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New Final HHS Rules on Readmissions

by Lyle Denniston

The federal government's release of to try to lower readmission rates at more than 3,800 acute-care and long-term care hospitals has started a clock that will give managers and staff about 14 months to adopt new care strategies – especially when it comes to monitoring the health of elderly patients after they have been sent home.

Under orders from Congress in the Affordable Care Act, the Department of Health and Human Services has adopted a deeply complex formula for evaluating when a hospital may risk a reduction in its Medicare payments, if it has an excessive rate of readmission of patients who have been treated for heart attack, heart failure or pneumonia.

It will take managers and their legal advisers a good deal of studyto master the requirements of the new "hospital readmission reduction program." The description of the program and its requirements are embedded in a 1,509-page document.

Although the new rules do not lay out in detail what hospitals must do to avoid those financial penalties, the descriptions of the problems that HHS has detected and its notions of how hospitals can confront those problems suggest that much more attention will have to be paid to the transition of care – from hospital to home – and to the quality of care that patients get from their own doctors as a follow-up to their hospital stay.

Involving Post-Acute Providers Is Among Recommended Interventions.
Under the new HHS mandate, hospitals would not have to provide care themselves after discharging their Medicare-eligible patients, but they would be expected to do enough follow-up to assure that patients and their doctors take steps to continue their recovery. Hospitals, federal officials believe, are the best situated to develop and maintain a care-monitoring system to lower the likelihood that older patients with serious illnesses will have to return for in-patient care.

The rules provide one example of what HHS has in mind for one of the three conditions that may lead to readmission: heart failure. In such cases, the rules say, "improved hospital and post-discharge care, including pre-discharge planning, home-based follow-up, and patient education, have been shown to lower heart failure readmission rates, suggesting that heart failure readmission rates might be reduced if proven interventions were more widely adopted."
The "proven interventions" outlined in the rules include these:

  • "Ensuring patients are clinically ready to be discharged."
  • "Reducing infection risk."
  • "Reconciling medications."
  • "Improving communication with community providers responsible for post-discharge patient care."
  • "Improving care transition."
  • "Ensuring that patients understand their care plans upon discharge."

The new rules, adopted Aug. 1, will be in full effect starting Oct. 1, 2012. A hospital will be in danger of having its Medicare payments reduced if it is determined that too many patients treated for the three identified conditions have been readmitted within 30 days of discharge.

Those three conditions, HHS has concluded, account for some of the highest rates of readmission, resulting in billions of dollars in Medicare spending. Hospital reimbursement is, of course, the largest outlay of Medicare funds, and the acute conditions HHS has selected for monitoring claim a good part of those payouts.

More Readmission Rules, Ratings to Come.
Congress has told HHS to consider adding other medical conditions as targets for lowering readmission rates, but those would not come until after Oct. 1, 2014.

Using three years of data for acute-care and long-term care hospitals, HHS will decide whether a given hospital's readmission rate has been higher than HHS believes it should be. With a complex formula that takes into account patient risk factors such as chronic ill health, each hospital will get a rating.

In the first year that Medicare reductions could actually be imposed, high-readmission hospitals could see a 1 percent cut, in the second year, 2 percent, and in the third, 3 percent.

To come under the program, a hospital would have to have at least 25 readmissions for each of the three conditions over the three-year study period. A readmission would be counted if it came within 30 days of initial discharge from the hospital.

HHS is putting the payment reduction program into effect in two stages. The Aug. 1 rules spell out the basic framework. A second set of rules, due out in about a year, will spell out how the payment reduction system will actually work.

Veteran legal reporter Lyle Denniston has been covering the U.S. Supreme Court for more than 50 years.

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