By Mark Dwyer
In 2012 our government enacted legislature that mandated U.S. hospitals to reduce readmissions by emergency departments (ED) admits for the first thirty days post-discharge. To force this change in behavior rather than wait for hospitals to choose to proactively address the overall health of their communities, the government began penalizing hospitals who had higher than average readmission rates through a deduction in their reimbursed Medicare payments.
This was a radical change in American healthcare; it put the onus of keeping patients well on the hospitals and providers who treated them. No longer could hospitals simply wait for individuals to require hospital care; instead it became their responsibility to proactively manage ED-admitted patients for at least the first thirty days post-discharge. If they were unsuccessful in providing the patient with the tools and help needed to keep them from readmitting, they bore the weight of a financial penalty.
Initially, the penalty amounted to 1 percent of the hospital’s total annual Medicare reimbursement. It was tied to three specific DRGs (diagnosis related groups): acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Each hospital was scored against its neighboring hospitals to determine which ones had readmission rates in the highest twenty-fifth percentile of the surrounding hospitals.
If a patient who had been admitted via the ED due to one of these three DRGs required readmission within thirty days post-discharge, and the hospital’s readmission rate was in the highest twenty-fifth percentile of hospitals in the area, the hospital’s overall annual Medicare reimbursement was reduced by 1 percent. Although 1 percent may not seem like a lot, when applied against the hospital’s entire Medicare reimbursement dollars, it was significant—especially for hospitals operating with only 2 to 3 percent profit margins.
But the government didn’t stop there. In year two of the program, the percentage of Medicare reduction was increased to 2 percent of the hospital’s total annual Medicare reimbursement amount. In year three, not only was the percentage again increased to 3 percent of the hospital’s overall Medicare reimbursement, but three additional DRGs were added: elective knee replacement, elective hip replacement, and chronic obstructive pulmonary disease (COPD).
At this point many hospitals began paying attention, especially when over 2,200 U.S. hospitals were penalized for failing to reduce their readmission rates. To address this ever-increasing reimbursement reduction, hospitals had to implement programs to manage Medicare patients post-discharge for at least the first thirty days. To do so, many homegrown programs were introduced with varying success.
A number of healthcare software vendors began developing and marketing programs to help educate and manage the patients post-discharge. Some of these programs involved on-site care management visits, phone calls, reminder texts, and emails. Some also involved extensive motivational programs designed to not only assist patients in remaining proactive about their care but also the patient’s caregiver. Too often the Medicare patient’s primary caregiver is an elderly spouse who is also battling a litany of health issues. Assisting them and other familial caregivers was determined to play a critical role in the process.
But what about the many patients who suffer from more than one chronic disease? Some vendors realized that many Medicare patients suffer from comorbidities. It is not unlikely for an individual with diabetes to also be obese, or someone with HF to have been admitted with an AMI DRG. Initially, since these various disease states were defined as separate care plans, patients suffering from comorbidities experienced multiple interactions post-discharge in order to manage all conditions that could possibly result in a costly readmission.
To motivate patients and their caregivers to follow post-discharge instructions regarding medications, to make and attend post-discharge provider appointments, and to integrate with the hospital’s care management or medical call centers, vendors have begun collaborating with leading content developers. By adding patient educational and motivational training content to their software programs, post-discharge programs can enable nurses or care coordinators conducting follow-up calls to select the specific information needed to address each patient’s multiple issues. This comorbidity program approach eliminates the need for redundant calls to address each of the patient’s healthcare issues. Instead it enables the nurse or care coordinator to select the content, surveys, motivational scripts, and other resources needed to meet all of the patient’s unique needs across a wide array of health conditions.
Future-thinking hospitals and providers who see the need for follow-up beyond the initial thirty days post-discharge are beginning to take a stand for long-term health management by using customizable comorbidity programs. This is a real step in the direction of healthcare management. Imagine a future where healthcare generates greater revenues from having empty beds, keeping area residents healthy and at home.