Wednesday, April 10, 2024

What Is The Medicare 30 Day Readmission Rule

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Controversial Inclusions And Exclusions

Bank Opening Time RBI Rule

The HRRP includes all unplanned readmissions within 30 days of hospital discharge. In fiscal year 2013, only two procedures were considered planned readmissions and did not impact the readmission measure: 1) acute myocardial infarction patients who later underwent coronary artery bypass graft surgery and 2) acute myocardial infarction patients who later underwent percutaneous coronary intervention. This initial algorithm penalized hospitals for any other planned admission including such procedures as implantable cardioverter-defibrillators in heart failure patients. Many planned readmissions, such as ICD placement, often represent high-quality care and should not be counted against hospitals. In response, CMS instituted an algorithm to account for a wider range of planned readmissions starting in fiscal year 2014.9

Balancing Index Length Of Stay With Readmission Risk

One of the more striking inter-hospital differences has been variation in the length of stay for the index hospitalization. This may relate to readmission. Countries with longer length of stay for heart failure hospitalizations appear to have lower rates of readmission within 30 days. In a large contemporary acute heart failure trial conducted across 27 countries, mean length of stay ranged from 4.9 to 14.6 days . There was an inverse correlation between country-level mean length of stay and readmission .39 Similar trends were observed across U.S. study sites. Longer index hospitalizations expend more resources and keep patients from being home yet, there appears to be a trade off in terms of readmission rates. Under the current system, IPPS-DRG-based reimbursement incentives are complemented by the HRRP, balancing a desire to limit unnecessarily long hospital stays while still discouraging unnecessary readmissions due to premature discharge.

What Are The Three Exceptions To The Medicare 72 Hour Rule

There are a few exceptions to Medicare’s policy cited below: Clinically unrelated services are not subject to the three-day window policy, if the hospital can attest that the services are distinct or independent from a patient’s admission. Ambulance services and maintenance renal dialysis services are also excluded.

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How To Improve The Accuracy Of Calculations

Shen doubted executives at individual hospitals could determine whether their organization wrongly faced HRRP penalties, given that they would need access to other hospitals data as well.

Number one is what kind of patient got readmitted, Shen said. Is there anything you can do about it, rather than to argue if this a mistake or not?

Follow-up research is needed to understand the effect of the misapplied penalties and then how to fix the problem, Shen said.

To narrow the associated margin of error and minimize the likelihood of misclassifying performance, CMS could extend data collection from three years to 12 years for acute myocardial infarction and to six years for heart failure and pneumonia. That would reduce the rate of penalty-status misclassification to from 31% to 20%, the authors wrote.

However, this would lead to substantial lag time between the period used to assess performance and the determination of financial penalties, they wrote.

A possible solution could involve switching from the 30-day readmission measure to the excess days in acute care measure to capture the full spectrum of hospital encounters including emergency department use within 30 days of discharge, according to another new study in the Annals of Internal Medicine, which Shen also co-authored.

Which Critical Access Hospitals Have The Highest All

Federal Register

St. Joseph’s Hospital in Buckhannon, West Virginia has the highest all-cause readmission rates among CAHs at 16.80%. Towner County Medical Center and Wills Memorial Hospital have readmission rates of 16.70%. Four of the CAHs on the list are located in Texas.

We might expect that hospitals with more total discharges to report higher readmission rates. With each patient discharge, there is a risk for 30-day readmission. Interestingly, there does not seem to be a correlation between total discharges and readmission rate.

For instance, some of the top 25 CAHs report more than 1,000 total discharges and have readmission rates similar to hospitals with about 200 discharges. Instead, these differences may be due to factors such as the case complexity or co-morbidities of recent patients receiving care at the hospital.

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Definitions Of Vulnerable Populations

Definitions of population vulnerability in the literature generally depend on the quartile of patient income or insurance types such as Medicaid . We used similar definitions to stratify the data into the four types of vulnerable populations as listed in the Background section.

