Preventing Readmissions

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1 Emerging Topics in Healthcare Reform Preventing Readmissions Janssen Pharmaceuticals, Inc.

2 Preventing Readmissions The Patient Protection and Affordable Care Act (ACA) contains several provisions intended to spur efforts to improve quality and efficiency of care in hospitals. Two such initiatives focus on reducing preventable readmissions 1 and preventing hospital-acquired conditions (HACs). 2 The Centers for Medicare and Medicaid Services (CMS) levies financial penalties against hospitals that readmit most Medicare beneficiaries with specific diagnoses within 30 days of discharge. 1 As part of the agency s effort to prevent readmissions, CMS also no longer reimburses for care given to a hospitalized beneficiary for any of 11 specified HACs. 2 Applicable diagnoses Under the Hospital Readmissions Reduction Program (HRRP), 7 primary diagnoses count toward a hospital s readmission rate. Penalties for 3 diagnoses took effect in fiscal year (FY) In FY 2015, the program expands to include 4 more diagnoses. Primary diagnoses included in HRRP 1,3,4 Patients affected Readmission measures apply to beneficiaries enrolled in fee-for-service Medicare and to Veterans Administration hospitals. 6 The following discharges do not count toward readmission rates: Planned readmissions or transfers to another hospital 7 Discharges from hospitals for which volume is too low to calculate accurate readmission rates 3 Patients who leave the hospital against medical advice 6 Financial implications CMS compares a hospital s readmission rates against a predetermined threshold. A hospital exceeding the threshold is penalized with a reduction in its base operating diagnosis-related group (DRG) rate. In FY 2013, about 2000 hospitals experienced DRG reductions 8 costing, on average, $125, In FY 2013, the maximum DRG reduction was 1%. The penalty ceiling increases to 2% in FY 2014 and 3% in Effective FY 2013 a Acute myocardial infarction Heart failure Pneumonia a Penalties took effect October 1, 2012, based on readmissions from July 1, 2008, to June 30, b Penalties take effect October 1, 2014, based on readmissions from July 1, 2010, to June 30, Hip-replacement surgery and knee-replacement surgery are not currently part of the program, but CMS is testing these diagnoses for possible inclusion in the future. 5 Selection of diagnoses Effective FY 2015 b Chronic obstructive pulmonary disease Coronary artery bypass graft Percutaneous transluminal coronary angioplasty Certain vascular conditions In 2007, the Medicare Payment Advisory Commission identified these diagnoses as responsible for 29% of potentially preventable readmissions. 4 These diagnoses are high-volume conditions that account for substantial economic burdens. 4 Hospital-acquired conditions Apart from the HRRP, HACs make up the other half of CMS s readmission-reduction strategy. CMS will not pay for readmission, nor can hospitals charge patients, for treatment of 11 rare or entirely avoidable 11 conditions that were not present upon the first admission 2 : Deep vein thrombosis/pulmonary embolism related to total hip replacement or knee replacement Foreign object retained after surgery Falls and trauma Air embolism Vascular catheter-associated infection Blood incompatibility Manifestations of poor glycemic control Stage III and IV pressure ulcers Surgical site infections Catheter-associated urinary tract infection Iatrogenic pneumothorax with venous catheterization 2 3

3 Implications of Readmissions Defining readmission CMS has taken an all-cause stance on 30-day readmissions. This means that, when calculating readmission rates, CMS includes anyone who is discharged after treatment for any of 7 primary diagnoses and who is readmitted within 30 days for any reason. 7,12,13 All-cause has wide-ranging implications. If, for instance, a skilled nursing facility sends a patient back to the hospital for additional inpatient services, or if a patient s lack of adherence to a treatment regimen results in readmission, these decisions may result in readmissions that can affect the hospital s DRG payment. Causes of readmission: a closer look In a study of 13 million Medicare beneficiaries hospitalized during FY 2004, nearly 1 in 5 who were at risk of rehospitalization were readmitted within 30 days of discharge, costing Medicare about $17.4 billion. 14 Put another way, 1 of every 6 dollars Medicare spends on hospital payments involves a potentially unnecessary readmission. 14,15 This study listed the most common diagnoses and reasons for readmission. The reasons are varied and underscore the importance of care coordination and patient communication upon discharge. Rehospitalization: rates and reasons 14 Primary diagnosis at discharge Medical conditions Heart failure 26.9% Psychoses 24.6% Chronic obstructive pulmonary disease 22.6% Pneumonia 20.1% Gastrointestinal problems 19.2% Surgical conditions Other vascular surgery 23.9% Other hip or femur surgery 17.9% Major bowel surgery 16.6% Cardiac stent placement 14.5% Major hip or knee surgery 9.9% % readmitted within 30 days Based on CMS incentives, hospitals have a strong incentive to work with postacute providers, case managers, and patients to coordinate care and ensure that patients understand their discharge instructions 4 5

