Reducing Hospital Readmission Rates

Policy Research-Medicare Readmission Rates

Authors Note:

The Maryland Health Services Cost Review Commission (n. d.),

The Health Services Cost Review Commission's (HSCRC’s) …the Commission began setting hospital rates in July 1974…its authority extended only to the rates hospitals charged to the non-governmental purchasers of care. In 1977, …Maryland was the first of five states granted a waiver by the federal government exempting the state from national Medicare and Medicaid reimbursement principles…all payers pay Maryland hospitals on the basis of the rates established by the HSCRC (About Us, para. 1).

Reducing Hospital Readmission Rates: Introduction

When patients are discharged from an inpatient stay the last thing patients’ want is a hospital readmission. Sometimes the admission is planned, but not desired which differs from a required readmission. Acute care readmission rates are a barometer of inadequate treatment, and an opportunity to improve treatment methods to eliminate readmissions. Determinants of readmission include initial poor care, lack of follow up, incomplete transference of care between providers, lack of communication between providers and settings, tests pending post discharge, and premature release.

According to Jenny Minott, “18 percent of Medicare patients discharged from the hospital have a readmission within 30 days of discharge accounting for $15 billion in spending (Minott, 2008, Background, para 1). Readmissions negatively influence the insurance payer, physician expenses, and satisfaction of care. Medicare implemented the prospective payment system, which pays a rate with a prescribed number of days for the diagnosis. If the patient discharges before the maximum allowable days the hospital receives the full payment. If the stay exceeds the allowable days the facility will not receive payment beyond the allowable days if the condition lacks a complicating co-morbidity. Studies suggest the need for readmission is medical, rather than operative treatment. Medical treatment is not as profitable as surgical treatment.

Decreasing readmissions is an opportunity to learn and improve upon shortcomings in clinical care to improve practices, decrease expenses, focus on patient care utilization, and improve value. The outcome from the patient perspective will keep trust, and faith in the care received by the provider and the organization. One cannot overlook the value in coordinating the care correctly the first time. Poor care is not necessarily negligible.

Evaluating best practices to reduce hospital readmissions rates is the focus of a new project with hospitals in Maryland, Julie Appleby of the Washington Post reported (2010). The voluntary experiment requires modifying current payment methods. Many large hospitals have agreed to place caps on payment for inpatient care for a period of three years. If reductions in readmission rates are successful the hospitals have the potential to acquire substantial means. If not successful and the rate rises the organization will run a loss.

The voluntary program objective is to work proactively with providers in the community with follow up post discharge, in a setting that is less expensive. The basis of the program is aggressive post discharge case management. Hospitals will dedicate clinicians to keep in contact with the patient regarding care, instructions, medications, follow up tests as necessary, and intervene for the patient if provider contact is required.

Conclusion

Reducing readmission rates is not only a value-based program, but also a quality improvement measure. Literature review provides little information on trends of readmission rates and attaching performance value to payment value as an incentive. Hospitals need enticements beyond improving quality care to reduce medical errors. Multiple factors contribute readmission rates. Case management of discharged patients has demonstrated with other studies to be effective. One such program reduced readmission rates between 20 to 40 % (Coleman, 2010). Case management is but one method and one target area to reduce readmission rates. Exploration with other methods requires further literature review and evaluation to accurately identify trends of readmission.

References

Appleby, J. (2010). Hospital effort could reduce readmission. The Washington Post. Retrieved from http://. http://www.washingtonpost.com/wp- dyn/content/article/2010/12/06/AR2010120607108.html

Coleman, E. A. (2010). Transition coaches reduce readmission for medicare patients with complex postdischarge needs. Agency for Health Research and Quality: Health Care Innovations Exchange. Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=1833

Feeney, D. (2010). Modifications to the maryland hospital preventable readmission (MHPR) draft recommendations. State of Maryland Department of Health and Mental Hygiene. Retrieved from http://www.hscrc.state.md.us/documents/CommissionMeetingDocuments/12-08-10/HSCRC_PreCommMeet12-08-10.pdf

