Assignment: Medicare’s Readmission Penalties

Assignment: Medicare’s Readmission Penalties
Assignment: Medicare’s Readmission Penalties
Review the story at the link below before posting to the discussion:
Rau, J. (2015). Half of nation’s hospitals fail again to escape Medicare’s readmission penalties. Kaiser Health News. Retrieved from
After you have finished, consider how you would respond to the following situation:
Your local hospital has received notice from CMS (Centers for Medicare and Medicaid) regarding their readmission rates.
As a BSN prepared nurse, you have been asked to serve as a consultant to suggest a new Quality (Performance) Improvement process for ONE of the areas of deficiency. Write some brief steps (suggestions) for improvement as you contemplate accepting the consulting opportunity.
Share practice improvements utilized from your own clinical nursing experiences that have led to enhanced patient outcomes.
Textbook:
Finkelman, A., 2016 Leadership and Management for Nurses: Core Competencies for Quality Care (3rd Edition), Pearson Learning Solutions, Boston, MA
& Two outside scholarly sources to be referenced within the last 10 years.
The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based buying program that encourages hospitals to improve communication and care coordination in order to better engage patients and caregivers in discharge plans and, as a result, prevent unnecessary readmissions.
By tying payment to the quality of hospital care, the initiative contributes to the national aim of improving health care for Americans.
Beginning October 1, 2012, the Secretary of the United States Department of Health and Human Services was obligated to limit payments to subsection (d) hospitals for excess readmissions under Section 1886(q) of the Social Security Act (that is, fiscal year [FY] 2013).
In addition, beginning in FY 2019, the 21st Century Cures Act requires CMS to evaluate a hospital’s performance in comparison to comparable hospitals with a same proportion of patients who are dually eligible for Medicare and full Medicaid services.
To ensure fiscal neutrality, the legislation requires expected payments under the stratified technique (that is, FY 2019 and beyond) to be equal to estimated payments under the non-stratified methodology (that is, FY 2013 to FY 2018).
CMS has included six 30-day risk-standardized unplanned readmission measures in the program that are condition or treatment specific:
Acute myocardial infarction (AMI) is a type of heart attack that occurs suddenly (AMI)
COPD stands for chronic obstructive pulmonary disease (COPD)
Insufficiency of the heart (HF)
Pneumonia
CABG stands for coronary artery bypass graft surgery.
Primary total hip and/or total knee arthroplasty (THA/TKA) is an elective procedure.
CMS determines each hospital’s payment decrease and component outcomes based on its performance during a rolling performance period.
The payment adjustment factor is a type of payment reduction that CMS employs to lower hospital payments.
During the fiscal year, all Medicare fee-for-service base operational diagnosis-related group payments would be reduced (October 1 to September 30).
The payment reduction is limited to 3%. (that is, a payment adjustment factor of 0.97).
Hospitals get confidential Hospital-Specific Reports (HSRs) from CMS once a year.
CMS provides hospitals 30 days to review their HRRP data as it appears in their HSRs, ask questions about how their results were calculated, and request adjustments.
The HRRP Review and Correction phase is only for anomalies in the payment reduction calculation and component findings.
CMS reports HRRP data in the Inpatient Prospective Payment System/Long-Term Care Hospital Prospective Payment System Final Rule Supplemental Data File on CMS.gov after the Review and Correction period.
Additionally, CMS publishes HRRP data from hospitals on Hospital Compare or its successor website.