For the first type of vulnerable population, patients were divided into four groups according to their income level. The NRD data measures a patients income level by quartiles of the median household income in their zip code of residence. For example, in 2013, a patient would fall into one of the following quartiles: $1 – $37,999 $38,000 – $47,999 $48,000 – $63,999 and $64,000 or more. We will refer to patients in Q1, Q2, Q3, and Q4 as low-income, middle-income, upper-middle income, and high-income patients, respectively.

For the third type, hospitals were separated into quartiles based on their proportion of Medicaid patients. Hospitals in Q1 had the lowest percentage, whereas hospitals in Q4 had the highest percentage. We will refer to the former as low-Medicaid hospitals and to the latter as high-Medicaid hospitals, respectively.

Outcome And Exposure Variables

We followed CMS reports to construct our analytical samples and 30-day readmission measures. For each of the index hospitalizations based on a patients principle ICD-9 codes as outlined in the CMS reports, a corresponding 30-day readmission indicator was set to one if readmission occurred within 30days of discharge. Planned readmissions, defined as intentional readmission within 30 days of discharge from an acute care hospital that is a scheduled part of the patients plan of care do not count as readmissions . Following the CMS definition, we excluded admissions for patients who died during hospitalization, were discharged against medical advice, or were transferred to another acute care facility. In addition, we created indicators for any-target readmissions and non-target readmissions. Any-target readmissions took the value of one if a patient had an either AMI, HF or PN 30-day readmission and zero otherwise. We use this measure to evaluate the HRRPs impact on the three targeted conditions as a whole. If a readmission was within 30days of discharge not from any targeted condition, then the non-target readmission indicator was set to one and zero otherwise. We use this measure to evaluate HRRPs impact on non-targeted readmissions.

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Additional Cms Information On The Hospital Readmissions Reduction Program

HRRP improves Americans health care by linking payment to the quality of hospital care. CMS incentivizes hospitals to improve communication and care coordination efforts to better engage patients and caregivers on post-discharge planning.

Weve included measures of conditions and procedures that make a big difference in the lives of large numbers of people with Medicare. HRRP, along with the Hospital Value Based Purchasing and Hospital-Acquired Condition Reduction Programs, is a major part of how we add quality measurement, transparency, and improvement to value-based payment in the inpatient care setting.

Research shows that hospital readmission rates differ across the nation. This gives us an opportunity to improve the quality of care and save taxpayer dollars by incentivizing providers to reduce excess readmissions.

Shifting Away From Fee

What Are the Advantages to a Medicare Set-aside?

For the first time, Medicare has set specific goals for alternative payment models and value-based payments. By 2016, Medicare seeks to have 85% of all Medicare fee-for-service payments tied to quality or value and 90% by 2018.40 With the increased attention from the ACA on improving outcomes, increasing access to care, and lowering costs, many payment providers are moving away from the fee-for-service model and towards an outcome-based payment model. Accountable care organizations are an example of this model, which assume joint accountability between providers and health care organizations. ACOs have incentives under the Medicare Shared Savings Program and Pioneer Model to manage care coordination and other factors affecting readmission rates. There are already examples of ACOs working to reduce readmissions. For example, Kaiser Permanente has shown a reduction in 30-day all-cause readmission rates with their transitional care programs and bundling elements.41 Similarly, Coloradoâs Accountable Care Collaborative, which pilots health care payment and delivery reforms through Medicaid, was able to show 8.6% fewer hospital readmissions than non-participating Medicaid enrollees within its first year.42

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What Is The Review And Correction Period

The 30-day Review and Correction period allows applicable hospitals to review and correct their HRRP Payment Reduction and component result calculations as reflected in their Hospital Specific Report prior to them being used to adjust payments. Hospitals cant submit corrections to the underlying claims data or add new claims to the data extract during this period.

Each program year, we let hospitals know the exact dates of the Review and Correction period on the QualityNet website.

The Hospital Readmission Reduction Program

When a patient is readmitted to the hospital, the associated costs are high and it can indicate shortcomings in treatment. One of the objectives of the 2010 Affordable Care Act was to combat these issues directly. The ACA included a provision establishing the Hospital Readmission Reduction Program , which requires Medicare to lower payments to hospitals with excessive readmission rates.

