Health care reform likely to penalize hospitals for readmissions
Health care reform likely to penalize hospitals for readmissions
Start now to keep patients from coming back
Now that hospitals' 30-day readmission rates for heart failure, heart attack, and pneumonia are being posted on the Hospital Compare web site, the stage is set for the Centers for Medicare & Medicaid Services (CMS) to start reducing or eliminating payments for patients who are readmitted to the hospital.
"The president and Congress have both identified the reduction of readmissions as a target area for health reform. When we reduce readmissions, we improve the quality of care patients receive and cut health care costs," says U.S. Health and Human Services Secretary Kathleen Sebelius.
According to CMS, 19.9% of patients admitted to a hospital for heart attack treatment will return to the hospital within 30 days; 24.5% of patients admitted for heart failure will be readmitted within 30 days; and 18.2% of patients admitted for pneumonia are likely to return to the hospital within 30 days.
The Hospital Compare web site began reporting hospital readmission rates in July, listing whether a hospital's readmission rate is "better than," "no different from," or "worse than" the national rate.
Readmission rates are posted on the Hospital Compare web site only for hospitals that have treated at least 25 cases of a diagnosis during the reporting period.
The data exclude patients who have been readmitted to the hospital within 30 days of a discharge after heart attack when the readmission is for the purpose of a planned cardiac treatment, such as a heart bypass or a coronary angioplasty, as well as patients with any diagnosis who left the hospital against medical advice.
Factors such as availability of post-acute care services in the community and noncompliant patients can affect readmission rates but are not included in the risk-adjustment process.
"Readmission rates will help consumers identify those providers in the community who are furnishing high-value health care with the best results," says Charlene Frizzera, CMS acting administrator.
Proposals for penalizing hospitals for readmissions being considered in Congress and by CMS include bundled payment for hospitals and post-acute care services within 30 days, penalties for hospitals experiencing higher-than-average readmission rates, and making readmissions a "never event."
Whatever ultimately comes out of the current health care reform movement, hospitals are going to have to find ways to reduce readmissions because they're not going to get paid, says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and health care consultant and partner in Case Management Concepts LLC.
What you can do to prevent readmissions
"Case managers are going to have to do a better job of assessing patients so they don't miss opportunities to provide post-acute services, follow-up care, and education that will keep patients from coming back to the hospital," she says.
A study in the New England Journal of Medicine showed that one-fifth (19.6%) of Medicare beneficiaries were rehospitalized within 30 days of discharge, at a cost of $17.4 billion.1 The study concluded that the average stay of rehospitalized patients was 0.6 days longer than patients in the same diagnosis-related group whose most recent hospitalization had been at least six months previously.
"Readmission of a patient to a hospital after a short post-acute stay not only costs a great deal but also interrupts patients, continuity of care, and is disruptive to their families. However, it is a potentially avoidable event," says Jackie Birmingham, RN, MS, CMAC, vice president of professional services for Curaspan Health Group, a Newton, MA, health care technology and services firm.
Though not all readmissions are avoidable and not all avoidable readmissions are the fault of the hospital, hospitals still should share accountability for readmission rates that could be much lower, she adds.
Hospitals are going to have to rethink the long-standing paradigm that a full bed is better than an empty bed, Cesta says.
"Now there are so many reimbursement penalties for inappropriate admissions that were payable in the past. We are going to have to look at things differently and keep inappropriate patients out of the hospital," she adds.
The intent of CMS is to make readmission rates the captain of the improvement process for the new few years, says Deborah Hale, CCS, president of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.
Medicare regulation published in the Medicare Claims Processing Manual, Chapter 3, Section 40.2.5 mandates that if a patient is readmitted due to inadequate or incomplete care during the first admission, the two admissions should be combined and paid as one DRG, Hale points out.
"This regulation is applied to all readmissions regardless of the time span between the two admissions. This has the effect of limiting reimbursement since the patient's second visit to the hospital will be part of the original DRG," she adds.
