In the world of healthcare insurance, there is an effort underway to find that perfect mix of policy and practice that will help to prevent patients from making a return to the hospital. And this matters.
“I never thought it would happen to me.” A man in his 60s, with no history of serious health issues went in to the emergency room, complaining of chest pains. He walked away the next day with a brand-new stent. Problem solved, right? Then why did this otherwise healthy man find himself right back in that same ER the very next week? He just became a victim of the 30-day return.
It's a Real Problem
According to the New England Journal of Medicine, it has been asserted that nearly 20% of hospitalized Medicare patients end up being readmitted within 30 days of discharge. Now, that is not an insignificant number. And that would indicate that something is going askew during that first hospital admission. In other words, the implication is that the patient’s health status is not being sufficiently addressed during the initial hospital stay. Yes, it’s true that most readmissions occur when the patient is of advanced age. And, yes, older patients tend to have more chronic illnesses and are perhaps more susceptible to certain side effects of treatment that are perhaps not particularly pronounced or discovered until after discharge (e.g., wound healing complications, staph infection, prolonged pain or immobility).
But 20%? How can that number be so high? If one in five Medicare patients has to be readmitted so soon after their initial stay, does that mean there is a fundamental flaw in the system?
Finding the Right Formula
Medicare has an incentive program that essentially penalizes hospitals that have a certain rate of returning patients. According to the Centers for Medicare and Medicaid Services (CMS), “the Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions.” The program aims to support CMS’ goal of improving healthcare for patients by linking payment to the quality of hospital care.
But how? How can a facility effectively and demonstrably reduce readmissions? Well, one insurance giant is working on that very problem.
Last month, Aetna announced its Aetna Clinical Collaboration (ACC) program, which aims to improve care outcomes for Aetna Medicare Advantage members, reducing their 30-day readmission rates and emergency room visits while also easing the administrative load on hospitals and clinical personnel. The program will be introduced to 10 hospitals by the end of this year; and, depending on its efficacy, will go nationwide thereafter.
The ACC program brings Aetna nurses together with hospital staff, working side-by-side to help Medicare Advantage members get the care and support they need to remain healthy when they return home from the hospital or make the transition into a skilled nursing facility. According to Dr. Ben Kornitzer, Senior Vice President and Aetna Chief Medical Officer:
Hospital discharge is one the most important—and vulnerable—moments in a patient's journey. Patients may be managing new diagnoses, complex medications, and follow-up needs, all while coping with the stress of transitioning back home or to a new facility. By embedding Aetna nurses within hospitals, we're partnering with care teams to ensure that members are supported every step of the way and have the right services to stay well and avoid complications that could lead to readmission.
But is this the right mix? Is it really as simple as inserting payer-affiliated nurses to work with hospital staff on cases involving their beneficiaries? Aetna launched a pilot version of the program earlier this year at one hospital and has seen promising outcomes. Once fully implemented at scale, the ACC program is projected to reduce year-over-year 30-day readmissions and hospital length of stay by five percent.
So, the cook is in the kitchen and has attained some initial success. The question is, will the protocols they put in place really drive down the rate of hospital readmissions to a significant degree on a nationwide scale and over the long haul? We look forward to seeing updates on Aetna’s progress in this regard. If ultimately proven to have the right formula, perhaps other payers and health systems will get on board.