The readmission rates initially only applied to Medicare patients suffering from heart failure, heart attacks, and pneumonia, but the program was expanded to encompass other conditions such as knee and hip replacements and coronary artery bypass graft surgery.

Since the implementation of the HRRP in 2012, hospital readmission rates for Medicare patients have decreased. Despite the apparent success, there is criticism about the program itself and whether it adequately deals with the issue at the expense of patient care.

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How Can Your Outpatient Pharmacy Help Your Hospital Reduce Readmissions

The simple answer is, of course, to help ensure that your outpatients take their discharge medications as directed. While there are a number of easy-to-use apps designed to improve medication adherence, there is a significant problem with patient acceptance of tracking apps.

According to a 2021 study by the Journal Of Managed Care + Specialty Pharmacy, More than 50% of smartphone users refused to use an app because they feared their personal information would be compromised. Practically speaking, the rate of refusal among smartphone users means that any pharmacy using medication-tracking software would be required to manage the majority of its patient follow-up with person-to-person contact. Which is exactly why ProxsysRxs Readmission Reduction Program is based on calling and communicating directly with patients.

Our program involves multiple steps including 1) assistance in making any necessary appointments, 2) thoroughly discussing prescription protocols, to ensure patients and their caregivers understand their own responsibilities, and 3) ensuring there are no potential interactions with patients existing medications. Whats more, our program calls for ten touches during the first 30 days post-discharge.

The Skilled Nursing Facility 30

Federal Register

This blog post is an excerpt from one of the articles in our free eBook: A Closer Look at Readmissions and Medical Errors: What healthcare leaders should know about the industry-wide struggle.

Hospitals, CMS and nursing homes have begun to take a closer look at the Transitions of Care data, particularly that of hospital readmissions that occur within 30 days of discharge from an acute care hospital to a skilled nursing facility. Under Value Based Purchasing , a financial penalty is attached to poor performance on the hospitals TOC measures which has led to more scrutiny on the causes of unscheduled readmissions, particularly those causes that may be beyond a hospitals control. These readmissions are costly, put patients at risk for complications and appear to be largely preventable.

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Adjusting The Penalties For Socioeconomically Disadvantaged Patients

Medicare divided all U.S. hospitals into quintiles based on the percentage of dual eligible patients. Hospitals were only compared to other hospitals within the same quintile for the purposes of penalty calculation therefore, a hospital with a high percentage of dual eligible patients was held to a different readmission rate expectation than a hospital with a low percentage of dual eligible patients. In fiscal year 2019, the dual eligible adjustment went into effect and the effect of this on the Medicare readmission penalties has now been analyzed in an article in the June 2019 issue of JAMA Internal Medicine. Hospitals that were more likely to be classified in quintile 5 were more likely to be:

  • Teaching hospitals
  • Northeastern and Western U.S. hospitals
  • Hospitals in neighborhoods with high prevalence of disabled persons
  • As one would expect, on average, hospitals in quintiles 1, 2, and 3 saw an increase in their readmission penalties whereas hospitals in quintiles 4 and 5 saw a decrease in their readmission penalties.

    Does Medicare Pay For Readmissions Within 30 Days

    Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery. A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.

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    What Is The 100 Day Rule For Medicare

    Medicare covers up to 100 days of care in a skilled nursing facility each benefit period. If you need more than 100 days of SNF care in a benefit period, you will need to pay out of pocket. If your care is ending because you are running out of days, the facility is not required to provide written notice.

    What Measures Are Included In The Hospital Readmissions Reduction Program

    A Quality Improvement Initiative Reduces 30-Day Rate of Readmission for Patients

    We use the excess readmission ratio to assess hospital performance. The ERR measures a hospitals relative performance and is a ratio of the predicted-to-expected readmissions rates. We calculate an ERR for each condition or procedure included in the program:

    • Acute Myocardial Infarction
    • Coronary Artery Bypass Graft Surgery
    • Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty

    HRRP doesnt include the Hospital-Wide All-Cause Readmission measure, which is included in the Hospital Inpatient Quality Reporting Program.

