Stephanie Whiteaker
Major Quality Improvement Initiative Research Paper
Ottawa University
June 22, 2018
Major Quality Improvement Initiative Research Paper
Hospital readmission is an admission to a hospital following an initial hospitalization. A common readmission timeframe measured by organizations such as the Centers for Medicare and Medicaid Services (CMS) is readmissions within 30 days of the index hospitalization. Readmissions are considered undesirable clinical outcomes because they suggest that the patient was discharged prematurely from the initial hospitalization or that the post- hospitalization care was sub-optimal (AbdelRahman, S. E., Mingyuan, Z., Bray, B. E., & Kawamoto, K., 2014). The Hospital Readmission Reduction Program (HRRP) created by CMS in 2012 and still in effect today can be attributed to section 3025 of the Affordable Care Act. This program went into effect in October 2012 and its purpose is to reduce hospital readmissions by limiting “payments to inpatient prospective payment system (IPPS) hospitals with excess readmissions” (CMS). Such payment reductions are “based on readmission rates for three conditions—heart failure, acute myocardial infarction (AMI), and pneumonia” (Gu et al 2015). Currently, excessive readmission for such conditions is defined as readmission to a hospital within 30 days after discharge from the hospital. Hospital’s excess readmission ratio is used to “calculate the readmission adjustment payment” (CMS) that a hospital can receive at any given time. The flaws of this program’s evaluation is that the methods used to determine excessive readmissions sometimes are not reliable and limiting possible readmission factors to only few conditions can be a problem. As a recommendation, I will like to see program evaluators appropriately mitigate risk assessment measures that could lead to a frequent readmission before penalizing a hospital. Also, evaluators should consider all, not only few factors that are causing increases in hospital readmissions.
The aim of my analysis on this topic and program is to shade light on the HRRP program itself, and to recommend possible fixes and a potential direction in the fight to reduce excessive readmission of vulnerable populations by hospitals. The purpose of the HRRP program is to pressure hospitals to reduce readmissions of dual eligible patients by cutting payments to hospitals that continue to have large volumes of readmissions within 30 days of patient discharge from the hospital. So, starting as from October 2012, if a hospital fails to reduce frequent readmission of dual eligible patients within 30 days of discharge, then it will be penalized in the form of payment cuts for the services provided to the patient or patients within that time frame. It’s estimated that the payment reductions will increase progressively by “1 percent in fiscal year (FY) 2013, 2 percent in FY 2014, and 3 percent in FY 2015 and beyond” (Gu et al). Patients are going to actually receive proper care because hospitals will do all they can to keep their patients healthy as a way to avoid frequent readmissions. Also, CMS rewards hospitals that reduce frequent readmission. Such measures will also benefit CMS in terms of the money it will save from the program.
This program originated from frequent readmission of Medicare and Medicaid patients within 30 days of discharge from the hospital. CMS was spending a lot of money on such readmissions and had to find a way to make sure that hospitals could reduce such rates. So, the program finally came about as a result of the affordable care act which allowed CMS to control the rising cost and try to make sure that dual eligible patients were receiving proper treatment and that hospitals did a better job at ensuring health and preventing unnecessary readmissions of these patients.
Proposed evaluation method to measure program access and quality
To make sure that hospitals and patients are comfortable and that the HRRP program is meeting its goals and objectives, we need to appropriately check the HRRP evaluation process. In this sense, it will be important that the parameters used to find excess readmission such as risk adjustment ratio, properly risks adjust by including all factors that influence frequent readmission of dual eligible patients, not just heart failure, acute myocardial infarction (AMI), and pneumonia. In recent years, the program has added a couple of factors such as “chronic obstructive pulmonary disease (COPD), total hip and/or knee arthroplasty (THKA), and coronary artery bypass graft surgery (CABG)” (Thompson et al 2016) to use as inputs in measuring excessive readmission. This is progress, but I will like evaluators to include almost all factors that can influence frequent readmission. Some of such factors included “social support, education, income, employment status, home stability, and risk behaviors” (Gu et al). This way, proper risks adjustment can ensure reliability and proper payment reductions for hospitals. Also, evaluators can include in a team of experts that actually check the progress of dual eligible patients discharged from hospitals within the 30-day time window. This can be done, by sending such experts to selected patient’s homes to actually check the patient’s condition since the last discharge. Questions to ask the patient maybe as simple as how well the patient is doing after his or her release from the hospital. Also, taking patient’s vital signs to actually see that there is improvement in the patient’s condition can assure evaluators that a reduction in frequent readmission is actually due to improved patient’s health as opposed to hospitals wanting to keep them home to avoid being charged. Follow-ups can be done through surveys as in the form of phone calls to the patient’s home as well.
Economic analysis
The cost drivers of this program are the rapidly rising cost of healthcare and unnecessary readmission of vulnerable patients in hospitals. Hospitals were adding about “$26 billion annually” (Edlin 2014) in readmissions. In terms of cost effectiveness, one can say that it’s effective the HRRP program is effective because the amount of money saved since program implementation is impressive. According to CMS, about “$12 billion in health care costs saved” in 2015 is as a result of the HRRP. Also, CMS indicates that health outcomes are improving and adverse health conditions are on the decline as a result of this program. Hospitals are actually getting it and finding new and better ways to keep patients healthy and away from its premises.
Responsibilities and ethics related to the evaluation and cost research of the HRRP program.
As successful as this readmission reduction program may seem, it is not immune to criticism. As I mentioned earlier, the program’s focus is on reducing readmission of patients to hospitals by threatening payment cuts for hospitals with excessive readmission. From an ethical standpoint, many are concerned that “inadequate risk-adjustment unfairly penalizes hospitals treating disproportionately more minority or low-income individuals” (Thompson et al 2016). As such, it will be irrational and harmful to wrongfully punish hospitals for excess readmission as a result of improper risks adjustment made by evaluators of this program. Already, there are potentials for error in evaluation methods used in this program. Evaluators seem to partially consider factors that can lead to excessive readmission, which in this case will definitely lead to wrong conclusions and wrongful punishment of hospitals for program evaluation errors that are not of the hospitals themselves. Also, hospitals may find ways to turn away patients that often visit the hospital, not because the patient’s conditions are better, but because it can help the hospital to avoid payment cuts.
Final Recommendations.
Since most of the frequent readmissions are for vulnerable patients with multiple conditions, it is important to appropriately risk adjust for potential frequent readmission. To do so, requires and inclusion of every risk factor that can cause a frequent readmission of a patient within the specified 30 day time frame. Extra patient monitoring steps in terms of follow-up visits or calls should be made after a patient leaves the hospital. This will prevent unnecessary readmissions and can potentially solve the cost, quality and access problems that we face in healthcare. CMS can also look to global budgets as a potential alternative to the HRRP program. Global budget payments have worked here in Maryland and can work throughout the country to meet the same goals of the HRRP program.