3. Thirty-day Readmissions
A number of decisions forthcoming this year focus on how the Centers for Medicare & Medicaid Services will determine those hospitals with higher rates of readmissions for congestive heart failure, pneumonia and heart attack diagnoses. One question is whether the agency will compare a hospital's readmission rates with just those within that hospital's state, or whether each hospital will be compared with the entire country as a whole.
The first option would guarantee that some hospitals in each state would receive negative reimbursement adjustments (CMS prefers that we not use the word penalty), even if those hospitals have far lower readmission rates than hospitals with the highest rates.
Another issue up for consideration is the risk adjustment criteria, whether payers including private insurance companies will begin looking at all-cause readmission rates and whether scheduled readmissions will continue to be included in the equation.
The penalties start at 1% for Medicare DRG discharges on or after Oct. 1, 2012, increase to 2% on or after Oct. 1, 2013 and to 3% on or after Oct. 1, 2014.
How hospitals, physicians, discharge planners, nurse case managers, skilled nursing facilities and in-home health services agencies will work together to avoid the "blame game" when a patient does end up as an "avoidable" readmission will be interesting to watch.
Look for providers and federal regulators to talk more about "all-cause" readmissions, or to include additional diagnoses such as hip replacements gastrointestinal resections, and eventually to lengthen the watch period to 60 or 90 days.
How aggressively will hospitals and doctors stress the need for patients to comply with physician appointments and medication regimens? Will hospital staff dare to tell patients that if there is a preventable readmission, it make the hospital look bad and hurt the bottom line?
4. Outcome measures versus process measures
The science of testing outcomes versus surrogate "process" measures will evolve, but this year and years to come, much more rapidly.
Starting in FY 2014, CMS will include 30-day mortality measures in value-based purchasing incentive payment algorithms. But don't expect publicly reportable outcome measures to stop there.
As James La Belle, Corporate VP of Quality, Medical Management and Physician Co-Management for Scripps Health explained, perhaps more meaningful metrics might include those covering "functional status," such as how quickly or completely a patient's cognitive function is restored, how far they can walk without assistance or how soon they can return to work. How long before the patient could say life was back to normal?