Atisfaction Case Study

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

The Affordable Care Act (ACA) added to the Social Security Act has increased the financial accountability of healthcare organizations for preventable readmissions. Hospitals have increased their awareness and are looking for system ways to assist in the reduction. The Centers for Medicare and Medicaid Services (CMS) have initiated a process for decreasing the reimbursement for readmitted patients within a 30-day period. CMS identified readmission measures for applicable conditions of acute myocardial infarction (AMI), heart failure (HF), pneumonia and in 2015 chronic obstructive pulmonary disease (COPD) and hip and knee replacement which are included within the measurement to calculate the readmission payment adjustment for

This article reviews the history of Medicare’s Hospital Readmission Reduction Program (HRRP) which began in October 2012. It examines why Medicare and Medicaid initiated the program, clarifies what conditions were originally included in HRRP and analyzes the reasoning behind adding Chronic Obstructive Pulmonary Disease (COPD) to the list of high priority conditions. It also, clarifies what information U.S Centers for Medicare and Medicaid (CMS) take into consideration when calculating readmission rates and points to the fact that high readmission rates could be due to non-hospital factors. The authors review new data that focuses on the potential harm of adding COPD to the list of conditions due to the increased level of patients from lower

The Affordable Care Act was enacted to improve health care and to lower health care cost in America. The ACA developed different strategies to meet these goals called the “pay for performance” programs. These strategies are aimed at the different providers to improve quality care. The strategy that I selected is the “Hospital Readmissions Reduction Program” this program/strategy is also known as the HRRP and was begun in October of 2012. HRRP is aimed at hospitals and penalizes hospitals that have a high 30 day readmission rate. The penalties are assessed and based on a number of comparisons, those such as, performance, patient demographics, comorbidities and frailty.

The Hospital Readmissions Reduction Program (HRRP) was passed in 2012 under the Affordable Care Act, to help hospitals to improve patient care and reduce costs. (Danner, 2016). The diagnoses with the highest readmissions rates associated with the highest expense are: acute myocardial infarction (AMI), pneumonia, and congestive heart failure. CMS also extended their program in 2015 to incorporate reimbursement reduction for hip/knee replacements, Chronic Obstructive Pulmonary Disease (COPD), and they also have plans in 2017 to include 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.

Your hospital will be penalized if you get readmitted within 30 days because of the chronic disease mismanagement. The Affordable care act (ACA) has changed the perspective of chronic disease management of hospitals, shifting their focus from treating the conditions to deciding ways to prevent them. Under ACA, hospitals will be penalized or rewarded depending upon their performance on 30-day readmissions, infection control and patient satisfaction levels (1). Government is playing his role to reduce the burden of chronic diseases in society but being a responsible citizen, do we realize the intensity of situation and the economic instability it is causing?

To encourage efforts of hospitals to reduce readmission, the Hospital Readmission Reduction Program (HRRP) was created under Affordable Care Act. The HRRP is mainly a payment penalty program designed to reduce hospital readmission rates for medically expensive conditions- such as heart attack, pneumonia, health failure (penalties levied in 2013 - ‘14). Under this program, hospitals with readmission rates that exceed the national average are penalized by payment cut across all-of their Medicare admissions. For 2015, CMS has added COPD, and elective hip or knee replacement, while types of pneumonia cases following CABG are included starting 2017. In addition to new conditions, the maximum penalty will increase up to 3 percent of the Medicare payment. This penalty is not limited to only above mentioned six conditions, but apply to all Medicare patients. (For HRRP program overview, see attachement-1)

Hospitals nationwide have been striving to reduce the rate of patient readmissions. Both the federal government and private insurers are tired of picking up the tab. In a 2009 study in the New England Journal of Medicine, researchers estimated that a year's worth of unplanned re-hospitalizations cost Medicare alone $17.4 billion. Congestive heart failure is a particularly big target, as one in four patients end up back in the hospital within 30 days of discharge. Starting in the fall of 2012, the government will cut Medicare reimbursements for hospitals with higher-than-expected 30-day readmission rates for heart failure and two other conditions: heart attack and pneumonia (Avril, 2011).

The Center for Medicare and Medicaid Services (CMS) have proposed policies that will penalize healthcare organizations for the increasing readmission rate related to patients who has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD). This readmission policy is part of the CMS Hospital Readmission Reduction Program (HRRP) which was enacted to further address the diminishing quality of health care services and to curb the rising cost of health care services by providing financial incentives to healthcare organization in order to promote gravitation toward Accountable Care Organizations (ACO) or Managed Care Organization (MCO). The main objective of levying reimbursement penalties on healthcare organizations is to move away from the fee-for-service method of reimbursement toward a patient-centric, and disease management approach where healthcare services are coordinated not just in the acute phase of disease, but also in the chronic of phase disease.

Mandated by the Patient Protection and Affordable Care Act (ACA), on October 1, 2012, the federal government launched the Hospital Readmissions Reduction Program. The objective of the program was to compel hospitals to improve quality and continuity of care. Hospitals with high rates of Medicare readmissions will suffer financial penalties. Readmissions are defined as returning to the hospital within 30-days of discharge for the same illness (www.cms.gov).

In the United States, our health care system is often characterized by communication failures. According to the American Nurses Association (2012), “Care coordination has been proposed as a solution to many of the seemingly intractable problems of American health care: high costs, uneven quality, and too frequent disappointing patient outcomes” (para. 14). Care coordination is a very important aspect in nursing roles and is extremely valuable because it can improve outcomes for everyone: patients, payers, and providers. Although it is obvious that the changes will improve patient care and general efficiency, applying changes in the general approach and everyday routines may be overwhelming. Luckily, there are resources available for those interested in taking a more coordinated approach to primary care practice (“Social Media’s leading Physician Voice,” 2012).

Across the U.S., many Medicare beneficiaries rely on hospitals servicing low-income areas for their care, placing additional financial pressure upon the institution. It is reported that each year within the U.S. one of five Medicare recipients returns to the hospital within 30 days of discharge, roughly costing the program $18 billion (Mittler et al., 2013). Many of these readmissions are for conditions that are thought be preventable had patients received the proper discharge planning, education, and support. Upon survey,

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.

It is apparent the Medicare readmission rates are a concern. In fact, to help reduce unnecessary readmissions, the government established a hospital readmissions reduction program (HRRP) in 2012 (CMS, 2016). This program requires CMS to reduce payments to those hospitals having avoidable readmissions (CMS, 2012). The CMS provides hospital compare datasets with information on hospital compliance to HRRP, or lack thereof. Because Advocate Health Care is the largest health system in Illinois and named among the nation’s top health systems based on quality, our group chose to research the readmission data on the hospitals within the Advocate system (Advocate Heath Care, n.d.). According to CMS’ hospital compare datasets (2016), the number of CHF readmissions among Medicare patients at Advocate Illinois Masonic Medical Center (IMMC) and Advocate Trinity Hospital (ATH) were 313 and 418, respectively, for the time period between July 1, 2011 and June 30, 2014. In 2015, Medicare reimbursement for IMMC was reduced by 1% as a result of having excess readmissions, which is an increase of 0.02% over 2013 (Chicago Tribune, n.d.). In the same year, Medicare reimbursement for ATH was reduced by 1.13%, which is an increase of 0.39% from 2013 (Chicago Tribune, n.d.). Both of these hospitals are located in Chicago,