The Affordable Care Act (ACA) enacted in March 2010 aims at making health insurance available and cost affordable to many more Americans. It provides Americans with house hold income between 100% – 400% of federal poverty level with premium tax credits that allows them to obtain insurance at a lesser cost, (kff.org, 2017). While not all states have the Medicaid expansion program, the ACA aims at expanding the Medicaid program to cover all adults with income below 138% of the federal poverty level. It also supports innovative medical care delivery methods designed to lower general healthcare cost. As a result of all these goals, the ACA came with several regulations aimed at reducing medical cost, improve patient quality of care and ensure better outcome. One of these regulations is contained in its section 3025. It levies penalties upon hospitals with excess readmission rate within 30 days.
Summarize the provision and how it was intended to achieve higher value Hospitalizations can be stressful and even worst when it results to a subsequent readmission. As our healthcare continues to seek measures through which they can improve quality of care at a lesser cost, section 3025 of the Affordable Care Act of 2010 introduced the Hospital Readmissions Reduction Program (HRRP), which requires the Centers for Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess 30-day readmissions for Medicare patients treated for certain conditions, effective for discharges beginning October 1, 2012. According to cms.gov (2018), these conditions include, Heart Failure (HF), Acute Myocardial Infarction (AMI), Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Total Hip/Total Knee Arthroplasty, and Coronary Artery Bypass Graft (CABG). Hospitals with any of the above measures having less than 25 cases under this provision are not considered to be having excess readmission ratio for that condition. Adjustments to a IPPS hospital’s Medicare payments are made only when the hospital performance is worse than average. Hospitals located in Puerto Rico are exempted. The final readjustment factor for FY 2018 was based on the above 6 readmissions measures.
In 2013, it was estimated that more than 2200 U.S. hospitals lose over $280 million in Medicare funds because their readmissions exceeded the expected rates stipulated by Section 3025 of the ACA. These readmissions were specifically linked to patients with congestive heart failure, pneumonia, and acute myocardial infarction (Williams, Javed, Hamid & Williams, 2014).
Synthesize the evidence about whether — when implemented — the policy has achieved higher value. The HRRP has gained significant attention since its implementation. Some experts however argue that its implementation has both positive and negative impact. According to Jencks, Williams, and Coleman (2009) nearly one in every five Medicare patients discharged from the hospital will be readmitted within 30 days (Jencks, Williams, & Coleman 2009). The Medicare Payment Advisory Commission indicated that about 12% of all these rehospitalizations are preventable, and reducing this by 10% could save Medicare over a billion dollar (Brown & Bold, 2015). Since its implementation, the HRRP has achieved significant higher value through “the creation of strong collaborative relationships within hospitals, medical institutions, and in the surrounding communities” which has helped improved patients overall experience through hospitalization and beyond (McIlvennan, Eapen, & Allen, 2015). According to McIlvennan, Eapen, & Allen (2015), the HRRP has also created more awareness and enhance collaboration at the national level, which has led to the creation of several National Quality Initiative measures. Thus, one national quality initiative, Hospital to Home was created in 2009 with aim of reducing unnecessary hospital readmissions, by facilitating transition of care after discharge from hospital. Researchers have found these efforts to help reduce readmissions and reduce cost. According to Medicare Payment Advisory Commission (MedPAC) preventable rehospitalizations are costing Medicare about $12 billion a year (Jencks, Williams & Coleman, 2009).
On the other hand, some argue, while the HRRP is aimed at reducing preventable rehospitalization, it resulted to care being drifted to focus only on these measures, to the extent of neglecting other important aspect of patient care. The HRRP has received criticism on its methods of calculating the excess readmissions. McIlvennan, Eapen & Allen (2015) argues that “the initial risk-adjustment models did not adjust for socioeconomic status” hence, this may worsen disparities as hospitals providing care to under deserved patients or patients with low socioeconomic status may be at a disadvantage by paying penalties compared to its counterparts. While some of the readmissions are unpreventable, a majority of the critics claim that most readmission diagnosis are usually not the same as their diagnosis upon initial admission (Kamerow, 2013). These critics further ague that most Medicare beneficiaries are elderly, disabled, at risk for other injuries/infections and frail which all makes them more vulnerable to rehospitalization.
