Logan Reid
Hospital readmissions have financial, emotional, and physical impacts on patients and their families, and they also strain healthcare resources. In the last decade, more programs have been introduced to reduce hospital readmissions, as this has become a top priority in U.S. healthcare reform. The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and reduce avoidable readmissions. CMS calculates the payment reduction and component results for each hospital based on its performance during a rolling performance period. The payment adjustment factor is the form of the payment reduction CMS uses to reduce hospital payments. Readmission within 30 days of discharge from the initial admission is considered unplanned and is subject to clinical review to determine if it is related to or similar to the initial admission.
| Characteristics | Values |
|---|---|
| Purpose | To improve health care and lower costs |
| Incentive | Hospitals are incentivized to improve communication and care coordination to better engage patients and caregivers in discharge plans and reduce avoidable readmissions |
| Payment | Medicare value-based purchasing program that links payment to the quality of hospital care |
| Reduction | Hospitals with excess 30-day readmissions have reduced Medicare payments |
| Data | Nationwide Readmissions Database (NRD) supports analysis of national readmission rates |
| Calculation | Excess readmission ratio (ERR) is used to assess hospital performance |
| Adjustment | Payment adjustment factor corresponds to the percent a hospital's payment is reduced |
| Review | Hospitals can review their data and request corrections within 30 days |
| Tools | Re-Engineered Discharge (RED) Toolkit helps hospitals re-engineer their discharge process |
| Patient Support | 'Taking Care of Myself: A Guide for When I Leave the Hospital' helps patients track medication and appointments |
| Clinical Review | Readmission within 30 days of discharge is subject to clinical review to determine relation to initial admission |
| Classification | Readmission is classified as subsequent acute care inpatient admission at the same hospital within 30 days of discharge |
| Strategies | Care transition programs, improved patient education, enhanced communication, and addressing social determinants of health |
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What You'll Learn
The Hospital Readmissions Reduction Program
Section 1886(q) of the Social Security Act sets forth the statutory requirements for the Hospital Readmissions Reduction Program. It required the Secretary of the U.S. Department of Health and Human Services to reduce payments to subsection (d) hospitals for excess readmissions beginning on October 1, 2012 (fiscal year 2013). The 21st Century Cures Act directs CMS to assess a hospital's performance relative to other hospitals with similar proportions of beneficiaries who are dually eligible for Medicare and full Medicaid benefits beginning in fiscal year 2019.
CMS calculates the payment reduction and component results for each hospital based on its performance during a rolling performance period. The payment adjustment factor is the form of the payment reduction used to reduce hospital payments. Payment reductions are applied to all Medicare fee-for-service base operating diagnosis-related group payments during the fiscal year (October 1 to September 30). The payment reduction is capped at 3% (a payment adjustment factor of 0.97).
CMS sends confidential Hospital-Specific Reports (HSRs) to hospitals annually. Hospitals have 30 days to review their Hospital Readmissions Reduction Program data, submit questions about the calculation of their results, and request calculation corrections. The Review and Correction period is only for discrepancies related to the calculation of the payment reduction and component results. After this period, CMS reports Hospital Readmissions Reduction Program data in the Inpatient Prospective Payment System/Long-Term Care Hospital Prospective Payment System Final Rule Hospital Readmissions Reduction Program Supplemental Data File on CMS.gov.
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Preventable readmissions
Preventable hospital readmissions are a key focus area for healthcare reform in the United States, with a national priority to reduce them. This is due to the emotional and financial toll that frequent readmissions can have on patients and their families, as well as the opportunity to improve the quality of care and reduce costs. The Hospital Readmissions Reduction Program is a key initiative in this area, aiming to incentivize hospitals to improve communication and care coordination to reduce avoidable readmissions.
There are several factors that can contribute to preventable readmissions. One significant factor is complications that arise during or shortly after a hospital stay, such as nosocomial infections, pressure ulcers, falls, and procedure complications. These issues can extend a patient's hospital stay or require readmission for further treatment. Therapeutic errors, such as medication reconciliation mistakes, are also common causes of readmission. These errors can lead to patients receiving duplicate medications or incorrect dosages, which can have adverse events that necessitate readmission.
Premature discharge is another preventable cause of readmission. Patients who are discharged prematurely, for reasons such as cost-effectiveness or to prevent hospital-acquired infections, may find themselves returning to the hospital sooner than expected. This can be mitigated by ensuring that patients are only discharged when they are medically stable and have appropriate post-discharge care plans in place. Social determinants of health can also play a role in preventable readmissions. Factors such as transportation issues, food insecurity, and housing instability can impact a patient's ability to follow treatment recommendations and access necessary care, increasing the risk of readmission.
To address these issues, hospitals have implemented various strategies, including enhancing communication and coordination, improving patient education, and addressing social determinants of health. Care transition programs can help patients smoothly transition from inpatient to outpatient care, reducing the risk of readmission. Additionally, discharge planning that involves patients and their families can improve understanding and motivation to follow recommended treatments. Analyzing data and implementing multidisciplinary teams can also help hospitals tailor their approaches to specific patient populations and conditions, further reducing readmission rates.
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Cost to patients
Hospital readmissions can have a significant emotional and physical impact on patients and their families. Frequent readmissions can be emotionally draining and disrupt patients' lives, affecting their ability to work, attend school, or care for their families. The financial burden associated with readmissions can also be substantial, especially for patients with limited financial resources or those who are uninsured or underinsured.
