Possible Reactions to HRRP Penalties: Reducing Readmissions

With the enactment of the Affordable Care Act in 2008, federal agencies began recording the rate at which Medicaid and Medicare patients were readmitted to hospitals within thirty days of a previous hospital stay. This data provides a great deal of insight into the quality of care and reimbursement procedures within major health systems. Financial penalties given to health systems with high rates of readmissions for Medicaid and Medicare patients can sometimes prove to be a burden but have proven to be an incentive to improve hospital readmission rates. The Readmissions Reduction Program (HRRP) examines several areas when determining payment amounts for American health systems. 

The Centers for Medicare & Medicaid Services evaluates the medical incidences for specific encounters, such as that for cardiologic issues. These encounters can include “acute myocardial infarction (AMI), heart failure (HF), pneumonia, chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG) surgery, and elective primary total hip or knee arthroplasty (THA/ TKA)” (Centers for Medicare, 2018, para. 9). Through further evaluation, the CMS evaluates the excess readmission ratio (ERR), which helps to determine the health system’s performance ratio (Centers for Medicare, 2018). This information is then inputted into a sliding scale, created as a provision of the ACA, to reduce the payments to hospitals starting at one percent (2014) and rose by one percentage point each subsequent year (Centers for Medicare, 2018). 

As an update to this policy, in 2019, the Centers for Medicare & Medicaid Services will determine peer groups to compare hospital and health system performance ratings, and thus make payment determinations with peer group guidelines in place. This addition to the policy adds a level of comparison between health systems and hospitals of similar sizes, nursing staff on hand, and patient volume. Since healthcare industry markets are variable across the country, this creates a system of fair evaluation for hospitals based on parameters that can accurately determine performance rating relative to competitors in a given market. 

The peer groups are determined with a specific set of guidelines constructed by the CMS. The informational website for this program states: 

Hospitals are stratified into five peer groups, or quintiles, based on the proportion of dual-eligible stays. A hospital’s dual proportion is the proportion of Medicare fee-for-service (FFS) and Medicare Advantage stays where the patient was dually eligible for Medicare and full-benefit Medicaid. The median ERR of hospitals within the peer group is used as the threshold to assess hospital performance on each measure. The median peer group ERR varies by measure and replaces the 1.0 threshold used to assess hospital performance and an ERR above the peer group median ERR enter the payment adjustment factor.

Since hospitals will be evaluated based on their readmission rates in comparison to the competitors in the given market, the rates of payment reductions will be relative to the total market in a given area. This is crucial to reducing overall readmission rates in a specific market by not comparing health systems to a national average, and instead to a local market average. 

The case study to be examined is regarding Brooklyn Presbyterian Hospital (BPH) during 2012. The federal government determined that BPH had worse readmission rates than the national average in two specific areas, in unplanned heart failure cases and unplanned readmission for pneumonia cases. According to a study completed in 2016 by Ziaeian and Fonarow, heart failure is the leading cause of unplanned hospital readmission in the United States. (Ziaeian & Fonarow, 2016). Taking this into consideration, the rate for unplanned hospital readmission due to heart failure could be deemed a public health concern, since many hospitals nationwide struggle with similar rates. 

If unplanned readmission for heart failure is a national trend across health industry markets, Brooklyn Presbyterian Hospital should not be penalized as harshly as if the readmission rates for heart failure were not a widespread concern for health systems nationwide. Statistical projections made by Ziaeian and Fonarow (2016) show that by the year 2030, there will be a total of 8 million people in the United States living with and suffering from heart failure. This is a steep increase from the 2016 rate of 5.7 million people living with heart failure concerns in the United States. These researchers also suggest that a possible clinical solution, such as the introduction of beta blockers into standard practical use. The study also suggests: 

Other drugs such as spironolactone and eplerenone have both been shown in randomized clinical trials to reduce death and hospitalizations, with benefits seen within 30 days of initiation of therapy.  Recent observational data from discharge confirm that the addition of an aldosterone inhibitor reduces HF readmissions.  With regard to diuretic therapy, torsemide has higher bioavailability with less variability when compared to furosemide. Small trials suggest that inpatients discharged on torsemide have a lower risk for readmission in comparison to furosemide. (Ziaeian & Fonarow, 2016, para. 11)

Since there are drugs that have proven in clinical trials to reduce the fatal indications of heart failure, a change in the standard clinical procedure may be necessary for Brooklyn Presbyterian Hospital as well as many hospitals nationwide to improve rates of unplanned readmission for heart failure. This change in policy can help to reduce the level at which Brooklyn Presbyterian Hospital is penalized for high readmission rates for these encounters and could influence the manner in which policies are created to evaluate the performance of the hospital.

