5 Questions to Determine Readmission Rate Effectiveness

Joan Moss, RN, MSN, Senior Vice President, Sg2, for HealthLeaders Media, June 30, 2011

Hospitals have always known that reducing readmissions should be a priority quality goal but, until now, the payment incentives have not been in place. Like it or not, health care reform has provided a new impetus to do the right thing.

Financial penalties on providers with "excess" readmissions will begin in fiscal year 2013, but claims data collection on those penalties starts this October. The Centers for Medicare & Medicaid Services (CMS) measures readmissions within a 30-day time frame after patients are discharged for their initial admission. A readmission to any acute care hospital, for any reason, regardless of whether it is to the hospital from which the patient was originally discharged, or whether the readmission has any relation to the original hospital stay, will be counted. This is the definition of an "all-cause" readmission and does not exclude elective or planned admissions.

CMS will risk adjust readmissions penalties based on comorbidities and other patient variables, and initial penalties will focus on excess readmissions for congestive heart failure (CHF), pneumonia and acute myocardial infarction (AMI). Additional readmission penalties for chronic obstructive pulmonary disease (COPD), coronary artery bypass graft, percutaneous coronary intervention and other vascular procedures will begin in fiscal year 2015. What these penalties really indicate, however, is a larger CMS goal to move to a value proposition in terms of what it will pay for. To make sure your organization is on the right side of that value proposition relative to readmissions, have your leadership team ask themselves the following 5 questions.

Question 1: What is our business exposure based on CMS penalties and future accountable care organization (ACO) quality reporting requirements?
Put another way, what is your strategy for managing readmissions based on your current readmission rates? How much of your revenue could be at stake?


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