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Metzger: Yes, you know they used to call them peer review organizations, and now they're quality improvement organizations (QIOs); and there has already been in place a program to look at cases that CMS has flagged for potential non-payment. The measures have been in IQR [the Medicare Inpatient Quality Reporting program] for years. But the QIOs were given some extra responsibility for looking at Medicare patient readmissions, up to and including the ability to recommend non-payment. Well, what the readmission reduction program does, it says, if you're a bad performer on readmissions, we're also going to hit your DRG [diagnosis-related group] payments with a penalty; so it's like a pile-on, on readmissions.
HCI: So this new proposed rule just reinforces and intensifies the focus on readmissions?
Metzger: Yes, basically what they're going to do is to calculate a readmissions performance ratio relative to other hospitals to see where you sit, and they said that the people who have an excess level compared to all hospitals will lose up to 1 percent of their base payments. Now, they did talk about how they're going to calculate the readmissions ratio, but they haven't explained exactly how that gets translated into the payment reduction. At least we now know what the measures are.
HCI: And the areas they're looking at-heart failure and pneumonia-are the most obvious ones, right?
Metzger: Well, they're the areas with the highest rates of readmissions. They've said, however, that they'll be expanding the list; they're always expanding things in some direction. Now, one of the things most challenging for hospitals is that this covers readmission for any condition, and it can be for readmission to any hospital. I think the rationale is that if you had a significant enough condition the first time around, it should have been addressed. So it makes it hard for hospitals in that a patient could go across town, right?
PROBABLY ONE OF THE MOST DIFFICULT AREAS FOR HOSPITALS IS THAT PATIENT EXPERIENCE MEASURES ARE PART OF BOTH THE VALUE-BASED PURCHASING AND SHARED SAVINGS PROGRAMS.
However, this whole area around working harder on discharge planning and discharge instructions, and connecting a patient to a PCP [primary care physician] so they will get follow-up care, there's even a lot in the literature around this. But with all this pressure coming from the aging of the population and the increasing burden of chronic illness-and of course you see all that in Medicare-this becomes very significant.
HCI: What do you see as the biggest implications of all this on the healthcare IT front?
Metzger: There's a whole range of things you can do to work on readmissions in particular, to begin with. You can know what the risk factors are, a major one being previous readmissions. And once you have the data electronically, you can certainly flag patients that you know you'll need to pay special attention to. You can use order sets, documentation templates, and patient tracking protocols, so that you're looking at those patients. You can make sure the patient has a follow-up appointment, and you can make sure the patient and family know about it. The case manager can have a call list. All of these care interventions to reduce the risk of admission, work amazingly better when supported by information technology gathering the data you need, and making it available to the folks on the front lines.
HCI: And you need really good data warehouses and report-writing capabilities, right?
Metzger: This is a really good example of where, let's say there's a health system with multiple hospitals-it would be really advantageous to know, across hospitals, admission history and other medical record information about patients-when they present for care, and so on. What's harder is when they present outside your corporate boundaries. But you need to capture the data, and you need really good analytic skills. It's not that long ago in hospitals that, once the coding had been done on a discharge, the information about the stay would be archived. That's not terribly ancient history.
At a minimum, you need to know, for the patients who have been seen in this particular hospital, what their admissions history has been. But that's just the tip of the iceberg of what you'd really want to know about the patient to resolve issues, understand them all, and send the patient home well-equipped in terms of follow-up appointments, support, and information, to minimize readmission.
That's just one of these programs. The same is true for value-based purchasing: you've got these measures, you've got patient conditions that are targeted, and there are going to be more. By the way, these are all familiar measures. However, patient experience is in value-based purchasing; and probably one of the most difficult areas for hospitals is that patient experience measures are part of both the value-based purchasing and shared savings programs. Was I treated with adequate courtesy, was I well-informed about what was going on, and so forth. The rules talk about that there will be more HCAHPS-related content [HCAHPS is the Hospital Consumer Assessment of Healthcare Providers and Systems program, from CMS]. Those measures have all been a part of the Hospital Compare.
