In fiscal 2013, payment penalties were based on 30-day hospital readmission rates for heart attack, heart failure and pneumonia. In fiscal 2015, cmS added readmissions for patients undergoing elective hip or knee replacement and patients with chronic obstructive pulmonary disease. CMS will add retakes for coronary artery bypass procedures in fiscal 2017 and will likely add more measures in the future. Despite the successes mentioned above, the method of calculating excessive readmissions has been the subject of much discussion. Initial risk adjustment models have not been adapted to socio-economic status. Several analyses have shown that caring for patients with lower socioeconomic status carries a higher risk of penalties.18, 44, 45 This means that the HRMP can inadvertently withdraw resources from hospitals such as safety net hospitals that serve disadvantaged populations. An expert panel convened by the National Quality Forum concluded that not taking socioeconomic factors into account could exacerbate disparities by punishing these hospitals.46 In MedPAC`s June 2013 report to Congress, they proposed comparing hospitals with other hospitals with patients of similar socioeconomic status to account for differences in current calculation strategies. but the implementation of these proposed changes and risk adjustment approaches has not yet taken shape.10, 47 In addition, Maryland hospitals have been excluded because Congress has allowed that state to establish its own rules for the distribution of Medicare funds and the treatment of readmissions. A hospital readmission is an episode in which a patient who has been discharged from a hospital is readmitted within a certain period of time.
Readmission rates are increasingly being used as a measure of outcomes in health services research and as a measure of the quality of health systems. In general, a higher readmission rate indicates the ineffectiveness of treatment in previous hospitalizations. Hospital readmission rates have been formally included in the Reimbursement Decisions of the Centers for Medicare and Medicaid Services (CMS) under the Patient Protection and Affordable Care Act (ACA) of 2010, which penalizes health care systems with higher-than-expected readmission rates through the Hospital Readmission Reduction Program.   Since the beginning of this sentence, other programs have been put in place to reduce hospital admissions. Examples of these programs include the Community Care Transition Program, the Home Independence Demonstration Program, and the Enhanced Care Pooled Payment Initiative. Although many delays have been used in the past, the most common delay is within 30 days of relief, and this is what CMS uses. The HRMP itself does not provide resources to hospitals to fund measures to reduce recovery and rethink care. However, the CMS has provided additional funding for transitional care through complementary programs.
The Community Care Transition Program (CCO), created by section 3026 of the ACA, aims to test models to improve care transitions and reduce relapses.22 Specifically, the PTCC allocates $500 million only to hospitals that have applied and been approved; It currently comprises 102 organizations. In January 2013, Transitional Care Management Services provided two new codes of current procedural terminology (CPT).23, 24 These CPT codes cover services provided to a patient whose medical or psychosocial problems require moderate or very complex medical decision-making during transitions in care. This includes discharge from a hospital hospital (acute care hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital or qualified care facility in the patient`s community (home, residence, retirement home or assisted living facility). While these codes offer higher billing for post-discharge visits within 7 or 14 days of discharge – depending on the code – they go to the ambulatory care provider and therefore do not help offset HRIP penalties unless there is a financial integration of inpatient and outpatient care. Similarly, the CMS will begin to pay physicians to provide services in the area of chronic care management, which provides further incentives to coordinate inpatient and outpatient care.25, 26 While one of the benefits of outcome measures is that they reflect the entire field of care leading up to an event, the CMS does not propose specific measures to improve them. Providers, hospitals, researchers and policy makers must then identify gaps in care processes and implement targeted solutions. Programs such as the H2H initiative,29 TARGET:HF,30 and Aligning Forces for Quality Network,59 that aim to exchange best practices between institutions and improve transitions in care are an important approach. A detailed review of outliers – hospitals where standardized mortality and reuptake rates at risk are high, high, low, and low risk – promises to identify some factors that vary in outcomes.60 Ultimately, a series of investigations are needed to develop more targeted, effective, and patient-centered interventions to improve transitions in care and patient outcomes. The HRRP has drawn attention and energy to these efforts.
Through the HRPP, the CMS calculates the reduction in payments and component results for each hospital based on the hospital`s readmission rates over a three-year performance period.  CMS first calculates the Excess Readmission Ratio (ERR), which is a measure of a hospital`s relative recovery performance compared to other HRRP hospitals.  The SERS is then used in a payment reduction formula to assess hospital readmissions for each of the six conditions or procedures contained in the PRRH.  CMS converts payment reduction into a settlement factor (“PAF”) to manage payment reductions.  CMS applies the PAF to reduce payments for all Medicare FFS-based DRG payments in effect in a given fiscal year. The conditions initially included in the HRRP were acute myocardial infarction, heart failure, and pneumonia, which in 2015 spread to patients with acute exacerbation of chronic obstructive pulmonary disease and to patients admitted for non-urgent total hip stents and total knee stents.9 Conditions are identified based on the diagnosis of primary discharge rather than the DRG assigned to hospitalization. In addition, hospitals must have at least 25 initial hospitalizations for a diagnosis to be measured. Public and possibly financial accountability then extends to hospital-wide readmission rates.10, 12 The HRMP further refines its guidelines, including previous changes to the methodology for calculating the adjustment factor for hospital recovery and review of planned readmissions. HrRP is a start. As with any quality measure, fairness is crucial. Therefore, validation of the risk normalization process is necessary and ongoing.
This should include further studies on the nuanced relationship between readmission rates and socio-economic factors that are not currently included in the risk adjustment methodology. This project was designed because an additional adjustment to socio-economic status could mask existing inequalities in the care of disadvantaged population groups. Conversely, ignoring the socio-economic environment disproportionately penalizes hospitals serving disadvantaged groups, thereby increasing differences in care. Therefore, simultaneous reporting of rates that include and exclude socioeconomic status may be more meaningful than choosing one measure or another. .