How Is The Hrrp Reducing Chf Readmissions?

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

United States Department of Health and Human Services (HHS), Healthy People 2020 (2018) recognizes cardiovascular disease as one of the most widespread and costly health problems in the United States, accounting approximately $320 billion in health care expenditures and related expenses annually. Healthy People 2020 (HP2020) identifies prevention of cardiovascular disease as one of the priorities and includes an objective “to increase overall cardiovascular health and quality of life for US population." (HHS, Healthy People 2020, 2018)

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).

There is a problem of avoidable hospital readmission rates for the Medicare and Medicaid populations that lead to adverse consequences not only for the patient, but also the payer and hospital. In order to decrease these avoidable readmission rates it is important to identify processes that can be implemented at the health plan level such as pre-discharge hospital visits by health plan staff, and post-discharge care coordination.

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

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.

In my current role a President of our integrated care network, one are largest cost outliers in our Medicare cost report was our 30 day readmission rate. The government has defined 30 days as the time period they feel a patient should be not readmitted to a hospital for certain diagnoses. Studies have looked at the groups that have had intervention in terms of discharge planning, and those with no intervention or discharged in a "usual" fashion from an institution. A study in the journal Circulation in 2013 looked at this exact question and found that following certain protocols could reduce the readmission rates in heart failure patients (Bradley, et al., 2013).

It may seem inevitable that high readmission rate is one of the challenges that an acute care setting is currently facing. According to studies, 20 percent of Medicare patients alone, get readmitted within 30 days of discharge. (Alper, E., O’Malley, T., & Grrenwald, J. 2017). Avoiding or preventing hospital readmission within 30 days of discharge can help Medicare save around $17 billion dollars yearly. (Morse, S. 2016). Understanding and getting to the root of why high re-admission rates still occur is highly important. Not only it will be cost effective but will also create a better well-being on the patients.

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.

The number of U.S. deaths due to cardiovascular disease has drastically increased over the past century.

“With shorter hospitalizations and high patient loads for both physicians and nurses, discharge planning is often hurried and incomplete” (Balaban, Weissman, Samuel, and Woolhandler, 2008). After reviewing national surveys regarding hospital discharge, they found that only 50% of patients with congestive heart failure received any sort of written instructions at the time of discharge. Other information revealed most patients were unaware of their discharge diagnosis, misunderstand the use of new medications, and receive insufficient discharge care, all of which are major contributors to hospital readmissions (Balaban et al., 2008). They proposed a similar model with the same goals and their findings supported the use of some sort of designated discharge coordination that connects the hospital and community, they were able to divert a significant number of revisits to the hospital for issues that had already been addressed and patients were simply uneducated regarding their condition or proposed treatment plan. Another study where the hospital set up an actual discharge clinic reported that in the first six months of operation they were able to “reduce emergency room visits and readmissions for targeted patients by 68%” (Beresford, 2011).

The Cardiac Rehabilitation (CR) model has been developed to encourage greater utilization of post-acute treatment for AMI or CABG patients in the 90-day post-discharge period. The goal of the models is to improve the quality of care for several heart conditions and surgery on hips other than total hip replacement.11 After the success of CJR, CMS expects the EPM and CR programs to significantly increase quality and reduce cost by the same principles. Moreover, while the mandatory programs show promise, voluntary-based bundle-based programs are also improving value-based care. For example, a study evaluating AMI, heart failure, and pneumonia demonstrated that hospitals that participated in these Medicare value-based programs led to a reduction in thirty-day standardized readmission rates.9 This study suggests that even in the absence of a mandatory episode of care based payment model, it may be to a hospital’s advantage to consider these programs as they may lower cost while increasing quality of care.

I also wrote about this provision HRRP. I believe that this provision is important to keep hospitalization readmits low therefore reducing healthcare cost. This will better assist in follow up care after hospitalizations. However, it is important that we take into consideration that not all readmissions are avoidable and many are actually related to initial admission. We need to continue to adjust for demographic populations, so that the penalties are proportioned to community populations. It is unfair to penalize hospitals on the same rate when there are many socio demographics that play a factor in readmits. I believe over time that the penalties will be re-calculated and adjusted.

The purpose of this study was to find out if more Americans are living longer with cardiovascular disease will increase costs while lowering their quality of