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    How Does The Hospital Readmissions Reduction Program Adjust Payments

    For each eligible hospital, we calculate the payment adjustment factor. The payment adjustment factor corresponds to the percent a hospitals payment is reduced. The payment adjustment factor is a weighted average of a hospitals performance across the readmission measures during the HRRP performance period. We apply the payment adjustment factor for all discharges in the applicable fiscal year, no matter the condition.

    You can find more information in the QualityNet Methodology section.

    What Is A Hospital Readmission

    A hospital readmission is an event that occurs when a patient who had been previously discharged is readmitted within a designated period. This is a bad situation for most patients, as it suggests inadequate care.

    Consider the following example: After a short stay, you leave the hospital with a new diagnosis of COPD, but you don’t fully comprehend how your inhaler works. You wanted in-depth instructions about self-care instead of the clinical and impersonal discharge you received. Anxious and frightened, you return home and end up back in the hospital three weeks later due to breathing problems.

    Unfortunately, the scenario is common for many Americans, but there are any number of reasons for a hospital readmission, including:

    • Patients suffering from new conditions
    • Recurrent exacerbation of chronic conditions
    • Complications due to prior medical or surgical care or
    • Adverse drug reactions.

    Additionally, the premature discharge to a setting where the patients’ needs aren’t met for post-hospital care makes it highly likely that the patients will be readmitted. They can also get sick from health care related illnesses. According to a CDC study, one out of 25 hospital patients develops an infection at a health care facility.

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    What Is The Medicare 100 Day Rule

    Medicare covers up to 100 days of care in a skilled nursing facility each benefit period. If you need more than 100 days of SNF care in a benefit period, you will need to pay out of pocket. If your care is ending because you are running out of days, the facility is not required to provide written notice.

    Stopping Care Or Leaving

    How We Help Capitated Organizations

    If you stop getting skilled care in the SNF, or leave the SNF altogether, your SNF coverage may be affected depending on how long your break in SNF care lasts.

    If your break in skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new hospital stay doesnt need to be for the same condition that you were treated for during your previous stay.

    If your break in skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

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    Readmissions: How Big Is The Problem

    The first thing to know is that the problem appears to be a fairly large one. CMS has used 2010 research to understand the size and complexity of the issue. Approximately one out of every four patients discharged from an acute care hospital to a SNF will be readmitted within 30 days. There are substantial differences in hospital readmission rates by state, ranging from a low of 15.1% to a high of 28.1% . The readmission rates do not appear to be related to income as the state with highest median income had a readmission rate that was somewhat similar to Mississippis .

    However, facility characteristics do appear to be related to hospital readmissions. Nursing homes with the following characteristics have higher hospital readmission rates:

    • Higher number of beds

    The Medicare Hospital Readmission Reduction Program

    The hospital readmission reduction program was created as a part of the Affordable Care Act as a way to improve quality of care and reduce overall Medicare costs. Readmissions are defined as a patient being readmitted to any hospital and for any reason within 30 days of discharge from the hospital being analyzed. The program began in 2013 by looking at readmissions for just 3 conditions: myocardial infarction, heart failure, and pneumonia. In 2015, the program expanded to 5 conditions by adding readmissions for chronic obstructive pulmonary disease and knee & hip replacement surgery. In 2017, the program further expanded to 6 conditions by adding coronary artery bypass graft surgery. Each year, Medicare calculates the penalties based on the previous 3 years readmission data and then hospitals are penalized up to 3% of their total Medicare payments the following year.

    The program has been controversial since inception with concerns that it preferentially penalized hospitals that care for sicker patients as well as for lower-income patients and underinsured patients who often lack the resources to get outpatient medical care that can keep them out of the hospital. Medicare responded by making 2 adjustments to the penalty based on a given hospitals patient demographics:

  • The severity of illness of the hospitals patients with the premise that the sicker a patient is, the more likely that patient is to be readmitted to the hospital.
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