Minott, J. (2008). Reducing hospital readmissions. Academy Health. Retrieved from http://www.academyhealth.org/files/publications/Reducing_Hospital_Readmissions.pdf

Reducing Readmission Rates, Part I of II

Policy, defined by Myint Htwe, of the World Health Organization as, “…a set of principles guiding decision-making. It provides a framework, against which proposals and activities can be tested and progress measured” (Htwe, 2006, para 6). Health care policy describes an issue, addresses, and monitors the resolution. Health care policy is a form of intervention and quality improvement. This includes short and long-term goals with thresholds. A health policy model has four stages including, “agenda setting, formulation, implementation, and evaluation” (Walt, Shiffman, Schneider, Murray, Brugha, & Gilson, Frameworks, para 2). The discussion focuses on reducing hospital readmission rates of Medicare patients in the United States.

Agenda Setting

Mechanisms that lead to readmissions include a variety causes such as a lack of discharge planning, understanding instructions for patients, caregivers, and subsequent follow up. These factors lack of coordination of care. Most of these patients have one or more chronic care diseases. This easily leads to end-stage problems as a reason for readmission. One cannot exclude medical and administrative errors as a cause. Medicare’s prospective payment system pays a pre-determined set rate for the discharge diagnosis, and sets an average length of stay. If the facility discharges a patient before the average length of stay expires the payment is not pro-rated, rather the stay is paid in full. This allows payment for a particular bed, even if another patient fills the bed. The potential to double the money per bed could encourage facilities to expedite discharges.

The Medicare Payment Advisory Panel (MedPAC) estimated in 2005 roughly 17 % of hospital readmissions within 30 days post-discharge (Stone, Hoffman, 2010).

In 2008, MedPAC published recommendations for policy changes to reduce rehospitalizations for Congressional evaluation. Medicare paid for all hospitalizations excluding readmissions 24 hours post-discharge. The panel suggested implementing risk-adjusted readmission rates to decrease payment for hospitals. The report estimated readmission costs at $12 billion a year (Jencks, Williams, Coleman, 2009). In 2009, the Patient Protection and Affordable Care Act addresses readmission rates by holding hospitals accountable for; discharge outcomes, and quality of care. The results of accountability include penalties, and incentives.

MedPAC using a report from 2007 described the lack of case management as a contributor to readmissions and a failure to keep statistical data on the rates. MedPAC studied three factors that influence readmissions, a) if the readmission is a planned stay or not within 30 days of discharge, b) the length of time an elevated risk exists for readmission c) Length of time and number of visits for outpatient follow-up care after discharge (Jencks, Williams, Colemen, 2009).

Formulation and Implementation

The Obama administration in February 2009, released the FY2010 budget, which included funding for health care reform. In March 2010, the Patient Protection Affordable Care Act became official with passage of the bill. The regulations for health care include reducing health care readmission rates. Medicare can decrease payments to hospitals with high readmission rates that are preventable.

Another regulation contained within the act included studies to restructure the prospective payment system and other payment classifications. Other studies include focusing on improved care for those with one or more chronic diseases while in the hospital, during the discharge planning and post-discharge to a variety of settings using comparative effectiveness. The estimated savings is, “$26 billion over 10 years” (College of Cardiology, 2009, para 6).

One important state to follow health care policy is Maryland. Maryland is in the process of finalizing a statewide voluntary program proposal by the Maryland Department of Health and Mental Hygiene. Maryland is the only state in the nation to hold a waiver from Medicare and Medicaid and sets its own rates for all-payers. The Maryland Health Services Cost Review Commission (MHSCRC) is an independent state agency that controls the payer rates. Large and small hospitals have agreed or are considering the proposal. The proposal focuses on improving patient care and decreasing hospital readmissions rates by agreeing to a freeze in pay rates for three years. The proposal is not unlike the Medicare program and proposal.

The Maryland Health Services Cost Review Commission has reservations but has agreed to consider the proposal to begin some time in 2011. Large facilities are willing to join the program but not all are in agreement with the proposal. The foundation of the proposal is to keep the readmission rate below the budgeted figure established for individual hospitals. Those that oppose are unclear how to identify readmissions and rewards for keeping under budget. Monitoring the changes requires costly expenditures to implement a new quality improvement and case management programs.

