30 Day Readmissions

Costs incurred in the management of diabetes can be categorized as either direct or indirect, direct being the costs incurred in the management of the disease through medication, laboratory tests, physician and nursing care. Indirect cost, on the other hand, includes the cost of incurring a loss of productive individuals since the disease is associated with high mortality and morbidity. Over time the cost of management of diabetes has been rising with the increasing number of new cases of the disease. The cost of care for instance in 1980 ranged between 14 and 20 billion dollars. However, in 2002 the cost had increased to $132 billion, while the cost of managing the disease in the year 2007 was estimated at $174 billion in the United States

In a world of budget cut and layoffs, medical corporations face new and different challenges in addition to helping and healing patients. I used to work as a medical biller in a physician’s office for five years and I experienced how difficult for the health care providers to get reimbursed. The government and the insurance companies have been limiting the budget towards the health care services. This action also affects the hospitals greatly because Centers for Medicare & Medicaid Services (CMS) and some policymakers have requested the hospitals to reduce the

Healthcare in the U.S is most expensive than any other developed country. The U.S spends far more on per capita as compared to any other developed. U.S scores low on many outcome measures, inefficiencies and wastes and quality measures as compared to other countries. The Patient Protection and Affordable Care Act is developed to strengthen these failures in the health care system. The U.S healthcare is transforming care from volume based reimbursements to value based payments. The healthcare law works around providing more patient centered care and better preventive care. One of the payment reforms with Obamacare is to penalize the hospitals with high readmission rates for the three conditions – Acute Myocardial Infarction, Heart Failures and Pneumonia.

Early rehospitalizations of patients in various disease states have been well studied in recent years. Research in this area has increased since the Centers for Medicare & Medicaid Services (CMS) made readmissions within thirty (30) days a major quality indicator for health care organizations. These admits consume a considerable amount of health care costs and interventions are needed that are aimed at reducing risks associated with rehospitalization (Hain, Tappen, Diaz, & Ouslander, 2012). Early readmissions in those with decompensated cirrhosis are costly, partially preventable, and linked to worse patient outcomes (Volk, Tocco, Bazick, Rakowski, & Lok, 2012). Developing specific disease oriented interventions can help decrease morbidity

According to The Center for Managing Chronic Disease at the University of Michigan (2011) website, chronic disease can be defined as any medical condition in which the treatment expectation is one of control, rather than cure. The website further states that up to 70% (1.7 million) of deaths in the United States can be attributed to chronic disease. This statistic is not limited to the United States. The World Health Organization (2014) website states chronic disease accounts for 60% of all deaths worldwide, and half of those deaths occurred in people under the age of 70. The diagnosis of a chronic disease impacts a person in

CMS 30 day-readmission penalties have motivated hospital to reevaluate discharge planning in hopes to reduce 30-day readmissions. Lopes et al. (2015) used the CRUSADE registry to evaluate causes associated with 30-day readmissions. This study included 36,711 patients with non-ST segment elevation myocardial infarction, age > 65 enrolled February 15, 2003 – December 29, 2006. This study evaluated comorbidities and cumulative incidence of readmissions over one year and found that readmissions with the very elderly having 50% mortality rate at 1 year which was thought to be impacted by co-morbidities, deconditioning and avoidance of core measure post-MI medications for various reasons. The final conclusion was that

This savings would be a direct result of decreased overpayment by Medicare to hospitals, physicians and insurance companies (Perez, 2013). As a result, Centers for Medicare and Medicaid is incentivizing increased quality care in hospitals. Consequently, hospitals are not getting reimbursed for hospital acquired conditions. In addition, CMS is penalizing hospitals for readmissions (Bauchner, 2015). Lawmakers are expecting resounding savings related to CMS expectations. The short term savings of more than $200 billion through 2016 (CMS, 2015). As a result, hospitals are in a paradigm shift from volume based care to value based care. The expectation is that hospitals will reduce waste and decrease inappropriate waste which will result in savings that be used for other therapies (Bauchner,

Healthcare costs in the United States (U.S.) have escalated exponentially in recent years due to many factors. The Affordable Care Act was legislation passed in 2010 to attempt to change the delivery of healthcare in the U.S. and circumvent the continued rising healthcare costs. A major factor contributing to healthcare costs is the Medicare population and their readmission rates to the hospital within 30 days of discharge. This factor involves many layers of services and financial implications. This paper will discuss how healthcare quality results in hospital readmission, the fines that are imposed by the government through Health Readmission Reduction Program, the changes implemented by hospitals to decrease readmission