4 Anticoagulants and Readmission Reduction Strategies Several readmission diagnoses CMS is targeting and testing involve some form of anticoagulation therapy. Warfarin, one of the most commonly used anticoagulants, can be difficult to manage because of its narrow therapeutic index and variability in dosing requirements. 16 In an Agency for Healthcare Research and Quality (AHRQ) study, about 20% to 25% of patients discharged on warfarin were readmitted within 30 days because of adverse drug events. 17 Novel oral anticoagulants offer potential benefits over warfarin, including a reduction in the frequency of testing and dose adjustments. 16 Anticoagulation therapy management may play a role in the prevention of HACs as well. CMS considers venous thromboembolism (VTE) related to total hip-replacement surgery or knee-replacement surgery an avoidable condition. 2 The AHRQ study found that 8.4% of HACs are VTE-related. 17 Opportunities to reduce readmissions Case studies have demonstrated that certain interventions at discharge can have a significant impact on reducing readmissions. These strategies include: Patient education about anticoagulation regimens Clear discharge instructions with attention to medication management Coordination of care across settings and timely follow-up visits Re-engineered discharge program reduces readmissions At a Massachusetts safety-net hospital, a program for patients and caregivers reduced postdischarge hospital utilization across all diagnoses over a 21-month period in 2006 and A package of services that included patient education, medication reconciliation, and individualized discharge instructions for patients and their primary care providers reduced hospital utilization (ER visits and readmissions within 30 days) by 30%. 18 Staff training about anticoagulants prevents readmissions In 2008 and 2009, inpatient staff at a Michigan hospital participated in a teaching program intended to improve patients understanding of their postdischarge anticoagulation regimens. Among patients who were educated through the program, 60-day readmission rates for anticoagulation-related and nonanticoagulation-related problems were below those of patients who were not educated through the service. 19 Identifying at-risk patients emerges as a strategy In a study (published in 2010) of more than 600 patients who underwent joint replacement and hip replacement or repair at a California teaching hospital, patients discharged to their home with home healthcare services had more than twice the rate of unplanned readmissions as those discharged to inpatient rehabilitation. 20 The authors suggest that identifying patients who may benefit from inpatient management and further medical management before discharge may be an important strategy in preventing readmission. 20 Let Janssen Partner With You Your Janssen representative can offer support tools to help hospitals, case managers, and postacute providers provide high-quality care, ensure smooth transitions across care settings, and help patients understand their self-care to prevent readmissions. Ask your representative for: Resources for case managers: Care-coordination flow charts Information on optimizing transitions of care Tips for helping patients stay adherent to therapy Postoperative follow-up care brochures Resources for hospital discharge planners: Discharge planning checklist Clinical practice guidelines Fact sheets on postdischarge disease risk and prevention Resources for postacute providers: Flow chart on managing disease risks Resources for patients: Materials explaining postoperative follow-up and care Patient self-care is an important part of ensuring positive outcomes. Sometimes, patients need help understanding their medications, managing side effects, and sticking to a medication regimen. CarePath by Janssen can help patients by providing: Product information Medication reminders Access and reimbursement assistance programs Means for providing feedback to physicians Tips on recovery and rehabilitation Visit JanssenCareCoordination.com and CarePathbyJanssen.com for more information 6 7

5 References 1. Centers for Medicare and Medicaid Services. Readmissions Reduction Program. Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Updated August 1, Accessed January 15, Department of Health and Human Services. Hospital-Acquired Conditions in Acute Inpatient Prospective Payment System Hospitals. Fact sheet. Published October Accessed January 15, USC 1395ww(q)(5)(B). Payments to Hospitals for Inpatient Hospital Services. Legal Information Institute website. Accessed January 4, Medicare Payment Advisory Commission. Payment Policy for Inpatient Readmissions. In: Report to the Congress: Promoting Greater Efficiency in Medicare. June Quality Net Dry Run Frequently Asked Questions. Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty and Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty. Quality Net website. Published August 30, Accessed January 15, Centers for Medicare and Medicaid Services. 30-day death and readmission measures data. hospitalcompare/data/rcd/30-day-measures.aspx. Accessed January 15, Reed Smith. Hospital Readmissions Reduction Program May Impact Post-Acute Providers. Readmissions-Reduction-Program-May-Impact-Post-Acute-Providers Published May Accessed January 15, Clark W. Hospital Readmissions Reduction Program to Affect Hospitals Beginning October 1. Healthcare Reform Insights.com website. Published September 5, Accessed January 15, Glass G, Lisk C, Stensland J. Refining the Hospital Readmissions Reduction Program. Medicare Payment Advisory Commission. September 7, Accessed January 15, Public Law An Act Entitled the Patient Protection and Affordable Care Act. March 23, Centers for Medicare and Medicaid Services. Hospital-Acquired Conditions. December 13, HospitalCompare/Data/RCD/Hospital-Acquired-Conditions.aspx. Accessed January 15, Federal Register Washington: US Government Printing Office. July 7, Federal Register Washington: US Government Printing Office. August 31, /pdf/ pdf. Accessed March 29, Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360: Centers for Medicare and Medicaid Services Statistical Supplement. Table 5.1b. Discharges, Total Days of Care, Total Charges, and Program Payments for Medicare Beneficiaries Discharged from Short-Stay Hospitals, by Type of Entitlement: Calendar Years MedicareMedicaidStatSupp/2007.html. Accessed March 29, Eikelboom JW, Weitz JI. New anticoagulants. Circulation. 2010;121: Munier WB. Adverse Drug Events in the Hospital-Acquired Conditions Measured for the Partnership of Patients. Presented at: Partnership for Patients National Priorities Partnership meeting, August 9, https://www.qualityforum.org/setting_priorities/ NPP/Partnership_for_Patients/Quarterly_PFP-NPP_Meetings.aspx. Accessed April 29, Jack BW, Chetty VK, Anthony D, et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150: Wilhelm SM, Petrovitch EA. Implementation of an inpatient anticoagulation teaching service: expanding the role of pharmacy students and residents in patient education. Am J Health Syst Pharm. 2011;68(21): Riggs RV, Roberts PS, Aronow H, Younan T. Joint replacement and hip fracture readmission rates: impact of discharge destination. PM R. 2010;2(9): Janssen Pharmaceuticals, Inc May 2013 K02X13106C Janssen Pharmaceuticals, Inc.

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