Small facilities in Maryland have a different proposal, which includes inpatient, and outpatient budgets. These budgets will be set at a percentage higher than the current budget in an effort to shift care when possible to primary care with due diligence. This will decrease admission rates. While decreasing readmission rates facilities will not lose money, rather be compensated for the decreased use of hospital beds. Some have already committed to the program.

The Commonwealth Fund Commission recommends applying new payment methods to acute care (Davis, Stremikis, 2009). Medicare will expand the prospective payment system to include physician payment, and up to 30 days after discharge. This will encourage better care coordination. Exercising due diligence will encourage hospitals to decrease admissions that virtually guarantees rewarding the hospital system. The Lewin Group estimates savings as a result of the Patient Protection and Affordable Care Act, “$211billion over 11 years from 2010-2021” (Davis, Stremikis, 2009, para 7). Evaluation

A number of options exist for evaluation. The Institute of Healthcare Improvement (IHI) designed an initiative called, State Action on Avoidable Rehospitalizations (STAAR). The Commonwealth Fund underwrites the STAAR funding. Currently, the initiative involves four states that include partnerships throughout the delivery system. The program aims to improve case management and the transition between providers and various health care settings such as long-term care.

The IHI includes materials and interventions to improve administrative clinical care. The IHI has a number of other programs for developing improvement programs to manage patient flow. A new website called CMS Innovation Center focuses on outcomes management across the health care continuum.

Director of Health Policy and Strategy for the IHI Amy Boutwell, identified 12 ways to reduce readmissions including, a) altering discharge summaries to anticipatory guidance for the patient, b) delay handing off patients to providers and other settings focusing on person centered care, c) fill the prescription medication rather than written prescription on discharge, d) include in discharge planning a follow-up plan, e) use of telehealth to communicate regularly with patients visually allows to pick up on visual clues of health, e) identify revolving door patients and disease characteristics for intense monitoring, f) understand post discharge in the same way as item e, using such software as SKYPE, g) bring back house calls, h) medication reconciliation to ensure the patient is taking the right medication, and avoid interactions with other prescriptions by eliminating multiple physicians prescribing medication using the primary, i) work with the patient so that the patient understand what is happening to the patient, using the repeat back method to reinforce the instructions, j) focus on the highest risk patients with intensive monitoring to identify trends k) take time and listen to the patient in the form of a care plan that incorporates treatment, condition, options, and the patients wishes for the patient, case management, and the provider to coordinate care effectively (Clark, 2010).

Conclusion

To improve both efficiency and quality of the nation hospitals, and in response to the requirements of the Deficit Reduction Act (DRA) of 2005, the Centers for Medicare and Medicaid Services developed three risk-standardized, 30-day readmission measures for acute myocardial infarction, heart failure, and pneumonia. Readmissions are an expensive adverse event for the patient. MedPAC identified the three risks as common, costly, and preventable. Using this information on outcomes allowed CMS to create incentives by evaluating the entire spectrum of care that they and affiliated providers furnish to patients. The incentive also includes an identification system, systemic or condition-specific changes that will make care safer and more effective. After outcomes identification, weaknesses are the areas worth investing in interventions. This will reduce complications of care. Follow-up planning will improve readiness for patient discharge. Shifting the scope of discharge reports; incorporate follow up, and transitional care. Ensuring discharge instructions are understood using the feedback method will enhance compliance with discharge follow up. Reconciling medications and providing the medication rather than the script eliminates a major step for some patients. Care coordination starts with discharge planning and proactive intervention for positive transitions.

