February 02, 2015
Preventing Readmissions: What the New Metric Means for Practice

Approximately 1 in 5 Medicare patients is readmitted to a hospital within 1 month of discharge. Even if you don’t think this figure is excessive, the Centers for Medicare and Medicaid Services (CMS) does — and, as a result, readmission rates have become one of the key indicators of the level of quality of care.

The Readmissions Reduction Program, mandated by the Affordable Care Act, is part of CMS’s drive to reduce costs and increase “value-based purchasing,” with the idea that lower levels of readmissions will indicate quality care — which will be financially rewarded — rather than merely quantity of care — which may be financially penalized. CMS defines a readmission as “an admission to a subsection(d) hospital within 30 days of a discharge from the same or another subsection(d) hospital.” Subsection(d) hospitals, as defined bythe act, include about 75% of short term inpatient acute-care hospitals; critical access, psychiatric, rehabilitation, long-term care, children’s and cancer hospitals are excluded.

Hospitals have therefore been incentivized to decrease readmissions by coordinating transitions of care and increasing communication between providers, departments and services when it comes to Medicare beneficiaries. The maximum financial penalty has increased over the last three years, and can now be as high as 3% of all Medicare payments — not just payments received for the readmitted patients, resulting in potentially huge losses to hospitals subject to the readmissions program.

According to Kaiser Health News, CMS will be fining 2,610 hospitals — a record number — for having too many readmissions. Thirty-nine of those hospitals will receive the maximum 3% penalty. The result: from October 1, 2013, through September 30, 2014, the fines will total about $428 million in lost Medicare revenue for the affected hospitals.

However, the program appears to be working: CMS estimates that hospital readmissions in Medicare declined by a total of 150,000 from January 2012 through December 2013. And readmission rates are expected to continue to fall. Furthermore, the aim of the program — whether we agree with the implementation or not — is a worthy one. It’s not just about lowering costs, the real goal is to ensure that hospitals discharge patients only when they are fully prepared and safe for continued care at home or in a lower-acuity setting. This might result in longer stays in some cases, but it will mean that patients are cared for appropriately.

Avoiding preventable readmissions and, therefore, financial penalties is a matter of making systemic change within hospitals. One list of “seven deadly sins” summarizes the failures that lead to readmissions:

  1. Poor discharge planning and patient education
  2. Absent post-acute-care partnerships
  3. Staying silent after discharge
  4. Ignoring the family or caregiver
  5. Not tracking metrics for service lines
  6. Treating all patients the same
  7. Poor triage practices

The common thread among these so-called sins? A lack of complete information that can be easily communicated to patients, caregivers and other providers, or used for data-tracking purposes. Using scribes is a solution that can ease reform within hospitals and among providers. With complete patient and care information recorded in real time, it is easier to share with other providers and facilities. Patients and their caregivers can be quickly provided relevant information that will aid post-discharge care — and elucidate when and when to not return to the hospital. Data can be extracted from these thorough records, to create trackable metrics.

High readmission rates need to be addressed. The key is not finding ways to keep patients from coming back but, rather, to ensure patient health records are complete; that relevant information about care is communicated to patients, caregivers and other providers; and that meaningful, standardized data can be extracted for tracking and service line improvements. The alternative may be losing up to 3% of Medicare payments.