Access has role to prevent penalties

ID problems causing avoidable readmissions

Hospitals are getting penalized for preventable readmissions, due to the Patient Protection and Affordable Care Act’s linking of Medicare payments to the quality of care that hospitals provide. Hospitals can lose up to 1% of Medicare inpatient revenue in Federal Fiscal Year (FFY) 2013, 2% in FY 2014, and 3% in FY 2015 and beyond.

Patient access areas have a “tremendous opportunity to help develop a holistic understanding of patient’s needs” by collaborating with case managers and discharge coordinators to prevent these costly penalties, according to Chad Mulvany, technical director in the Washington, DC, office of the Healthcare Financial Management Association (HFMA). “It’s well-documented in any number of studies that economically challenged patients are more likely to be readmitted,” says Mulvany.1,2

It’s more difficult for individuals who lack of financial resources to obtain medications and follow-up care, which contributes to an increased probability of readmissions, he explains. “In many instances, patients are hesitant to discuss financial issues with caregivers. However, patient access areas and financial assistance counselors certainly are aware of resource issues,” says Mulvany.

Not just clinical issue

The first step is for patient access leaders to understand the problem, says Dan Schulte, executive vice president of revenue cycle solutions for The Outsource Group in St. Louis, MO.

“Readmission is a clinical issue only at the first glance,” he says. “Look below the medical illness causing the readmission, and likely you will see a psychological issue or a social issue.” It might be that a patient has mental illness or incapacity that is preventing good decision-making, is homeless, or has a home that is not conducive to post-admission care.

“Patient access can help by ensuring that the discharge coordination efforts include the members of a successful cross-functional team: clinical, social work, and finance,” says Schulte. The goal is to ensure that patients have clear instructions, solutions to related medical issues, and a safe harbor when they leave the hospital, he explains.

“I spent many years working on all three sides of the emergency room, as a unit secretary, a registration/finance manager, and a community activist,” says Schulte. “If we could join together as clinical, administrative, and community leaders to address the ‘biopsychosocial’ issues of these patients, we could significantly reduce a number of problems.”


1. Joynt KE, Orav EJ, Jha AD. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA 2011; 305(7):675-681.

2. Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: A systematic review. VA-ESP Project #05-225; 2011.