References

Clark, Cheryl. (2010). Retrieved from 12 ways to reduce hospital readmissions http://www.healthleadersmedia.com/page-5/QUA-260658/12-Ways-to-Reduce-Hospital-Readmissions

College of Cardiology. (2009). Retrieved from Obama budget proposal commits to health reform http://qualityfirst.acc.org/advocacy/Pages/2010Budget.aspx

Davis, Karen, Stremikis, Kristof. (2009). Retrieved from: Ensuring accountability: how global fee could improve hospital care and generate savings http://www.commonwealthfund.org/Content/From-the-President/2009/Ensuring-Accountability.aspx

Jencks, S. F., Williams, M. V., Coleman, E. A. (2009). Patients in Medicare fee-for-service-program. Retrieved from the New England Journal of Medicine; 360: 1418-1428: http://healthlegislation.blogspot.com/2010/10/medicare-hospital-readmissions-issues.html

Htwe, M. (2006). Formulation, Implementation and Evaluation of Health Research Policy. Regional Health Forum WHO South-East Asia Region (5): 2. Retrieved from the World Health Organization: http://www.searo.who.int/en/Section1243/Section1310/Section1343/Section1344/Section1354_5294.htm

Stone, J., Hoffman G. J (2010). Medicare hospital readmissions: issues, policy options, and ppaca retrieved from http://healthlegislation.blogspot.com/2010/10/medicare-hospital-readmissions-issues.html

Terry, K. (2010). A proposal for hospitals: cut readmissions, earn more money. Retrieved from Bnet http://www.bnet.com/blog/healthcare-business/a- proposal-for-hospitals-cut-readmissions-earn-more-money/2214

Walt, G., Shiffman, J. Schneider, H. Murray, S. F., Brugha, R., &Gilson, L. ‘Doing’ health policy analysis: methodological and conceptual reflections and challenges. Health Policy and Planning. (23): 5 p 308-317 retrieved from:

http://heapol.oxfordjournals.org/content/23/5/308.full#ref-55

Reducing Readmission Rates Part II

The Past and the Future

Author’s notes:

The United States health care stratum includes governmental, and private entities (Abood, 2007). Political action groups and associations affect health care policies. This sector develops from regulation at all levels of government. Health care policies come from private sectors as well, for instance the Joint Commission. (Abood, 2007). The policy-making process includes analysis and rebuts activated by an occurrence postulated by stakeholders. Political action involves members of Congress to support the position (Appendix I). Sometimes the member advocates to analyze the benefit, or official indoctrination.

Legislative proposals compel Congress to draft a positional retort. The retort may include drafts of legislation, complete the outcomes, or solicit research. The action may include assignment to a specific committee evaluate the action. Sometimes proposals get lost in the face of higher priority legislation. The passage of a bill at times requires implementing a law ratified by the president. A time line also becomes a part of the implementation. Sometimes specific government legislation dictates the implementation.

Health Care Policy: Reducing Readmission Rates Part II

Policy, defined by Myint Htwe, of the World Health Organization as, “…a set of principles guiding decision-making. It provides a framework, against which proposals and activities can be tested and progress measured” (Htwe, 2006, para 6). Health care policy describes an issue, addresses, and monitors the resolution. Health care policy is a form of intervention and quality improvement. This includes short and long-term goals with thresholds. A health policy model has four stages, including “agenda setting, formulation, implementation, and evaluation” (Walt, Shiffman, Schneider, Murray, Brugha, & Gilson, Frameworks, para 2). The discussion focuses on evaluation, analysis, revisions, the purpose, and methodology process for further analysis and revision of the public policy, to reduce hospital readmission rates of Medicare patients in the United States.

Evaluation, Analysis, and Revision

Evaluation is the contribution, and production, in two stages, which are ex ante, and ex post (Slack, n. d.). The ex ante stage includes how well the policy applies to the objectives. This stage includes the process of establishing performance goals set for ex post review. The process of these stages sets methods and potential for method redesign. Valuation includes official appraisal, and party self-education in the policy.

Policy analysis permeates many processes and entities. The policy environment whether organizational, or network has influenced by domestic policies and practices, and international policies. Making policies are not explicit or have a standard design. Policies may emerge as a result of action occurring that is observable or not observable. Policies at times may result in challenges in need of compromise, as a result of the recommendations of policy making. The policy environment can make information gathering complex. This is a complicated process when maintaining balance dependence, and commitment. A key to easing the complexity is confidence with the body recommending changes, and the policy makers.