In addition, the rates of unplanned readmission for pneumonia are also of concern for Brooklyn Presbyterian Hospital. Similar policy changes can be made in this case as well. Careful evaluation of the standards of clinical practice as well as the procedures in nursing care should be evaluated for inefficiencies or lack of standardization. By improving the standards of care, the rates of readmission should be reduced and thus align Brooklyn Presbyterian Hospital with national averages for rates of readmission. The improvement and adaptation of internal practices will be crucial to ensuring that Brooklyn Presbyterian Hospital will meet HRRP criteria in the future. Healthcare laws and regulations are placed in order to ensure that high quality care is delivered to American patients, however, the need for continued improvement and adaptation to laws and regulations is necessary for success in a changing healthcare environment.

In the event that Brooklyn Presbyterian Hospital sought to create a new program charged with reducing the rates of unplanned readmission for cases of heart failure, pneumonia, and potentially others, this would also greatly improve the likelihood of the hospital meeting HRRP criteria. The key elements to ensuring the highest level of reimbursement as a result of reducing readmission rates include throughout data evaluation, adaptive leadership, and the careful coordination of clinical services. These elements, in tandem, can help to reduce the rate of readmissions and identify procedures and policies that could potentially be altered to improve the overall hospital performance. 

In order to maximize the rate of reimbursement possible by reducing the number of unplanned readmissions within thirty days, Brooklyn Presbyterian Hospital needs to determine a set of attainable goals to foster the improvement of policies and procedures throughout the hospital. These goals should include increasing the efforts to standardize operating procedures throughout the hospital. This will ensure that the staff is operating efficiently, and providing high quality care along with evidence based guidelines (Graham & Harrison, 2002). Another goal should be to implement a new program to evaluate departments or specific areas that may be struggling with rates of readmission. This would include cardiology procedures as well as examining the care models for patients with pneumonia. Another goal is to be clear and transparent when collecting data and reporting on hospital rates of readmission to internal and external agencies. Maintaining the integrity of the hospital’s data collection process will ensure that no mistakes or continuity errors are present when information is collected for HRRP. Additionally, the Brooklyn Presbyterian Hospital should strive to foster an environment that thrives on providing high quality care to its patients. This can be done through various initiatives to involve interdisciplinary teams in the planning of policies and procedures as well as reviewing the available resources to the hospital to allocate and improve utilization. Finally, Brooklyn Presbyterian Hospital should aim to reduce its rates of readmission by the necessary percentage to fall within the national averages. This will show that the efforts put forth by hospital administrators and executives were concentrated on a single goal, and with continued improvement and the introduction of peer groups for evaluation, Brooklyn Presbyterian Hospital should correct its position with the HRRP. 

Brooklyn Presbyterian Hospital has an opportunity to drastically improve its internal operations and provide its community with quality healthcare services. By creating programs to improve internal operations and alter policies that will result in positive patient outcomes, the hospital will improve its position within its geographic market as well as nationally. Ideally, Brooklyn Presbyterian Hospital should implement improvement initiatives to alter procedures and policies under a pilot program format. This allows for a controlled environment in which changes can be made to facilitate operational success. The aim of these programs should be to improve the average rate of readmissions to be below the national average. In 2019, when peer groups are introduced by the CMS, Brooklyn Presbyterian Hospital will be ranked among its market competitors and reimbursement rate determinations will be made based on the performance of the hospitals in these groups. This could potentially be an advantage for Brooklyn Presbyterian Hospital, depending on the current quality of care provided by other hospitals or health systems in its market. Ideally, the goal of the pilot programs would be to implement changes widespread, in all departments across the hospital to improve patient care and standards of practice. Within one to two years, the programs should help to reduce the rates of readmission and allow for the maximum reimbursement through the HRRP.

References

Centers for Medicare & Medicaid Services. (2018). Readmissions reduction program. Retrieved from https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html

Graham, I. & Harrison, M. (2002). Facilitating the use of evidence in practice: Evaluating and adapting clinical practice guidelines for local use by health care organizations. Journal of Obstetric, Gynecologic & Neonatal Nursing. 31(5), 599-611. Retrieved from https://www.sciencedirect.com/science/article/pii/S0884217515340053

Ziaeian, B. & Fonarow, G. C. (2016). Epidemiology and aetiology of heart failure. Nature Reviews. Cardiology, 13(6), 368–378. Retrieved from http://doi.org/10.1038/nrcardio.2016.25