The U.S government spends about 17% of GDP on healthcare industry which is enormously high as compared to any other industrialized nation. President Obama signed the comprehensive healthcare reform – Patient Protection and Affordable Care Act on March 23, 2010. The law worked on the principles of triple aim to reduce healthcare cost, improve quality and access for the U.S citizens. One of the fundamental component of Affordable Care Act that will affect the caregiving to the U.S citizens is payment cuts to the hospitals if they do not provide quality care to their patients. The reason behind these payment cuts is because Part A Medicare Trust may go bankrupt by 2017. Hence, it is necessary to bring the cost of healthcare under control along with providing quality care to the patients. In order to contain cost, ACA proposed Medicare Readmission Program. Effective October 1, 2012 Medicare will reduce payments to the hospitals that will have higher percentage than the specified amount of preventable readmission rates. Effective fiscal year 2015, Medicare will penalize the hospitals by 1 % that will show higher number of hospital acquired infections (KFF, 2013). CMS has reported that approximated one out of every 5 Medicare patients are admitted back to the hospital within 30 days of their prior inpatient stay. Readmission rates are generally high for hospital that serve more vulnerable population like safety net hospitals. The high readmissions are caused by a

Helping patients stay out of hospitals is not only an important quality improvement objective but also a financial one especially after the advent of Affordable Care Act (ACA). Efforts to improve clinical outcomes and reduce readmissions have been ongoing for several years, but still high readmission rates continue to be an issue for most healthcare organizations. Although many hospital readmissions cannot and should not be avoided, a wide variation in readmission rates across the hospitals nationwide, has led the researchers and Center for Medicare and Medicaid Services (CMS) to believe that hospitals can implement various quality improvement strategies to reduce their readmission rates and improve patient care as a whole. In an effort to reduce readmission rates and achieve better quality outcomes, CMS has started Hospital Readmission Reduction Program (HRRP) under which the hospitals will be penalized by up to 3% of total Medicare reimbursements, for readmission cases within 30 days specifically for conditions like heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and elective hip or knee replacement. The percentage of hospitals receiving a penalty in 2014 was around 64%, which has increased to about 78% in FY 2015 making it a high priority quality improvement concern for healthcare organizations in order to retain their Medicare patients and balance their Medicare reimbursements.

Hobbs et al. (2016) examined current research to determine the efficacy of post-discharge follow-up phone calls in reducing the 30-day readmission rate for patients with HF. They identified that while patients who received calls ultimately had better outcomes, evidence to support that telephone follow-up could independently prevent readmissions was insufficient (Hobbs et al., 2016). Nonetheless, telephone follow-up coupled with other interventions such as clinic follow-up and telemonitoring did prove to have positive effects on post-acute transitions of care in HF patients (Hobbs et al., 2016).

As millions of Americans suffer from the preventable illness and chronic disease, more than 75% of nation’s health spending is on treating the chronically ill people. The website

For years, healthcare costs have continued to increase in the United States and policymakers are constantly trying to find ways to reduce spending. According to reports, in 2011, about $900 billion out of the $2.6 trillion annual health care spending was wasteful spending. In the following year, there was a reported $690 billion wasted annually on healthcare. This wasteful spending is attributed to ineffective health care delivery, cost of adverse events, and poor care coordination that has led to avoidable readmissions (Lallemand, 2012). In the United States, readmissions are the highest amongst patients with chronic diseases accounting for about 90% of avoidable readmissions in 30 days after discharge, and costing the industry an estimated $17 billion. These readmissions are a result of inadequate discharge planning, lack of follow-up, and lack of education on disease management (Jayakody et al., 2016). Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care.

According to the CDC, as of 2010 diabetes effects about 1% of the population aged 20 years or less in the United States, with 13,000 children under the age of 18 diagnosed with type one diabetes per year. In 2007 it was found that an average expenditure was $11,744 per year. This amount includes direct attributes to diabetes such as medical costs, as well as lost work days, restricted activity and disability related to diabetes. This amount is “approximately 2.3 times higher than what expenditures would be in the absence of diabetes” (Center for Disease Control and Prevention (CDC), 2012).

The United States burns through $2.2 trillion a year on health care: over five times more than the defense budget. In fact, they pay more per individual in health care than any created nation in the world, yet Americans are sicker than ever before. Obesity, diabetes, heart disease, and high blood pressure are just a few of the diet related health issues that cost the U.S. billions of dollars every year. Every minute a person is killed by heart disease and diabetes is on the rise, particularly among the younger population (Stone).