Discuss how the policy effort is attempting to improve quality outcomes and decrease costs. Since 2009, the CMS is expected to measure and publicly report hospitals’ Excess Readmission Ratios (ERRs) on the Hospital Compare website, which in tend help adjusts hospital reimbursements. By adjusted hospital reimbursements, CMS primarily levy penalties on hospitals based on the 30 days excess readmission rule. In order do this successfully, the ACA added Section 1886(q) to the Social Security Act which established the HRRP through which IPPS hospitals participating in the readmission reduction programs can be monitored, evaluated and sanctioned. As a result, the HRRP has since October 1, 2012, require that the CMS reduce payments to IPPS-participating hospitals with excess readmissions (Brown & Bold, 2015). The HRRP has as aim to reduce hospital readmissions for Medicare patients. Research has found that HRRP has reduced readmissions about 4 percent in aggregate and has generated nearly $2 billion dollars in penalties. The program however appears to be lowering targeted preventable hospital readmissions as planned.
Describe the specific evidence based nursing efforts that would directly support achieving the intended outcomes. Hospital readmission is a recognized indicator of poor quality of care. This is often seen as resulting from poor discharge planning, poor quality of care and inadequate care coordination. While some rehospitalizations can be unanticipated, several studies have shown that hospitals can reduce reemission rate by instituting certain measures. Some of these include determining patients risk for readmission upon admission, clarifying patient discharge instructions, properly instituting transitional care measures, coordinating patient’s care with post-acute care providers, their primary care physicians, and reducing medical complications during patients’ initial hospital stays (Dizon, & Reinking, 2017).
Furthermore, evidence has shown that appropriately staffed hospitals experience lower rates of readmissions (McHugh, Berez & Small, 2013). When there is appropriate staffing, nurses have time to monitor for complications, adverse events and to effectively use the available resources to execute care processes that influence readmission. Starting from admissions, nurses start planning for patient discharge, they make sure they engage patient and families in their care process and ensure they understand their treatment course. They also identify barriers to compliance in treatment and address them during patient stay in the hospital. Some of these include language barriers where they use the services of an interpreter to make sure the patient understands the teaching. They also, incorporate care givers, families into patient care. It was found that engaging patient and families in the care process will help improve quality of care by preventing harm, reducing hospital readmission and prevent medical errors (Sofaer, & Schumann 2013). While research on post discharge follow-up phone calls have been argued as being inconclusive in influencing readmission for the general population, studies show that those made targeting Medicare patients and those enrolled in chronic disease management program have been the most effective at preventing readmissions (Harrison, Auerbach, Quinn, Kynoch & Mourad, 2014).
Many studies have associated readmissions to the prompt follow-up of the patients by the primary care providers (PCPs) or other healthcare professionals. Typically, patients are often expected to have a follow-up appointment within 48 hours to 7 days after discharge. The hospital or discharging nurse sometimes call to set up this appointment before patient is discharged from the hospital, rather than providing the patient with a number to call themselves. These are often scheduled based on patients’ preferences. The nurse can also identify and possibly address barriers to follow-up appointments and by incorporating families and care givers, the nurse emphasizes to them the importance of follow-up appointments. Patients are encouraged to call back after discharge if they have any questions or concerns.
Multifaceted and interdisciplinary care programs, coordinated by nurses have also been found to be helpful in reducing hospital readmissions (Dizon & Reinking, 2017). Through the multifaceted nursing interventions, nurses upon admissions can help identify high risk patients, evaluate discharge readiness and help facilitate transition from hospital to home by tailoring an individualized discharge plan that best meet the needs of the patient.