In 2010, when the Affordable Care Act (ACA) became law, one of its lesser known provisions (section 3025) instituted a “Readmissions Reduction Program” (RRP). This was a mandate that required Centers for Medicare & Medicaid Services (CMS) to impose penalties on hospitals that exceeded certain readmission metrics. The RRP came into effect in 2012. Specifically, the ACA focused on three admitting diagnoses: acute myocardial infarction, heart failure, and pneumonia. In 2017, coronary artery bypass surgery admissions were added to the list.
Section 3025 came into being for good reason. Hospital readmissions are a substantial source of preventable health care spending. Every year, 36 million or more Americans are discharged from acute care hospitals. Seventy-five percent of these went home and the other 25% went to either specialized nursing facilities, rehabilitation hospitals or long-term care facilities. Approximately 50%, or 18 million, of these discharges were Medicare members. Of these, 3.6 million were readmitted to the hospital within 30 days.
According to the Kaiser Family Foundation, in 2017 hospitals paid Medicare $528 million in readmissions penalties, $108 million more than in 2016. Nevertheless, savvy Medicare Advantage (MA) planners have stayed ahead of the curve and have found innovative ways to reduce hospital readmissions. Many have done so for all the right reasons – not because reducing readmission saves MA plans money but because RRPs focus on taking better care of patients.
A phone call away
One innovative plan takes advantage of the most powerful technology in medicine: the telephone. After patients are discharged from the hospital, a dedicated nurse-manager calls the patient to make sure that the member is safe and has a transition plan in place. The nurse-manager works with the member to look for any gaps in care that may be in place, and then to fill those gaps. A particular area of interest is medication compliance and adherence. Medication errors make up a substantial portion of hospital readmissions. A simple phone call can help stave off an unnecessary readmission because of a medication mistake.
Falls are also an unfortunate cause of hospital readmission. The nurse-manager discusses the member’s particular needs: does she require home health visits or durable medical equipment? Are there caregivers nearby who can help the member manage activities of daily living? Finally, the nurse-manager arranges follow-up visits with the member’s primary care physician and the surgeon as needed. These visits can help catch post-discharge complications that often lead to readmissions.
One of the oldest concepts in medicine is that diet matters. The concept fell out of favor during the medical revolution, when it appeared that pills would cure whatever ailed a patient. Fortunately, “food as medicine” is making a comeback. Increasingly, the medical community is coming to realize how important adequate nutrition is for well-being in general, and to avoid hospital readmission in particular. A study in Journal of the Academy of Nutrition and Dietetics in 2013 pointed out that inadequate nutrition was a major risk factor for hospital readmission. Many seniors, by definition Medicare recipients, are at risk for food insecurity at any given moment. Food truly is medicine.
One health plan realized that post-discharge nutrition was a cost-effective method of reducing hospital readmission. Medicare Advantage plan managers connected their members with a food service that delivered ready-to-eat meals to for up to a month after discharge. As a bonus, the food service unpacks the meals and even puts them in the member’s freezer.
The integrated approach
As MA plan managers experiment with various plans to deliver high-quality care that reduce hospital readmissions, a set of best practices for an integrated approach to the problem has been emerging. A common feature is a single point of contact for the member, usually a nurse manager, although some physicians serve as the point of contact. This “point person” manages and coordinates the member’s various providers and services according to the member’s particular needs. The key to making this work is building high-performing networks of post-acute care providers who are preauthorized for quality and connectedness.
The latest piece of the integrated approach is data-driven technology. Data analytics for stratification of patient risk helps identify which patients are most appropriate to receive care at home, and which require care in specialized nursing facilities. Holding all the pieces together are technology platforms that connect caregivers to members at every point of care.
The diversity of Medicare Advantage plans allows experimentation and innovation to flourish. Data analytics permit the system to learn from experience. The various components of the system are on track to continue to reduce hospital readmissions and, most importantly, improve outcomes for patients.