Hospital Readmissions Reduction Program

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

In 2012, the ACA found an excessive amount of readmissions of patients that were hospitalized within 30 days for the same medical conditions. This factor viewed under the ACA as a quality issue and CMS implemented value-based incentive payments based on performance in a set of quality measures. The plan is to implement a pay for performance (P4P) in formulas used by Medicare to reimbursement providers. “The objective is to link reimbursement to quality and efficiency as an incentive to improve the quality of health care, as well as reduce system-wide costs” (Shi and Singh, 2015). In addition to the P4P, nonprofit hospitals also focus on continual improvement, data and cost containment throughout the organization (Adamopoulos,

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.

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).

This memorandum describes Central Health’s Readmission Reduction Program set to commence in May 2017. The Centers for Medicare and Medicaid Services (CMS) has raised concern over the increasing readmission rate and poor quality of care. To address this issue, Congress has created Hospital Readmission Reduction Program (HRRP) statute under the Affordable Care Act, 2010, which was recently updated under 21st Century Cures Act of 2016. Under the constant pressure of a penalty, Central Health has considered to establish its own Hospital Readmission Reduction Program to address specific imperatives, such as care-coordination, treatment adherence program, and streamlined patient discharge process.

Readmission to a hospital creates strain and added expense for the patient and hospital; in 2011, hospital costs due to readmission were almost $41.3 billion (Hines, Barrett, Jiang, & Steiner, 2014; Rau, 2014). There are many aspects of healthcare associated with readmission, such as lack of discharge planning and education, which need to be addressed i to decrease the amount of preventable re-hospitalizations.

This newer reimbursement system has been a topic of contention amongst a large portion of the professional medical community due to the perceived unfairness that it brings in certain situations where a patient must be readmitted and, as a consequence, the primary care providers may not be reimbursed for the readmission regardless if they were responsible. With the introduction of the Affordable Care Act in 2010, further criteria such as the Readmissions Reduction Program have been added that determines the eligibility of a primary care provider being reimbursed through the Medicare/Medicaid program. These new requirements have led to new avenues of contention amongst healthcare professionals and, in some cases, new avenues for fraud and patient discrimination.

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,

Preventable hospital readmissions remain among one of the many serious quality issues plaguing the healthcare industry today. Readmissions can carry fiscal implications, impact patient safety, and outcomes of care (Helm, Alaeddini, Bretthauer, & Skolarus, 2016). The cost of unplanned hospital readmissions is estimated to be upwards of $15 billion dollars annually of which $12 billion has been associated with preventable admissions (Helm et al., 2016). It is highly recognized that as many as 20% of Medicare beneficiaries are presently being readmitted within 30 days of discharge (Hunter, Nelson, & Birmingham,

The aim of the Affordable Care Act (ACA) is to reduce hospital readmission and to increase implementation of transitional care coordination for low health care cost. One benefit of establishing this

Under the ACA there is a new method of payment called value-based purchasing (Yuh et al., 2015). Value-based purchasing focuses on aspects of quality care such as: patient safety, efficient care, and customer satisfaction. By providing quality care, physicians and hospitals are offered incentives that deter them from providing avoidable and pricey care (Yuh et al., 2015). Another way that the ACA is enhancing quality care is through the Readmissions Reduction Program. This program will decrease the reimbursements that the hospital will receive if there are a surplus of readmissions within a 30 day period. Overall, this will also improve quality of care by making sure that the patient is really ready for discharge when leaving the hospital and also strengthen efforts to reduce nosocomial infections (Aoughsten et al.,

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

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

In an effort to curb these costs, in 2013 the Center for Medicare and Medicaid Services (CMS) enacted the Hospital Readmissions Reduction Program. Under this program, hospitals are penalized for readmissions occurring in the first 30 days. The penalties apply to specific conditions for CMS recipients including acute myocardial infarction, heart failure, coronary artery bypass graft

Readmissions is a basis for financial penalties to hospitals as a provision of the Affordable Care Act by reducing payments to hospitals with an” excess” 30-day readmissions. The data showed that patients living in high poverty neighborhoods were more likely to be readmitted, older and male patients were more likely to be readmitted as opposed to young and female patients. Lastly, patients with CHF, acute myocardial infarction, and those with certain diseases, such as diabetes, liver and kidney disease were at higher risk of being readmitted. The data also showed married patients were less likely to have a readmission because of more social support (Study Links Social, Community Factors with Hospital Readmissions,