2. More readmission penalty conditions and exclusions
The PPACA specifies that effective Oct. 1, 2014, penalties for higher rates of 30-day readmissions may apply to four additional conditions that brought the patient to the hospital the first time.
So instead of penalties just for those hospitals with higher rates of 30-day readmissions among patients initially treated for congestive heart failure, pneumonia and heart attack, penalties may extend for patients admitted for a coronary artery bypass graft procedure, placement of a stent, vascular surgery, or care for chronic obstructive pulmonary disease. Eventually, readmissions for hip and knee replacement procedures will be included.
Hospital insiders say they expect federal officials to telegraph these rules with the rollout of the inpatient prospective payment system rule in April.
Much of how the proposed rule is written depends on acceptance and endorsement of such measures by the National Quality Forum, which has already rolled out two endorsements for all-cause readmissions.
Nancy Foster, vice president for the American Hospital Association, says her group is still fighting for a risk adjustment mechanism that takes into consideration a patient's socioeconomic status.
Officials for some hospitals that serve poorer populations and have higher 30-day readmissions believe they have a much tougher problem, the solution for which is less within their control, and are therefore unfairly penalized.
However, one issue may have been partially solved, says Foster. That is the exclusion of certain diagnostic categories from the readmission algorithm. For example, those readmissions that were planned or expected, or readmissions that could not have had anything to do with the quality of care during the index admission, would not be counted.
A patient who is treated in a hospital for congestive heart failure, but who is readmitted for cancer surgery within 30 days, is now counted as a readmission, but shouldn't be, Foster says.
3. Health insurance exchanges must be accredited
The Affordable Care Act requires that all health insurance plans that operate within state or federal health insurance exchanges starting in 2014 be accredited.
That means they have to meet an expansive array of clinical quality measures such as those defined by HEDIS (the Healthcare Effectiveness Data and Information Set), and the doctors they contract with must measure up with high patient experience scores.
Physician networks must include a certain mix of physician generalists and specialists who are confirmed to be accepting new patients, with reasonable wait times for appointments, and within certain geographic areas. They must have certain quality improvement strategies that work to reduce disparities in healthcare.
This generally has not been a problem for states that already require health plans and their insurance products to be accredited in order for their sales to be legal in those states. However several states, such as Montana, Indiana, and Wyoming, don't require accreditation. In some states there has been market domination, so there hasn't been much push to accredit these health plans since consumers don't have much choice.
CMS in November designated the National Committee on Quality Assurance and URAC as the two organizations charged with accrediting all plans offered under state or federal exchanges.
They're going to have an enormous job ahead of them to get all these unaccredited plans approved before Oct. 1, especially in states that don't require accreditation. Many plans will probably seek extensions until next April, NCQA officials say.
That may mean some patients who join exchanges will have to choose plans won't be accredited, at least until some time in 2014. Here's hoping they make the right choices.