The Affordable Care Act (ACA) of 2010 has been one of the most heavily debated health care laws of recent history. Its full impact on the United States health care system has yet to be fully determined; however, sections of the ACA are already starting to affect how hospitals are being reimbursed for hospital stays. One such section is the Hospital Readmissions Reduction Program (HRRP), which constitutes Section 3025 of the ACA. 

Starting October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) will start to calculate a readmission payment adjustment for three diagnoses: acute myocardial infarction (AMI), pneumonia (PNA) and heart failure (HF). The CMS will look at patients readmitted within 30 days at a specific hospital and adjust that rate based on readmission rates at similar hospitals. If a hospital’s readmission rate exceeds the average rate, then they will eventually be penalized by up to 1% of their total Medicare reimbursements. The maximum penalty will continue to increase up to 3% over the next several years. 

Although there are penalties for hospitals with above average readmission rates, there is no financial incentive for hospitals with below average readmission rates. This structure could potentially be counterintuitive, since one of the major aims of the HRRP is to reduce the excessive costs associated with readmitting patients.

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Although the CMS is primarily focusing on the readmission rates for AMI, PNA, and HF patients, it is expected that the number of diagnoses being scrutinized will continue to expand. One group of patients in which readmissions are frequent, and could become increasingly important under the HRRP, are those with cancer. Oncology patients represent a very complex subset of patients in which the determination of readmission rates might not be as straightforward as those with HF or PNA. 

In addition to the three primary targets of the HRRP, some of the most common admission diagnoses for cancer patients include chemotherapy-induced side effects, initiation of chemotherapy, infectious causes (eg, neutropenic fever, sepsis), anemia, and dehydration (including electrolyte abnormalities). It is yet to be determined how readmissions for chemotherapy-related side effects and chemotherapy initiation and/or maintenance will be handled under the HRRP; however they will undoubtedly be a source for debate and controversy between the government and hospital billing.

Regardless of how the HRRP plays out in oncology, hospitals need to start considering interventions specific to cancer patients in order to prevent readmissions. Prior to discharge, a more coordinated effort will be needed between social work, case management, and the medical teams to identify potential patient risk factors for readmission. Closer follow-up by medical, pharmacy, and nursing health care professionals may be needed post-discharge in order to ensure that the patient is compliant with all of their office visits, medication refills, and laboratory work.

Questions to Readers:

  • Besides AMI, PNA, and HF, what other admission diagnoses in oncology patients pose a risk for high readmission rates?
  • What additional interventions do you believe could prevent the readmission of oncology patients?