Hospital readmissions are receiving a lot of attention in business plans these days – rightly so – due to The Affordable Care Act (ACA) creating a financial penalty for “excessive” readmissions as a means to curb poor quality of care and excessive spending. Under the ACA, the Centers for Medicare & Medicaid Services (CMS) will target three specific disease states in Fiscal Year 2012 (which begins this October) – Myocardial Infarction (AMI), Heart Failure and Pneumonia.
CMS will calculate the average risk-adjusted, 30-day hospital-readmission rates for patients with these conditions using claims data. If a hospital's risk-adjusted readmission rate for such patients exceeds the industry average, CMS will penalize the hospital in the following year for all Medicare admissions in proportion to its rate of excess rehospitalizations. Payments for hospitals with below-average rehospitalization rates for all three conditions won't change.
Eventually, CMS plans to expand this program to include other common diagnoses for which readmissions are theoretically preventable, so all hospital executives should consider preparing for the potential impact to reimbursements as a new, permanent requirement in business strategy.
For hospitals just starting to think about compliance to reduce reimbursement penalties, below are a few helpful guidelines to consider in your organizational plans:
1. The best way for a hospital to understand their specific risk is to analyze current readmissions data relating to the three specific disease states that are being targeted – then enlist in a credible, third-party source for outside data to find out where your organization stands as compared to other hospitals. Those hospitals in the bottom 25 percent will have reimbursement at risk. Because all hospitals will be focusing on improving readmissions, this threshold will be a constantly changing target that will need continuous monitoring.
2. The next step is to understand your specific causes for readmissions by performing a "deep dive" through chart and case review. Use that information to develop improved care processes that prevent those causes. Develop a process that identifies high risk patients at the point of admission to assure they get what they need throughout the care process. Effective risk stratification technologies are available that can automate this function
3. Develop effective discharge planning and case management processes that assure comprehensive patient and family education, reliable hand-offs of care, timely information transfer, mobilization of community support activities and medication reconciliation.
4. If you haven’t already, begin forging alliances with post-acute care providers in your community to assure necessary outpatient services and care coordination including home health, social services, community support services, skilled nursing facilities (if needed), primary care and specialty care services
Click HERE to learn more about MedAssets Readmission Management solution.
David Munch, M.D., senior vice president and chief clinical officer, MedAssets