2010 Affordable Care Act

Posted on May 1, 2013 in Legislative Updates | 0 comments

The 2010 Affordable Care Act specified penalties to hospitals whose severity-adjusted readmission rate exceeded expected levels for Medicare beneficiaries. On Oct. 1, 2012, more than 2,000 hospitals throughout the country were notified of penalties for excessive readmission rates, ranging from 0.01 percent-1.00 percent of Medicare reimbursements. Alta Bates Summit Medical Center was one such hospital. Beginning in October 2013, the maximum penalty becomes 2.00 percent and then 3.00 percent in 2014. 

In a large Medicare study, 20 percent of patients were readmitted to the hospital within 30 days.  More than half of those readmitted patients had no evidence of an outpatient visit prior to readmission. Identifying those patients with likely readmission is important as we transition care through our health care system. In case management, a risk assessment tool, called the 8Ps has identified patient factors linked to high readmission rates. The 8Ps are as follows:

  • Problem medications (e.g., warfarin, insulin)
  • Polypharmacy
  • Psychological conditions such as depression
  • Principal diagnosis (e.g., CHF, COPD, stroke)
  • Poor health literacy
  • Patient support (or absence thereof)
  • Prior hospitalizations (especially in the last six months)
  • Palliative care

Additional factors might include a lack of primary care and poor mobility status.

By Dean J. Nickles, M.D.
Medical Director, Utilization Management


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