Revisions include an analysis and alteration when current policies require amending or updating to adjust changes. Major revisions may take multiple revisions periodically. Small alterations require less scrutiny. These revisions are easily understood and require little work to complete. Revisions evaluate cohesion, precise clarity, and specifically relates to the need of the stakeholders.

The final stages include decision when on a formal agenda then Congress deliberates and makes judgment. Outcomes include approval; offer an oppositional application, negotiation, and rejection. The outcome is the execution development with required conventions, and mandates if needed. After execution, careful consideration of the potential shortcomings follows. The finality process begins the analysis with reaction, and evaluation-modification issues follows. If an issue arises the stage starts anew.

Description of Purpose

Mechanisms that lead to admissions include a variety of causes, such as lack of discharge planning or understanding of instructions for patients, caregivers, and subsequent follow-up. This is a lack of coordination of care. Most of these patients have one or more chronic disease. This easily leads to end stage problems as a reason for readmission. One cannot exclude administrative and medical error. Medicare prospective payment system pays a flat rate for the discharge diagnosis, and sets an average length of stay. If the facility discharges a patient before the average length of stay expires the payment is not pro-rated, rather the stay is paid in full. This allows payment for a particular bed, even if another patient fills the bed. The potential to double the money per bed could entice facilities to expedite discharge. Currently, Medicare does not cover the readmission for the same diagnosis on the initial stay, if readmitted within 24 hours of discharge.

The Medicare Payment Advisory Panel (MedPAC) estimated in 2005 roughly 17% of hospital readmission within 30 days post-discharge (Stone, Hoffman, 2010).

In 2008, MedPAC published recommendations for policy changes to reduce rehospitalizations for Congressional evaluation. Medicare pays for all hospitalizations excluding readmissions 24 hours post-discharge. The panel suggested implementing risk-adjusted readmission rates to decrease payment for hospitals. The report estimated readmission costs at $12 billion a year (Jencks, Williams, Coleman, 2009). In 2009, the Patient Protection and Affordable Care Act addressed readmission rates to hold hospitals accountable for discharge outcomes, quality of care, using risk-adjusted penalties, and incentives.

MedPAC using a report from 2007 described the lack of case management as a contributor of readmissions and a failure to keep statistical data on the rates. MedPAC studied three factors that influence readmissions, a) if the readmission is a planned stay or not within 30 days of discharge, b) the length of time an elevated risk exists for readmission c) Length of time and number of visits for outpatient follow-up care after discharge (Jencks, Williams, Colemen, 2009).

The Obama administration in February 2009 released the FY2010 budget. The regulations for health care included reducing health care readmission rates. To accomplish this Medicare can decrease payments to hospitals with high readmission rates that are preventable.

Another regulation contained within the act included tests to reform the prospective payment system. Other studies include focusing on improved care for those with one or more chronic diseases while in the hospital, during the discharge planning and post discharge in a variety of settings using comparative effectiveness. The estimated savings is, "$26 billion over 10 years" (College of Cardiology, 2009, para 6).

Medicare will expand the prospective payment system to include physician payment, and up to 30 days after discharge. This will encourage better care coordination. By exercising due diligence will encourage hospitals to decrease admissions that virtually guarantees rewarding the hospital system. The Lewin Group estimates savings as a result of the Patient Protection and Affordable Care Act; “$211billion over 11 years from 2010-2010” (Davis, Stremikis, 2009, para 7).

Hospital-Based Purchasing Program Legislation

Reducing readmission rates for the Medicare population is currently in the ex ante stage. To improve this situation as a result of House Resolution (H. R.) 3590 111^th Congress: Patient Protection and Affordable Care Act of 2009 Title III, subtitle A. Transforming the Health Care Delivery System (Government Printing Office, 2010). Section 3001 addresses the need for improved quality and efficiency by establishing a hospital-based purchasing program for the Medicare population. This sets pay for performance standard that improves and rewards quality rather than quantity. This act provides substantial improvements of performance and delivery of care across the continuum.

Section 3021 Establishes the CMS Innovations Program to develop and test method to improve outcomes during the transition phase from inpatient to home, or other health care facilities. This program addresses and reinforces the Quality Improvement Program of CMS that will administer the transitional program. In the section 3026, Community-Based Care Transitions program provides funding for acute care, and community health organizations to use evidence-based care that is demographic specific at risk for readmission.

