Hospital Readmissions and the Affordable Care Act
Authors: Robert P. Kocher, Eli Y. Adashi
Journal: JAMA (2011)

HOSPITAL READMISSIONS HAVE BEEN THE SUBJECT OF ever-increasing scrutiny. Indeed, they are an important focus of the US Patient Protection and Affordable Care Act (ACA). Identified by the Medicare Payment Advisory Commission as a major action item for some time, hospital readmissions remain prevalent, costly, and largely preventable. The recently updated Hospital Compare Web site reveals that the national 30-day readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia have had limited if any improvement from 2007 through 2010. “Payment incentives to avoid readmissions” have been cited in the Department of Health and Human Services’ strategic plan for 2010 through 2015 as an example of quality of care improvement. Hospital readmissions also have been singled out for improvement by the Centers for Medicare & Medicaid Services’ (CMS’s) National Strategy for Quality Improvement in Health Care. The goal of the CMS’s strategy is to effect a 20% reduction in hospital readmission rates by the end of 2013, thereby potentially preventing 1.6 million hospitalizations and saving an estimated $15 billion. We describe the various strategies embedded in the ACA that focus on this important challenge. The first initiative launched in the effort to reduce hospital readmissions was the Community-Based Care Transitions Program (CCTP). This Medicare demonstration project was mandated by §3026 of the ACA and is intended to reduce hospital readmissions by targeting the quality and safety of care transitions between the inpatient and outpatient arenas. To this end, the CCTP, a nationwide 5-year $500 million program, proposes to underwrite (on a per-eligibledischarge basis) the services of partnerships between hospitals and community-based organizations focused on the reduction of hospital readmissions. Further assistance will be provided by carefully selected expert “hospital engagement” and other dedicated contractors prequalified by the Department of Health and Human Services. The premise of the CCTP is that partnerships between hospitals and community-based organizations, heretofore uncommon and nonreimbursable, will prove successful in reducing hospital readmission rates by coordinating care transitions. Effectiveness will be maximized by emphasizing high-risk beneficiaries and partnerships between hospitals with high admission rates and medically underserved communities. Unlike earlier, more-limited efforts to foster partnerships between hospitals and the community as an approach to fragmented postacute care (eg, the 14-state Care Transitions theme of Medicare’s quality improvement organizations), the CCTP operates on a national scale that previously was unattainable. As such, the CCTP appears positioned to improve the quality of care transitions, reduce hospital readmissions, and document measurable cost savings. There is no overestimating the insights likely to be gained or the prospect of their broad dissemination and implementation. A related initiative is the soon-to-be launched Independence At Home Demonstration Program (IAHP), authorized by §3024 of the ACA. Under the IAHP, a 3-year $25 million effort, primary care teams directed by physicians or nurse practitioners will evaluate service delivery models for home-bound chronically ill Medicare beneficiaries. Aiming to provide highly intense care, the IAHP is to be comprehensive, coordinated, continuous (24-hour, 7-days/ week), accessible (in-home), and multidisciplinary, thereby hopefully averting readmissions. The IAHP will also be testing novel payment models wherein revenue sharing by health care teams (consisting of physicians, nurses, physician assistants, pharmacists, and other health and social services staff) can be realized subject to meeting specified quality and savings targets. The IAHP is limited to a total patient cohort of 10 000, and viewed broadly, stands out for its demanding focus on readmission-susceptible beneficiaries whose extant home-centered care is in need of intensification and coordination. The IAHP is slated to begin January 1, 2012, and may well have a salutary effect on hospital readmission rates while effecting other measureable improvements in the quality, efficiency, and cost of the care provided. Perhaps the most important program in the effort to reduce hospital readmissions is the multipronged Hospital Readmission Reduction Program (HRRP), the product of §3025