Highmark health insurance wants to reduce patient readmissions to ...

When patients need to be readmitted to the hospital, it?s often because of a lapse in the health care they received.

Yet hospitals get paid for the readmission just like they do for the first hospital stay. That?s no incentive for preventing readmissions, critics argue.

On Wednesday, health insurer Highmark announced plans to strengthen the incentive for hospitals to reduce readmissions, which many experts contend are usually preventable.

The effort will involve 90 Pennsylvania and West Virginia hospitals that participate in Highmark?s pay-for-performance program. The affected Harrisburg-area hospitals are Holy Spirit Health System, Penn State Milton S. Hershey Medical Center and PinnacleHealth System.

Hospitals that don?t meet Highmark?s standard will be paid 1 percent to 3 percent less by Highmark, which pays for the medical care of about 1 million people in central Pennsylvania. The amount depends on the hospital?s contract with Highmark.

?It?s not a small amount of change for most hospitals. It makes a distinct difference in getting people serious,? said Page Babbit, Highmark?s director of provider engagement.

The effort focuses on patients who are readmitted within 30 days of the end of their original stay. According to the Pennsylvania Health Care Cost Containment Council, about 14 percent of adult hospital stays resulted in such a readmission in 2010. About 6 percent resulted from an infection or medical complication.

Those figures also include planned readmissions, which can involve situations such a cancer patient returning for additional procedures or a heart attack patient who ends up needing heart surgery.

Still, unplanned readmissions are considered a huge driver of high health care costs, adding roughly $500 million to the amount spent by Medicare annually on hospital care in Pennsylvania. That figure doesn?t include money spent on readmissions by private insurers.

Babbit said most unplanned readmissions are preventable, although she noted that some aren?t the direct fault of the hospital.

Some result from things like patients who don?t follow after-care instructions, or who don?t obtain medications or have follow-up appointments with their regular doctor or specialist.

Others stem from factors such as poor communication between a hospital and nursing home or home health agency that cares for the patient after discharge.

Highmark?s effort is based on the premise that hospitals are in good position to address many of the reasons for readmission and to help patients with things such as understanding their discharge instructions and scheduling follow-up appointments. For example, many readmissions can be avoided through better collaboration between hospitals and after-care facilities such as nursing homes or home health agencies, Babbit said.

Previously, hospitals participating in Highmark?s pay-for-performance program had a choice of where to focus their improvement efforts. Now their efforts must include re-admissions.

Harrisburg-based PinnacleHealth System had already chosen to focus on readmission rates and has attained a readmission rate that?s lower than the state average, said Joan Silver, Pinnacle?s vice president for quality.

?We realize there are many things we might be able to control or do better to prevent people from being readmitted,? she said.

She said Pinnacle recently received $4 million as a result of Highmark?s pay-for-performance program.

Much of Pinnacle?s effort to reduce readmissions focuses on things that happen after the patient leaves the hospital, she said.

One component involves calling discharged patients within 48 hours to ask how they are feeling and whether they have obtained prescribed medications and made follow-up appointments with doctors.

Pinnacle will make up to three calls to reach the patient, and it succeeds in reaching about 70 percent, said Silver, who noted that some patients provide faulty contact information or don?t respond to calls.

It also includes an intensified effort to make sure patients and their caregivers fully understand how to maximize their recoveries and prevent problems.

Silver took issue with the idea that because hospitals get paid for readmissions, they lack financial incentive to prevent them.

She stressed that hospitals often have no control over how much they will be reimbursed or whether their full costs will be covered, and she argued that hospitals don?t substantially benefit from readmissions.

?My goal is to forget about the financial, and make sure the patient gets the right care in the right setting at the right time,? Silver said.

Highmark?s focus on readmissions comes as the federal government, as part of the Affordable Care Act, plans to begin penalizing hospitals that don?t sufficiently address readmissions and other items that reflect on quality of care given to patients.

Beginning in October, Medicare will reduce, by 1 percent, the amount paid to hospitals that have high readmission rates. The penalty will rise to 3 percent. The goal is to shift the payment model toward paying for quality rather than volume.

Patients and their families or friends can help prevent readmissions by making sure they fully understand the patient?s medical conditions and steps that are needed to maximize their recovery and keep them healthy, Babbit said.

Source: http://www.pennlive.com/midstate/index.ssf/2012/07/insurer_to_fight_hospital_read.html

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