All Entries Tagged With: "readmissions"

Readmission reduction pilot program saves hospital thousands

A recent article in The Miami Herald describes a readmission reduction pilot program at Jackson Memorial Hospital that saved it an estimated $400,000 in readmission charges.

Jackson nurses visit recently discharged heart patients at their homes to ensure that they’ve filled their prescriptions and understand medication instructions.  The nurses also leave frozen healthy meals and check in with patients regularly to monitor their conditions and provide more meals.

The article describes Jackson’s pilot program as a predecessor to accountable care organizations (ACO). The ACO model is widely praised, but this article explains the need to address several challenges. Antitrust and anti-kickback healthcare laws require revisions that will allow healthcare providers to refer patients to entities with which they have a financial relationship. However, some groups warn that relaxing antitrust laws could allow healthcare providers to create the monopolies that these laws were enacted to prevent.

Editor’s note: Read the article at http://www.miamiherald.com/2011/08/03/2344316/will-acos-create-a-revolution.html

IPPS final rule confirms HRRP provisions

Approximately 60 pages of the 1,500-page Inpatient Prospective Payment System (IPPS) final rule focused on confirming the framework of the Hospital Readmissions Reduction Program (HRRP).

In addition to finalizing many provisions of the IPPS proposed rule, CMS also has given providers a glimpse of potential future HRRP readmission measures. For the first two years of the program (FY 2013 and 2014), CMS will review readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. These conditions are among seven that account for almost 12% of potentially preventable readmissions, according to MedPAC’s 2007 “Report to Congress”.

CMS plans to add more conditions in FY 2015 and will consider the other four conditions identified in the MedPAC report:

• Chronic obstructive pulmonary disease,
• Coronary artery bypass graft surgery,
• Percutaneous transluminal coronary angioplasty, and
• Other vascular procedures.

One commenter warned CMS that use of only three conditions in the FY 2013 HRRP will create opportunities for gaming the system. For example, hospitals may change coding practices to avoid reporting patients with AMI, heart failure, or pneumonia.  CMS said it would “monitor trends in admissions and readmissions to ensure there no systematic shift in patients’ primary discharge diagnoses codes occurs as a result of implementation of the Hospital Readmissions Reduction Program.”

Multiple readmissions

CMS also clarified that it will not count multiple readmissions. For example, a patient is discharged with AMI, readmitted five days later, discharged three days later, and then readmitted a second time five days later. CMS will consider this one readmission. The final rule states:

The readmissions measures are designed to measure whether a patient experienced at least one readmission within 30 days of an initial (or “index”) discharge as a single binary (yes/no) event, rather than counting the number of readmissions experienced within 30 days of discharge as a separate readmissions. For any given patient, only the first readmission they have will be counted for the Hospital Readmissions Reduction Program. In addition, only one readmission during the 30 days following the discharge from the initial hospitalization will count as a readmission for purposes of calculating the ratios set forth in section 1886(q) of the Act. For any given patient, none of the subsequent readmissions they experience within 30 days after discharge would be counted as a new “index” admission (that is, an admission evaluated in the measure for a subsequent readmission). Any eligible admission after the 30-day time period will be considered a new index admission.

Unrelated readmissions

Commenters also asked CMS to consider excluding readmissions for certain patients with the following conditions:

• Cancer
• Trauma, burns
• End-stage renal disease
• Psychiatric disorders
• Substance abuse
• Rehabilitation

CMS said it intends to explore whether to exclude other readmissions  from the HRRP, but that it could not do so now. FY 2013 measures require National Quality Forum (NQF) endorsement, and the NQF-endorsed measures do not exclude such readmissions.

Payment adjustment

CMS will address further details of the HRRP in next year’s IPPS final rule. The adjustment CMS will use to reduce payment is a key element that is missing..The final rule states:

Although we did not propose specific policies regarding the payment adjustment under the Hospital Readmissions Reduction Program in the FY 2012 IPPS/LTCH PPS proposed rule, we believe that it is still important to set forth the general framework of the Hospital Readmissions Reduction Program, including the payment adjustment provisions, in order for the public to understand how the measures discussed and finalized in this rulemaking will affect certain hospital payments beginning in FY 2013.

Will readmission reduction hurt your hospital’s bottom line?

The Hospital Readmission Reduction Program (HRRP) will reduce reimbursement to hospitals with high readmission rates to encourage them to prevent patients from returning after discharge. However, a new study suggests that hospitals will see an even bigger reduction in reimbursement if they experience fewer readmissions.

The issue is simple math. The current system pays hospitals for episodes of care. If hospitals reduce their readmissions they will have fewer episodes to bill. Fewer bills mean less reimbursement.

Brett Stauffer, MD, and colleagues, is the author of  an Archives of Internal Medicine report, which examines the financial impact of reducing heart failure readmissions at a community hospital in Garland, TX. Although the hospital reduced preventable heart failure readmissions by 48%, it also lost an average of $751 for each heart failure patient. The authors estimated that the HRRP will reduce the hospital’s negative financial impact, but by only 10%.

