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Cost Containment Corner - The importance of redesigning care for at-risk patients

May 10, 2017
Business Affairs
From the May 2017 issue of HealthCare Business News magazine

By Neil Smiley

The risk burden for hospitals has been increasing steadily since the implementation of the Hospital Readmissions Reduction Program (HRRP) in 2012. Hospitals have been working to lower readmission rates, especially for at-risk populations, in order to avoid the associated penalties. Despite the rapid expansion of electronic medical records and additional economic incentives to reduce readmissions as a result of episode payment models (EPMs), comprehensively addressing readmission risk remains a challenge.

The costs and causes of readmissions
Readmissions can be costly for hospitals. According to data provided by the Centers for Medicare & Medicaid Services (CMS), about 2,500 hospitals lost reimbursements totaling $528 million in payments for readmissions between July 2012 and June 2015 under HRRP. While some readmissions are unavoidable, others are readily addressable. Patients readmit for different reasons.

However, there are opportunities to make an impact. Medication adherence failures cost the health care system nearly $300 billion a year in additional doctor visits, emergency department visits and hospitalizations, and claim the lives of 125,000 Americans annually. Improvements in the medication adherence rates of high-risk patients directly translate to reductions in readmissions.

Another area providing an opportunity for impact is improving visibility and communication between providers, facilities and patients during and after a hospitalization. Care transitions have long been recognized as a problem area. A study published in 2016 in JAMA Internal Medicine estimated that about one-fourth of admissions are avoidable with improved collaboration across the care continuum.

As more data have become available, other risk factors have been identified. Patients with multiple comorbidities, including mental health conditions, represent a population at higher risk of readmission and are responsible for a disproportionate share of health care costs. A 2014 CMS study of dual-eligible beneficiaries noted that patients with two to five comorbidities, including mental health issues such as depression, had twice the amount of monthly expenses as compared to those beneficiaries with no physical or mental health condition on record. Associated health care costs double yet again if a patient has five or more comorbidities. Leveraging effective data analytics to proactively engage this small, yet disproportionately high-risk population with effective care models is key to reducing overall costs.

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