Here’s what you need to know about the plan all-cause readmissions measure

We want to help you better understand the plan all-cause readmissions measure that is a HEDIS measure as well as a star ratings measure.

About the measure
Plan all-cause readmissions measures the number of acute inpatient hospital stays for patients during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, as well as the predicted probability of an acute readmission.

• The commercial measure looks at patients ages 18 to 64.
• The star measure applies to patients 18 and older.

Patients must be members of their plan for one year before being identified for the measure.

HEDIS defines potentially preventable readmissions as those that are directly tied to conditions that could have been avoided in the inpatient setting.

Why the measure is important
Understanding readmission rates is important because discharge from a hospital is a crucial transition point in a patient’s care. According to the Centers for Medicare & Medicaid Services, about one in five Medicare patients is readmitted within 30 days. Poor care coordination at discharge can lead to adverse events for patients and potentially preventable readmissions.

While not all readmissions are avoidable, many potentially preventable readmissions can be avoided when hospitals and providers actively manage the complexities of transitioning care to another setting after hospitalization. The Mayo Clinic found that only 42 percent of discharged patients knew their diagnoses and only 37 percent could explain the purpose of their medications.

Readmissions also cost Medicare about $15 billion annually. To bring readmission rates down, CMS implemented its Hospital Readmissions Reduction Program. It will withhold $528 million in payments under this program in 2017.

According to a study by the University of California San Francisco, there are steps to reduce the need for readmissions. They include:

• Improving communication between patients and clinicians as well as between primary care and hospital doctors
• Assessing patients’ readiness for discharge
• Offering better post-discharge resources to patients

How can doctors help prevent unnecessary hospital readmissions?
Encourage your patients to schedule visits with you after they have been discharged from a hospital or other facility, preferably within seven days of discharge. If you learn that a patient was discharged, have your office staff reach out to schedule a visit.

Before the post-discharge visit:

• Review the patient's hospital discharge summary and get any test results that weren’t available when the patient was discharged.
• See if the inpatient facility’s doctors discontinued medications that you think the patient needs.

As part of the visit:

• Make sure the patient understands:
• His or her diagnosis
• Why he or she was admitted
• Signs and symptoms of when he or she should call you (during and after office hours) or when he or she should go to the emergency room
• Conduct post-discharge medication reconciliation by:
• Comparing the hospital discharge medications to the patient’s office medications
• Documenting it in the patient’s medical record
• As part of medication reconciliation, help your patient understand:
• Newly prescribed medications
• Which medications he or she should stop taking
• Talk about conditions and events (e.g., medication adherence) that contributed to the patient’s hospitalization and discuss the plan of care with the patient.
  
  
• Ask if the patient has completed or scheduled prescribed outpatient work-ups or other services, such as physical therapy and home health care visits, and ordered durable medical equipment.

For Medicare Advantage PPO members, bill $10 for CPT^® II category code *1111F for medication reconciliation. The *1111F description reads, “Discharge medications reconciled with the current medication list in the outpatient medical record.” MA PPO members can be identified by the XYL prefix on the member ID number.

For commercial and BCN members, we don’t currently reimburse for *1111F. However, we’ll begin reimbursement for commercial members in 2017. Please watch The Record for more information.

Steps to reduce the need for readmissions include improving communications between patients and clinicians as well as between primary care and hospital doctors, assessing patients’ readiness for discharge and providing better post-discharge resources.

For more information on medication reconciliation and reimbursement, please read the following articles from The Record:

“New Medicare star ratings measure: Medication reconciliation post-discharge"

“Providers receive reimbursement for conducting medication reconciliation post-discharge for MA PPO members"

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.