The study raises an interesting question. Although reducing hospital readmissions will save money for Medicare and other payers, what does it mean for hospitals?

“While we are not-for-profit entities, at the end of the day we still have to make payroll,” Stauffer told HealthLeaders Media. “We have bills to pay and have to maintain enough margin to pay for capital expenses, build new facilities and keep them updated, and that’s got to be paid for by somebody,” he said.

The hospital, which does not admit a large number of CHF patients, will continue its efforts to reduce readmissions because it is the right thing to do, said Stauffer. Other hospitals may share this perspective. The report seems to suggest that providing hospitals an incentive might require moving away from a pay-per-episode model and rewarding hospitals for positive outcomes. The Value-Based Purchasing program final rule may prove to be a step in that direction. Stay tuned.

CMS eyes Readmission Payment Reduction Program expansion

It appears that CMS is beginning to plan an expansion of the Readmission Payment Reduction Program.

The Readmission Payment Reduction Program, which will becomes effective at the start of FY2013, will reduce the aggregate DRG payments to hospitals that have a high readmission rate for three select conditions—acute myocardial infarction , heart failure, and pneumonia.

However, CMS announced June 9 that it is accepting comments on a new measure currently in development, “Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate following Vascular Procedures.”

“I know [CMS] want[s] to expand the readmission reduction program from the current rule so this is the way they would do it—announce and ask for public comment and then finalize,” says Debbie Mackaman, RHIA, CHCO, regulatory specialist at HCPro, Inc., in Danvers, MA.

The new measure will likely not be added until to the program until FY2014 to give CMS time to collect the appropriate data.

CMS invites all comments on the new measure, but is particularly interested in feedback that addresses the following areas:

• Definition of the cohort
• Definition of the outcome
• Risk adjustment
• Technical Expert Panel comments

CMS will accept comments until Thursday, June 30, 11:59 pm EDT. Submit comments and review the measure specifications at www.CMS.gov/MMS/17_CallforPublicComment.asp.

Readmissions reduction program beginning to take shape

CMS has begun to lay the foundation for the coming hospital readmission reduction program as part of the inpatient prospective payment system (IPPS) proposed rule posted April 19.

The program, which was mandated by The Patient Protection and Affordable Care Act (PPACA), will reduce Medicare payments to hospitals that have high readmission rates.

Within the IPPS proposed rule, CMS adopted the National Quality Forum (NQF) definition of readmission:

…as occurring when a patient is discharged from the applicable hospital to a non-acute setting (for example, home health, skilled nursing, rehabilitation or home) and then is admitted to the same or another acute care hospital within a specified time period from the time of discharge from the index hospitalization.

CMS specified the readmission time frame is 30 days; however, there are exclusions for readmissions unrelated to the original diagnosis, as specified by the HQF, Kimberly Anderwood Hoy, director of Medicare and compliance at HCPro, said in a recent blog.

CMS will reduce payments using an adjustment factor that will apply to a particular hospital’s DRG base amount. The adjustment factor can be no more than 1% in FY2013, the first year of the program, and will be phased in until the full adjustment factor of 3% is reached in FY2015. In FY2013, CMS will apply the adjustment factor to the excess readmission ratio for the following applicable conditions: myocardial infarction, heart failure, and pneumonia.

However the number of applicable conditions may increase in the coming years. Gloryanne Bryant, RHIA, CCS, CCDS, suggests in a recent HCPro article that hospitals prepare for the program by identifying their top readmission conditions. Bryant is regional managing director of HIM, NCAL Revenue Cycle, at Kaiser Foundation Health Plan, Inc., & Hospital in Oakland, CA.

“I would recommend that hospitals run some data to look at readmission rates to determine what their top three to five readmissions conditions are,” she says. “It’s clear that readmissions are a topic of concern for the federal government. Even though we in the industry have talked about readmissions for years, this federal mandate means we need to look at it even more closely.”

Applying for the Community-Based Care Transitions Program

Assuming Republicans in Congress don’t make good on their promise to defund and repeal the Affordable Care Act, 2011 will bring new initiatives designed to improve quality of care. One such initiative is the Community-Based Care Transitions Program (CCTP) demonstration project, which will fund efforts to improve transitions from hospitals and reduce readmissions.

Acute care hospitals with high readmission rates can claim a piece of the $500 million allocated to the program if they can demonstrate a relationship with community-based organizations. Selected hospitals will be expected to report process and outcome measures on their results and participate in an ongoing learning collaborative. CMS also expects participants to perform the following tasks:

• Initiate care transition services no later than 24 hours before discharge
• Provide timely, culturally, and linguistically competent post-discharge education
• Ensure timely and productive interactions between patients and providers
• Review and manage patient medications
• Support patient-centered self-management

How to apply

Linda Magno, Director of the Medicare Demonstrations Program Group at CMS said in early December 2010 that CMS would release a solicitation of applications by the end of the year, but it failed to do so. However, that doesn’t mean interested facilities shouldn’t begin to gather the necessary application information.

