile following hospitalization. New technology that allows closer home monitoring could also play a role in helping to reduce readmissions.

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