Hospital readmissions are costly and often preventable events. Yet intense efforts to decrease readmissions rates and avoid penalties under the 2010 federal healthcare reform law have yet to have a significant impact, as one in five hospitalized Medicare beneficiaries are still being readmitted within 30 days of discharge.
According data compiled by the Centers for Medicare and Medicaid Services (CMS) as part of its Readmission Reduction Program, more than 2.3 million Medicare patients -- almost one fifth of hospitalized Medicare beneficiaries -- are readmitted within 30 days of discharge. Many of those readmissions were related to quality and coordination of care issues that are within the control of healthcare providers.
The same data suggests that if hospitals lowered readmission rates to the levels achieved by the top performing regions identified by CMS, Medicare could save $1.9 billion annually.
To address this problem, CMS is taking a "carrot and stick" approach to combating unnecessary spending related to readmissions. Through its Readmission Reduction Program, it is providing incentives to organizations with low readmission rates and levying penalties on those whose rates remain unacceptably high.
Beginning in October 2012, hospitals face a 1 percent reduction in Medicare payments for higher-than-expected 30-day readmission rates for potentially preventable conditions, including acute myocardial infarction (heart attacks), heart failure, COPD and pneumonia. Penalties will increase by 1 percent each year, topping out in 2015 at 3 percent.
CMS' efforts to reduce readmissions extend to Accountable Care Organizations (ACOs), which must report on 33 quality measures if they wish to receive incentives under the Medicare Fee-for-Service Shared Savings Program. Included in this are quality standards for care coordination and patient safety, patient experience, preventative care and disease management.
Impact on ACOs
Under CMS' standards of care coordination and patient safety, ACOs must monitor and reduce the number of readmissions for the aforementioned potentially preventable conditions. Those that achieve low readmission rates by successfully managing coordination of care will share in any savings they generate. Those that do not meet the quality expectations outlined by CMS, including those tied to reducing readmissions, will be penalized. For those operating under the ACO model with both shared savings and losses, this will mean paying out-of-pocket to cover losses.
ACOs primarily comprised of local hospital and physicians will need to develop care management that follows the patient along the care continuum – not only during the inpatient stay, but after discharge including home health, utilization management, case management, outpatient primary and specialist visits, medication reconciliation, medical and pharmacy data integration, laboratory data integration, etc. Medicare Advantage Plans have invested tens of millions of dollars in developing their own longitudinal care management strategy, with results showing re-admission rates are 15-20% lower than Fee For Service Medicare (Lemieux, JAMC,Feb 2012). Newer care models are also evaluating in-home devices for real time monitoring of blood pressure, pulse, weight, and other metrics to provide actionable data for those patients at risk.
Reducing readmissions, improving outcomes
For ACOs, partnering with technology organizations that provide integrated actionable healthcare will be the key to improved quality outcomes. By integrating patient data from multiple clinical and administrative sources and making it available in real-time to hospitals, physicians and other providers, these solutions arm ACOs with the information they need to improve coordination across the care continuum.
Further, they allow ACOs to better manage high-risk and recently discharged patients by identifying when interventions are necessary, reducing unnecessary readmissions and encouraging better patient self-management. Cloud-based solutions also eliminate several important barriers to success, such as upfront and ongoing expenses, interoperability issues and slow speed-to-market.
By providing a means by which to share actionable information across the continuum of care, actionable healthcare solutions enable communication between all stakeholders and ensure that providers have access to a complete picture of each patient under their care.
Solutions that drive integrated actionable healthcare ensure that physicians, hospitals and other providers have access to the information they need, when they need it. They help ACOs better manage patient populations, identify care gaps and trigger interventions before readmission is needed -- a major driver in achieving quality outcomes and shared savings under CMS.
Anil Kottoor is the CEO and president of MedHOK.