Applicants must complete a root-cause analysis that identifies factors that contribute to a high readmission rate in a community. Applicants also must draft a proposal that explains their plans:

• To address root causes
• To work with accountable care organizations and medical homes
• To align the organization’s care transition program with other related initiatives

Magno said CMS expects applicants to show they are ready to implement their initiatives immediately. Hospitals that have already established relationships with a CBO and begun to train staff on improving transitions are more likely to be accepted.

Section 3026 of the Affordable Care Act directs CMS to give preference to physician group practices and other applicants that meet the following requirements:

• Participate in a program administered by the HHS Administration on Aging
• Provide services to medically underserved populations, small communities, and rural areas

A dozen ways to prevent readmissions

The new year is almost here, and many hospitals are resolving to reduce preventable readmissions.

The federal government will begin penalizing hospitals with high readmission rates starting in October 2012, and hospitals may begin to see regulations that will enforce these penalties emerge in 2011. Regardless of regulations, it would behoove hospitals to get an early start.

Testament to the virtual certainty that readmissions will be a major issue in 2011 is “12 Ways to Reduce Hospital Readmissions.” It tops the list of most popular articles on HealthLeaders Media.com.

The article offers tips from readmission experts, Stephen F. Jencks, M.D., Amy Boutwell, MD, Timothy Ferris, MD, and Estee Neuhirth. Here is their list:

1. Dictate discharge summaries within 24 hours of discharge
2. Improve communication between hospital discharge planners and receiving facilities
3. Provide patients a 30-day medication supply upon discharge
4. Schedule follow-up appointments before discharge
5. Use telehealth technology to monitor patients after discharge
6. Identify patients who frequent the ED
7. Identify cracks in the system that occur after discharge
8. Provide home healthcare on wheels
9. Consider physician medication reconciliation
10. Use the teach-back method when giving patients discharge instructions
11. Shift resources to patients with conditions who readmit more frequently
12. Listen to patients

Read about these strategies in greater detail at HealthLeaders Media.com.

CMS will hold National Care Transitions Conference December 3

CMS will hold a National Care Transitions Conference December 3 to provide guidance for hospitals and other healthcare providers about the upcoming Community-based Care Transitions Program (CCTP).

According to CMS, community-based organizations provide care transition services across a continuum of care through arrangements with subsection (d) hospitals (as defined in section 1886(d)(1)(B) of the Social Security Act) and whose governing body includes sufficient representation of multiple health care stakeholders, including consumers.”

The conference will cover several topic including:

• An overview of the CCTP
• Evidence-based care transition models
• Lessons learned from participation in the Quality Improvement Organizations’ (QIOs) 9th scope of work care transitions sub-national theme
• Hospital-based interventions to reduce readmissions
• Positive financial implications of successfully reducing readmissions

Those interested in attending the CMS National Care Transitions Conference can do so either in person or via a webinar. To register for the event visit CMS website.

Address fragmented care to prevent readmission denials

Hospitals that admit patients for services that should have been provided during an earlier admission can expect denials from their quality improvement organizations (QIO), according to Jackie Birmingham, RN, BSN, MS. Birmingham is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group in Newton, MA.

The OIG recently has been monitoring consecutive-stay sequences, such as when a patient moves from inpatient care to a SNF and then back to an inpatient stay, writes Jackie Birmingham in “Myth Busting: The Truth About Medically Necessary Readmissions” published in Curaspan Connections. Because each admission triggers payment for an entire episode of care, providers may appear to be circumventing the prospective payment system.

Hospitals must address fragmented care when developing strategies for preventing inappropriate or avoidable readmissions. Birmingham suggests working closely with hospitalists, specialists, and community-based primary care physicians to ensure all necessary care for an episode of care is complete before discharge.

Birmingham offers the following suggestions to prevent fragmented care:

• Plan. If the patient needs diagnostic tests, determine whether the tests can be conducted on an outpatient basis. If tests require admission, don’t discharge the patient until tests are complete.
• Communicate. If discharging a patient before certain test results are available is permissible, and the patient is medically ready for discharge, be sure to communicate the results to all physicians involved in the patient’s care and to the patient. Unreported test results may preclude medical interventions that leave the patient at risk for another admission.
• Document. If readmission is likely to become necessary, perhaps for a second joint replacement or because the cardiac surgical team wasn’t available, document these facts. Clinicians responsible for discharge planning—including case managers, social workers, staff nurses, and physicians—must detail in their discharge notes specific information about justification for a possible medically necessary readmission.

Case managers say medically necessary readmissions are being denied

We all know that Medicare will not pay for preventable readmissions that occur within 30 days. But many providers are reporting that certain Medicare managed care plans are also denying medically necessary readmissions.

Several case managers on the American Case Management Association’s LearningLink listserv have shared their experiences on the subject. Most say they have received denial letters of readmissions that occur within 30 days regardless of whether the reason for the second stay relates to the first.

According to some LearningLink contributors, attempts to appeal the denials fall on deaf ears. Providers have presented clinical evidence that shows the admissions are appropriate, meet criteria, and not related to the original admission, but contractors have not reversed the denials.

Has this been happening at your facility?