Section 3025 Hospital Readmission Reduction program specifies the use of adjusted payments for hospitals with high readmission rates using a percentage on dollar value of potentially preventable re-admissions for specific measures. A number of laws have overlapping goals (Appendix I).

Congress in 2006 passed into, “Law 109-171 the Deficit Reduction Act of 2005 (DRA), which under Section 5001(b) authorizes CMS to develop a plan for Value-Based Program (VBP) for Medicare hospital services commencing FY 2009” (United States Department of Health and Human Services, 2007, p. 1). Section 5001(a), includes provisions for Medicare’s Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program (United States Department of Health and Human Services, 2007). The program also known as a pay-for-reporting program uses Medicare payment in return for reporting care provided for all patients, including non-Medicare payers. The program originated under the Medicare Modernization Act.

The Medicare Modernization Act of 2003, RHQDAPU mandated that acute care facilities using the prospective payment system to report specific data. The data required includes specific performance measures. The consequence for not reporting is monetary reductions in the Annual Payment Update (APU). As a result hospitals have submitted data since 2004.

Centers for Medicare and Medicaid Services on January 13, 2011 submitted a proposed rule to implement a Hospital Value-Based Purchasing program under section 1886 (o) of the Social Security Act (SSA) (Federal Register, 2011). The program pays per fiscal year to qualified facilities that meet performance standards. The program applies to discharges on and after October 1, 2012 (Federal Register, 2011). The law supports the SSA. The program also applies to section 3001(a) of the PPACA, and amended with the Health Care and Education Reconciliation Act of 2010 also known as the PPACA. This was enacted on March 23, 2010. The program is a division of the Medicare Hospital Inpatient Quality Reporting Program formerly (RHQDAPU).

Conclusion

To advance competence and value with acute care organizations the Deficit Reduction Act (DRA) of 2005, allows CMS to implement performance measures for the 30 days following discharge. Readmissions have consequences aside from the physical, psychological, and use of multiple services, but also the cost is exorbitant. These readmissions can have permanent adverse events with dire consequences. MedPAC has identified the three risks as common costly, and preventable.

After outcomes identification the weak content may require further intervention. This reduces the complications of care. Follow-up planning will improve readiness for patient discharge. Changes in transitional care to post-hospitalization should include expanding the scope of discharge reports to include planning for post-hospitalization. This will incorporate specific instructions, and provide the outpatient provider with a summary of the hospitalization. Ensure correct relay of communication for discharge instructions using the feedback method will enhance compliance with discharge plans. Reconciling medications and providing the medication rather than the script at discharge eliminates a major step for some patients. Care coordination starts with discharge planning and proactive intervention for positive transitions.

References

Abood, Sheila. (2007). Retrieved from Influencing health care in the legislative arena (12): 1 Online Journal of Issues in Nursing. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No1Jan07/tpc32_216091.aspx

Clark, Cheryl. (2010). Retrieved from 12 ways to reduce hospital readmissions.

http://www.healthleadersmedia.com/page-5/QUA-260658/12-Ways-to-Reduce-HospitalReadmissions

College of Cardiology. (2009). Retrieved from Obama budget proposal commits to health reform. http://qualityfirst.acc.org/advocacy/Pages/2010Budget.aspx

Davis, Karen, Stremikis, Kristof. (2009). Retrieved from: Ensuring accountability: how global fee could improve hospital care and generate savings. http://www.commonwealthfund.org/Content/From-the-President/2009/Ensuring-Accountability.aspx

Federal Register. (2011). Retrieved from Medicare Program; Hospital inpatient value-based Purchasing http://www.federalregister.gov/articles/2011/01/13/2011-454/medicare-program-hospital-inpatient-value-based-purchasing-program#p-3

Htwe, M. (2006). Formulation, Implementation and Evaluation of Health Research Policy. Regional Health Forum WHO South-East Asia Region (5): 2. Retrieved from the World Health Organization: http://www.searo.who.int/en/Section1243/Section1310/Section1343/Section1344/Section1354_5294.htm

