Hospital Readmissions and Medicare
Created by FindLaw's team of legal writers and editors | Last reviewed September 26, 2018
The term "hospital readmissions" has very different meanings for hospitals and government programs than it does for patients. Rehospitalizations are problematic for Medicare because they reflect a failure in care and subsequent hospital readmissions result in greater costs. This article discusses the relationship between hospital readmissions and Medicare, including the following:
- The Hospital Readmission Reduction Program (HRRP);
- What constitutes an official "readmission;"
- The HRRP's impact on patient care; and
- Steps patients can take to avoid hospital readmissions.
What is a Hospital Readmission?
A hospital readmission is an event that occurs when a patient who had been previously discharged is readmitted within a designated period. This is a bad situation for most patients, as it suggests inadequate care.
Consider the following example: After a short stay, you leave the hospital with a new diagnosis of COPD, but you don't fully comprehend how your inhaler works. You wanted in-depth instructions about self-care instead of the clinical and impersonal discharge you received. Anxious and frightened, you return home and end up back in the hospital three weeks later due to breathing problems.
Unfortunately, the scenario is common for many Americans, but there are any number of reasons for a hospital readmission, including:
- Patients suffering from new conditions;
- Recurrent exacerbation of chronic conditions;
- Complications due to prior medical or surgical care; or
- Adverse drug reactions.
Additionally, the premature discharge to a setting (usually their home) where the patients' needs aren't met for post-hospital care makes it highly likely that the patients will be readmitted. They can also get sick from health care related illnesses. According to a CDC (Center for Disease Control) study, one out of 25 hospital patients develops an infection at a health care facility.
Medicare Definition of Hospital Readmission
According to Medicare, a hospital readmission is "an admission to an acute care hospital within 30 days of discharge from the same or another acute care hospital." However, a readmittance for follow-up care does not constitute a "readmission" for Medicare.
The Hospital Readmission Reduction Program (HRRP)
When a patient is readmitted to the hospital, the associated costs are high and it can indicate shortcomings in treatment. One of the objectives of the 2010 Affordable Care Act (ACA) was to combat these issues directly. The ACA included a provision establishing the Hospital Readmission Reduction Program (HRRP), which requires Medicare to lower payments to hospitals with excessive readmission rates.
The readmission rates initially only applied to Medicare patients suffering from heart failure, heart attacks, and pneumonia, but the program was expanded to encompass other conditions such as knee and hip replacements and coronary artery bypass graft surgery.
Since the implementation of the HRRP in 2012, hospital readmission rates for Medicare patients have decreased. Despite the apparent success, there is criticism about the program itself and whether it adequately deals with the issue at the expense of patient care.
Concerns About the HRRP
By making a connection between compensation and the quality of hospital care, the HRRP uses financial incentives to facilitate goals of reducing hospital readmissions. There's also a public relations incentive because Medicare publicizes the readmission rates. It's a public policy concern that's perceived as reflecting a measure of the quality of hospital care.
Financial incentives that are legally mandated can trigger inappropriate care approaches. This can take many forms of manipulating the system to avoid the penalties, to the detriment of patients. For example: discouragement of triage for emergency care or delaying hospital readmissions beyond 30 days. Providers can hold patients longer than necessary in observation units, areas meant for short-term care that are coded as outpatient admission. The treatment under observation could result in a denial of coverage for a patient's follow-up care.
Hospitals must comply with the statutory requirements of the ACA concerning hospital readmissions or suffer the consequences. As a patient, if you're negatively impacted, you can investigate whether you're a victim of medical malpractice and file a lawsuit accordingly.
Ways to Avoid Hospital Readmissions
Obviously, patients can't carry the full burden of working to avoid hospital readmissions. Providers and care managers must work on better practices that give the patients more information, resources, and proper instructions on how to take care of themselves. However, patients must have agency in ensuring that their health care needs are satisfied. Here are some ways to achieve this:
- Ask questions when talking to health care providers.
- Bring a family member or friend (or interpreter) to help take notes.
- Ask for a detailed discharge plan.
- Record discharge directions on your phone.
- Follow the discharge plan.
- Take medication as prescribed.
- Go to follow-up doctor appointments.
- Know what symptoms to look out for and follow up if they occur.
- Use available resources and community services.
Concerned about Hospital Readmissions? Find an Attorney
If you're a Medicare patient who suspects that you've received inadequate care associated with a hospital readmission, then consider talking to an attorney. A health care attorney can provide answers for you and can give you guidance on necessary steps to take.
You Don’t Have To Solve This on Your Own – Get a Lawyer’s Help
Meeting with a lawyer can help you understand your options and how to best protect your rights. Visit our attorney directory to find a lawyer near you who can help.