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Pressure to intensify with more penalties, rewards
HallHospital readmissions, long established as a key healthcare quality indicator, are at the forefront of Medicare initiatives because of the Affordable Care Act (ACA). Section 3025 of the ACA created the Hospital Readmissions Reduction Program, which penalizes hospitals for excessive readmissions within 30 days of a patient’s discharge. The third phase of the program begins on Oct. 1, 2014 and raises the maximum penalty from 2% of a hospital’s Medicare payments to 3%.
The problem of hospital readmissions is pervasive. Two-thirds of the approximately 3,400 hospitals included in the readmissions program incurred penalties totaling $280 million in the program’s first year. A Robert Wood Johnson Foundation report released in 2013 indicated that one in eight Medicare patients were readmitted within 30 days of being released after surgery, and one in six who were hospitalized for reasons other than surgery were readmitted.
Readmissions cost Medicare more than $25 billion annually. Worse, because they are often the result of ineffective patient care and/or communication regarding post-discharge care and treatment, readmissions can result in a significant patient treatment regression and negatively affect the patient’s prognosis. In addition, hospitals with the highest readmission levels are among those that care for the poorest patients. Hospital readmissions among these patients have an even more profound impact on their families and their already fragile finances.
While there is no industry consensus as to what constitutes an appropriate level of hospital readmissions, there is agreement that the current level is too high and that most readmissions are preventable.
Numerous programs have been developed to identify the characteristics of preventable readmissions and develop appropriate measures that can have the greatest impact.Some of these programs focus on reducing hospital-caused infections that result in clinical complications for discharged patients. Others are as simple as having a nurse call a patient within 24 hours of discharge to identify potential complications or misunderstandings of post-discharge care that could result in a readmission.
Checklists that begin with the admission of a patient through his or her hospital stay and discharge planning have proved to be helpful, as well as providing in-home physician care in lieu of a readmission. With the exception of unforeseen clinical complications, preventing hospital readmissions may ultimately come down to how actively patients and their caregivers are engaged in their own care.
Managed care organizations are supporting patient engagement by increasing their efforts to manage hospital readmissions through integrated delivery systems approaches like accountable care efforts, as well as using tools that can identify high-risk members, evaluate care and discharge plans, and engage these members in their care through incentives and stepped-up services.
The pressure on reducing preventable hospital readmissions will only intensify as managed care organizations, accountable care organizations, healthcare business coalitions, commercial carriers and state Medicaid programs develop more forceful penalties and rewards aimed at getting better results.
Clearly, when two-thirds of hospitals fail to hit the target, there is great room for improvement.
See our full coverage on reducing readmissions here.
Don Hall, MPH, is principal of DeltaSigma LLC, a consulting practice specializing in strategic problem solving for managed care orginaztions. He also is an editorial advisor for MHE.