When it comes time for a patient to choose their healthcare provider, it's important for them to understand who they're choosing to help ensure they are getting the best care possible. One sure way for the patient to know what to expect from their provider is by reviewing rankings and ratings around quality measures before deciding.
These quality measures are not only helpful for patients but also allow providers to see which areas they are performing well in and where they can improve, with Medicare’s star rating representing an important measure for hospitals and health systems.
Overview of the Medicare Star Rating
Hospitals receive a Medicare star rating that summarizes quality information and performance across five areas:
- Safety of care
- Patient experience
- Timely and effective care
These measure groups are weighted in CMS’ star rating calculation: Mortality, safety of care, readmission, and patient experience are each weighed at 22%, and timely and effective care is weighed at 12%. If no measure exist in a particular group, the weighted percentage is redistributed proportionally to the other measure groups to add up to 100%. The more stars a hospital receives, the better it has performed on the specified quality measures. (Note: Some hospitals may not be eligible for star ratings if they are new or small.)
Connecting the CMS Readmission Rule and Star Ratings
Of all the CMS’ quality measures, readmissions has received a significant increase in focus within recent years. To better understand why, we must first review how Medicare established the 30-day readmission rule. The Patient Protection and Affordable Care Act (ACA) established the Hospital Readmission Reductions Program (HRRP), a Medicare value-based purchasing program, as a way to encourage hospitals to reduce avoidable readmissions. According to the Agency for Healthcare Research and Quality (AHRQ), there were 3.8 million 30-day all-cause adult hospital readmissions in 2018 (the most recent data on the metric). The estimated cost of unplanned hospital readmission is between $20 to $40 billion annually. Previous research has shown that reducing readmissions in hospitals would result in reimbursement gains of $10,000 to $58,000 for each Medicare discharge.
Not only are hospital readmissions costly, but they can indicate patients did not receive the proper treatment while hospitalized or that their post-discharge care was not properly organized and executed. According to a classic and frequently cited study, nearly 20% of patients have adverse events within three weeks of discharge, and nearly three-quarters of those readmissions could have been prevented.
Readmission data is publicly reported, and that data is available to view through Medicare’s Care Compare tool — and patients are taking notice. This tool allows patients to compare different types of Medicare providers and see their overall star rating and patient survey rating. Such helps patients make informed decisions about where to receive care.
The availability of readmission data provides greater transparency into our healthcare system. When patients have access to information, whether it’s related to pricing or care quality, it can lead to improved health outcomes and better patient experiences.
What Readmission Areas Affect Star Ratings?
The publicly reported, 30-day risk-standardized unplanned readmission measures are divided into three areas: condition-specific, procedure-specific, and hospital-wide.
Condition-specific measures under HRRP, sometimes referred to as the CMS readmission rule, includes:
- Acute myocardial infarction
- Chronic obstructive pulmonary disease
- Heart failure
Procedure-specific measure includes coronary artery bypass graft, total hip arthroplasty and/or total knee arthroplasty. While the hospital-wide measure includes hospital-wide all-cause 30-day readmission. According to CMS, patients receiving high-quality care during their hospitalizations and transitions to outpatient settings will likely have better outcomes.
The star ratings for readmissions factor in 11 different measures:
- Hospital return days for heart attack patients
- Rate of readmission for coronary artery bypass graft (CABG) surgery patients
- Rate of readmission for chronic obstructive pulmonary disease (COPD) patients
- Hospital return days for heart failure patients
- Rate of readmission after hip/knee surgery
- Hospital return days for pneumonia patients
- Rate of readmission after discharge from hospital (hospital-wide)
- Rate of unplanned hospital visits after an outpatient colonoscopy
- Rate of unplanned hospital visits for patients receiving outpatient chemotherapy
- Rate of emergency department visits for patients receiving outpatient chemotherapy
- Ratio of unplanned hospital visits after hospital outpatient surgery
Some hospitals be unable to report data on every measure depending on the number of patients they treat.
Strategies for Reducing Readmissions in Hospitals
There are several ways hospitals can work toward reducing readmissions and improving their Medicare star rating in the process. But first, it is important to understand why readmissions happen in the first place. Common causes of hospital readmissions include:
- Patient disengagement and noncompliance
- Condition complications
- Inadequate transition of care, including early discharge or poor care coordination
- Misinterpretation of discharge instructions
- Demographics, such as socioeconomic status
Identifying social determinants of health (SDoH) barriers, such as limited transportation, can help hospitals flag patients who may be at an elevated risk for readmission, according to PatientEngagementHIT. Similarly, patients who have limited health literacy or English proficiency may also be at a higher risk for readmission. Hospitals and health systems should work to address the factors that increase the risk of a readmission. This can include discussing ways to navigate SDoH challenges, using plain language to explain health information, and providing educational material in the patient's native language.
Medication issues also lead to readmissions. According to Frontiers in Pharmacology, 16% of readmissions are medication-related, and 40% of those are potentially preventable. That includes prescribing errors, medication non-adherence, and transition errors. Patients may also have trouble affording medication, or they may be worried about side effects. They may also be taking multiple medications at once, which may interact with each other in unwanted ways.
Improving communication between patients and providers, as well as between providers themselves, can go a long way toward reducing readmissions in hospitals. It is important to ensure that patients fully understand their discharge instructions, but it is also critical to make sure any transitions in care are as seamless as possible.
Medication reconciliation can also aid in reducing readmissions in hospitals. Providers must make sure they have a complete and accurate list of all of a patient’s medications to reduce the risk of adverse drug events and prevent medication mishaps. A transitions of care pharmacist can assist with medication reconciliation and medication reconciliation post-discharge (MRP) while providing medication-related education to patients and their caregivers.
Get Help Reducing Hospital Readmissions
Although reducing readmissions may seem like a daunting task, it is crucial for improving patients' health outcomes and star ratings. An effective hospital readmission reduction program requires a multi-pronged approach involving patient engagement, medication management, and improved care coordination to keep patients from returning to the hospital.
Cureatr provides comprehensive medication management services by combining software and human interaction to facilitate improvements that lower readmissions, increase quality rankings, and boost star ratings. To learn practical strategies to help address poor medication management, download the guide “Improving Patient Care with Medication Management: Everything Clinicians Must Know” or contact Cureatr to find out more about how we help hospitals and health systems better address the complex readmission issue.