By Marisa Torrieri | December 4, 2014
The New Year is weeks away but healthcare organizations have already resolved to
strengthen their focus on reducing hospital readmissions, which waste at least $26
billion annually (http://healthaffairs.org/blog/2013/03/14/thehumanfaceofhospitalreadmissions/).
Thanks largely in part to Affordable Care Act's Hospital Readmissions Reduction
which requires CMS to reduce payments to hospitals with excess readmissions, hospitals and medical practices are feeling increased pressure to keep patients out of the ER after hospitalizations.
"CMS started focusing on readmissions with pneumonia, heart attacks, and [CHF],
so payment adjustments were focused on just those three, but in 2015, CMS added
hip and knee replacements, and in 2016, it will add COPD," notes Laura Palmer, the
director of professional development for the Medical Group Management
Making things more intense is the fact that hospitals are starting to feel the financial
impact of this legislation: In October 2014, CMS announced that 2,610 hospitals will receive lower
payments, totaling an estimated $428 million due to readmissions penalties. The shift to valuebased care, industrywide, is also playing a big role.
"One of the most impactful elements of the ACA is the subtle migration of risk from payers to providers"
says Wayne Sensor, CEO of Ensocare, a carecoordination technology provider and the former CEO of Alegent
Health. "Collectively programs such as the Medicare Shared Savings program, bundled payments, valuebased purchasing and accountable care organizations have caused the provider community to enlist a broad range of initiatives to more
effectively manage the episodes of care, regardless of the setting.
Examples include12/4/2014 leveraging technology to more efficiently and effectively discharge patients and to
coordinate care postdischarge, as well as the use of medical homes."
Hospitals Under Pressure
Unfortunately, the ACA provision that calls for payment penalties has had the
greatest effect on hospitals who serve some of the neediest patients. These
hospitals are being unfairly penalized because the sociodemographic characteristics
of the patients they serve mean it is more likely these impoverished patients will
need readmission, notes Akin Demehin, senior associate director, policy, for the
American Hospital Association.
Recent data from CMS show that approximately 77% of hospitals serving the
poorest patients incur a readmissions penalty. By contrast, only 36% of hospitals
with the fewest poor patients will receive a penalty.
"Hospitals treating the poorest patients tend to get the stiffest penalties."
"We certainly agree with the goal to address readmissions that should be prevented,
but hospitals are concerned with the structure of the program," says Demehin. "Your
likelihood of being readmitted has to do a lot with factors the hospitals can't control.
Sometimes communities where patients live don’t have primarycare physicians, or
patients have difficulties in getting medications. Hospitals treating the poorest
patients tend to get the stiffest penalties."
Even with those challenges, hospitals are stepping up their game.
"Planning patient discharge has become a real focus for hospitals," says Demehin.
"In terms of understanding what their risk of readmission might be, and which
patients are at higher risk. Discharge planning has become something that’s woven
into the care plan."
In addition, hospitals have have amped up their patient education efforts and formed
better collaborative relationships with their healthcare partners, such as nursing
homes and home health agencies. Efforts such as these have led to a "pretty steady
decrease in the national rate of readmission," he notes.
New Technology is Helping
The ACA hospital readmission penalties, coupled with the EHR Incentive
"meaningful use" program and other initiatives, have led to a huge growth in
technology designed to help providers address readmissions.
"From just a datatracking standpoint, medical practices need to have good
information from the hospital," says Palmer, adding that monitoring devices are just
one example of a technology that has allowed physicians to make sure patients are
receiving timely followup care. Because primarycare physicians are taking on more
responsibility as care coordinators, much of the technology on the market is aimed at
them, she adds.
And while EHRs have helped carecoordination and data collection efforts, there is a
growing market for business intelligence technology that helps healthcare
organizations have a better understanding of risk factors.
"Once EHRs are in place, other enabling technology can leverage the rich data for
the benefit of better patient care," says Sensor. "Examples include data mining by
diagnosis to improve the delivery of care and alerts for the provider that may indicate
a need for clinical intervention."