For patients readmitted within 24 hours of discharge, the hospital is expected to combine the two admissions and be reimbursed for one DRG unless the same-day readmission is completely unrelated to the first admission. In this scenario, the hospital may add Condition Code B4 to the claim for the second admission and be paid the DRG for both admissions, Hale says.
In recent years, many Fiscal Intermediaries or Medical Administrative Contractors have expected that all same-day readmissions be combined even without evaluation of the medical record to determine whether they are related, she adds.
Discharge planning part of UR process
Discharge planning must be a more aggressive part of the utilization management process, Hale says.
"Case managers play a major role in helping avoid readmissions. As they perform discharge planning, they should make sure the patients receive appropriate education on what to do after discharge so they don't come back because they didn't follow instructions. They should make sure the patients have the means to pay for their medications so they won't come back because they didn't get their prescriptions filled," she says.
More than half (50.2%) of the rehospitalized patients in the New England Journal of Medicine study had not seen a physician for follow-up between the time they were discharged and came back to the hospital.1
In addition, a MedPac study showed that 64% of patients readmitted within 30 days did not receive post-acute care, such as home health, between discharge and readmission, Cesta says.
Interventions that have been shown to reduce readmissions include better care during the hospitalization; more complete care plans; emphasis on coordination of care at the point of transition to home or post-acute care; better use of after-hospital care; and more involvement of the patient and caregivers in decision making, Birmingham says.
When the staff at Patient Response, a Milburn, OK, health care consulting firm, conduct audits of readmissions for client hospitals, they find exactly the same reasons for readmissions that have been cited in numerous studies, according to Brenda Keeling, RN, CPHQ, CPUR, president.
Many of the root causes of readmission were a failed discharge plan, she adds.
Patients who were readmitted didn't get their prescriptions refilled or understand how to take them. They failed to have a follow-up visit with a physician and/or didn't have the resources to buy food or medication. In some cases, the family didn't understand the discharge plan or failed to provide the care the patient needed. Some of the patients were discharged prematurely, Keeling says.
Sometimes the patients came in and were discharged the next day before the case manager got in to see them to determine their discharge needs, Keeling says.
"Everybody says they don't have these kinds of problems at their hospital, but every hospital we've audited did have these problems on at least one of the three diagnoses being tracked by CMS," she says.
CMs should access every patient
Forget the longstanding illusion that not every patient needs case management, Cesta advises.
"The days of picking and choosing who gets case management are over in today's health care environment. If hospitals are going to prevent readmission, case managers are going to have to assess every patient every day to make sure their discharge needs are met," she adds.
The practice of assessing a patient for post-acute needs on admission and never seeing the patient again has led to patients falling through the cracks, Cesta says.
"Patients can have setbacks during hospitalization and can leave the hospital much frailer than when they came in. Models where case managers don't see patients every day or they see only those for certain diagnoses or when there is a referral from a care provider have to be changed if we are going to prevent readmissions," she says.
The challenge is going to be convincing hospital management teams to increase the case management staff so that case managers can ensure the patients' discharge needs are met, Keeling adds.
In the past, when hospital administrators looked at case management effectiveness, they looked at case mix index and length of stay and did not consider the discharge planning process, she points out.
"At some point, the administrative team will understand that they can't just keep giving case managers more and more to do. Hospital administrators must understand that when case managers have to wear too many hats, they simply can't do everything effectively. Case managers should have reasonable caseloads that allow them the time to complete all their duties, not just concentrate on commercial payers," she says.
(For more information, contact: Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management, Lutheran Medical Center, e-mail: [email protected]; Brenda Keeling, RN, CPHQ, CPUR, Patient Response, e-mail: [email protected]; Deborah Hale, president, Administrative Consultant Services LLC, e-mail: [email protected]; Jackie Birmingham, RN, MS, CMAC, vice president of professional services, Curaspan Health Group, e-mail: [email protected].)
Reference
- Jencks S, Williams M, Coleman E. "Rehospitalizations among patients in the Medicare fee-for-service program." N Engl J Med 2009:360; 1,418-1,428.
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