Jencks, S. F., Williams, M. V., Coleman, E. A. (2009). Patients in medicare fee-for-service-program. Retrieved from the New England Journal of Medicine; 360: 1418-1428:http://healthlegislation.blogspot.com/2010/10/medicare-hospital-readmissions-issues.html

Peterson, R. J. (2009). The policy process life cycle. Retrieved from EDUCAUSE Review (44): 1 74-75 http://www.educause.edu/EDUCAUSE+Review/EDUCAUSEReviewMagazineVolume44/ThePolicyProcessLifeCycle/163805

Stone, J., Hoffman G. J (2010). Medicare hospital readmissions: issues, policy options, and ppaca retrieved from http://healthlegislation.blogspot.com/2010/10/medicare-hospital-readmissions-issues.html

United States Department of Health and Human Services. (2007). Medicare hospital value-based purchasing plan development. Retrieved from Centers for Medicare and Medicaid Services https://www.cms.gov/AcuteInpatientPPS/downloads/hospital_VBP_plan_issues_paper.pdf

Appendix I

Medicare Legislation and Reform

1960 - PL 86-778 Social Security Amendments of 1960

1965 - PL 89-97 Social Security Act of 1965- Established Medicare benefits

1980 - Medicare Secondary Payer Act of 1980 - establishes protection of the Medicare Fund so that payment for services and items that other providers has the primary insurance status for payment.

1988 - PL 100-360 Medicare Catastrophic Coverage Act of 1988- and expansion of benefits.

1989 - Medicare Catastrophic Coverage Repeal Act of 1989

1997 - PL 105-3 Balanced Budget Act of 1997- tightened Medicare expenditures to providers and plans expand types of plans to participate with Medicare, and increased premiums in effort to balance the federal budget.

2003 - PL 108-173 Medicare Prescription Drug, Improvement and Modernization Act: President Bush attempted close gaps in prescription drug coverage left by the Medicare Secondary Payer Act enacted in 1980

2003 - 2004 President Clinton tried to revamp Medicare through his health care reform plan, but failed to get the bill past congress

2007 - The US House voted to reduce payments to Medicare Advantage provides in order to pay for expanded coverage of children’s health insurance program.

2008 - Medicare Advantage plans cost, on average, 13% more per person insured than direct payment plans. Economists concluded that Medicare advantage providers were excessive. The Senate, after heavy lobbying from the insurance industry, declined to agree to the cuts in Medicare Advantage proposed by the House. President Bush subsequently vetoed the SCHIP extension. That President Obama signed into law in 2009.

2010 - Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010.

Health Care Policy Brief Reducing Medicare Readmission Rates

The background on Medicare readmission rates accounts for major expenditures for the Center for Medicare and Medicaid Services. Payment Advisory Panel (MedPAC) estimated in 2005, Readmissions account 17.6% of all hospitalizations 30 days after discharge (Stone, Hoffman, 2010). Medicare readmission expenditures estimate is $12 billion 11-years (Jencks, Williams, Coleman, 2009). 76 % of readmission rates are potentially avoidable. The results align with the Medicare Readmission Reduction Program, in section 3025 of the Patient Protection and Affordable Care Act (PPACA) of 2009 (Appendix I). Successful pilots and research demonstrates the rates are reducible.

This brief supports the Medicare Readmission Reduction Program. The premise specifies using adjusted payments for hospitals with high readmission rates. The calculation uses a percentage on dollar value. Research identifies a strong need for transitional care between the post-discharge and the 30-day window of readmission risk.

In section 3025 Medicare Readmission Reduction Program has estimated savings, “$211billion over 11 years from 2010-2021” (Davis, Stremikis, 2009, para 7). The premise is to shift the care from quantity of days, to quality of care. MedPAC described the lack of case management as a contributor to readmissions. Several pilots and research (Appendix I, and II) have thus far demonstrated success with transitional care.

This demonstrates support of the changes of recent legislation to begin the next phase of the research, to implement these programs from local to the national level. Thank you for your time and consideration on this matter. For further information contact Ms. Jones at (555) 123-4567.

