This book includes a plain text version that is designed for high accessibility. To use this version please follow this link.
● RAC Audits

Examining Medicare

patients stay as healthy as possible – and avoid readmissions. But as new delivery and payment models emerge that tie reimbursements to medical outcomes, hospitals have another motiva- tion. T ey are receiving a stern warning from healthcare payers, Medicare in particular: High readmission rates for ostensibly prevent- able conditions could cost you. Rules outlined by the Patient Protection


and Aff ordable Care Act (PPACA) require the Centers for Medicare and Medicaid Ser- vices (CMS) to adjust payments to hospitals with higher-than-average readmits begin- ning Oct. 1, 2012. On Aug. 1, 2012, CMS released its Inpatient Prospective Payment System (IPPS) fi nal rule, including the initial framework for the Hospital Readmission Reduction Program (HRRP). HRRP, un- like the inpatient quality reporting program currently in place, could result in reduced payments to hospitals with high readmission rates for certain conditions. T e Medicare Payment Advisory Com- mission (MedPAC) reported in 2005 that about 11 percent of hospital stays resulted in readmission within 15 days of discharge and 18 percent within 30 days, accounting for $17 billion in spending. Examining data from 10.7 million hos- pital discharges of Medicare patients, the Dartmouth Institute for Health Policy and Clinical Practice found that readmissions

22 March 2013

ou’ll rarely hear “hope to see you soon” in an acute care setting. Clinicians are gener- ally motivated to help their

following surgery in 2009 were at about the same level as in 2004.

Payment adjustments impact revenue Under the new rules, the program will begin with three applicable conditions: acute myocardial infarction (AMI), heart failure and pneumonia. Hospitals with above-average 30- day readmission rates for patients with these three conditions could lose up to 1 percent of their Medicare reimbursements. And that’s just the beginning: T e payment reduction is slated to rise to a 3 percent risk-adjusted maxi- mum by 2015 and cover more conditions, including many related to vascular surgeries. According to a 2010 T omson Reuters study, a hospital with 250 heart failure patients and a readmission rate 20 percent higher than the national average should expect to see a Medicare payment reduction of $250,000. Hospitals that serve higher numbers of

low-income and indigent patients are at greater risk of payment reductions. Unfor- tunately, this anomaly isn’t addressed in the CMS regulation. Nor does the agency plan to reward high-performing hospitals, which has some pundits questioning how eff ective the new rules will be.

Assessing the problem Experts point to a variety of systemic

failures that lead to high readmission rates, including the reality that many patients don’t adequately follow their care plans. In fact, the Dartmouth Atlas Project found that more than half of discharged Medicare patients fail to visit their primary care physician within


readmissions Strategies to mitigate potential revenue hits. By Carla Engle

Carla Engle is a director of product management at Emdeon and a former contributing editor at RACMonitor. For more on Emdeon: www.

the typically recommended timeframe of two weeks – a situation that can be improved with better ongoing care coordination eff orts by providers, according to Dr. David Goodman, lead author of the Dartmouth study. Poor care handoff s, which can include a lack of standardized procedures guiding the transition process, are also a source of blame for high readmission rates. Addressing the problem of sentinel events, for example, the Joint Commission reported in 2005 that 70 percent of these unintended occurrences were caused by communication failures, with at least half of the problems occurring during care handoff s. It’s well known that healthcare provid- ers often lack complete or accurate patient medication histories. Without adequate medication data, patients are at increased risk of drug-related errors. Today’s clinicians acknowledge they must do a better job of ensuring their patients aren’t soon readmitted to the hospital. And they are looking to solutions – such as medication reconciliation technologies, utilization and case management tools, population health and disease management eff orts, and advanced IT analytics – to assist their eff orts.

Applying effective solutions Medication reconciliation solutions, for example, applied at key points in the care continuum, such as during care handoff s when patients are most likely to receive new medications or alternative doses, are playing a bigger role in the prevention of readmissions. Among the solutions, clinicians increasingly

Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32