With one RAC - HealthDataInsights, for Region D - having set its sights on readmissions as a possible target - could the other RACs have a collection strategy in the works?

Studies estimate that as many as 20 percent of hospitalizations are readmissions that occur within 30 days of discharge, and 34 percent are readmissions that occur within 90 days. These readmissions are costly, potentially unsafe, and often preventable.

Not surprisingly, the Obama administration has noticed the readmission problem, not just because of the safety issue but because of the costs it adds to Medicare (now estimated at $17.4 billion yearly).1 It is not surprising to see the inclusion of a Hospital Readmissions Reduction Program in the Patient Protection and Affordable Care Act (Affordable Care Act).²

IPPS Payments to Link to Readmission

Beginning in fiscal year 2013, inpatient prospective payment system (IPPS) rates will be adjusted based on the dollar value of each hospital's percentage of potentially preventable Medicare readmissions for the three conditions with risk-adjusted readmission measures that are currently endorsed by the National Quality Forum (NQF) (http://www.qualityforum.org/). These conditions are heart failure, pneumonia and acute myocardial infarction.

The risk-adjusted readmission measures were calculated as part of the Reporting Hospital Quality for Annual Payment Update (RHQDAPU) program requirements for the 2010 payment update and are posted on the Centers for Medicare & Medicaid Services (CMS) website. Hospitals were given the opportunity to preview these data by May 8.

In addition to hospital readmission rates, tuture reporting, measure definitions, and methods can be found under the "Hospitals - Inpatient" tab at the QualityNet website (http://www.qualitynet.org/).

According to the IPPS final rule for FY 2009³, higher hospital readmission rates are linked to higher costs and also to lower quality of care received during hospitalization and after the initial hospital stay. CMS increasingly promotes quality and efficiency of care through the application of value based purchasing (VBP) tools. The VBP methodology is meant to promote adherence to evidence-based best practices by rewarding high-achievement.

New Law Increases Oversight

The Affordable Care Act includes several new, and important, provisions related to acute care hospitals. Two of these provisions are described below.

• Payment adjustments for excessive readmissions. Adjustments in IPPS rates will be made to account for excess readmissions during FY 2013 and beyond (on and after October 1, 2012). Each adjustment will be calculated with a percentage based on a comparison of the facility's aggregate payments for excess readmissions and aggregate payments for all discharges. The Department of Health & Human Services (HHS) Secretary will make these changes available to the public.
• Patient safety organizations: Via the Affordable Care Act, Congress added a new section to the Public Health Services Act (PHSA) entitled the Quality Improvement Program for Hospitals with a High Severity Adjusted Readmission Rate. This provision applies to hospitals that the HHS Secretary determines have 1) a high rate of risk-adjusted readmissions for conditions or procedures that are high volume or have high expenditures under Medicare⁴ and 2) have not taken appropriate steps to reduce such readmissions and improve patient safety.⁵

¹Rehospitalizations Among Patients in the Medicare Fee-for-Service Program by S.F. Jencke, et.al. N Engl J Med 360;14, April 2, 2009

² Patient Protection and Affordable Care Act: Law, Explanation, and Analysis Explanations, Chapter 7--Health Care Quality Improvement:  Development of New Patient Care Models:  ¶749, Hospital Readmissions Reduction Program

³The FY 2009 inpatient PPS final rule can be found at https://www.cms.gov/AcuteInpatientPPS/IPPS2009/list.asp.

⁴This information can be found in the Social Security Act (SSA), Section 1886(q)(8)(A), can be found athttp://www.socialsecurity.gov/OP_Home/ssact/title18/1886.htm.

⁵PHSA, Sec. 399KK, as added by Sec. 3025(b) of the Affordable Care Act) at http://thomas.loc.gov/cgi-bin/query/F?c111:7:./temp/~c111JSF5jr:e949445