Why Medicare Readmission Penalties May Have Peaked | Geneia

Why Medicare Readmission Penalties May Have Peaked

March 28, 2019
Ronda Rogers, Director, Population Health and Consumer Engagement


The Theon® platform can help hospitals address patient safety and readmissions

As one who spent much of my career working with hospitals and healthcare systems, I suspect I’ll always have a keen interest in their fate and the patients they serve. Undoubtedly that’s why I took particular notice of the recent headline, Medicare Trims Payments To 800 Hospitals, Citing Patient Safety Incidents

Kaiser Health News analyses of the Hospital Acquired Conditions (HAC) Reduction Program found:

  • 800 hospitals will lose one percent of their Medicare payments for patients discharged between October 2018 and September 2019 because of comparatively high rates of infections and patient injuries
  • 1,756 hospitals – nearly 30 percent of the more than 6,200 hospitals nationwide – have been penalized at least once in the five years since the HAC took effect
  • 110 hospitals have been assessed penalties for five straight years

The penalty rates are even greater in the Hospital Readmissions Reduction Program. Under this program, Medicare can cut as much as three percent per discharged patient although the average is typically lower. This year, 2,599 hospitals will lose an estimated $566 million. “The number of hospitals and the average penalty – 0.7 percent of each payment – are almost the same as last year,” according to Kaiser Health News.

Hospital penalties are the kind of problems I noodle on at night

I’m the kind of person who noodles on big problems, often waking up in the middle of the night with ideas that eluded me during the day. Hospital penalties is one of those kind of challenges. As much as hospital administrators across the country might wish, there aren’t one or two easy fixes to reduce rates of patient safety occurrences and readmissions.

I joined Geneia four months ago as the director of population health and consumer engagement. In this position, I consult with Geneia’s clients to help them solve their specific uses cases around population health and care management. Another focus of mine is informing and working with our product team to build care management workflows, reporting and dashboards that help our clients succeed in population health and value-based care.

The Theon® platform can help hospitals address patient safety and readmissions

Knowing my long tenure as a registered nurse as well as my current role at Geneia, I was bound to consider whether there are ways the Theon® analytics and insights platform can help hospitals address patient safety and readmissions. I’m pleased to focus on one.

The heart of the Theon® platform is identifying and stratifying subpopulations of patients – often by applying analytics – that the healthcare system – hospitals, health systems, physicians, health plans and increasingly employers – wants to engage in a coordinated and personalized way to prevent health deterioration and the associated costs. 

Our Lucy* story is the perfect example. 

In short, Lucy unknowingly was prediabetic. Her physician, in collaboration with her health plan and health system, identified her as at-risk of metabolic syndrome. Her health plan’s HEDIS® director used the Theon® platform to review BMI trends to generate lists of members at-risk for or with a metabolic syndrome diagnosis, which were then shared with the plan’s value-based care physician practices. As a part of the pre-visit planning, her physician ordered the fasting blood glucose test that showed Lucy, in fact, was prediabetic. 

Lucy learned about her diagnosis from her physician. Hearing about her condition and the necessary lifestyle changes directly from her physician motivated Lucy. She worked with a health plan care coordinator to create a personalized, achievable care plan to improve her diet and activity-level. Each of the professionals with an interest in Lucy’s health – her health plan care coordinator and nutritionist, her physician and his staff, and her employer – used the Theon® platform to monitor her progress and work collaboratively to reverse her prediabetes.

Read Lucy's story

Identifying and Focusing Resources on the Highest Risk and Highest Cost Patients

By extension, hospitals can use the Theon® platform to identify, upon admission, the patients with the highest risk and/or the highest cost as well as those with diagnoses that are likely to lead to an acute exacerbation such as heart failure and COPD. Chances are these are two sub-populations are contributing to hospital readmissions. 

Once identified, hospitals are able to target resources to more closely manage the discharge and post-discharge processes for these groups of patients. Prior to discharge, hospitals can assign a care manager to each of these patients and inform the patient in advance, e.g. “Our care manager, Ronda Rogers, a registered nurse who works with our hospital and your physician, will call you shortly after you are discharged. She’s going to check-in, review your discharge instructions, be sure you have all your medications and know how to take them, and confirm the timing of the follow-up appointment with your doctor.”

I believe there is reason to hope Medicare readmission penalties have peaked. The combination of earlier, more effective identification of hospital patients with a high risk of readmission and a care manager who can personalize her outreach to recently discharged patients has great potential to reduce readmission rates and the associated penalties.

* Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.

 

 


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