In an effort to slow the hemorrhage of Medicare expenditures, the Center for Medicare and Medicaid Services (CMS) stopped reimbursing hospitals for the occurrence of "never events" beginning October 1, 2008. The National Quality Forum (NQF) defines never events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients. These events jeopardize patient safety and call into question quality of care. Examples of never events on the NFQ list include death or serious disability associated with medication errors and falls experienced by patients under the care of a healthcare facility as well as hypoglycemia and the development of a stage 3 or 4 pressure ulcer.
Why should the home care field take note of never events specific to hospital care? They herald a low-hanging fruit just waiting for harvest-preventable rehospitalizations.
The CMS fully intends to work with Congress on legislation to reduce cost by supporting payment adjustments based on quality and efficiency of care. Reducing unnecessary hospitalizations has long been a health reform goal because readmissions are costly Medicare-covered services. The rate for patient return to the hospital after discharge is staggering, as are the costs associated with admissions considered to be preventable.
The Report to the Congress: Promoting Greater Efficiency in Medicare (June 2007) shows that Medicare spending for preventable readmissions reached $5 billion, $8 billion, and $12 billion for cases readmitted, respectively, within 7, 15, and 30 days. The average Medicare payment for preventable readmissions totaled approximately $7,200 in 2005.
Reimbursement policy change in the form of nonpayment for readmissions deemed preventable represents a significant opportunity to reduce cost. This change improves the likelihood of simultaneous improvements in healthcare quality. Healthcare providers will be forced to address shortcomings in care delivery to achieve needed results. What a wonderful hemorrhage tourniquet this could be!!
Leaders in the health reform movement, such as the Commonwealth Fund and the Leapfrog Group, have begun to highlight the causes of rehospitalization facilitated by the current CMS reimbursement methodology. They have been calling for change. There is consensus that by paying each provider separately, the impetus for coordinating care across settings is absent. There also is lack of payment for services found to reduce rehospitalizations, such as postdischarge phone calls or remote patient monitoring for the early detection of medical exacerbations. The current lump sum payment for diagnosis-related groups (DRGs) rewards hospitals to shorten the length of hospital stay with no responsibility on the hospital's part to accept accountability for a higher risk of rehospitalization among certain vulnerable patient populations.
A fractured care juncture exists and shows wide cracks in healthcare as a "system of care." The business-as-usual process of providers operating in independent silos has been identified as a direct cause of specific untoward events such as serious medication errors. Home care agencies have firsthand experience with the consequences of poor handoffs and lack of communication when the patient transitions from an acute care environment to home. Rehospitalizations during an episode of home care not only negatively effects an agency's own outcomes but also can have grave consequences for the patient's financial status and ultimately his or her quality of life.
Patients with chronic diseases are even more vulnerable for care errors due to specialization and fragmentation in healthcare delivery. Multiple doctors manage patients in an uncoordinated manner, and many patients are cared for by hospital personnel who may not communicate with the patient's primary care physician.
Medicare soon will begin to adopt policies specifically designed to address shortcomings due to current reimbursement methods. Policy reforms most likely will take shape via public disclosure of hospital-specific, risk-adjusted readmission rates. Public reporting will provide Medicare with the data needed for further policy redesign that ties pay to performance. The CMS will have the information needed to benchmark high-performing hospitals with low-performing facilities and will be able to compensate accordingly.
The CMS recognizes how other providers such as skilled nursing facilities and home health agencies are instrumental in preventing readmissions. Sound reimbursement policy would include a method to align incentives across providers to improve the likelihood of care coordination, possibly in the form of bundled payments to systems instead of individual providers. Home health agencies will be included as a financial target for reimbursement reform related to readmission rates, either as an individual entity or bundled with other providers.
Home care has a responsibility to lead by reaching out to its healthcare provider partners to identify methods for sealing cracks in a fissured transition juncture. Agencies can initiate a strategic dialogue with hospital partners so they see the value of home care to help meet hospital goals. One fact to highlight, as mentioned in the Report to Congress (June 2007), is that 64% of readmissions are for beneficiaries discharged to home who had not received any additional postacute care.
Another hurdle to cross will be that of changing the mindset that sees more patient days as achieving a healthier hospital profit margin. Many hospitals experience lower margins for readmitted patients with chronic conditions. Hospitals that invest in reducing readmissions by partnering with home care agencies must understand that the reward they reap is the ability to fill their unused beds with more profitable patients.
Home care leaders have a sufficient body of evidence to make their case for partnership. Home care has efficient and effective methods for reducing hospitalizations, including the use of principles for chronic disease management, remote patient monitoring, and the nurse case management model. The Home Health Quality Improvement National Campaign has excellent resources and reference materials relating to the use of these methods, available through their Best Practice Intervention Packages.
Dialogues with potential hospital partners might be facilitated with a focus on the DRGs with high volume and high rates of readmissions. Good candidates include patients with heart failure, chronic obstructive pulmonary disease (COPD), or coronary artery bypass graft (CABG), conditions that account for almost 30% of all readmissions within 15 days of discharge. What a fertile ground for conducting a focused demonstration project between a home health agency and a partner hospital.
Healthcare is at a crossroads. We can and must do better. Let us take a leading role by extending our hand across provider silos and fragile junctures to demonstrate our value. Let us collaborate to improve the lives of those whose healthcare is in our hands today, with great promise for a better tomorrow.