References

Jencks, S. F., Williams, M. V., Coleman, E. A. (2009). Patients in medicare fee-for-service-program. Retrieved from the New England Journal of Medicine; 360: 1418-1428: http://healthlegislation.blogspot.com/2010/10/medicare-hospital-readmissions-issues.html

Stone, J., Hoffman G. J (2010). Medicare hospital readmissions: issues, policy options, and ppaca retrieved from http://healthlegislation.blogspot.com/2010/10/medicare-hospital-readmissions-issues.html

Appendix 1

Timeline 2007-2009

MedPAC June 2007 and 2008 reports highlight avoidable rehospitalizations as an area of poor quality; recommend data reporting and payment reform;

· May 2008 NQF endorsement of 5 outcome measures for care transitions;

· June 2008 Florida becomes first state to publicly report potentially

· Preventable rehospitalizations rates and launch statewide effort to improve;

August 2008 CMS launch of Care Transitions contracts in 14 communities

With the specific aim of improving transitions and care

Coordination across the continuum to reduce rehospitalizations;

· November 2008 The National Priorities Partnership announced 6 priority

For the United States, including care coordination and reducing 30-day readmissions:

February 2009 Obama Administration highlights avoidable rehospitalizations as an area of poor quality, and recommends paying hospitals a flat fee for a hospitalization and the 30 days of follow-up care.

Affordable Care Act 3025

• Performance improvement incentive
• FYI 2013 (October 1 2012)
• Hospitals with higher than expected CMS 30-day rehospitalizations rates subject

To penalty

• Initially, 3 conditions (AMI, HF, PNA)
• Initially, sliding scale penalty up to 1% of total Medicare charges
• Number of conditions will increase:

Hospital compare all-cause risk adjusted for AMI, PNA, and CHF

Under review: PCI (stents)

In development: stroke, elective hip, & knee

Planned: CABG, COPD, other vascular

• Magnitude of penalty will increase to 3%

This is not just about heart failure

ACA: Section 3026

“Community-Based Transitions Care Program”

• 5-year program projected to start in 2011
• Provide funding to eligible entities that provide improved care
• Transition services to high-risk Medicare beneficiaries
• Eligible entities:

Community-based organization

Arrangements with hospitals

Priority to applications partnering with AAA agencies

Priority to underserved, rural communities

Appendix II

Other CMS Initiatives

• CMS Center for Innovation
• Very interested in readmissions
• Central concept – NOT JUST THE WORK OF HOSPTIALS

First major initiative will be state based improvement of care

Coordination for dual-eligible beneficiaries

10th Scope of Work

Almost certainly will include care transitions national theme

• Value-based purchasing
• Bundled services
• Take-A ways

In past 2 years, rapid changes in concept of readmissions, and

Levers to improve care

Predominant focus is on multi-sector nature of improvement

Payment reform will be one of several key components

Payment reform by itself won’t “solve” readmissions

Epidemiology

Provider Based Initiatives

• Florida Hospital Association Collaborative to Reduce Readmissions

90 hospitals, 2 years (2008-2010)

Goals to reduce readmissions for certain conditions by 40-50%

Locally adapt best practices through quality improvement approach

• Project BOOST

_35 hospitals across US

_ BOOST toolkit, mentoring, adopts quality improvement approach

_ ACC/IHI H2H

Approximately 1200 enrolled

• Coleman Care Transitions Coaches trained

Provider based initiatives

FL HA collaborative to reduce readmissions

Goal to reduce for certain conditions by 40-50%

Project Boost

Toolkit, mentoring, adopts QI approach

ACC/IHI H2H

Coleman Care Transitions Coach

Promising Approaches to reduce

Improve transitions

Project RED

BOOST

IHI transforming care at bedside, and STAAR

Hospital to home AAC/IHI

Supplement transitions post discharge from the hospital

Care transitions intervention- COLEMAN

Transitional care Interventions NAYLOR

Enhance ongoing management=high risk pt

Evercare model

VNSNY home care model

HF clinics

Intensive care management from primary care or health plan