The cost of hospital readmissions for patients can vary depending on several factors, including the country, healthcare system, insurance coverage, and the patient's specific circumstances. In countries with universal healthcare systems, such as the National Health Service (NHS) in the United Kingdom, patients typically do not incur direct costs for hospital readmissions as these services are covered by the government. However, in countries with private or mixed healthcare systems, such as the United States, patients may face significant out-of-pocket expenses.
In the United States, the cost of hospital readmissions can vary based on insurance coverage and the specific policies of the hospital or healthcare provider. Patients with private insurance or those enrolled in Medicare or Medicaid may have some or all of their readmission-related costs covered, depending on the specifics of their plan. However, patients without insurance or with inadequate insurance coverage may have to bear the full cost of their readmission, which can be financially devastating.
Several factors can influence the cost of hospital readmissions for patients:
- Length of Stay: The longer a patient stays in the hospital, the higher the overall cost will be. Extended hospital stays can result in increased charges for room and board, medical tests, treatments, and medications.
- Complexity of Treatment: Readmissions involving complex medical procedures, surgeries, or intensive care may result in higher costs compared to less complex cases.
- Medication Costs: Prescription medications, particularly specialty drugs or prolonged medication regimens, can add significantly to the overall cost of readmission.
- Diagnostic Tests: Extensive diagnostic testing, such as MRI scans, blood tests, or medical imaging, can contribute to higher costs for patients.
- Hospital Fees: Different hospitals may have varying charges for room rates, medical staff fees, and administrative costs, which can impact the overall expense of readmission.
To mitigate the financial burden on patients, some hospitals offer financial assistance programs, payment plans, or discounted rates for uninsured or underinsured individuals. Additionally, patients may seek support from government assistance programs, non-profit organizations, or community initiatives that help cover medical expenses.
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30-day review and correction period
The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that aims to improve the quality of healthcare for Americans by linking payment to the quality of hospital care. The program incentivizes hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions.
The program includes 30-day risk-standardized unplanned readmission measures that capture unplanned readmissions that happen within 30 days of discharge from the initial admission. Readmission within 30 days is subject to clinical review to determine if it is related or similar to the initial admission. If the clinical review indicates that the readmission is for a similar condition, it may be considered a continuation of the initial admission for reimbursement purposes.
The 30-day Review and Correction period allows hospitals to review and correct their Hospital Readmissions Reduction Program payment reduction and component result calculations as reflected in their Hospital-Specific Reports (HSRs). Hospitals have 30 days to review their data, submit questions about the calculation of their results, and request calculation corrections. This period is only for discrepancies related to the calculation of the payment reduction and component results. Hospitals cannot submit corrections to the underlying claims data or add new claims to the data extract during this time.
The payment adjustment factor is a weighted average of a hospital's performance across the readmission measures during the Hospital Readmissions Reduction Program performance period. It is used to reduce hospital payments and is capped at 3%.
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Strategies to reduce readmissions
Readmissions are costly and can negatively affect the quality of care and patient satisfaction. It is important to identify patients at high risk of readmission, as this can help healthcare providers develop tailored care plans to prevent readmissions. Some factors that influence readmission include age, medication, caregiver support, financial challenges, and living conditions.
One strategy to reduce readmissions is to improve care coordination and communication among care teams. This includes comprehensive post-discharge follow-up, which can help address potential health issues before they escalate. For instance, the Re-Engineered Discharge (RED) Toolkit assists hospitals in re-engineering their discharge process, and the "Taking Care of Myself: A Guide for When I Leave the Hospital" helps patients track medication schedules, upcoming medical appointments, and important phone numbers. Additionally, the BOOST (Better Outcomes for Older Adults through Safer Transitions) discharge bundle includes medication reconciliation forms, a checklist for patient-centered hospital discharge education, and a checklist for post-discharge continuity checks.
Another strategy is to involve caregivers more in post-discharge care and facilitate patient access to follow-up care with specialists. Building a robust support network around at-risk patients can enhance their chances of a smoother recovery and reduce the likelihood of readmission.
Furthermore, hospitals should maintain adequate nurse-to-patient ratios. Proper staffing ensures better patient care and significantly lowers unplanned readmissions. Hospitals can also delegate non-clinical tasks to support staff, allowing nurses to focus on patient care and spend more time enhancing communication and providing comprehensive discharge instructions.
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Frequently asked questions
The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions. This program improves Americans’ health care by linking payment to the quality of hospital care.
Reducing hospital readmissions is a top priority in U.S. healthcare reform. It improves the quality of care and saves taxpayer dollars by incentivizing providers to reduce excess readmissions. It also helps to reduce the emotional and physical impact on patients and their families, as well as the overall cost of care.
Hospitals can utilize various strategies and resources to reduce readmissions, such as:
- Focusing on preventive measures, including better discharge planning, patient education, and post-discharge follow-up.
- Utilizing tools like the Re-Engineered Discharge (RED) Toolkit and patient guides to assist in discharge planning and patient education.
- Implementing technology-based solutions through Health IT projects.
- Analyzing national readmission rates and causes of preventable readmissions through the Nationwide Readmissions Database (NRD).
- Improving the nurse work environment, especially for patients with limited English proficiency.
Readmission is typically classified as a subsequent acute care inpatient admission to the same hospital or another acute care hospital for the same patient within 30 days of discharge from the initial admission. Readmissions within the same day or within 24 hours are often processed as a single claim. Readmissions after 30 days are subject to clinical review to determine if they are related or similar to the initial admission for reimbursement purposes.
