Healthcare News & Insights

Readmissions: New penalties & current status of CMS initiative

Despite all the recent unrest over healthcare reform, readmissions penalties from the Centers for Medicare & Medicaid Services (CMS) are proceeding, full steam ahead. Under the Hospital Readmissions Reduction Program, thousands of hospitals are being penalized for their performance in keeping patients from returning to the hospital. 

According to an analysis from Kaiser Health News, 2,573 hospitals are being punished for their 30-day readmission rates this year with six conditions: pneumonia, heart attacks, heart failure, hip and knee replacements, coronary artery bypass graft surgery and chronic lung disease.

While that’s about two dozen fewer facilities than the number that was penalized last year, it still amounts to penalties for about 80% of hospitals CMS examined, including the majority of hospitals in many states.

As of Oct. 1, these hospitals will see their Medicare payments reduced by an average of 0.73%. The maximum penalty is a 3% cut to Medicare reimbursement – 48 hospitals will experience this in the fall.

Future of readmissions program

The federal penalties have been effective in reducing readmissions long-term. Since the program began in 2007, readmissions for targeted conditions have decreased from 21.5% to 17.8%. However, progress has stalled in recent years.

Per an analysis from the Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation, between 2012 and 2015, there was no decrease in the overall rate of 30-day readmissions (though there were slight decreases to readmissions for CMS’ six targeted conditions). The most progress was made in 2010, shortly after the Affordable Care Act was passed.

Because readmissions are still stable, many healthcare experts and hospital executives believe facilities have done as well as they can with reducing them under the requirements of the federal program.

As written in an article from Modern Healthcare, many of the factors that cause a patient to be readmitted are outside a hospital’s control. Hospitals have tried many strategies to affect these areas, from offering patients transportation to follow-up appointments to having pharmacists call homes after discharge to make sure patients are taking their medications as directed.

But there’s only so much a facility can do to help, especially if patients don’t make their needs known to providers. Experts say it’s best for the feds to start collecting data about the socioeconomic factors that impact patients’ health and readmissions rates – then work with hospitals to come up with solutions.

CMS plans to account for patients’ socioeconomic status when looking at readmissions penalties next year, which is designed to even the playing field for hospitals that treat a large proportion of poor and at-risk patients. However, some say the agency should go further and start looking at other elements that can also impact recovery, such as food insecurity.

Additionally, placing focus solely on reducing readmissions ignores the patient as a whole. Readmissions may be unavoidable for frail older patients with multiple chronic conditions and acute illnesses. It may be wiser to look at the patient’s level of care and well-being instead – and federal initiatives such as value-based purchasing, bundled payments and the Quality Payment Program already fill that role.

Hospitals’ current role

Time will tell whether the Hospital Readmissions Reduction Program will experience major revisions like the recent updates to the Quality Payment Program under MACRA. But, as things currently stand, facilities must continue to do their best to lower patients’ readmissions.

Although hospitals can’t change patients’ finances or living situations, clinical staff can take proactive steps to provide high-quality care while people are hospitalized, prioritizing communication that keeps patients in the loop about their medical conditions and the steps they can take to improve their recovery once they’re discharged.

Hospitals can also continue forging partnerships with others, whether they’re social services organizations, fellow facilities or community groups, to expand patients’ access to resources that can improve their health and decrease their chances of being readmitted.

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