This blog post excerpts an article by Robin L. Rose, MBA, Vice President, Healthcare Resource Group, HealthStream, in the Q3 2015 issue of PX Advisor , our quarterly magazine designed to bring you thought leadership and best practices for improving the patient experience.

As required under the Affordable Care Act, CMS began imposing a penalty on hospitals with excessive Medicare readmissions in FY2013 (October 1, 2012) as part of the Hospital Readmissions Reduction Program (HRRP). CMS defines a “readmission” as someone who has been readmitted to the same or another acute care facility within 30 days of an initial hospital stay. For the first two years, the HRRP applied to Medicare patients with diagnoses of acute myocardial infarction (AMI), heart failure, or pneumonia, but the program was expanded in FY2015 to include elective hip or knee replacement and congestive obstructive pulmonary disease (COPD) patients. CMS will expand the program again in FY2017 with the addition of coronary artery bypass graft (CABG) patients. The program excludes patients who are transferred to another acute care facility within 30 days and patients who have planned readmissions for things such as chemotherapy or rehabilitation. The HRRP applies to all IPPS facilities but excludes psychiatric, rehabilitation, long-term care, children’s, cancer, and critical access hospitals as well as all hospitals located in Maryland. In the nearly three years the program has been in place, hospitals and regulators alike  have learned a great deal about readmissions and the key factors driving them. We have even witnessed some unintended consequences from the HRRP. Following are some things you will want to know about this important topic.    

1. Readmissions are common and expensive. 

In the U.S. today, one in five elderly patients is readmitted to the hospital within 30 days of discharge, costing Medicare some $15 billion per year. However, readmission rates vary greatly by hospital and by state, providing us with an indication that we might have the opportunity to reduce rates by improving hospital processes.     

2. Certain types of patients are at high risk of hospital readmission. 

There are a number of known factors, such as sociodemographic status and healthcare history, that place someone at high-risk for a readmission. As might be expected, frail, elderly, and lower income patients who lack support at home are at highest risk. 

3. CMS is focused on high volume, high cost diagnoses. 
The HRRP Program is focused on five diagnoses (orange in the table below) that are responsible for a high percentage of 30-day readmissions and a high percentage of total Medicare cost due to readmissions.  Although these diagnoses are among the Top 10, they are not the Top 5 based on rank. 

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While the conditions in the table above have a high number of 30-day readmissions, they do not necessarily represent the conditions with the highest readmission rate. Conditions that have the highest readmission rate are as follows.