Rand’s Synopsis “Preventing emergency readmissions to hospital”

Extensive deviation in descriptions of readmission, measurements of the preventable readmissions, and classification of features exist regarding unavoidable readmission. The average 30-day readmission window may identify the distinction with acute care influences, and continued care post-discharge.

The consensus opinion using the 30-day window seems 15 percent to 20 percent of readmissions are avoidable. The potential intercession to avoid readmission relies on synchronization and communication with the discharge planning process to community care.

Using readmissions to evaluate performance and aligning reimbursement has danger of inadvertent penalty. Consider the following strategy when reimbursement aligns with readmission:

1. Reimbursement centers on sub par quality, increasing reimbursement. Most readmissions do not meet the criteria for avoidability.

2. Financial incentives should be substantial enough to induce hospital behavior to change. However, use care with the amount of penalty for readmissions: the better the enticement or deterrent, the larger the probability of unforeseen penalty.

3. Monetary enticements must center on agreeable results with quality progress.

4. The threshold measures center on accomplishments of top performing facilities.

5. Carriers must not command detailed care practices for acute care facilities to get reimbursement for the carriers practice criteria rather than evidence base, which may differ.

6. Monetary incentive determination should center on comparative accomplishment, patient-specific payment incentives.

7. Determination of performance requires risk adjustment to consider severity of illness.

It is not possible to analyze the dissimilarities among the percentages measured as preventable. The results are implausible due the various subjects and healthcare systems.  Futures analysis should include evaluating preventable readmissions clinical features related to readmission. The clinical features maybe related to readmissions. Clinical features may also be adjustable to avert readmission. A distinct diagnostic related group or group of diseases might not be accountable for an elevated share of readmissions. In general, readmissions are predominately sicker patients discharged to nursing homes, and/or those who are socio-economically disadvantaged. However, recent literature indicates these patients have a lower rate of readmission because of the step down care provides. Readmissions subsequent to prior surgical stays reflect quicker readmission rates and are likely to be insufficient care, while readmissions, following medical stays result from insufficient outpatient primary care or poor discharge planning.

  

One topic under discussion is which if any illnesses should have exclusion including behavioral health, chemotherapy, labor and delivery, and palliative care.

Some are at odds on with including behavioral health. Others accept behavioral health readmissions being an applicable marker. Similarly, unexpected readmissions for specific behavioral health illness can be a means to examine the value of behavioral health.

However, for chemotherapy, labor and delivery, and palliative care inclusion for performance measures may damage patient care, and skew the actual results of readmissions.

Beginning an innovative metric can have latent constructive betting. As an example boosting earnings by accepting a smaller amount of complex, care that increases revenue and lowers readmissions. Another thought to consider is depending on the admission type falsely entering data when performance ties to revenue. . 

Widely understood improving discharge planning is a key component to reducing readmission rates. Specifics of the efficiency of community care after discharge varies. Consideration to a single method assesses only the potential for partial impression on readmission.  Many features of care exist, if afforded an insufficient characteristic, might lead to a readmission. Specific clinical division, will have observable entrants for perusing. Infectious disease and blood clots will benefit from strict discharge planning orders communicated thoroughly with the patient, the care provider, and the caregiver.

Readmission prediction models currently developed require improvement before implementation at the point in time. Without established current data makes it impossible to be accurate or close to.  

Compelling relations connecting of readmission medical features count diagnosis, and socio-demographic aspects including age and background. Do we use risk adjusting readmission rates to include these influences? Risk adjustment for diagnosis and complications are accurately weighed against. Hospitals do not have the same case-mix from one to another.

There are unsatisfactory admissions and readmission data for most settings to provide dependable assessment of unnecessary readmission rates.  Diagnoses have to be comprehensive with larger categorization or using methods the National Committee for Quality Assurance using systematic three-year mean. Benchmarking using local

best practice or evaluate as opposed to improvement in opposition to subjective principles.

Maryland’s Multi-payer Patients Centered Medical Home Program

As the result of legislation, insurance carriers required to participate are the following Aetna, CareFirst, BlueCross, BlueShield, CIGNA, United Healthcare, and Coventry. Carriers who gross more than 90 billion are required participators

The Centers for Medicare and Medicaid Services announced a pilot project so that any state-sponsored programs may participate.

The program requires that all participating practices apply for NCQA’s recognition program for level 1+ or higher within 6 months. By December 2011 and level 2+ within 18 months of implementation. The practices must pass categories within each of the nine NCQA domains. The elements are strongly linked to potential cost savings to purchasers, and patients. 

  

Selection criteria including primary care physicians, and nurse practitioners. Geographic diversity, practice size, and ownership type are a part of the criteria selection too.

According to the NCQA recognition requirement nurse practitioners are not recognized however, NCQA will review applications and forward the details to the MHCC, if they meet level 1+ and level 2+ requirements. The caveat is they will not be recognized by NCQA.

Practices may participate in Maryland’s MHCC program and single payer programs, such as CareFirst if the program is site specific, using NCQA requirements; CareFirst is enrolling practices at the organization level. Participation with both programs requires following patient participation rules, payment methodologies, and quality reporting according to both programs. In other words not combining information into one report if variances between the reporting requirements differ.  CareFirst may supplement MHCC payment system consistent with Care First’s for the practice using both payment systems. Other practice locations not in the MMPP will follow the CareFirst conventions.

In order for cost-effectiveness for the practice, the practice needs to participate with 2-5 of the required carriers.

Patient participation includes an op-out option. The payment for those patients opting out who opt-out are excluded from the payment and quality measures.

Every six months patients joining and leaving the practice will be added to the payment program. The quality measure includes providing a list of patients and their insurer to MHCC. The information is matched against enrollment records and claims histories. The patient according to where most primary services received using E&M codes for the prior two years are matched to the primary provider. If the patient has not received services within the window, the patients are evaluated with pharmacy claims. Those patients who have changed carriers within the window are in the process of determining verification.

Do I want the government knowing what I am being treated for and how is that information used? What other entities have access to the information.

It is irrelevant the number of locations within the practice, all locations is included in the payment system.

Practices performance measures for monitoring are at least one disease including diabetes, heart/stroke management, and asthma control. These measures align with Medicare and Medicaid’s EHR meaningful use definition for bonus payments and Medicare’s PQRI standards. Incentive payment guidelines including meeting thresholds in reduction.

The payment structure is different from managed care capitation. PCMH offers a fixed and incentive payment in addition to the fee-for-service payment. The fixed and incentive payments differ for treatment services.

Payment includes two types of reimbursement. Practices will receive per patient monthly payment for those patients participating with the program. This is to cover the cost related to the program. This payment is semiannual. Adjustments include the number of patients, payer category, and NCQA recognition standards. Practices that decrease emergency department visits and hospital utilization are included in payment as well. Fixed payments begin April 1, 2011. The semiannual payment is retrospective and depends upon meeting quality thresholds.

How much is per patient, is the carrier required to report this information to MHCC? How does it benefit the carriers who pay the fixed payment?  If the practice receives bonuses for decreasing hospital services and ER services then how is that a savings for the state? What is the projected savings with and without using this incentive?

  

If the practice receives subsidy from a private carrier for house bill 706 and participate in the program the subsidy payment will be a countable cost in shared savings computation.  The example provided is if a practice location receives $15,000.00 in HER subsidies in 2011, those payments will be counted as expenses to the practice when the shared savings are calculated. The treatment of the subsidy is identical to the fixed payments are considered in the share savings computation.